Triage System Can Save Time, Money in Diagnosing Vestibular Disorders By asking targeted questions before a patient’s initial visit, a vestibular clinic efficiently addresses complaints of dizziness and imbalance. All Ears on Audiology
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All Ears on Audiology  |   November 01, 2016
Triage System Can Save Time, Money in Diagnosing Vestibular Disorders
Author Notes
  • Margot L. Beckerman, AuD, CCC-A, is the assistant director of the Vestibular Testing Center in the Department of Otolaryngology-Head and Neck Surgery within the University of Michigan Health System. Beckerman chairs ASHA’s Audiology Advisory Council and is an affiliate of ASHA Special Interest Group 8, Audiology and Public Health. margotbe@med.umich.edu
    Margot L. Beckerman, AuD, CCC-A, is the assistant director of the Vestibular Testing Center in the Department of Otolaryngology-Head and Neck Surgery within the University of Michigan Health System. Beckerman chairs ASHA’s Audiology Advisory Council and is an affiliate of ASHA Special Interest Group 8, Audiology and Public Health. margotbe@med.umich.edu×
  • See ASHA’s Practice Portal for information on various balance disorders, including assessment and treatment of BPPV. Patient education handouts on BPPV are also available.
    See ASHA’s Practice Portal for information on various balance disorders, including assessment and treatment of BPPV. Patient education handouts on BPPV are also available.×
Article Information
Balance & Balance Disorders / All Ears on Audiology
All Ears on Audiology   |   November 01, 2016
Triage System Can Save Time, Money in Diagnosing Vestibular Disorders
The ASHA Leader, November 2016, Vol. 21, 14-16. doi:10.1044/leader.AEA.21112016.14
The ASHA Leader, November 2016, Vol. 21, 14-16. doi:10.1044/leader.AEA.21112016.14
Audiologists who find efficient ways to identify or rule out a common form of vertigo in a patient’s initial visit can save clinicians and patients time and money.
That’s why our clinic—the Vestibular Testing Center within the University of Michigan Health System—specializes in evaluation and treatment of patients with symptoms of vertigo, dizziness, lightheadedness and/or imbalance (difficulties experienced by approximately 40 percent of the U.S. population over the course of a lifetime, according to the National Institute on Deafness and Other Communication Disorders).
We’re primed to detect benign paroxysmal positional vertigo (BPPV)—widely regarded as the most common peripheral vestibular disorder and accounting for approximately 50 percent of dizziness reported in older adults (see sources). Formal vestibular testing, including videonystagmography (VNG), rotational chair testing and computerized dynamic posturography, is generally not of high diagnostic yield in patients with BPPV. In contrast, a focused visit to identify and treat BPPV is relatively inexpensive.
Our clinical team, which includes audiologists, physical therapists (PTs) and otologists, uses a triage process prior to appointment scheduling to ensure that each patient receives the most appropriate level of care during their initial clinic visit.
But first, what do you need to know about BPPV?

Important clues about onset, duration and nature of symptoms are highly valuable, as vertiginous symptoms experienced with BPPV have unique characteristics.

Facts about BPPV
BPPV is thought to be extremely rare in children but can affect adults of any age, becoming more common with age. BPPV has a lifetime prevalence of 2.4 percent, which increases to 3.4 percent for people 60 or older and close to 10 percent by age 80 (see sources).
Although BPPV is benign and not life-threatening, its effect can range from mild annoyance to significant debilitation. Symptoms can be disruptive to daily activities, and can pose an increased risk of falls associated with dizziness and imbalance.
BPPV produces a sensation of vertigo that is both paroxysmal (occurring suddenly) and positional (provoked by a change in position of the head), and happens when loose otoconia (“crystals”) migrate from the utricle into a semicircular canal where they may float freely in endolymph (canalithiasis variant) or adhere to the cupula (cupulolithiasis variant).
The importance of case history cannot be overstated for patients with dizziness or balance system complaints. Important clues about onset, duration and nature of symptoms are highly valuable, as vertiginous symptoms experienced with BPPV have unique characteristics. BPPV is most often triggered by a change in position of the head, is of sudden onset and lasts a few seconds to a minute. Common movements that trigger BPPV symptoms include rolling over in bed, tilting the head upward and bending over.
Positively identifying BPPV includes the relatively simple Dix-Hallpike maneuver and the roll test. These bedside tests allow the clinician to observe for nystagmus elicited in response to a specific change in head position. Video-oculography (VOG) goggles are useful, although not required, for improved viewing and recording of the nystagmus during these tests.
The problematic semicircular canal can be identified based on the characteristics of the observed nystagmus. Treatment for most forms of BPPV involves canalith repositioning procedures (CRP) that systematically move the displaced otoconia out of the affected semicircular canal. CRP can be performed by a skilled clinician with relative ease.

If symptoms could indicate BPPV, the initial evaluation appointment is scheduled with a physical therapist who specializes in vestibular rehabilitation.

The triage process
Before appointments are scheduled in our clinic, the schedulers ask each patient a brief set of triage questions. An audiologist will then review the patient’s responses, along with any supporting information from the referring provider.
If the patient’s symptoms could indicate BPPV, the initial evaluation appointment is scheduled with a PT who specializes in vestibular rehabilitation. In particular, we focus on symptoms that are triggered by position changes, last less than a minute, and are characterized by a spinning sensation. If symptoms are not indicative of BPPV, the patient is scheduled for vestibular testing and/or consultation with an otologist.
A word of caution: Clinicians should keep in mind that there are signs and symptoms that warrant further medical workup. These include BPPV that does not resolve after a reasonable course of treatment, signs of central pathology and concerning auditory symptoms, such as sudden hearing loss or unilateral tinnitus.
Vestibular rehabilitation is included in ASHA’s scope of practice in audiology. Specifically, it includes identifying various forms of BPPV and performing appropriate treatment, as well as serving on a multidisciplinary team managing patients with balance disorders and/or dizziness. In our setting, audiologists work alongside a team of specialized vestibular PTs.
Research has suggested the use of a subset of questions from the Dizziness Handicap Inventory (DHI) as an effective screening tool for BPPV (see sources). Our triage questions specifically ask about motion-provoked symptoms using questions from the DHI (numbers 1, 5, 13 and 25). Also critically important are the temporal characteristic of symptoms (seconds to minutes versus hours or days) and the nature of symptoms (spinning versus lightheadedness). Our questions include:
  • Does looking up cause dizziness?

  • Does getting in and out of bed bring on dizziness?

  • Does turning over in bed increase or bring on dizziness?

  • Does bending over cause dizziness?

  • How long does the dizziness usually last?

  • Do you have a sensation of spinning?

  • Do you have a sensation of lightheadedness?

  • Before this, have you ever had any spell of vertigo or severe dizziness that lasted for hours or days?

We also ask “yes/no” questions about sudden changes in hearing, tinnitus and migraine/headache status.
Using this triage system and considering each patient’s symptoms have been highly effective in pinpointing those with suspected BPPV when scheduling appointments. As a result, fewer patients undergo unnecessary and costly vestibular testing only to result in a diagnosis of BPPV.
Sources
Whitney, S. L., Marchetti, G. F., & Morris, L. O. (2005). Usefulness of the dizziness handicap inventory in the screening for benign paroxysmal positional vertigo. Otology & Neurotology, 26(5), 1027–1033. [Article]
Whitney, S. L., Marchetti, G. F., & Morris, L. O. (2005). Usefulness of the dizziness handicap inventory in the screening for benign paroxysmal positional vertigo. Otology & Neurotology, 26(5), 1027–1033. [Article] ×
Jacobson, G. P., & Newman, C. W. (1990). The development of the Dizziness Handicap Inventory. Archives of Otolaryngology—Head and Neck Surgery, 116(4), 424–427. [Article] [PubMed]
Jacobson, G. P., & Newman, C. W. (1990). The development of the Dizziness Handicap Inventory. Archives of Otolaryngology—Head and Neck Surgery, 116(4), 424–427. [Article] [PubMed]×
Von Brevern, M., Radtke, A., Lezius, F., Feldmann, M., Ziese, T., Lempert, T., & Neuhauser, H. (2007). Epidemiology of benign paroxysmal positional vertigo: A population based study. Journal of Neurology, Neurosurgery & Psychiatry, 78(7), 710–715.
Von Brevern, M., Radtke, A., Lezius, F., Feldmann, M., Ziese, T., Lempert, T., & Neuhauser, H. (2007). Epidemiology of benign paroxysmal positional vertigo: A population based study. Journal of Neurology, Neurosurgery & Psychiatry, 78(7), 710–715.×
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November 2016
Volume 21, Issue 11