Experiences Engaging Healthcare When Dizzy

Utilization of Face-to-Face Vestibular Support Groups: A Comparison to Online Group Participation

OBJECTIVE

This study compared the utilization and outcomes of face-to-face (F2F) vestibular support groups and online support communities (OSC) for individuals with vestibular disorders.

METHODS

We distributed a 31-question anonymous electronic survey through the Vestibular Disorders Association (VeDA) to F2F participants, categorizing user involvement in F2F, OSCs, or both and assessed impact on medical decision-making, psychosocial benefits, and goals achieved.

RESULTS

The F2F cohort consisted of 97 individuals comprising primarily of non-Hispanic White women (mean age = 57 years, SD ± 14 years) with diagnoses including persistent postural-perceptual dizziness (19%), Meniere's disease (15%), and vestibular neuritis (13%). Most participants were diagnosed by an otolaryngologist (65%) and attended F2F meetings monthly or less frequently (78%). The OSC group comprised of 551 individuals, primarily of non-Hispanic White women, but was younger in age (mean age = 50 years, SD ± 13 years). OSC participants notably engaged more, with 36% participating on a daily basis and 32% multiple times a week. F2F participants were older (mean age 57 years vs 50 years, P < .001) and more commonly referred by medical professionals (22% F2F vs 6% OSC, P < .001). Both groups had similar achieved goals, including hearing from others with the same diagnosis (84% vs 89%, P > .05) and similar impact on medical decision-making (75% vs 78%, P > .05). More F2F participants reported increased development of coping skills (79% F2F vs 69% OSC, P = .037). OSC participants typically found the group via an online search (75%), compared to 51% for F2F. OSC participants had higher daily engagement (36%) compared to F2F (1%).

CONCLUSION

F2F users are older and more commonly referred by medical professionals. Despite less frequent engagement, F2F participants reported similar influences on achieved goals, medical decision-making, and impact on psychosocial benefits. These findings highlight the importance of both F2F and OSC support groups for individuals with vestibular disorders.

Feasibility of gamified visual desensitisation for visually-induced dizziness

Visually-induced dizziness (visual vertigo) is a core symptom of Persistent Perceptual Postural Dizziness (PPPD) and occurs in other conditions and general populations. It is difficult to treat and lacks new treatments and research. We incorporated the existing rehabilitation approach of visual desensitisation into an online game environment to enhance control over visual motion and complexity. We report a mixed-methods feasibility trial assessing: Usage and adherence; rehabilitation potential; system usability and enjoyment; relationship with daily dizziness. Participants played online with (intervention, N = 37) or without (control, N = 39) the visual desensitisation component for up to 5-10 min, twice daily for 6 weeks. Dropout was 45%. In the intervention group, N = 17 played for the recommended time while N = 20 played less. Decreases in visual vertigo symptoms, anxiety and depression correlated with playtime for the intervention but not control. System usability was high. Daily symptoms predicted playtime. Qualitative responses broadly supported the gamified approach. The data suggest gamified visual desensitisation is accessible, acceptable and, if adherence challenges can be overcome, could become a useful addition to rehabilitation schedules for visually-induced dizziness and associated anxiety. Further trials are needed.

Healthcare Utilization Among Adults With Vestibular Vertigo in the United States

OBJECTIVES

Vestibular vertigo has been shown to have a high lifetime prevalence. Previous studies have described the increased morbidities associated with vestibular vertigo.

DESIGN

In this cross-sectional study of the 2016 National Health Interview Study, we sought to explore whether individuals with vestibular vertigo were more likely to utilize healthcare resources compared with those without vestibular vertigo. We characterized utilization of specific healthcare resources including general doctors, specialist doctors, emergency departments, mental health professionals, and others among individuals with vestibular vertigo to better understand how individuals with vertigo interact with the US healthcare system.

RESULTS

In multivariable analyses, participants with vestibular vertigo had an increased number of nights in the hospital in the last 12 months (mean difference = 0.67 days, 95% confidence interval [CI] = 0.37 to 0.97), increased odds of receiving healthcare 10 or more times in the last 12 months (odds ratio = 2.22, 95% CI = 1.99 to 2.48) and increased number of visits to a healthcare professional in the last 2 weeks (mean difference = 0.17 visits, 95% CI = 0.14 to 0.21). In addition, participants with vestibular vertigo had increased odds of visiting both general doctors, specialist doctors, and other healthcare professionals.

CONCLUSIONS

These findings characterize how individuals with vestibular vertigo utilize and interact with healthcare resources compared with those without vestibular vertigo.

Association of Head Injury, Neck Injury or Acoustic Trauma on Phenotype of Ménière's Disease

The aim of the present study was to investigate adverse effects of head injury, neck trauma, and chronic noise exposure on the complaint profile in people with Ménière's disease (MD). The study used a retrospective design. Register data of 912 patients with MD from the Finnish Ménière Federation database were studied. The data comprised case histories of traumatic brain injury (TBI), neck trauma and occupational noise exposure, MD specific complaints, impact related questions, and the E-Qol health-related quality of life instrument. TBI was classified based on mild, moderate, and severe categories of transient loss of consciousness (TLoC). The mean age of the participants was 60.2 years, the mean duration of the disease was 12.6 years, and 78.7% were females. Logistic regression analysis, linear correlation, and pairwise comparisons were used in evaluating the associations. 19.2% of the participants with MD had a history of TBI. The phenotype of participants with TBI was associated with frequent vestibular drop attacks (VDA), presyncope, headache-associated vertigo, and a reduction in the E-QoL. Logistic regression analysis explained the variability of mild TBI in 6.8%. A history of neck trauma was present in 10.8% of the participants. Neck trauma associated with vertigo (NTwV) was seen in 47 and not associated with vertigo in 52 participants. The phenotype of NTwV was associated with balance problems, VDA, physical strain-induced vertigo, and hyperacusia. Logistic regression analysis explained 8.7% of the variability of the complaint profile. Occupational noise exposure was recorded in 25.4% of the participants and correlated with the greater impact of tinnitus, hyperacusis, and hearing loss. Neither the frequency, duration, or severity of vertigo or nausea were significantly different between the baseline group and the TBI, NTwV, or noise-exposure groups. The results indicate that TBI and NTwV are common among MD patients and may cause a confounder effect.

Social Media Utilization in Otolaryngology: A Scoping Review

OBJECTIVE

Social media (SM) is an increasingly popular medium for the medical community to engage with patients, trainees, and colleagues. This review aimed to identify reported uses of SM in otolaryngology-head and neck surgery (OHNS), assess the quality of evidence supporting these uses, and identify gaps in the literature. With the relative lack of regulatory guidelines for the development of SM content, we hypothesized that the quality of content available on SM would be highly variable.

DATA SOURCES AND METHODS

A scoping review was performed of English-language peer-reviewed studies published to date discussing SM use in any form within OHNS. Three reviewers independently screened all abstracts. Two reviewers independently extracted data of interest from the full text of articles identified from the preliminary abstract screen.

RESULTS

171 studies were included, with 94 (54.9%) studies published between 2020 and 2022. 104 (60.8%) studies were conducted in the US. 135 (78.9%) used cross-sectional or survey-based methodology; only 7 (4.1%) were controlled studies. SM was most commonly employed for professional networking (n = 37 [21%]), and within subspecialties of otology (n = 38 [22%]) and rhinology/allergy (n = 25 [15%]). Facebook was most frequently used for study recruitment (n = 23 [13.5%]), YouTube for patient education (n = 15 [14.6%]), and Twitter for professional networking (n = 16 [9.4%]).

CONCLUSION

SM use within OHNS is increasing rapidly, with applications including patient education, professional networking, and study recruitment. Despite myriad articles, there remains a paucity of well-controlled studies. As SM becomes integrated into healthcare, particularly for applications directly impacting patient care, higher levels of evidence are needed to understand its true impact. Laryngoscope, 133:2447-2456, 2023.

Regional differences in patient-reported outcomes as a proxy of healthcare practices for Americans living with vestibular symptoms

BACKGROUND

Geographical location is known to affect health outcomes; however, evidence regarding whether location affects healthcare for persons suspected to have vestibular dysfunction is lacking.

OBJECTIVE

To investigate whether location affects healthcare seeking and outcomes for adults with symptoms of vestibular pathology.

METHODS

We assessed for regional disparities associated with demographics, diagnosis, chronological factors, and financial expenditures from Americans who participated in the Vestibular Disorders Association registry (N = 905, 57.4±12.5 years, 82.7% female, 94.8% White, and 8.1% Hispanic or Latino). Respondents were grouped per geographical regions defined by the United States Census Bureau.

RESULTS

There were no significant between-region differences for age (p = 0.10), sex (p = 0.78), or ethnicity (p = 0.24). There were more Asian respondents in the West versus the Midwest (p = 0.05) and more Black respondents in the South versus the West (p = 0.05). The time to first seek care was shorter in the Northeast (17.3 [SD = 49.5] weeks) versus the South (42.4 [SD = 83.7] weeks), p = 0.015. The time from the first healthcare visit to receiving a final diagnosis was shorter in the Northeast (46.5 [SD = 75.4] weeks) versus the South (68.9 [SD = 89.7] weeks), p = 0.015. Compared to the Midwest, fewer respondents in the Northeast reported "no" out-of-pocket financial impact, p = 0.039.

CONCLUSIONS

Geographical location affects healthcare seeking and outcomes for persons suspected to have vestibular dysfunction.

Vestibular Migraine: Clinical Aspects and Pathophysiology

VM is a common yet debilitating migraine variant that has taken many monikers in the past. As a relatively new diagnostic entity, public and provider awareness of this disorder can be improved. Symptoms include vertigo episodes in addition to photophobia, phonophobia, nausea, and headache. Diagnosis is primarily based on clinical history as pathognomonic signs via testing are not reliable. Standardized treatment algorithms have yet to be created and current recommendations have been adopted from migraine guidelines.

An Exploration of Online Support Community Participation Among Patients With Vestibular Disorders

OBJECTIVES/HYPOTHESIS

To formally document online support community (OSC) use among patients with vestibular symptoms and gain an appreciation for the perceived influence of participation on psychosocial outcomes and the impact on medical decision-making.

STUDY DESIGN

Self reported internet-based questionnaire.

METHODS

The Facebook search function was paired with a comprehensive list of vestibular diagnoses to systematically collect publicly available information on vestibular OSCs. Next, a survey was designed to gather clinicodemographic information, OSC characteristics, participation measures, perceived outcomes, and influence on medical decision-making. The anonymous instrument was posted to two OSCs that provide support for patients with general vestibular symptoms.

RESULTS

Seventy-three OSCs were identified with >250,000 cumulative members and >10,000 posts per month. The survey was completed by 549 participants, a cohort of primarily educated middle-aged (median = 50, interquartile range 40-60), non-Hispanic white (84%), and female (89%) participants. The participants' most cited initial motivation and achieved goal of participants was to hear from others with the same diagnosis (89% and 88%, respectively). Daily users and those who reported seeing ≥5 providers before receiving a diagnosis indicated that OSC utilization significantly influenced their requested medical treatments (72% daily vs. 61% nondaily, P = .012; 61% <5 providers vs. 71% ≥5 providers P = .019, respectively). Most participants agreed that OSC engagement provides emotional support (74%) and helps to develop coping strategies (68%). Membership of ≥1 year was associated with a higher rate of learned coping skills (61% membership <1-year vs. 71% ≥1-year P = .016).

CONCLUSIONS

The use of OSCs is widespread among vestibular diagnoses. A survey of two OSCs suggests these groups provide a significant source of peer support and can influence users' ability to interface with the medical system.

LEVEL OF EVIDENCE

N/A Laryngoscope, 2021.

Efficient Use of Vestibular Testing

While the majority of vestibular disorders may be diagnosed solely on clinical grounds, a variety of clinical scenarios exist in which objective functional assessment of the vestibular system provides data that facilitate diagnosis and treatment decisions. There exists a veritable armamentarium of sophisticated vestibular test modalities, including videonystagmography, rotary chair testing, video head impulse testing, and vestibular-evoked myogenic potentials. This article aims to help clinicians apply an accessible decision-making rubric to identify the clinical scenarios that may and may not benefit from data derived from specific vestibular function tests.

Approach to the History and Evaluation of Vertigo and Dizziness

PURPOSE OF REVIEW

This article reviews a method of obtaining the medical history of patients presenting with dizziness, vertigo, and imbalance. By combining elements of the history with examination, the goal is to identify patterns and an effective differential diagnosis for this group of patients to help lead to an accurate diagnosis.

RECENT FINDINGS

Studies over the past dozen years have changed the historical approach to patients with dizziness from one based primarily on how the patient describes the sensation of dizziness. This older approach can lead to misdiagnosis, so a preferred method puts greater emphasis on whether the dizziness is acute or chronic, episodic or continuous, or evoked by or brought on by an event or circumstance so that a pattern may be derived that better narrows the differential diagnosis and focused examination can further narrow to a cause or causes.

SUMMARY

Dizziness is a common symptom of many possible causes. This article will help clinicians navigate gathering the history and examination to formulate a working diagnosis in patients affected by dizziness.

Complex nystagmus in traumatic benign paroxysmal positional vertigo: A case study on the critical value of knowing semicircular canal excitation and inhibition patterns

A 73-year-old female presented to the emergency department with chief complaint of dizziness after sustaining a fall one month prior to dizziness onset. Although careful examination of eye movement patterns during positional testing was attempted at varying stages of her inpatient admission, her complex nystagmus patterns as a result of traumatic benign paroxysmal vertigo were difficult to manage. In particular, the nystagmus pattern from this case suggests the BPPV was variable and affecting either 1) left posterior semicircular canal (pSCC) exclusively 2) left pSCC and right anterior semicircular canal, 3) left and right pSCC canal. This case illustrates the importance of two critical details; positional testing should include observing nystagmus with fixation removed and an experienced clinician should be involved as early as possible.

Clinician Use and Payments by Medical Specialty for Audiometric and Vestibular Testing Among US Medicare Beneficiaries

Importance

Variations in diagnostic test use may indicate that there are opportunities for quality improvement in vestibular health care. To date, the extent to which clinician acquisition of tests varies nationwide by region and specialty of the clinician is unknown.

Objective

To quantify variation in clinician use and payments for audiograms and vestibular tests across all geographic regions of the United States and by specialty of practice.

Design, Setting, and Participants

This cross-sectional study used a population-based sample of 1 307 887 audiovestibular test claims from fee-for-service Medicare beneficiaries aged 65 years or older in the Medicare Provider Utilization and Payment Public Use File from January 1 through December 31, 2014. The analysis was completed from January 2 through June 1, 2019.

Exposures

Diagnostic audiograms, caloric testing, and rotary chair testing.

Main Outcomes and Measures

Test utilization was analyzed by hospital referral region, medical specialty, and total payments.

Results

In 2014, clinicians performed 1 213 328 audiograms, 317 880 caloric tests (ie, single caloric irrigations), and 62 779 rotary chair tests, for a total of $38 647 350.21 in Medicare payments from the Centers for Medicare & Medicaid Services. No patient or clinician demographic characteristics were available. Across health care referral regions, rates of testing per 100 000 beneficiaries varied from 166 to 12 021 for audiograms, 15 to 4271 for caloric tests, and 13 to 3556 for rotary chair tests between the lowest-use and highest-use regions. Most audiograms and caloric tests were billed by audiologists (797 957 audiograms [65.8%]; 112 485 caloric tests [35.4%]) and otolaryngologists (376 728 audiograms [31.0%]; 70 567 caloric tests [22.2%]). In contrast, primary care physicians (18 933 [30.2%]) and neurologists (15 254 [24.3%]) billed the largest proportion of rotary chair tests compared with other specialists, including audiologists (7253 [11.6%]) and otolaryngologists (6464 [10.3%]).

Conclusions and Relevance

Substantial geographic and clinician-level variation may have been observed in use of audiovestibular tests. Quality improvement efforts in vestibular health care may need to target a range of clinicians, including primary care physicians to be successful.

Vestibular migraine: An update on current understanding and future directions

BACKGROUND

Vestibular migraine is among the most common causes of recurrent vertigo in the general population. Despite its prevalence and high impact on healthcare cost and utilization, it has remained an under-recognized condition with largely unknown pathophysiology. In the present article, we aim to provide an overview of the current understanding of vestibular migraine.

METHODS

We undertook a narrative literature review on the epidemiology, presentations, clinical and laboratory findings, pathophysiology, and treatments of vestibular migraine.

RESULTS

Currently, the diagnosis of vestibular migraine relies solely on clinical symptoms since clinical tests of vestibular function are typically normal, or difficult to interpret based on inconsistent results reported in earlier studies. The challenges related to diagnosis of vestibular migraine lie in its relatively broad spectrum of manifestations, the absence of typical migraine headaches with vestibular symptoms, and its very recent definition as a distinct entity. Here, we highlight these challenges, discuss common vestibular symptoms and clinical presentations in vestibular migraine, and review the current aspects of its clinical diagnosis and evaluation. The concepts related to the pathophysiology and treatment of vestibular migraine are also discussed.

CONCLUSION

Vestibular migraine is still underdiagnosed clinically. Future studies are needed to address the pathophysiological mechanisms and investigate effective treatment regimens.

Vestibular Toxicity: Causes, Evaluation Protocols, Intervention, and Management

The loss of vestibular function, typically bilateral, due to chemical solvents and pharmacological agents is not rare and has been investigated and reported for many years. The successful treatment of bacterial infections and sepsis with IV antibiotics and cancer-fighting drugs like cisplatin makes the decision to use these life-saving drugs less of a debate, despite their potential deleterious effect on balance and equilibrium. The purpose of this article is to provide the reader with an overview of the more common substances found in industry and medicine which may decrease or permanently destroy peripheral and/or central vestibular function. A review of bedside and clinical evaluation protocols will be discussed as well as best practice intervention with balance retraining therapy. Finally, the role of the audiologist and opportunities for participation in an interdisciplinary approach to evaluation and management will be presented.