Practice What You Preach
Last Sunday, I had an up close and personal encounter with Vestibular Neuritis. It hit suddenly, somewhere between buttering the toast and sitting down to breakfast. I was completely symptom free 2 minutes earlier, buzzing around my kitchen making eggs and pouring coffee. I noticed a little lightheaded feeling and blurred vision as I carried my plate to the table, but when I put the plate down, I noticed the round table was spinning in a clockwise direction. I was in full blown vertigo within 20 to 30 seconds.
The irony here is that I am the director of the Balance Disorders Program at Wake Forest University Medical Center, and I teach young doctors how to evaluate patients complaining of vertigo. Irony only gets you so far when the world is spinning, but my training and experience did allow me to practice what I preach. I have seen hundreds of patients over the years with various stages of Vestibular Neuritis, the vast majority having undergone numerous expensive medical tests, Ct Scans, and/or Cranial MRI’s which I have preached are typically unnecessary if you know what to look for.
I was completely incapacitated, couldn’t walk, and had a decision to make: have my wife call an ambulance and go to the Emergency Room, or get to my bedroom and do a self examination. I chose the latter, knowing that a focused examination is more sensitive than a CT Scan or MRI at separating stroke from a more benign inner ear attack. My wife helped me to the bedroom, got me a bucket for the anticipated and ever so pleasant nausea and vomiting, and videotaped my eye movements with my iPhone.
Using the HINTS technique, within about 15 minutes of the onset of my symptoms, I was comfortable that I did not need imaging, therefore, no trip to the ER. How did I do this?
HI for Head Impulse
I sat on my bed and tried to find something to visually fixate on. This tends to slow down the sensation of vertigo. I locked onto to the doorknob of the closet door. Once I established how stable my vision was with my head still, I started doing small head turns (impulses) to the left and right. It was very clear that when I moved to the left, I could keep my eye on the doorknob, but when I moved to the right, there was no way. My eyes just went with my head and I consistently lost the doorknob target. That alone made me over 90% confident I was not having a stroke, which by the way, is a higher confidence level than a cranial MRI.
N for Nystagmus
Since I knew that vertigo is generated by involuntary, jerking eye movement called nystagmus, I asked my wife “Are my eyes bouncing back and forth?” Certain patterns of nystagmus suggest stroke, others suggest a benign inner ear disorder. In Vestibular Neuritis, the eye movements always beat in the same direction, but speed up when you look away from the culprit ear, and slow down when you look toward the culprit ear. Since the intensity of the vertigo is directly related to eye speed, I could feel this difference immediately. Watching the video of my eye movements confirmed for me that I had “direction fixed left beating nystagmus following Alexander’s law” which is highly indicative of an acute inner ear disorder on the right side. If the nystagmus had changed direction when I moved my eyes, I would have been on the way to the hospital.
TS for Test of Skew
This is basically a check to see if I was having double vision (diplopia). So again, I tried to fixate on something and alternately closed my right eye, then left, then right, and so on. This was not easy because my eyes were bouncing around, but I could not detect any double vision.
This all took about three or four minutes, but the test pattern was highly suggestive of vestibular neuritis on the right. I checked a few other things. I made sure I had no trouble speaking or swallowing. I noted I had no headache, and I had no deficit in some simple motor control tests like “finger to nose pointing” and “rapid alternating hand movements.” For several hours I could not walk unassisted, but I was comfortable this was due to the intensity of the vertigo, and should improve, rather than worsen, as the day progressed. Which it did.
I did learn one important lesson about managing the acute, intense vertigo phase. For years, I have told people to try to visually fixate on an object, looking out of the corner of their eye to slow down the vertigo. This worked, but I was much more comfortable with my eyes closed. Who knew?
Today, I am one week out from the incident; this computer screen is still a bit of a challenge but I am back at work. I won’t be driving for a while. And I have given up ballroom dancing for now.
In my next post, I will show you what all this looks like with some video and testing results.