Secondary care vestibular function testing for management of balance disorders
This is a prospective study on the outcome of vestibular function tests for the investigation of dizziness in patients referred to an ENT department in a district general hospital in Wales
Design, setting and participants Videonystagmography (VNG) is carried out as initial assessment of the integrity of the peripheral vestibular function in patients with balance dysfunction. The study was carried out in district general hospital and 110 patients were included in this study. Patient information were collected with the aid of questionnaire. Dizziness, a common symptom of imbalance in adults is commonly under treated and often becomes chronic; it can lead to deterioration in quality of life with substantial socioeconomic impact. It is a common problem in patients managed in primary care.
Main outcome measure The aim of the study was to quantify the number of patients referred by general practitioners to ENT for investigation and what proportion were further referred for vestibular function tests.
Results We wanted to establish the usefulness of VNG in the management of dizzy patients. In a large proportion of patients it was difficult to establish the true nature of dizziness.
Conclusion We found that VNG is useful for exclusion of peripheral vestibular disorders and often to corroborate adequate vestibule-ocular reflex.
Key points
Dizziness is common, largely untreated and often becomes chronic resulting in to great personal loss and on large scale economic loss
The aim of the study was to quantify the number of patients referred by general practitioners to ENT department for investigation and what proportion was further referred for vestibular function tests
Videonystagmography is carried out as initial assessment of the integrity of the peripheral vestibular function in patients with balance dysfunction.
We found that VNG is useful for exclusion of peripheral vestibular disorders and often to corroborate adequate vestibule-ocular reflex.
Introduction
Dizziness is a term used to describe a range of sensations, such as feeling faint, woozy, and weak or unsteady6. It is a symptom usually described by patients. When present it can be related to balance dysfunction but this is not always the case. Vertigo is a sensation of motions or spinning that is often described as dizziness7. It is not the same as being lightheaded. Vertigo is a characteristic manifestation of peripheral vestibular dysfunction often related to inner ear or vestibular nerve pathology. Clinical examination can provide some qualitative information of the vestibular function and differentiate central from peripheral Vestibular dysfunction. Not every patient with dizziness requires qualitative vestibular function testing.
Dizziness is a common symptom presenting to primary care, it is largely untreated, often becomes chronic with a resulting deterioration in the patients quality of life and on a larger scale great socioeconomic loss1. Balance function deteriorates with age and is one of the most common reasons for patients aged over 75 to seek advice in primary care. It has been quoted that almost three million UK residents suffer from dizziness 2. Unfortunately the initial treatment of patients with dizziness is often haphazard and largely ineffective. It has been reported that one third of dizzy patients remained symptomatic after five years and only one in four received treatment. Studies from other countries support the evidence of high prevalence of dizziness and a large proportion of patients without treatment.
2:Material and method
2.1
No ethical approval was required as all individual responses were anonymised
2.2 Participants
This is a prospective, single institution observational study of patients who presented with balance disturbance to the ENT department of one district general hospital in South West Wales.
2.3 Setting
This study was carried out in ENT department of district general hospital in south Wales. The measurement of main outcome measure was carried out on patients referred to the audiology department at Glangwili hospital in Carmarthen for vestibular assessment.
2.4 Study design
The data was collected by the help of a questionnaire. We designed 5 questions to see whether videonystagmography helps to deal with patients who do not fit in to any specific category of ENT vertigo. The questionnaire were given to our audiologist who performed the videonystagmography and recorded the results according to questionnaire. All vestibular function tests were performed by same audiologist. Research protocol included exclusion criteria which was, age under 18 years, patients unable to tolerate VNG and history of ear surgery with open mastoid cavity. majority of patients with a clear history and clinical presentation of vertigo due to peripheral vestibular dysfunction, were diagnosed and treated accordingly. Subsets of patients presenting atypical clinical findings were sent for vestibular function testing for further investigation to aid to diagnosis. Simple statistical analysis were performed to analyse data. Data collection was based on a five-question pro forma:
Data collection form
Pertinent information was collected with the aid of a questionnaire as follows:
Numbers of patients referred to ENT by primary care.
Number of patients referred from ENT to Audiology for vestibular assessment (vestibular function tests).
Main purpose of referral: Detection of vestibular dysfunction or confirmation of integrity of vestibular portion of balance system ( vestibulo-ocular reflex).
Outcome of investigation. Detection of vestibular dysfunction or confirmation of integrity of peripheral vestibular system.
Was further management required: ENT, Audiology, and Neurology?
Results
The average total number of patients referred to ENT was 5400 in one year. Of these on average 343 were referred for investigation of balance disturbance (vertigo is mentioned but in the referral it is not always clear). Furthermore 130 out of these 343 patients on average were referred for vestibular function tests. Our study was conducted for 10 months and 110 patients were included. 20 patients did not fulfil the inclusion criteria and therefore were excluded. The outcome of the study showed that 37 patients were referred for vestibular rehabilitation that were continuously dizzy and were difficult to place in to any specific ENT dizziness. In these 37 patients VNG did show some weakness of one sided peripheral vestibular function. 41 Patients showed normal vestibular function test with no further complaint of dizziness and were discharged back to their GP. 14 patients were found to have BPPV (benign paroxysmal vertigo) and underwent Epley’s manoeuvre with no further follow up required. The remaining 18 patients who were referred back to ENT department had normal VNG but still were very symptomatic with dizziness. These patients were referred to neurology for their opinion and further management.
Management
Dizziness increases with age and around one third of the population in 50-60 years of age suffer with this problem 3.
. Over 75 years of age dizziness is the most common cause to seek a general practice consultation 4. Despite this the treatment is haphazard and largely ineffective. Yardley et.al reported that 1/3 of the patients with dizziness remained symptomatic after 5 years and only ¼ ever received treatment 5. Peripheral dizziness can easily be distinguished from central dizziness by simple bedside test. Negative head impulse test, direction reversing gaze-evoked nystagmus and vertical skew deviation suggest central vestibular lesion 8. On the other hand positive head impulse test, unilateral nystagmus and no vertical skew deviation indicate peripheral vestibular lesion 9.
Videonystagmography is a useful test to exclude any peripheral vestibular disorder. There are more than 3 million people with dizziness but still very poorly managed. 14 patients who were diagnosed as BPPV could have easily been managed in the clinic rather than being referred for vestibular function test. We feel that dedicated clinics are required to deal with dizzy patients at a district general hospital and preferably it should be a one stop clinic including ENT surgeon, Audiologist and or neurologist.
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