Treatment Protocols
1. Videonystagmography (VNG): The VNG is composed of three primary components. The first is the oculomotor examination, which allows the audiologist to observe the patient’s eye movements as they follow a moving target. The second component is performed with different positions of the patient’s head while lying on an examination table. Third is the caloric test, which evaluates the horizontal semicircular canals and superior portion of the vestibular nerve from each ear independently.
2. Computerized dynamic posturography (CDP): CDP is a unique assessment technique used to objectively quantify and differentiate among the wide variety of possible sensory, motor, and central adaptive impairments of balance control. CDP can identify and differentiate the functional impairments associated with the pathological processes. The CDP allows the audiologist to determine which senses the patient is using to maintain an upright stance.
3. Neurotologic Test Center (NOTC) Battery and Rotational Chair Examination: The rotational chair is the gold standard for quantifying bilateral vestibular system weakness, independent utricle function and allows the audiologist to thoroughly assess vestibular compensation. The rotational chair also enables us to identify central vestibular system disorders in the presence of a normal caloric testing and when used in conjunction with the VEMP allows an entire assessment of the otolith system. This is also the vestibular examination of choice for children, since they find it more tolerable than caloric testing.
The rotational chair also examines each utricle independently via otolith sub testing. The otolith system consists of the utricles and saccules, which are the sensory organs in the inner ear that convert linear acceleration into an electrical code the brain can use. The utricle is responsible for sensing horizontal acceleration. Following stimulation of one of the utricles, the patient perceives that the environment is tilting. This is assessed utilizing unilateral centrifugation (UC) and off axis vertical rotation (OVAR) testing.
4. Vestibular Evoked Myogenic Potential (VEMP): The VEMP provides viable information regarding the integrity of the saccule and inferior vestibular nerve. The saccule is very close to the middle ear and thus is sensitive to high-intensity sound. When the saccule is stimulated by sound, the response travels through the inferior vestibular nerve to the vestibular nucleus in the brainstem. Neural impulses are then relayed through the vestibulospinal tract to the neck muscles. The most accessible muscle and the one we record the VEMP from is the sternocleidomastoid muscle.
5. Vestibular Autorotation Testing (VAT): The VAT provides information of the high frequency horizontal and vertical vestibulo-ocular reflex (VOR). The primary function of the VOR is to stabilize the eyes to allow clear vision during motion, including normal daily life activities such as walking, bending and turning. The sensation of disequilibrium or dizziness can occur if the VOR does not function properly. During the VAT test, the patient is asked to move their head side to side or up and down to a computer generated tone. Electrodes record eye movements and two micro sensors record the head motion. The first portion of the test evaluates the smooth pursuit system. The second portion of the test measures the responses of the inner ear (gain, phase and asymmetry).
6. Computerized Dynamic Visual Acuity Test (CDVAT): The CDVAT provides additional information regarding the VOR function in the horizontal and vertical planes.
7. Comprehensive Diagnostic Audiological Evaluation: The diagnostic audiological evaluation includes video otoscopy, tympanometry, acoustic reflexes with ipsilateral and contralateral presentation, otoacoustic emissions (OAEs), pure tone audiometry, speech recognition thresholds and word recognition thresholds.
8. Cochlear Hydrops Analysis Masking Procedure (CHAMP): CHAMP is used to identify cochlear hydrops or Meniere’s disease. The CHAMP is a modification of the standard auditory brainstem response (ABR) test. The standard ABR is measured with a click stimulus that activates the entire cochlea. With the CHAMP, the click stimulus is mixed with increasing amounts of high-pass masking noise. The cutoff frequency of the masking is successively lowered from one run to the next, thus masking progressively lower frequency regions of the cochlea. The resulting waveforms represent five frequency bands from five different frequency regions in the cochlea. In a normal individual, as increasingly more masking is introduced, the latency of Wave V will be prolonged. With the presence of cochlear hydrops, as with Meniere’s disease, the response of the basilar membrane is altered resulting in little or no shift in the latency of Wave V. The CHAMP is analyzed by determining the latency delay between the click ABR and the click with 500 Hz high-pass masking ABR.
Vestibular Rehabilitation:
Vestibular Rehabilitation is a successful and exciting treatment for patients with chronic unresolved motion intolerance and imbalance. Patients are returning to their daily activities quickly and efficiently. This management strategy is being utilized by some of the leading medical facilities in the world! Click here for more info on Vestibular Rehabilitation.
Types of Vestibular Rehabilitation: Vestibular Ocular Reflex (VOR) Therapy, Treatment and Fall Prevention
- Clinic Directed programs in conjunction with a home therapy regime are typically the program of choice.
- Balance Retraining Therapy is for individuals who have a loss of balance and unsteadiness. Most of these patients do not report dizziness or vertigo. There is an emphasis on practical solution to common problems, i.e. difficulty getting around in the dark, walking on uneven surfaces, and negotiating steps and curbs. Fall prevention, movement coordination, and improved participation in everyday activities are all high priorities in the program.
- Canalith Partical Repositioning (Epley Maneuver) is a technique used to reposition the otoconia back into the utricle, from which they have been dislodged. This is the treatment of choice for Benign Paroxysmal Positional Vertigo (BPPV).
What is meant by Fall Prevention?
Falls are a leading cause of fatal and non-fatal injuries in people ages 65 and older in the United States. The cost of these injuries among older people is enormous, due to the high death toll, as well as the disabling conditions, requiring recovery in hospitals and rehabilitation institutions. Research has proven that there is a pattern to falls among the elderly...the fear of falling and an actual fall are the major reasons that people lose their independence and need to be relocated to a nursing or assisted living home. If you don’t treat the medical cause of dizziness and balance disorders...people will fall.
In the health care industry, the term “fall prevention” is a very generic term. Many providers and health plans state that they provide “fall prevention” programs...but most only address the environmental factors. They tell patients to get rid of their rugs or give them hip pads with hopes of preventing a broken hip. At Newport-Mesa Audiology Balance and Ear Institute, we have identified four factors that are critical in offering a comprehensive fall prevention program. These four are:
Physiological: Identify and treat the medical cause of falls.
Psychological: Identify and address the contributing psychological causes of falls, such as the “cycle of fear.”
Activity Level: Increase a patient’s level of activity to prevent deconditioning and the cycle of fear.
Environmental: Make the surroundings safer, both in and out of the home.