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Q & A With Dr. Sanders

Q: How did you become interested in 'dizziness'?

A: As a neurologist and neuro-ophthalmologist, a large part of my fellowship training involved studying and analyzing eye movements, including what we call 'nystagmus'. Abnormalities affecting the inner ear or brain, which lead to dizziness or imbalance, manifest as abnormalities in how the eyes move, either spontaneously, or with specific stimuli, such as head position or head rotation, or warming or cooling the fluid in one of the fluid-filled canals of the inner ear in a test know as 'calorics'. Thus, vestibular medicine, the study of dizziness and imbalance, seemed to be a natural fit with my training.

Q: Have there been recent advances in how the 'dizzy' patient is managed?

A: Enormous advances in our knowledge and technology and how we approach the diagnosis and treatment of 'dizziness' have occurred over the past two decades. We are now able to diagnose and treat conditions that we were unable to treat prior to 1992. In fact, much of what I know now was not taught when I was in medical school or when I was a resident in training to become a neurologist. As I often relate to other physicians, what we learned in our medical training is outdated. We now have much better and more effective ways of diagnosing, and in curing, 'dizziness' than we did just 15-20 years ago.

Q: Then where did your knowledge on vestibular medicine come from?

A: Two main sources: Seminars and books. I have traveled many places around the country, including Florida, Georgia, Washington DC, California, and Ohio, attending multi-day seminars on the subject of vestibular disorders. Most notable were the yearly seminars put on by Dr. Judy White at Cleveland Clinic and Susan Herdman, PhD and Dr. Ron Tusa at Emory University, in Atlanta. I have compiled no fewer than 15 textbooks over the years which deal specifically with vestibular system disorders.

Q: There are many places that patients suffering from dizziness could go for help. Why should patients seek the services of a neurologist or neuro-ophthalmologist, rather than an Ear, Nose and Throat (ENT) physician?

A: There are many ENT physicians, or otolaryngolgists, who do well in managing the 'dizzy' patient, especially those with fellowship training in neuro-otology. But part of our updated knowledge on the 'dizzy' patient has to do with whether 'dizziness' in general is more often an inner ear or a neurologic problem. We now know that across the board, the most common cause of dizziness is neurologic, that is, as related to headaches, specifically migraine headaches. This particular condition is often referred to as 'migraine-associated dizziness' or 'vestibular migraine' and likely encompasses somewhere between 60-80% of all 'dizzy' patients. Less than 1/3 of those suffering from 'dizziness' have an inner ear disorder, most of which have BPPV (benign paroxysmal positional vertigo), a condition easily diagnosed and treated by any physician who has learned how to identify and treat the various types of BPPV. So, the vast majority of what causes ‘dizziness’ is easily handled by a neurologist, especially a neurology trained neuro-ophthalmologist who has a background in treating migraine and in recognizing different types of nystagmus.

Q: How is BalanceMD different from other facilities involved in the diagnosis and treatment of 'dizziness'?

A: Excellent question, and there are a number of factors to consider in the answer.

BalanceMD is the only full-service clinic in central Indiana for the 'dizzy' patient. What I mean by this is that BalanceMD was founded on the basis of being a "balance center", utilizing the services of physician, audiologist and physical therapist, working together in the same location for optimal outcomes at the lowest cost, i.e., high value care.
The healthcare specialists at BalanceMD all have the most updated knowledge and many years of experience in helping cure or significantly reduce symptoms in literally tens of thousands of patients over the years. In fact, we all speak at educational seminars, teaching others, on a regular basis, and most recently I spoke at a Physician Assistant convention on October 2, 2013. This year, in 2013, I have spoken at a Nurse Practitioner convention, a Family Practice convention, an Ophthalmology convention and a Physician Assistant convention. Both Audiologists (Sandy Bratton in Lafayette and Michelle Koley in Indianapolis) at BalanceMD have roles as instructors to Purdue University’s Vestibular Disorders coursework for the Audiology Department. We also attend regular continuing education seminars to be certain that our knowledge is as up date as possible. Most recently, we attended a two day vestibular disorders seminar in Tampa, FL in October 2012.
BalanceMD utilizes only the most skilled audiologists for the diagnostic evaluation (vestibular function testing) and physical therapist to provide vestibular rehabilitation therapy. Other facilities simply train one of their staff, someone with no prior working knowledge of vestibular disorders, to run the test.
BalanceMD has the latest in diagnostic testing equipment available, including rotary chair and VEMP, both of which are unavailable at most other testing facilities. There are no short cuts regarding the expertise of staff or the diagnostic equipment available at BalanceMD.

Q: So why do most other facilities not have rotary chair and VEMP?

A: Expense mostly. Together, these two pieces of equipment might cost upward of $150,000. However, the rotary chair gives us very important information regarding the status of the vestibular system that we do not get from the videonystagmogram (VNG) alone, and is the gold standard in the diagnosis of a bilateral loss of vestibular nerve function. The VEMP is our best way to evaluate the lower half of the vestibular nerve, something that the VNG neglects to address at all. So, if someone has suffered damage to the lower division of the vestibular nerve, this may go undetected with just a traditional VNG. The VEMP test is also very good a picking up a recently described inner ear condition known as superior canal dehiscence syndrome.

Q: You mention "optimal outcomes at the lowest cost". What do you mean by that?

A: Part of what we have learned over the past two decades has to do not only with what works to diagnose and treat the 'dizzy' patient, but what DOESN'T work.

It is rare that a CT or MRI scan of the brain, in the presence of normal neurologic exam and normal hearing, to reveal a cause for dizziness or imbalance. Thus, most neuro-imaging studies performed for the symptom of 'dizziness' are a waste of healthcare dollars.
From a blood flow standpoint, neurologic and inner ear symptoms of dizziness do not come from the carotid arteries, so carotid doppler evaluation is also not a useful test of dizziness.
Without a history of seizures or syncope (passing out), it is unlikely that a seizure is going to cause dizziness, so an EEG is not a useful test.
Unless there is another reason to check blood count, thyroid tests, or EKG, these 'lab' tests are also not useful. Unfortunately, all of the above tests continue to be regularly performed.

Q: So what is the best way to evaluate the 'dizzy' patient?

A: The best way is to start with a thorough history and physical examination. As I am evaluating a patient, I am asking pointed questions to best characterize their symptoms over time. By the end of each patients visit, I would say that about 80-85% of the time, I have a very good idea about what is causing their symptoms. If they have symptoms suspicious for BPPV, I will check for this at their first visit, and if present, perform the appropriate repositioning maneuver, most commonly the modified Epley maneuver, and send them on their way home 92% of the time CURED. Otherwise, if they do not have orthostatic hypotension, no recent change in medication, or other non-vestibular system cause for their symptoms that is obvious, they will return to have the best diagnostic evaluation for dizziness, which we call "vestibular function testing" and includes the VNG, rotary chair, VEMP and audiogram.

Q: How do you see what you do as reducing the long-term costs of healthcare?

First, by reducing the cost of the evaluation of the 'dizzy patient' through the most thorough clinical history and examination and immediately curing the vast majority of those who have BPPV. In these cases, no further evaluation is needed. Some facilities require the patient FIRST have the vestibular function evaluation performed BEFORE seeing the doctor, which is simply a waste of healthcare dollars.
As we discussed previously, MRI or CT scans of the brain, carotid doppler, EEG and laboratory testing are rarely helpful, so we avoid ordering these tests.
Once the initial visit is complete and those with BPPV have been cured, the remaining patients then proceed with the most appropriate diagnostic evaluation based on their symptoms. Often, this is the vestibular function test.
Once the most likely diagnosis is reached, targeted treatment, which might include a medication for prevention of migraine symptoms or physical therapy (vestibular rehabilitation), is recommended.
Finally, in reducing or eliminating dizziness or imbalance, fewer painful falls will result and the reduction in the long-term costs of care associated with this can be astronomical. Fewer bone fractures requiring fewer surgeries, fewer hospital and inpatient rehabilitation stays, not to mention the improvement in the quality of life of those we are are helping.
Q: How do the costs for vestibular function testing you do at BalanceMD compare with costs of similar testing at other facilities, including hospitals?
A: I can’t say for sure, as I am not aware of what others are paid for these services. What I do know, and what is becoming general knowledge, is that many services performed in a hospital-owned facility are MUCH more expensive than services performed at independent facilities, such as BalanceMD. Hospitals are buying physician practices at a rapid rate and patients are noticing that when this happens, their out-of-pocket costs go up, often as much as 3-4 times. Something that previously cost the patient $500 now costs upwards of $1,500 - $2,000, with the only difference being that their physician’s practice is purchased by the hospital. As many patients now have high deductible health savings accounts (HSA), this difference in charges that patients are now responsible for can be shocking. The discrepancy in higher payments to hospital-owned facilities has to do not only with the negotiating power that large hospital systems have with health insurance companies, but some hospitals also charge an additional “facility fee”. I would encourage all patients to not only research the best facility to have necessary testing performed, but to also price compare, something most patients are not accustomed to doing.

Q: Thank you, Dr. Sanders, for taking the time to chat with me today, and sharing your insights into the world of the “dizzy” patient.

A: It’s my pleasure. I hope this discussion will be helpful for those who suffer with dizziness, vertigo and/or imbalance.