Development and Preliminary Findings of the Dizziness Symptom Profile

Development of an Automated Triage System for Longstanding Dizzy Patients Using Artificial Intelligence

Objective

To report the first steps of a project to automate and optimize scheduling of multidisciplinary consultations for patients with longstanding dizziness utilizing artificial intelligence.

Study Design

Retrospective case review.

Setting

Quaternary referral center.

Methods

A previsit self-report questionnaire was developed to query patients about their complaints of longstanding dizziness. We convened an expert panel of clinicians to review diagnostic outcomes for 98 patients and used a consensus approach to retrospectively determine what would have been the ideal appointments based on the patient's final diagnoses. These results were then compared retrospectively to the actual patient schedules. From these data, a machine learning algorithm was trained and validated to automate the triage process.

Results

Compared with the ideal itineraries determined retrospectively with our expert panel, visits scheduled by the triage clinicians showed a mean concordance of 70%, and our machine learning algorithm triage showed a mean concordance of 79%.

Conclusion

Manual triage by clinicians for dizzy patients is a time-consuming and costly process. The formulated first-generation automated triage algorithm achieved similar results to clinicians when triaging dizzy patients using data obtained directly from an online previsit questionnaire.

Probabilities of Isolated and Co-Occurring Vestibular Disorder Symptom Clusters Identified Using the Dizziness Symptom Profile

OBJECTIVES

Dizziness is among the most common reasons people seek medical care. There are data indicating patients with dizziness, unsteadiness, or vertigo may have multiple underlying vestibular disorders simultaneously contributing to the overall symptoms. Greater awareness of the probability that a patient will present with symptoms of co-occurring vestibular disorders has the potential to improve assessment and management, which could reduce healthcare costs and improve patient quality of life. The purpose of the current investigation was to determine the probabilities that a patient presenting to a clinic for vestibular function testing has symptoms of an isolated vestibular disorder or co-occurring vestibular disorders.

DESIGN

All patients who are seen for vestibular function testing in our center complete the dizziness symptom profile, a validated self-report measure, before evaluation with the clinician. For this retrospective study, patient scores on the dizziness symptom profile, patient age, and patient gender were extracted from the medical record. The dizziness symptom profile includes symptom clusters specific to six disorders that cause vestibular symptoms, specifically: benign paroxysmal positional vertigo, vestibular migraine, vestibular neuritis, superior canal dehiscence, Meniere disease, and persistent postural perceptual dizziness. For the present study, data were collected from 617 participants (mean age = 56 years, 376 women, and 241 men) presenting with complaints of vertigo, dizziness, or imbalance. Patients were evaluated in a tertiary care dizziness specialty clinic from October 2020 to October 2021. Self-report data were analyzed using a Bayesian framework to determine the probabilities of reporting symptom clusters specific to an isolated disorder and co-occurring vestibular disorders.

RESULTS

There was a 42% probability of a participant reporting symptoms that were not consistent with any of the six vestibular disorders represented in the dizziness symptom profile. Participants were nearly as likely to report symptom clusters of co-occurring disorders (28%) as they were to report symptom clusters of an isolated disorder (30%). When in isolation, participants were most likely to report symptom clusters consistent with benign paroxysmal positional vertigo and vestibular migraine, with estimated probabilities of 12% and 10%, respectively. The combination of co-occurring disorders with the highest probability was benign paroxysmal positional vertigo + vestibular migraine (~5%). Probabilities decreased as number of symptom clusters on the dizziness symptom profile increased. The probability of endorsing vestibular migraine increased with the number of symptom clusters reported.

CONCLUSIONS

Many patients reported symptoms of more than one vestibular disorder, suggesting their symptoms were not sufficiently captured by the symptom clusters used to summarize any single vestibular disorder covered by the dizziness symptom profile. Our results indicate that probability of symptom clusters indicated by the dizziness symptom profile is comparable to prior published work on the prevalence of vestibular disorders. These findings support use of this tool by clinicians to assist with identification of symptom clusters consistent with isolated and co-occurring vestibular disorders.

Quality assessment of patient-reported outcome measures for patients with multiple ear complaints

INTRODUCTION

There is an increased demand for well-validated PROMs in otology. This study will systematically assess the methodological quality of all published patient-reported outcome measures (PROMS) for patients with multiple ear complaints and to identify the best suitable PROM for use by clinicians treating patients with multiple ear complaints.

METHODS

An extensive systematic mapping review of all otology questionnaires was performed to identify questionnaires measuring multiple ear complaints. The 'Consensus-based standards for the selection of health measurement Instruments' (COSMIN) checklists were used to evaluate the quality of the questionnaire by two researchers. The worst item score per aspect of the methodological assessment counted.

RESULTS

Twelve multiple-complaint questionnaires were included in the study for quality assessment. Ten questionnaires were disease-specific (COMQ-12, CES, ZCMEI-21, MD-POSI, PAN-QOL, ETDQ-7, MDOQ, GYSSCDQ, COMOT-15 and DEU-MDDS). Two questionnaires were ear domain-specific (OQUA and COQOL). The majority of multiple complaint questionnaires lacked good design with concept elicitation and patient involvement.

CONCLUSION

For the majority of questionnaires, the quality assessment was inadequate as only a few authors consulted with patients affected by the complaints in the development. Modifications of earlier versions of PROMS or combinations of multiple questionnaires lead to ongoing (cross-cultural) validation of these questionnaires albeit mediocre design and validation. The two domain-specific questionnaires are the COQOL and OQUA, both with adequate quality but different focus. COQOL to quantify the quality of life and OQUA to measure and evaluate the severity and impact of ear complaints. [Correction added on 26 January 2024, after first online publication: In the preceding sentence, the spelling of the abbreviation COQOL has been corrected in this version.].

Validation and reliability analysis of the Questionnaire on the Emotional Impact of Vertigo-CIEV version translated to the Brazilian Portuguese language

PURPOSE

To determine the internal consistency and reliability of the "Questionário de Impacto Emocional da Vertigem (CIEV)" and to validate the instrument with respect to the Dizziness Handicap Inventory (DHI) in a sample of individuals with balance disorders.

METHODS

38 subjects participated in the study, males and females, aged from 23 to 85 years, who presented dizziness, vertigo, and/or falls complaints and attended to the Vestibular Disorders clinic at the University Hospital. Individuals with hearing complaints and/or tinnitus unrelated to dizziness, previous psychiatric comorbidities, and/or cognitive impairments were excluded. We performed an anamnesis and collected complementary data from the medical records. After that, the self-perception questionnaires, DHI, and CIEV, were applied. Statistical analysis was performed in which the Cronbach's alpha verified the internal consistency of the CIEV. Reliability and validity of the CIEV related to the DHI were calculated using Intraclass Correlation Index (ICC) and Pearson's correlation test, respectively.

RESULTS

There was a statistically significant correlation between the scores obtained, for both reliability and validation analysis (p<0.001). The mean ICC showed a moderate correlation between the total scores (0.695) and a strong correlation with the physical, emotional, and functional DHI domains (0.706 to 0.869), being the emotional aspect the highest degree (0.869). Pearson's correlation showed strong correlation between the total scores (r=0.820) and varied from moderate to strong, with strongest correlations to the DHI emotional domain (r=0.788).

CONCLUSION

The outcomes illustrate important contribution to validation parameters to consider clinical use of the CIEV in the Brazilian population, aiming to identify emotional aspects in patients with balance disorders.

Prevalence and Risk Factors of Self-reported Dizziness in Post-9/11 Service Members and Veterans

INTRODUCTION

Dizziness is prevalent in the general population, but little is known about its prevalence in the U.S. military population. Dizziness is commonly associated with blast exposure and traumatic brain injury (TBI), but the potential independent contributions of blast and TBI have yet to be evaluated. This study's goal was to estimate the prevalence of dizziness among post-9/11 service members and Veterans and to examine independent and joint associations between military TBI history, blast exposure, and self-reported dizziness.

MATERIALS AND METHODS

The study sample consisted of service members (n = 424) and recently separated (< ∼2.5 years) Veterans (n = 492) enrolled in the Noise Outcomes in Service members Epidemiology (NOISE) Study. We examined associations between self-reported history of probable TBI and blast exposure and recent dizziness using logistic regression. Models were stratified by service member versus Veteran status and adjusted to account for potentially confounding demographic and military characteristics.

RESULTS

Overall, 22% of service members and 31% of Veterans self-reported dizziness. Compared to those with neither TBI nor blast exposure history, both service members and Veterans with TBI (with or without blast) were three to four times more likely to self-report dizziness. Those with blast exposure but no TBI history were not more likely to self-report dizziness. There was no evidence of an interaction effect between blast exposure and a history of TBI on the occurrence of dizziness.

CONCLUSION

Self-reported dizziness was prevalent in this sample of service members and Veterans. Probable TBI history, with or without blast exposure, was associated with dizziness, but blast exposure without TBI history was not. This suggests that treatment guidelines for TBI-related dizziness may not need to be tailored to the injury mechanism. However, future efforts should be directed toward the understanding of the pathophysiology of TBI on self-reported dizziness, which is fundamental to the design of treatment strategies.

Outcomes and Patient Experience in Individuals With Longstanding Dizziness

PURPOSE

This study aimed to describe the relationship between changes in pre and post self-perceived dizziness handicap, scores on the patient health questionnaire, and perceptions of patient's value of being evaluated and managed by a multidisciplinary team.

METHOD

Seventy-eight patients completed the Dizziness Handicap Inventory (DHI) and Patient Health Questionnaire-Fourth Edition (PHQ-4) questionnaires post multidisciplinary clinical consultations and testing for the chief complaints of dizziness, unsteadiness, vertigo, or balance problems. The diagnoses of each patient were recorded from the clinical reports of each specialty consultation and were classified as structural, functional, or psychiatric. They were contacted by phone at least 6 months after their visit to obtain feedback regarding their symptoms and overall patient experience.

RESULTS

The change in DHI total score did not differ significantly by diagnosis (p = .56), indicating that patients experienced an improvement in DHI total score regardless of diagnosis. PHQ-4 anxiety scores worsened by a mean of 0.7 points for those with structural diagnoses (p = .04), improved by a mean of 0.7 points for psychiatric diagnoses (p = .16), and improved by a mean of 0.3 points for functional diagnoses (p = .39). Only seven patients would not recommend the team to a family or friend; these patients tended to report worsening DHI total scores (p = .27) compared to the significant improvement in DHI total scores for patients who would make such a recommendation (p < .001). Similarly, only 13 patients did not feel the information they received had a positive impact; these patients tended to report worsening DHI total scores (p = .18) compared to the significant improvement in DHI total scores for patients who did feel the information had a positive impact (p < .001).

DISCUSSION

The assessment and management of patients with chronic dizziness is challenging due to symptoms arising from multiple etiologies. Our finding of a vast difference between high satisfaction and relatively unchanged dizziness handicap suggests that there is value in seeing a multidisciplinary team where consultations are unhurried, care is coordinated, and expectations regarding treatment can be managed.

Disruptive Dizziness Among Post-9/11 Veterans With Deployment-Related Traumatic Brain Injury

OBJECTIVE

To identify disruption due to dizziness symptoms following deployment-related traumatic brain injury (TBI) and factors associated with receiving diagnoses for these symptoms.

SETTING

Administrative medical record data from the Department of Veterans Affairs (VA).

PARTICIPANTS

Post-9/11 veterans with at least 3 years of VA care who reported at least occasional disruption due to dizziness symptoms on the comprehensive TBI evaluation.

DESIGN

A cross-sectional, retrospective, observational study.

MAIN MEASURES

International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis codes of dizziness, vestibular dysfunction, and other postconcussive conditions; neurobehavioral Symptom Inventory.

RESULTS

Increased access to or utilization of specialty care at the VA was significant predictors of dizziness and/or vestibular dysfunction diagnoses in the fully adjusted model. Veterans who identified as Black non-Hispanic and those with substance use disorder diagnoses or care were substantially less likely to receive dizziness and vestibular dysfunction diagnoses.

CONCLUSIONS

Access to specialty care was the single best predictor of dizziness and vestibular dysfunction diagnoses, underscoring the importance of facilitating referrals to and utilization of specialized, comprehensive clinical facilities or experts for veterans who report disruptive dizziness following deployment-related TBI. There is a clear need for an evidence-based pathway to address disruptive symptoms of dizziness, given the substantial variation in audiovestibular tests utilized by US providers by region and clinical specialty. Further, the dearth of diagnoses among Black veterans and those in more rural areas underscores the potential for enhanced cultural competency among providers, telemedicine, and patient education to bridge existing gaps in the care of dizziness.

A Systematic Review of Clinical Vestibular Symptom Triage, Tools, and Algorithms

OBJECTIVE

The evaluation of peripheral vestibular disorders in clinical practice is an especially difficult endeavor, particularly for the inexperienced clinician. The goal of this systematic review is thus to evaluate the design, approaches, and outcomes for clinical vestibular symptom triage and decision support tools reported in contemporary published literature.

DATA SOURCES

A comprehensive search of existing literature in August 2020 was conducted using MEDLINE, CINAHL, and EMBASE using terms of desired diagnostic tools such as algorithm, protocol, and questionnaire as well as an exhaustive set of terms to encompass vestibular disorders.

REVIEW METHODS

Study characteristics, tool metrics, and performance were extracted using a standardized form. Quality assessment was conducted using a modified version of the Quality of Diagnostic Accuracy Studies 2 (QUADAS-2) assessment tool.

RESULTS

A total of 18 articles each reporting a novel tool for the evaluation of vestibular disorders were identified. Tools were organized into 3 discrete categories, including self-administered questionnaires, health care professional administered tools, and decision support systems. Most tools could differentiate between specific vestibular pathologies, with outcome measures including sensitivity, specificity, and accuracy.

CONCLUSION

A multitude of tools have been published to aid with the evaluation of vertiginous patients. Our systematic review identified several low-evidence reports of triage and decision support tools for the evaluation of vestibular disorders.

Development and validation of the dizziness symptoms questionnaire in Thai-outpatients

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History taking plays an essential part in evaluating patients with dizziness.

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The algorithm of the SAQ-1 had been developed based on timing-trigger approach.

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The SAQ-1 might be used to triage the cause of dizziness of outpatients.

Introduction

“Dizziness” is a common complaint in clinical practice that can occur with anyone. However, since the symptom is caused by a wide range of disorders, a general clinician usually faces some difficulty to detect the cause.

Objective

This study aimed to formulate and validate a simple instrument that can be used to screen and predict the most likely cause of dizziness in Thai outpatients.

Methods

This study was divided into two phases. Phase I included 41 patients diagnosed with common causes of dizziness to determine the algorithm and construct the “structural algorithm questionnaire version 1”. In addition, to test and retest its content validity and reliability until the instrument had an acceptable level of both. Phase II of the study pertained to evaluating its accuracy in clinical trials, 150 patients with dizziness had a face-to-face interview while they were waiting for their medical appointment.

Results

The degree of agreement between the algorithm results and clinical diagnoses was within an acceptable level (κ = 0.69). Therefore, this algorithm was used to construct the structural algorithm questionnaire version 1. The content validity of the structural algorithm questionnaire version 1 evaluated by seven experts. The content validity index values of the questionnaire ranged from 0.71 to 1.0. The Cohen’s kappa coefficient (κ) of intra-rater reliability of the structural algorithm questionnaire version 1 was 0.71. In clinical trials, 150 patients with dizziness had a face-to-face interview while they were waiting for their appointment. The overall agreement between their questionnaire responses and final diagnoses by specialists showed a moderate degree of clinical accuracy (κ = 0.55).

Conclusions

The structural algorithm questionnaire version 1 had a well-developed design and acceptable quality pertaining to both validity and reliability. It might be used to differentiate the cause of dizziness between vestibular and non-vestibular disorders, especially of outpatients with dizziness symptoms.

Perspectives: Evaluation of Older Adult Cochlear Implant Candidates for Fall Risk in a Developing Country Setting

Dizziness, vertigo, and falls are common in older adults. Data suggest that cochlear implant candidates are no different and could be argued to be at elevated risk due to the presence of hearing loss and likely vestibular involvement. Perspectives contextualizes current testing and screening paradigms for vestibular deficits and fall risk and suggests a protocol suitable for use in developing country settings.

Case Study: Depersonalization and Vestibular Impairment

BACKGROUND

 We describe herein the case of a patient whose primary complaints were episodic vertigo and "depersonalization," a sensation of detachment from his own body.

PURPOSE

 This case study aims to further clinical knowledge and insight into the clinical evaluation of vertiginous patients with complaints of depersonalization.

RESEARCH DESIGN

 This is a case study.

DATA COLLECTION AND ANALYSIS

 A retrospective chart review of vestibular function testing done on a vertiginous patient with complaints of depersonalization was performed.

RESULTS

 Vestibular function testing revealed absent cervical and ocular vestibular evoked myogenic potentials on the left side with normal vHIT or video Head Impulse Test, videonystagmography, and rotational chair results, suggesting peripheral vestibular impairment isolated to the left saccule and utricle.

CONCLUSION

 The otolith end organ impairment explains the patient's postural deviation to the left side during attempts to ambulate. We recommend that clinicians should be attentive to patient complaints of depersonalization and perform vestibular evoked myogenic potential testing to determine whether evidence of at least a unilateral peripheral otolith end organ impairment exists.

Two Symptoms Strongly Suggest Benign Paroxysmal Positional Vertigo in a Dizzy Patient

Introduction: This prospective cohort study determined which questions in patient history are most likely to identify symptoms that are independently associated with a diagnosis of benign paroxysmal positional dizziness (BPPV) in patients presenting with dizziness, and to evaluate whether the patient's age and type of BPPV are of influence. Methods: We included adult patients with dizziness referred to our dizziness center, Apeldoorn, the Netherlands, from December 2018 to November 2019. All patients completed a questionnaire, underwent vestibular testing and received a diagnosis. Symptoms strongly suggesting BPPV were tested with multivariable analysis to determine their independent associations with BPPV. Subgroup analysis was performed for patient age, and the type of BPPV. Results: We included a total of 885 patients, 113 of whom (13%) were diagnosed with BPPV. The duration of dizziness spells <1 min (Q2) and dizziness provoked by rolling over in bed (Q4) were independently associated with the diagnosis BPPV. Q2 showed a sensitivity of 43%, and a specificity of 75%; Q4 scored 81% and 68%, respectively. Overall, the way patients perceived their dizziness (vertigo, light-headedness or instability) was not independently associated with the diagnosis BPPV. In younger patients, light-headedness and instability decreased the likelihood of BPPV compared to vertigo. Conclusion: The most reliable predictors for BPPV in patient history are a short duration of the dizziness spell and provocation of dizziness by rolling over in bed. Unlike younger patients, elderly patients with BPPV do not only perceive the dizziness as vertigo, but also as a feeling of instability.

Multiple Co-Occurring Vestibular Disorders Identified Using the Dizziness Symptom Profile

Purpose The purpose of the current investigation was to determine the interrelations among vestibular disorders from a data set generated from the patient perspective as compared to previous data generated from the physician's perspective. Method The data for the current investigation originated from a previously published study describing the development of the Dizziness Symptom Profile (DSP; Jacobson et al., 2019). The DSP is a 31-item patient self-report tool designed to help primary care physicians in the development of a differential diagnosis using the patient's level of agreement with each dizziness and symptom-related statement. Responses to these items converge on common vestibular diagnoses and were previously found to agree with ear specialist differential diagnoses 70.3% of the time. Data were collected for 131 subjects (M _age = 56.7 years, 72 women) seen for evaluation in a tertiary dizziness specialty clinic. For this study, the data were analyzed using descriptive statistics to determine the frequency of single diagnoses, multiple diagnoses, co-occurring diagnoses, and patterns of co-occurrence. Results Results indicated that 52.7% of patients endorsed a single vestibular diagnosis and 47.3% endorsed two or more vestibular diagnoses. Benign paroxysmal positional vertigo (BPPV) and vestibular migraine were the most common single diagnoses and also the most common co-occurring diagnoses. As the number of diagnoses endorsed on the DSP increased, so did the percentage of time that BPPV and vestibular migraine would occur. Conclusions Results support and extend the work of others but using data generated from the perspective of the patient. A slight majority of patients endorsed a single disorder, but almost as many patients endorsed more than one vestibular diagnosis. BPPV and vestibular migraine were the most common single vestibular diagnoses and also the most common co-occurring vestibular diagnoses; vestibular migraine was more common when multiple diagnoses were endorsed. Results suggest it is common for patients to volunteer symptoms that cannot be explained by a single vestibular diagnosis. This finding is in agreement with physician-generated diagnosis data. Clinicians should consider the possibility of co-occurring diagnoses in complicated patients or in patients who are not responding optimally to management of a single vestibular disorder. The DSP is a tool that encourages clinicians to consider multiple co-occurring vestibular disorders as the source of patient complaints.