Innovations in Vestibular Testing and Treatment

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 this week's episode of Head and Neck Innovations. I'm your host, Paul Bryson, Director of the Cleveland Clinic Voice Center in our Head and Neck Institute. You can follow me on Twitter @PaulCBryson and you can get the latest updates from our institute by following @CleClinicHNI. That's @CleClinicHNI. Today, I'm excited to talk with Dr. Julie Honaker, our Audiology Section Head in Cleveland Clinic's Head and Neck Institute. You can follow Dr. Honaker on Twitter @JulieHonakerPhD. Dr. Honaker, welcome to Head and Neck Innovations.

Julie Honaker:Thank you so much for inviting me. I'm excited to be here.

Paul Bryson:Well, I'm very much looking forward to learning about our vestibular program and some of the services that you've developed for patients and caregivers, but let's start by having you share some background on yourself for our listeners, where you're from, where you trained, how you came to Cleveland Clinic.

Julie Honaker:Sure. I was born and raised in Ohio, so actually southwest Ohio. I grew up in Hamilton and went to school at the Ohio State University and University of Cincinnati where I started off in special education. And I had to have a major as part of that, and I fell in love with communication disorders, in particular speech language pathology and audiology. And from there I took the path of audiology and completed my master's and then went on for my PhD at the University of Cincinnati. I did post-doctoral training for clinic and research with an emphasis on vestibular imbalance disorders at the Mayo Clinic in Rochester, Minnesota for two years. And then I actually took, my first real career position was at the University of Nebraska Lincoln, where I was an assistant professor, had a full-fledged research lab related to vestibular disorders and concussions.

So I did a lot with the athletes at University of Nebraska and was there through my tenure, I was an associate professor. And then I actually got a call asking if I would be interested in coming to the Cleveland Clinic and starting up an audiology vestibular program. And it just was a natural fit at the time for my family and for my career to kind of dive back into the clinic and kind of integrate my research actually with the patient population again.

Paul Bryson:Yeah, that's great. I don't think I knew that. I wanted to find out how did you choose vestibular disorders and balance. Walk me through that. What sort of excited your intellectual curiosity about that?

Julie Honaker:Great question. I've always been one to take the road less traveled, and I think in audiology, if I had to pick a facet, it would be balance and vestibular just because it was different and unique, and I was just fascinated with all the questions related to vestibular physiology. But what really turned the corner is that when I was at the University of Cincinnati where our allied health program was, it was right integrated in the medical school, so we were like one building over. So a lot of my friends at the time were medical students, and they were going through their rotations in the ED while I was learning about vestibular physiology. And they're like, well, that's great with how the balance system works, but I'm seeing the other end of the spectrum with all these patients coming in with hip fractures or fall related injuries or dizziness related to something going on.

And they're like, why don't you focus your time on why they're developing this and how the balance system breaks down? And I was like, oh, okay. So just from there, I just decided that that was really a passion and something that I wanted to really focus my career on. And I sought out experts across the country, which kind of led to my time at the Mayo Clinic. I went to University of Pennsylvania for an externship and worked under a great audiologist in the field of vestibular, and I don't know, just kind of decided that I had more questions than I had answers for. And that's what really led me down this path. And I still have questions, which is why I love what I'm doing.

Paul Bryson:Well, it's so important. Just from hearing about concussions to falls to hip fractures and things like that. I mean, it has a real importance I think, in public health. Can you give the listener a high level view? How many Americans are affected each year by vestibular disorders like dizziness or vertigo or how would you even take a more foundational step? How do you describe vestibular disorders? What's sort of the patient experience in this regard?

Julie Honaker:Well, I'll start with the second part to that. What's the patient experience? And then I'll get into kind of prevalence of this vestibular disease. For the patient experience, I would say there's kind of broad categories of symptoms. It's hard for a patient to describe because it's something that's not overt. It's what they're feeling, and they can have kind of a myriad of symptoms that all can fit under this umbrella of dizziness, vertigo, imbalance or lightheadedness. Dizziness is often described as a spatial disorientation of kind of perception of the world around you. Vertigo is often you're internalizing, the sense of internal motion or the world around you. Your environment is moving oftentimes in a circular or rotary type fashion. Imbalance is that you have the perception that you have disequilibrium or you're not able to maintain your postural control. And then lightheadedness kind of fits under the syncope category.

What's challenging with vestibular disorders is that, or I should say under this category of all these symptoms, is that we often think it could be related to some sort of vestibular condition, but that's not always the case really. Patients can present with dizziness, vertigo, imbalance, lightheadedness, syncope due to a myriad of problems. So it can be something neurological, heart related, anxiety, medication related, or actually due to some natural progression of the aging process, which makes it challenging for us as clinicians to try to decipher what could be the cause and why we spend so much time trying to listen to the patients and ask them questions to try to decipher what could be going on. In getting to the first part of your question about prevalence, I think it depends on the studies that are being published and also what they're using for their diagnostic tools.

So there's some studies that mention a range from 6 percent to 35 percent of adults could have vestibular related disorders, but it really depends on what they're using to classify vestibular disorders. So I would say as a whole, vestibular meaning inner ear related conditions is probably lower prevalence. For patients reporting dizziness, it's probably the second most common reason why patients would go to their primary care physicians, aside from maybe headaches or a cold or something like that. As we age, we are more susceptible to vestibular or inner ear conditions. Probably the most common is referred to benign paroxysmal positional vertigo or BPPV, which is a common inner ear thing. I can go into detail if you're interested. For kiddos, it can happen, but it's not as common. So the prevalence is really low for those younger children.

Paul Bryson:Well, it sure seems there's a really diverse array of etiologies, things that can contribute to this. Can you walk us through what does the multidisciplinary collaboration look like or perhaps a care path for a referring provider? Or how does a patient meet with your team, or what does that look like? It sounds complicated, so how do you try to work with the patients to get them in and get them cared for?

Julie Honaker:Absolutely. I would say from a patient perspective, it's always best to go to your home base, which is your primary care physician. So that individual or provider, I should say, that individual is going to help to decipher whether or not there is some medication or aging or cardiovascular issue that needs to be further investigated. When a patient is presenting with symptoms of true vertigo, meaning a spinning sensation or perhaps dizziness that they're not sure of the cause, that's where really vestibular audiology can come into the mix. So we are kind of the detectives for vestibular disorders to help decipher what could be a potential cause. May not always be ear related, but we're going to spend a lot of time listening to the patients. Our appointments are upwards of two hours, so it's the most time that a patient can have to really explain what they're feeling, and we can help guide that out of them.

And then our evaluation tools are really to help decipher if its ear related, perhaps central nervous related, and what would be that next step in the care planning for the patients. So it's good to help make sure and triage that patients are getting to the right providers and for the right management.

Paul Bryson:We do have, our audience for this podcast are all presumably medical professionals. So can you walk us down, what are some of the tools that your team has? What are some of the diagnostic maneuvers, equipment, things like that, that are in your armamentarium for these patients?

Julie Honaker:Good question. Well, as I said, our main job is vestibular audiology, and I should say that we work very closely with our partners in rehab, so vestibular PT. So we work together not in the same facility, but as a team to help with assessment and management for these patients. But for our diagnostic patients, we really are able to get a good idea of function and physiology of all aspects of the vestibular system. So much like the hearing system, we can perform an audiogram looking across frequency range for hearing. We can do the same for vestibular testing by integrating certain components of the vestibular system. In particular, looking at semicircular canal function, we can actually fill in gaps where a disorder may lie for somebody and whether or not is a complete loss of function, just a mild loss of function, what's spared within the system, and that will help with determining outcomes for rehab and helps us better understand what we really need to focus on for our rehab efforts.

So I would say with the advanced and modern technology that we have in our laboratories, we're able to evaluate all five vestibular end organs across the frequency spectrum, and we can get a good idea of the function of that system, site of lesion, how a person's compensating from loss of vestibular function, and whether or not there's possibly some other contributors to a patient's symptoms such as central nervous system disorders.

Paul Bryson:Oh, that's fascinating. I mean, to see some of the equipment in the lab, it's amazing that you're able to interrogate it with that level of specificity. With new technology, it's always very interesting to see how some of the wearables and things like that exist to try to help people rehabilitate things. Can you share what are some of the new technologies on the horizon for either diagnosing or rehabilitating vestibular disorders? How does that seem to be playing out?

Julie Honaker:Yeah. I would say from the assessment end, which I'm more closely tied to, it's really fascinating with a lot of our work is videography. So we have video cameras that we're using to track pupil displacement over time so that we can quantify a reflex between the vestibular system and the ocular motor system. I would say with the technology, we're getting more sophisticated that we're able to measure all planes of eye movements now. Where it used to just be two dimensional, horizontal, vertical, we're now able to measure torsional eye movements, which makes it easier to capture disorders of vestibular organs that were a little more challenging to test. We're able to look more at the function in real time and what's happening with the system. From a rehab standpoint, I think that that technology that we have from assessment can carry over into rehabilitation. And just with looking at all of the, even my phone, I just upgrade my phone. I mean, even these systems now in my watch, I'm able to monitor not only my heart rate, but if I'm going to fall.

There's so much that we have of accelerometers that we're able to use to provide real time biofeedback, and I think that's the real push for rehabilitation now is to provide those cues to be able to help correct for patients so that we can circumvent a fall event. We can help them realign their center of gravity and help them with their symptom resolution. A lot with VR too, so that's really exciting with virtual reality.

Paul Bryson:Yeah, I mean, having not tried one of those headsets before, I would imagine that that stimulates the vestibular system.

Julie Honaker:Oh, it does. Yes, it does very much. And just your visual optokinetic system. So there's a lot with VR that can be beneficial in providing simulations to help patients overcome fear of falling and being in a safer environment, but sometimes just the use of those VR systems can be symptom producing. So there's a lot of research that's being marked into that.

Paul Bryson:Yeah, I mean, I didn't think about it in a rehabilitative way, but you're right. It almost allows for biofeedback in a safe way. Like you said, fear of falling or perhaps even simulating the home environment or areas where you're like, oh, I'm worried about this, or, oh, this seems to be a trigger for instability.

Julie Honaker:Yeah, there's a lot that's happening with that. Even eye tracking systems that are able to monitor. I did some work at the University of Nebraska where we actually were looking at patients with fear of falling. And we were monitoring their eye tracking, looking at just still images of scenarios of rooms with clutter and scenarios where they have obstacles in a walkway, and it's just amazing what you can pick up with even subtle saccadic movements of the eyes that are much different than other patients who don't have concerns of falling. And that we're really seeing some kind of honing in on some things that you can work on from a rehab standpoint to help them best prepare and have more kind of pro saccade to be able to inform the environment that they're in so they don't fall.

Paul Bryson:Yeah, that's fascinating. I mean, it just seems smart, and it seems almost customized to the person's environment.

Julie Honaker:Very much.

Paul Bryson:Yeah. Well, we're nearing the end of our time. What else? Anything else you want to talk about before we wrap up or other take home things that you wanted to share about the program that maybe we didn't talk about? What else? I mean, the floor is yours. We're very proud of the program, and I have to say in my work in voice, I don't get to interact as much clinically with you with patients.

Julie Honaker:I would just say from an audiology standpoint, and probably what we're looking into most as far as my lab and what I'm working on with my vestibular fellow right now, and really looking at vestibular audiology as a whole, we're really trying to fine tune the specific test battery that is most appropriate for patients based on their symptoms and presenting signs. And that's the one thing that we really try to aim for at the Cleveland Clinic is that patients don't go through the same thing every time. The clinical decision process is really dependent on what they're presenting with, what we're seeing from kind of a bedside examination, and then we tailor the testing based on that. And I'm excited. I think we might be part of a beta site looking at some software algorithm to help kind of even fine tune this even more with some of our objective testing. So that's really exciting and on the horizon for us.

Paul Bryson: That's great. With the beta site, will that be a clinical trial that patients could inquire about?

Julie Honaker: Well, we're looking into that, so I'd say stay tuned. I think it's probably a first phase and then possibly a trial.

Paul Bryson: Okay. Well, that's very exciting. Make sure you keep us posted so we can let patients know.

Julie Honaker: Absolutely.

Paul Bryson: Well, I just wanted to thank you again for spending time with me today and telling me about your program and your interests. Great to talk with you.

Julie Honaker: Thank you so much, likewise.

Paul Bryson: When vertigo, dizziness and balance disorders have you or your patients feeling off balance, count on the experts at Cleveland Clinic to help. For more information on vestibular treatment and evaluation at Cleveland Clinic, please visit clevelandclinic.org/vertigo. That's clevelandclinic.org/vertigo. And to speak with a specialist or submit a referral to our Head and Neck Institute, please call 216.444.8500. That's 216.444.8500. Thanks for joining us today for Head and Neck Innovations.

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