Vestibular Screening Exams
In 1997, George Carlin published his book, Brain Droppings. According to the cover, the book contains page after page of “”jokes, notions, doubts, opinions, questions, thoughts, beliefs, assertions, assumptions, and disturbing references” and “comedy, nonsense, satire, mockery, merriment, sarcasm, ridicule, silliness, bluster, and toxic alienation.” Any fan of George Carlin will know that this is not an exaggeration. Sometimes disconnected thoughts just “drop” out, and I am not sure what to do with them. Here are a few brain droppings from the vestibular “trenches,” therefore, I have made no attempt to organize the following:
You will learn much more from taking a patient history than you will learn from any test. You need to be skilled and patient when taking the history. I block out 20 to 30 minutes per patient, and sometimes that is not enough. It is sometimes very difficult to get the patient to answer specific questions, and it can be a challenge to keep the patient on task while being pleasant at the same time. If you express frustration during the history interview, you are off to a bad start. The patient will sense (whether true or not) that you don’t have time for them, or that you must have other things to do that are more important to you than they are. Take the time. Be nice. Hang in there and get the information you need. That first 30 minutes is going to set the tone for your entire relationship with that patient.
I will often think out loud with the patient at the end of the history interview. I will tell them what I am suspecting, and what tests need to be done to confirm or rule out that suspicion. All patients are sent a handout and questionnaires before they arrive for the appointment. It describes the tests, but I will usually talk them through each test so they know why I am doing it, and what they will experience. That removes a lot of fear. (fear of the unknown, eh?)
Occasionally, you get the chance to look really smart. Some patients present with such a clear history that there is very little doubt of the diagnosis, and the tests are just confirmatory. I think what’s most impressive is when a patient describes a history consistent with a severe vestibular neuritis (sudden onset vertigo, nausea, vomiting, resolving over a few days; no auditory symptoms, residual motion intolerance and dysequilibrium). Typically, these patients have been admitted to the hospital for at least a few days, undergone cranial MRI, EKG, been seen by Neurology, Cardiology, and of course all tests have been negative. The patient arrives at your office a week or two later, pretty convinced that no one is going to figure out why they have been so sick. You do a quick Head Thrust/Impulse Test, see an abnormal response, and tell the patient, after a 5 second exam, “It is your left ear.” The head thrust test is very specific (although not so sensitive), and you can be pretty confident that your quick diagnosis will be proven correct on additional exam.
Next week, we discuss scenarios where the test results and the history don’t match so well.