Managing Vertigo in Adults and Children: How New Care Paths & Shared Medical Appointments Can Help

By: Julie Honaker, PhD, CCC-A

Dizziness brings approximately 10 million Americans to a primary care provider each year for treatment. While dizziness can be a co-occurring symptom of another diagnosis and is commonly a side effect of medication, an undiagnosed etiology may also be responsible. Cleveland Clinic’s Section of Vestibular & Balance Disorders in the Head & Neck Institute provides a comprehensive approach to diagnosing and treating patients with vestibular dysfunction.

New care paths in the treatment of vertigo

Benign paroxysmal positional vertigo (BPPV) is the most common cause of vertigo. A review of patient history and physical examination, followed by an in-office Dix-Hallpike position test, are key clinical tools to effectively diagnose BPPV. If a patient tests positive for BPPV and symptoms of dizziness/imbalance/vertigo are provoked with changes in position (such as rolling over in bed or getting out of bed), we recommend referral to vestibular rehabilitation. However, if symptoms are inconsistent with BPPV and/or Dix-Hallpike testing is negative, we recommend that a patient receive a vestibular test battery (formal vestibular and balance testing) for an accurate diagnosis to guide subsequent management of care. Vestibular rehabilitation may be recommended as well. Interestingly, research shows that a head CT scan is of limited value in evaluating dizziness. In fact, less than 1% of head CT scans ordered for dizziness/vertigo have resulted in information that led to improved clinical outcomes. As such, we advise against this as a diagnostic tool.

Dizziness/Vertigo care path guide

Shared medical appointments for dizziness and/or imbalance

Shared medical appointments (SMA) are another option for patients experiencing dizziness or imbalance with an unconfirmed diagnosis. This model has become increasingly popular in recent years as it fosters small-group discussion with providers and patients, in addition to developing a comprehensive care plan. This appointment type is often a faster route to care than one-on-one visits with a provider. The SMA offers the following:

• A group visit with four to five patients at both Cleveland Clinic main campus and Beachwood Family Health and Surgery Center.
• Family members or loved ones are welcome to attend the 90-minute appointment.
• All patients receive a private examination but also participate in group discussion of symptoms and common causes.

Advanced testing for children with vestibular dysfunction

Our vestibular program is also designed to treat children with dizziness and balance dysfunction. Studies show that children with sensorineural hearing loss and bilateral vestibular loss may have significantly worse visual acuity during head movements, which can negatively impact school performance. Like our adult patient population, vestibular testing is essential to confirm diagnosis of suspected disorder and improve clinical management. We use several advanced testing techniques to provide assessments for children of all ages, including infants:

• For children over 5 years old, we typically recommend videonystagmography, including caloric irrigations.
• For children over 4 years old, we are able to complete video head impulse testing, which examines the function of all six semi-circular canals.
• For children under 5 years old, rotational chair testing can be utilized to fully evaluate the horizontal semicircular canal.
• Appropriate for any age, vestibular evoked myogenic potentials can isolate otolith organ function.

About the Author

Dr. Honaker is the Director of the Vestibular and Balance Disorders Program within the Head and Neck Institute. She is an audiologist specializing in state-of-the-art assessment and management planning for all patients with dizziness, imbalance and falling risk concerns.