Dizzy Discourse: Updates in Vestibular Care

Podcast Transcript

Paul Bryson: Welcome to Head and Neck Innovations, a Cleveland Clinic podcast for medical professionals exploring the latest innovations, discoveries, and surgical advances in otolaryngology - head and neck surgery.

Thanks for joining us for another episode of Head and Neck Innovations. I'm your host, Paul Bryson, Director of the Cleveland Clinic Voice Center. You can follow me on X, formerly Twitter, @PaulCBryson, and you can get the latest updates from Cleveland Clinic Otolaryngology-Head and Neck Surgery by following @CleClinicHNI on X. That's @CleClinicHNI. You can also find us on LinkedIn at Cleveland Clinic Otolaryngology - Head and Neck Surgery, and Instagram at Cleveland Clinic Otolaryngology.

Today I'm joined by a returning guest, Dr. Julie Honaker, Section Head of Audiology, as well as a new guest, Dr. Evalena Behr, an audiologist in our Vestibular and Balanced Disorders Program. Dr.’s Honaker and Behr, welcome to Head and Neck Innovations.

Julie Honaker: Thanks so much for having us.

Paul Bryson: Well, I encourage everyone to go back and listen to our first podcast with Dr. Honaker, it's an episode on vestibular disorder management. And for our new listeners, let's start by having you share some background on yourselves, where you're from, where you both trained, how you came to Cleveland Clinic.

Julie Honaker: Well, again, thank you for having us. It's so nice to come back and join you here on the podcast. I'm Dr. Julie Honaker and I am Ohio born and raised in southwest Ohio. I actually did my education at the Ohio State University and the University of Cincinnati where I went on for my master's in audiology, and then I was right on the cusp of the doctorate in audiology and I decided to go on and pursue my PhD. I just ended up having more questions than I found answers for in my graduate program, and decided I wanted to have a clinical research degree. After my training in Cincinnati, I went on to do a postdoctoral fellowship at the Mayo Clinic where I worked with Dr. Neil Shepherd who was an expert in the field of vestibular disorders. I spent two years there and then I moved all the way to Nebraska where I was an assistant professor and then tenured to associate professor. And around I want to say January of 2016, I received an email from Dr. Craig Newman, who is the former section head of audiology at Cleveland Clinic, asking if I had any interest in coming back to Ohio to start a vestibular and balance disorder program and it seemed to be the right time for my family. So we made the move and I've been here ever since.

Paul Bryson: Well, we're glad that you did and we're glad you're here, and it's been an exciting time to see so much growth in your group.

Julie Honaker: Yeah, we are. It's very exciting and recently hired just a few years ago, hired Evalena Behr, so I'll let her tell you a little bit about her story.

Evalena Behr: Perfect. So I am from south Florida. I went to grad school at the Nova Southeastern University, so I went to the Doctor of Audiology program unlike a PhD route. So our last year is just a pure clinical externship year and you can really go wherever you liked. When I was looking at different programs, I actually did a presentation in class on fall risk and noticed I was citing a lot of Julie Honaker's work. So when I interviewed at the Cleveland Clinic, I was interviewing with Dr. Honaker and it was just someone that I really wanted to work with, and that was honestly one of my top reasons for coming to the Cleveland Clinic in Ohio. People always ask, why did you leave South Florida to come to Ohio? And from there I finished my externship and I was lucky enough to get a vestibular fellowship with Dr. Honaker. And from there I finished that about almost a year ago. So I've been on board as a provider for about a year at the Cleveland Clinic.

Paul Bryson: Well, congratulations on finishing your program and it's great to have you as part of the staff here this last year.

Evalena Behr: Fun to be here.

Julie Honaker: I'm lucky to have her.

Paul Bryson: Well, we'll dive in here a little bit. Our listener is, it might be patients, it might be other healthcare providers, but yeah, I'll dive in with some clinical questions and we'll talk a little bit about the center and things like that. So when patients present with symptoms like hearing loss or vertigo, what role does the vestibular test battery evaluation play and how's it helped identify or guide patient treatment?

Evalena Behr: So what we always tell patients is that we act as little investigators for the referring provider or the medical doctor or advanced practice provider like an AP - nurse practitioner or PA. So we really measure the function of the vestibular system, not necessarily the structure. And we're looking at are the ears sending or the vestibular system sending equal and symmetrical information to the brain about really where the head and body is in space. So one thing that we're looking at with that is we can help localize - the vertigo is coming from the right ear versus the left - and sometimes it's important for our referring providers to correlate that with hearing to help discern the diagnosis.

We can look at where the patient's at in their healing process or what we call the compensation process. A lot of our findings can help guide treatment for our physical therapists, which we may talk about later when we talk about some of our research. And then sometimes for surgical candidacy, our results can help determine if the patient's a cochlear implant candidacy or if it would be better to implant the right versus the left ear. We can also pull out sometimes very fine details about if there's any central versus peripheral vestibular involvement. So our testing can help our referring providers in many ways we believe.

Paul Bryson: Yeah, I appreciate that explanation. I'll tell you as a no-otologist, sometimes vestibular issues can be a little intimidating and we really need a little bit of guidance. What are some of the care paths that can be used to treat vestibular disorders in which treatment options do you see most commonly as a starting point?

Julie Honaker: I think the one thing just kind of shed some light on vestibular disorders. It really comes down to our role kind of as those investigators and getting to the root cause of the patient's symptoms. So dizziness and balance and vertigo. Those are debilitating symptoms that one may experience, but they're internal symptoms and it's often very difficult for patients to describe truly what they're experiencing and for providers to identify what to be the culprit because there's so many different systems, whether it's peripheral, neurologic, cardiovascular, blood pressure related, even medication related causes and natural aging effects that could be a source for why somebody would be experiencing those symptoms. So oftentimes we say the best care path is for patients to first have a conversation with their primary care or their family practice provider regarding their symptoms. From there, depending on the symptoms, if there’s something that sounds like it's more triggered, there is an ear related co-occurrence where they're having perhaps hearing related problems, ringing in the ears, pain in their ears or discharge that might send them more our path within the realm of ENT-audiology and where our testing may come into play to help determine what could be the cause.

Sometimes if it's just something that's more position trigger changes for their symptoms, their symptoms are very brief and they're truly something that's isolated where they can really tell you what's bringing it on, it's only lasting for a few seconds. Sometimes they can still see us as a first care path or sometimes they can even be seen by physical therapy as a route to rule out the most common cause for vertigo and dizziness, which is a problem referred to as benign paroxysmal positional vertigo or where somebody has tiny little dense gravitational crystals within their ear structures can become dislodged and when this happens, it can bring on transient symptoms of vertigo. Sometimes if they have neurologic causes, it's a path to get them to neurology first. So it's oftentimes having patients just open up with their family practice to determine what the symptoms are, what are associated symptoms and triggers, and that can help allude to what path might be the best route for management first.

Paul Bryson: It sounds like a really multidisciplinary approach, and it sounds like as is the case with us sometimes, sometimes we're the first point of entry and then you get to do the evaluation and maybe find, hey, you might be better served by going and seeing this provider or that provider. Have you had a good amount of buy-in from a multidisciplinary approach? Can you talk about how you coordinate care in a multidisciplinary fashion or how you are coordinated as part of care in a multidisciplinary fashion?

Evalena Behr: So that's a great question. We noticed the same thing where it is a complex team and there's often many causes to dizziness and vertigo and being at the Cleveland Clinic, sometimes patients come from all over and our vestibular test battery appointment is typically two hours. So if someone comes from out of state, it's really hard for them to do an add-on VTB. So what Caitlin Sukalac, one of our otology Pas, and I noticed is this issue, and we try to fix it by creating a Dizzy Clinic. So it's mostly for out of state patients, but sometimes they can even be local or just two hours down the road, an hour down the road. But really it's kind of the one stop shop. They see her, they get a vestibular test battery and they get a hearing test all in a two or three hour span. Then she and I sit and we talk about the results and we talk about it from her medical lens and my lens, the audiologic lens where I'm looking at the function of the system. And I think we've had really good outcomes with that so far. Patients seem to really enjoy it. They can get everything done at once and they know they have two providers coordinating and talking about their symptoms and their care.

Paul Bryson: I mean, that's fantastic. I mean, you're right. Sometimes people are just looking to try to find the right person. So to be able to provide that patient experience is really commendable. So congratulations on being able to roll out that clinic. I also wanted to talk a little bit, I heard you mention earlier Dr. Behr, just sometimes the impact of balance in the context of surgical candidacy, maybe with cochlear implants, maybe with other things. Just recently we spoke to Dr. Bassim and to Dr. Sydlowski, two of your other colleagues on cochlear implantation and expanded candidacy. Can you talk a little bit about how balance and cochlear implant candidacy play together? I am not as familiar with that, but it certainly makes sense.

Julie Honaker: With respect to anyone who may be considering a cochlear implant with significant hearing loss, and I know that they're expanding the candidacy to include individuals with the less profound hearing loss as it was many years age, but anytime there's someone with a concern of hearing loss, just because of the nature of how close in proximity the hearing organs are to the vestibular organs, we always have to wonder if they could also have a balance problem. And for treatment for someone with hearing loss, the surgeons are inserting an electrode ray into the ear, which is in such close proximity to the balance organs that we always have to wonder if we're helping one part of the system that could be causing any damage to the other, and what's the starting point for somebody because we want to make sure that we're treating the whole person. And because there's a lot of research that's been coming out over the past decade just looking at association of fall risk and hearing loss, we want to make sure that we can best manage these patients so that they have positive outcomes for their hearing as well as their balance both pre and post-surgery.

So we're including now as part of a research study, we're looking at the impact of cochlear implantation on balance, which is pretty well known in the literature, but we have actually done a thorough literature review, looked at what are some triggers that might warrant individuals to have balance testing pre as well as post. And we're checking the outcomes for those individuals so that we can get the best management in place for them.

Paul Bryson: That's great. Thank you for that. What else is on the horizon as far as research that you both are excited about you? You mentioned falls, we talked about cochlear implants. What else are you excited about?

Evalena Behr: So like I mentioned earlier, some of our testing can help guide physical therapy and their treatment, and there's multiple routes like Dr. Honaker talked about. They can go to PT first or they can come see us first. And one of our research questions, and we collected the data, we did a nice presentation at a national conference a week or two ago about it, but we're looking at the number of sessions when they see us first, because we have that information about the healing process versus when they see PT first. So similar to when you have knee pain and your primary care doctor says, go to PT first and then we'll come back and maybe get an imaging study or two or do more diagnostic testing. So we wanted to look at what triggers when they go to PT first should warrant a complete vestibular evaluation because sometimes, not in every case, but they can do several sessions where there's a lot of opportunity and economical cost to going to PT and not having a clear diagnosis versus coming to us first receiving that information about the function, the site of lesion, the status of compensation, and then going to PT afterwards.

And we have some pretty good results, and I think we're going to have some good information coming out pretty soon about it, but I think we'll help guide interdisciplinary practice in general so that patients can still be seen by physical therapy, but then also physical therapists can be armed with the knowledge when just refer them to us to help guide their treatment plan.

Paul Bryson: Yeah, congratulations on that project. Thank you. That's exciting.

Dr. Honaker, you recently had a paper published on interprofessional education interventions to improve the delivery of safe and effective patient care with respect to vestibular disorders. Can you share some background as well as your findings?

Julie Honaker: Sure. Well, thanks so much for asking about this. I have to admit though the paper wasn't with respect to vestibular disorders, but just patients in general. I had the pleasure of serving on the American Speech Language Hearing Association board of directors, and part of my role was Vice President for Academic Affairs and Audiology, and I served with other disciplines as part of this interprofessional education collaboration where we conducted a scoping review over a five-year period from 2015 to 2020 where we were really looking at “does interprofessional education make a difference for our patient as far as their outcomes?”

So we did this extensive scoping review and we whittled it down to about 94 articles, and we really were trying to key some specific highlights. Does interprofessional education, meaning more than one discipline, either it's providers or students working together to tackle training, does that improve patient outcomes? And it actually did, and they had health measures that we found where there was reduced length of stay in the hospital, reduced medical areas, or excuse me, improved patient satisfaction, improved provider satisfaction for what they're doing and more, less burnout because of this. And really that working together, the adage of two heads are better than one. It does work. And that's really what we try to do even with our research questions. We're trying to have an interdisciplinary lens with this to see how we can improve the management and the care path for our patients with their debilitating symptoms.

Paul Bryson: That's great. I know a lot, there's a lot of attention appropriately so to adults with falls and other vestibular conditions that you mentioned earlier in the podcast, but I understand vestibular care can be extended and can involve our pediatric patients too. What type of work can we expect from the group with regards to our pediatric patients?

Evalena Behr: Yeah, that's a great question. Dr. Honaker and I just added more a pediatric-focused slots on our template. So we're seeing more pediatric patients, and there's a lot of new data out showing that there can be longstanding impacts when patients have pediatric vestibular dysfunction as a child, when they have bilateral loss. So when they have dysfunction of both ears, their balance can kind of plateau at four years of age. And that's worked from Dr. Cushing's lab at SickKids in Toronto. And if we think about that, we would never let a child's language plateau at four years. So I think that really shows the importance of pediatric vestibular testing, and I think even so this clinic in particular because young children cannot always articulate their symptoms well, so objective information is often helpful in diagnosing and again, helping with the management and pediatric vestibular disorders.

Paul Bryson: That's very exciting. That's great to hear. And I think your example, we hear so much about newborn hearing screening and detecting hearing loss at a young age. It seems just the same that you would hope to identify vestibular opportunities at the youngest age possible as motor skills develop and whatnot.

Evalena Behr: You got it. Exactly.

Paul Bryson: Well, I appreciate your time, both of your time being here on the podcast as we wrap up today, any final take home messages for our listeners?

Julie Honaker: I think just again, if you're experiencing, if you're a patient who's experiencing or have a loved one who's experiencing dizziness, vertigo, or imbalance, have a conversation with your family practice or internal medicine physician or provider. From there, you might be coming our way, and we're going to do our best to work as detectives to try to discern what could be the culprit for your symptoms and get you to that right provider for management.

Paul Bryson: Well, when vertigo, dizziness and balance disorders have you or your patients feeling off balance, count on the experts here, Dr. Behr and Dr. Honaker at Cleveland Clinic to help. For more information on vestibular treatment at Cleveland Clinic, visit ClevelandClinic.org/Vertigo. That's ClevelandClinic.org/Vertigo. And to connect directly with a specialist or to submit a referral, call 216.444.8500. That's 216.444.8500. Finally, be sure to follow our audiologists on Instagram and Facebook at Cleveland Clinic Hearing and Balance.

Dr.’s Behr and Honaker, thanks for joining Head and Neck Innovations.

Evalena Behr and Julie Honaker: Thank you. Thank you for having us. Take care.

Paul Bryson: Thanks for listening to Head and Neck Innovations. You can find additional podcast episodes on our website clevelandclinic.org/podcasts. Or you can subscribe to the podcast on iTunes, Google Play, Spotify, BuzzSprout, or wherever you listen to podcasts. Don't forget, you can access realtime updates from Cleveland Clinic experts in otolaryngology – head and neck surgery on our Consult QD website at consultqd.clevelandclinic.org/headandneck. Thank you for listening and join us again next time.