Last week we began the discussion about why there are so few vestibular specialists, and I wrote that I thought it had to do with lack of awareness, and economics. This week, we discuss lack of awareness, next week we discuss economics.
Lack of awareness: As an example, the most common cause of episodic vertigo is the result of a simple condition with a long name –Benign Paroxysmal Positional Vertigo (BPPV). BPPV accounts for about one half of all inner ear disorders, and about one fourth of all complaints of dizziness and vertigo. The symptoms can be resolved in one office treatment session about 90% of the time. The diagnosis and treatment of this condition do not require any expensive, sophisticated equipment. The treatment (Canalith Repositioning) is known to be safe, inexpensive and effective. Sound great? The most recent estimate is that less than ten percent of patients with BPPV are ever offered this treatment. How can this happen? A recent survey shows that less than half of primary care physicians are familiar with this treatment.
Another issue complicating matters is the vernacular. “Dizziness” is a vague term that can have a variety of meanings. It can mean vertigo (spinning), lightheadedness, loss of balance, spatial disorientation, or unsteadiness. These are very different sensations with many different possible causes. Unless the examiner asks for a more specific description of symptoms, the direction of logical diagnostic testing or treatment is unclear. A recent study found that only about one third of Geriatricians (physicians specializing in the elderly) inquire about a more specific description of “ dizziness.” Fortunately, things are better when seeing a specialist, with over 80% of audiologists asking for a more detailed description{{1}}[[1]]Polensek, S., Sterk, C. & Tusa, R. (2008). Screening for vestibular disorders: A study of clinicians’ compliance with recommended practices. Med Sci Monit, 14(5), 238-242.[[1]]. One study showed that only 25% of complaints of dizziness involve vertigo (and we know most of that is BPPV), with about 75% meaning lightheadedness or off balance sensation{{2}}[[2]]Tinetti, M.,Williams, C., & Gill, T. (2000). Dizziness among older adults: a possible geriatric syndrome. Ann Intern Med, 132(5), 337–344.[[2]]
This leads to the next obstacle, that is, a clear understanding of the role of medications in treating “dizziness.” Many patients are given Antivert (Meclizine) for the complaint of dizziness. While Antivert can be helpful in dealing with the nausea associated with acute vestibular vertigo or motion sickness, it is not helpful for complaints of imbalance, unsteadiness or lightheadedness. Antivert does nothing to speed recovery from inner ear disorders, in fact, it can actually slow down the natural recovery process. The recent clinical guideline for BPPV recommends against the use of Antivert for that condition, yet every day I still see BPPV patients being treated with Antivert.
