Ask the Experts: Vestibular Audiology with Dr. Erin Piker
Join us in this informative episode of VeDA’s Ask the Experts series, featuring audiologist and researcher Dr. Erin Piker. In this video, Dr. Piker provides valuable insights into the world of vestibular audiology and answers some of the most common questions about vestibular testing.
Outline & Transcript
VeDA uses otter.ai to create machine-generated transcripts and outlines. This transcript may contain errors.
- Audiologist and researcher Dr. Erin Piker diagnoses and treats hearing and balance disorders, including BPPV and Vestibular issues.
- Dr. Piker explains Vestibular testing procedures and insurance coverage.
- Dr. Piker addresses patient concerns about dizziness and test stimuli.
- Dr. Piker explains how tests are conducted to measure Vestibular system function, including video NYSAC monography and eye movements.
- Tests assess ocular motor system function, spontaneous eye movements, and how eyes move in different positions.
- The caloric test is a common hearing test that involves changing the temperature in the ear to stimulate the Vestibular system and cause a sensation of motion.
- If the tests are normal, it doesn’t necessarily mean that there is no issue with the inner ear or the Vestibular system, as other tests may be necessary to determine the cause.
- Dr. Piker explains Vestibular testing and its limitations.
- Normal test results don’t necessarily mean no Vestibular issue exists.
My name is Erin Piker. I’m an audiologist. I’m also a Vestibular scientist. One of the questions I often hear is what’s an audiologist or what to audiologists do. So, audiologists are healthcare providers, and we provide a lot of different services to treat your hearing and balance systems. So we’re we’re most known for assessing and managing hearing. And that includes a whole bunch of different hearing tests as well as things like hearing aids and cochlear implants and bajas. But we also specialize in tinnitus and auditory processing disorders and hyperacusis in hearing conservation, and hearing loss prevention, and of course, balance disorders, which is what I do. So my main role with the stimulator patients is really being part of the diagnostic team. This includes conducting some advanced testing, interpreting the test counseling patients, and then we can treat some things like BPPV or Benign Paroxysmal Positional Vertigo. Some Vestibular issues are very straightforward and others are very complicated and they’re best diagnosed and managed with a multidisciplinary team and audiologist is a key part of that team. Our role is largely diagnostics when it comes to the superior patient. So another common question is, when do I need the stimulator testing? Think about that question a lot, because there’s no straightforward answer to that. Some Vestibular issues do not need a lot of testing, they can be diagnosed and treated relatively straightforwardly. For example, something like BPPV. The current guidelines say if you have that, we can quickly assess it and then go right into treatment. But unfortunately, a lot of times we can’t tell what’s going on or what’s causing your symptoms. And the symptoms that can be associated with a Vestibular disorder can also be associated with a lot of different things. And it can be really serious stuff like a stroke or a brain tumor. And it can be something relatively benign, like your your blood pressure needs to get checked. And that’s often when the audiologist comes in to do some Vestibular tests, maybe we can rule in or rule out the inner ear as being being a cause of some of the symptoms you have. And we have to do some pretty advanced testing to do that, because I can’t look in your ear and tell you how your Vestibular system works. And I can’t look at an MRI study or imaging to tell you how it looks. To access that system, we’ll have to do some kind of different little tests that we have. Might be some reasons you need the sealer testing. Another question on here is how do I get a referral for Vestibular testing? That at least in the US is very practice specific. Usually your physician or depending on the state, maybe your physician assistant or nurse practitioner would have to put a referral in. In my experience, most of my referrals come from EMT or neurology on occasion, I’d get someone from primary care. On this, again, this differs by practice. But typically the way insurance works is you can’t just walk into an audiologist practice and get some Vestibular testing. Well, you could but not if you want your insurance to cover it. On top of that, not all audiologists provide Vestibular services. So hopefully your physician or wherever you’re working with would know someone in town who provides the services and they put in a referral for you to have testing done. I get a lot of questions about the tests themselves. And one of the most common one is, will these tests make me dizzy? Ideally, no, that’s not the goal. We don’t want to just make you dizzy and see what happens. What we mostly do is essentially, we look at an input and an output. And we try to come up with our best assessment of what’s going on in the middle there what the Vestibular systems doing. So the input needs to be a stimulus that acts on your Vestibular system and the outputs usually your reflex that’s Vestibular driven. So we can stimulate Vestibular system, check out a reflex and hopefully get down to the bottom of what the actual inner ear is doing at that time. And this can be kind of tricky. Stimulating the Vestibular system is is complicated because it’s a sensory system, but it’s not like some of our other senses. So the example I often explain to patients is with hearing or vision, the stimulus is external. So if it’s hearing I can put a sound out here and you can tell me what you hear and hear and if it’s vision, you know, it’s light so I can have something free to look at You can simply tell me do you see it with your Vestibular sensory system, everything’s coming from inside the stimulus is inside because it senses you, it senses your head movement and your orientation. So to, for us to test the system, we have to find some sort of input that we can control, and then have some sort of output, we can see, a lot of times that inputs going to be motion, so we might turn your head, we might have to move your head, we might rotate your full body. And we might also do a couple different things where we in essence, fool your Vestibular system into thinking your heads moving, and then we can trigger that reflex and take a look at it. Unfortunately, when we fool your Vestibular system or brain into thinking you’re moving, you might perceive that you’re moving. And that could be a sensation of dizziness that some of the testing can cause. It’s normal to feel motion during some tests, it’s also normal for you don’t feel it. What you feel during the test isn’t really part of what we’re measuring. And we do try to do everything we can to avoid making you feel uncomfortable. The most common test that we do is something called V ng, or video NYSAC monography. And that’s actually more of a method. But often the test is called that so video, because we’re going to video your eyes. And this steganography is the name of the eye movement, that we’re looking at something called Miss darkness. And there’s three parts to this. So we’ll put some goggles on you. And for the first part, you’re gonna check some lights. And really what we’re looking here is your ocular motor system. So how are your eyes moving, there are certain things that affect your ocular motor system that can cause you to feel dizzy. And so we want to rule that rule those in or rule those out. We also need to know that your eyes are moving the way we expect them to be. Because later on, we’re going to look at those eyes and see what your Vestibular system is doing. The second part of that test will move you so we might let you down turn your head puts you in different positions. Again, we’ll be looking at your eye movements. Sometimes we’re looking to see if your eyes spontaneously move. And sometimes we’re seeing if moving you in a certain position causes your eyes to move. And all that gives us a lot of information of how your inner ears working. And then the third part of the test, which is the one most people are familiar with is something called a caloric test. The caloric in the sense actually refers to heat. So what we do in this test is we change the temperature in your ear. And we’ll use either air or water that’s warmer or cooler than your body temperature. And we’re going to circulate that in your ear canal for 30 seconds, maybe 60 seconds. What happens when we heat up this part of your ear, it’s going to get a little bit of heat into your inner ear, your inner ear has fluid in it, and that fluids going to start to move because we’ve heated or cooled it. So when when we move that fluid in your ear with temperature, we’re in essence, making your Vestibular system think you’re moving. That’s why this test can cause that sensation of motion. It’s not the purpose of the test to cause you to feel that way. But it could be a side effect of it. And when that happens, we test your eyes that that have a reflex that comes on in response to that. And then we can test the other side. So that’s a caloric test. That’s the most common test. There’s some huge advantages to the caloric test. There’s also some disadvantages. One of those being it can cause some discomfort. And the other one being it’s only going to test one sensor in your ear and you have five sensors in each of your ears. And so the test doesn’t give me a full picture of what’s going on with your ear. But it does give me an idea. There’s lots of other tests that audiologists do the the V and g and the clerk are probably the most common tests. So if you have something done, it’s probably going to be one of those. However, most of our other tests do not cause any sensation or emotion or dizziness, we maybe play some vibration or sound in your ears and record from sensors on different muscles. There’s lots of different tests that are now available to try to figure out what’s going on in there. Another pretty common question, and it’s it’s a serious question, and it’s definitely worth discussing is what happens if my tests are normal? I think if you just had one test, which was probably the V and G with a caloric, then all we can say is we rolled out one small part of your Vestibular system that was also working on the day that we tested you. So a normal test is not mean you don’t have a Vestibular issue. It means the test didn’t show anything that day. And the thing to know is our tests are not perfect. And there’s no one test to rule them all. There’s
no One test that tells me about your entire Vestibular system, you might have to come back for a battery of tests. You might also have to have your tests interpreted in light of what’s going on. Is this a fluctuating type of symptom? Is it a one time event? Maybe we tested you on a good day. You know, if it’s if it’s fluctuating, we might have gotten you in between an episode. And if it’s a one time event, it could mean that you recovered, and there’s no permanent damage that we can measure. It’s also possible that there is another similar issue at all, and we need to get you to a different specialist. But ultimately, the testing needs to be just part of the decision making. And preferably, you might have multiple different tests combined with what are your symptoms, what’s your medical history? What’s your case history, where else is going on? So because it gets complicated, that’s why we have this team approach. And hopefully, you have a team member that’s explaining all of this to you. And in my experience, that person might be the audiologist, we might have two hours to do testing with you. And we’re going to do a lot of talking and answering a lot of questions. And it’s really important as the patient that you get your questions answered, and then you understand everything that’s happening around you or happening to you. So basically, if your test is normal, someone needs to explain to you what that means to you. And in your context, because a normal test for one person doesn’t mean the same thing as a normal test for someone else. All the testing is going to serve a purpose. And I’d say most of us are very happy to answer your questions. And it’s really important to advocate and ask what does this test mean in my specific situation? So I hope this gives you a little bit more information about not just what an audiologist is, but what our role is with the stimulator testing Vestibular Disorders and being part of the Vestibular team. If you have questions, any more questions about the stimulator issues or even about audiologists in in general? VeDA is a great resource for that. So please feel free to reach out and ask questions and I hope you learned something today.