Audiology Department Vestibular Assessment and Rehabilitation Procedure

Transcription

1 Audiology Department Vestibular Assessment and Classification: Clinical Guideline Lead Author: Neil Summerfield Additional author(s): Maxine Holden Authors Division: Audiology Unique ID: TWCG08(16) Issue number: 1 Expiry Date: February 2018 Contents Section Page Who should read this document 2 Key Messages 2 Background/ Scope 3 What is new in this version 4 Management of Appointments 4 Location 4 Waiting times 4 Referral in to Vestibular Service 4 Equipment Set up 5 Patient Prepartation 6 Appointment 6 Current Vestibular Diagnositic testing provided 7 Contraindications 9 Vestibular Rehabilitation 10 Reporting of results 12 Ice Caloric testing 12 Advanced Practitioner Assessment 13 Standards 13 References and Supporting Documents 13 Roles and responsibilities 14 Appendix 1: Acoustic Neuroma Pathway 15 Document control information (Published as separate document) Document Control Policy Implementation Plan Monitoring and Review Endorsement Equality analysis Page 1 of 17

2 Who should read this document? Staff groups related to this document: Advanced Practitioner in Audiology (Band 7) Highly Specialist Audiologist (Band 7) Specialist Audiologist (Band 6) Audiologist (Band 5) supporting clinic Student Health Care Scientist observing Any staff completing these procedures should hold up to date RCCP certificate and evidence of necessary training and qualifications within their CPD Audiology staff have a responsibility to: Ensure they read and understand the policy Ensure they adhere to the policy and seek help or guidance from the Audiology manager if they do not understand or can not comply with the policy for whatever reason. Ensure that no breach of this policy document occurs from their actions. Bring to the attention of their manager any area that could be more effectively managed, or risk minimised by a further review of this policy Key Messages This document outlines the provision of vestibular assessment and rehabilitation within the Audiology department of Salford Royal Foundation trust. The aim of this policy is to standardise the departmental procedure for Vestibular and Balance Assessment using either: Videonystagmography (VNG) or Electonystagmography (ENG) Bi-Thermal Water / Air Caloric / Ice Caloric testing Electrocochleography (EcochG) Cervical Vestibular Evoked Myogenic Potential Measurements (c-vemps) a Vestibular Rehabilitation. Page 2 of 17

3 It outlines the additional assessment processes carried out by the Advanced Audiology Practitioners within the department and methods reporting and onward referral. Background & Scope This document has been developed following the recommendations made in the Department of Health Provision of Adult BalanceServices: A Good Practice Guide (2009) and the NHS Improvements (2011) Audiology Improvement Programme, Pushing the Boundaries: Evidence to Support the delivery of Good Practice in Audiology. Facts and figures: Dizziness is in the top 10 most common complaints presented by men and women over the age of 65 years old. (Holmes and Padgham, 2011) 1 in 10 adults of working age described some degree of dizziness related handicap. (Nazareth and Yardley, 2002) Dizziness can by caused by a wide variety of factors which include vestibular weakness, anxiety, orthostatic hypotension, impaired somatosensory function, and adverse effects of medication. (Menant et al 2013). Between 40 to 80% cases of dizziness and vertigo go undiagnosed (Neuhauser et al 2008) Dizziness can effect sufferers by reducing quality of life, social interaction due to anxiety of falling, poor health and cause depression One of the most significant dangers to a patient suffering from dizziness is the risk of falls. The falls service in Salford Royal Foundation trust (SRFT) suggested in a year 11,600 people in the Salford area over the age of 65 would fall with 7000 of these sustaining some form of injury (Pyburn and Greene. 2007) Due to these factors it is vital that dizzy patients and those at risk of falls receive prompt holistic assessment and treatment in order to reduce the impact on their lives and also on their risk of secondary injury. The vestibular service within Salford Royal NHS Foundation Trust will assess all pateints of any age who are suspected of having vestibular problems appropriately amending any test battery for patients under the age of 16 years old. Page 3 of 17

4 What is new in this version? The document replaces the 2010 Salford Community Health Document: Audiology Department Vestibular Assessment &. It includes additional information outlining the assessment of patients with vestibular problems by Advanced Audiology Practitioners and expanded information on how assessments will be reported. Management of Appointments Do not Attend (DNA) or cannot attend (CNA) appointments will be managed in line with the Salford NHS Foundation Trust Patient Access Policy guidelines. Location All diagnostic testing will be completed at the Audiology Department - Walkden Gateway. Advanced Audiology Practitioner assessments may take place in any location including Eccles, Pendleton, Swinton and Walkden Gateway, Pendlebury health centre and Salford Royal. Patients will be made aware that if further clinical diagnoistic testing is required this will only be carried out within Walkden Gateway. Waiting Times Patient will be seen within the 18 week pathway criteria for initial assessment and appropriate treatment. Referral in to Vestibular Service Referrals into this service are accepted via: ENT / ENT & AP Joint Clinic Neurology Advanced Practitioner GPs Page 4 of 17

5 Equipment Set Up VNG / ENG & Bi-Thermal Caloric Equipment (Including Ice Caloric) Desktop/laptop with network connection to Practice Navigator & Patient Centre Otoscope Disposable Speculae Tympanometer Disposable Tympanometer tips Blood Pressure Monitor & cuff (Sphygmomanometer) for lying and standing BP Lightweight Light Bar Otometrics Chartr 200 ICS VNG / ENG Software VG-40 VNG Goggles Disposable EP Electrodes & Cables (For ENG) Skin preparation material Bi-Thermal Caloric Water Irrigation tanks Irrigator Water & Air Cable Bi-Thermal Air Irrigation machine Disposable water and air irrigation nozzles / tubes Ice Cubes 10ml Syringe Thermometer Kidney bowl Clean Towels Clinical Bed Hand Gel EcochG and c-vemp Equipment Desktop/laptop with network connection to Practice Navigator & Patient Centre ABR Biosense Software & Equipment Otoscope Disposable Speculae Tympanometer Disposable Tympanometer tips ER-3 insert phones & Disposable Tips ICS patient cable Skin Electrodes Extra Tympanic Electrodes Skin preparation material Patient cables Y Cable with green Jumper Syringe Page 5 of 17

6 Electrode conductive Gel Sphygmomanometer Clean Towels Clinical Bed Pillow if Possible Hand Gel Vestibular Rehabilitation Equipment Desktop/laptop with network connection to Practice Navigator & Patient Centre Charter VNG / ENG Software VG-40 VNG Goggles (To measure Nystagmus on Dix-Hallpike If necessary) Clinical Bed Access to Salford Royal Foundation Trust Exercises Database Assistive support Hand Gel Patient Preparation 1. Prior to appointment the patient will be sent an appointment letter with information regarding the appointment details. Attached to this letter is the Salford Community Health Vestibular Assessment leaflet which offers information regarding the appointment procedure and advises the patient regarding: a. Travel Arrangements The patient is advised not to drive immediately after the appointment and should attend the appointment accompanied by a family member / friend who can take the patient home or accompany them home on public transport b. Medication The patient is advised to stop taking certain medications 48hours prior to the assessment date/time. The relevant medications are listed in the leaflet and the patient is given contact details of the department if they need to check any medication details with the Audiologist prior to the assessment c. Alcohol Consumption The patient is advised to refrain from consuming alcohol 48hours prior to the assessment date / time d. Make Up Patients are advised not to wear heavy eye make up. 2. Dizziness Handicap Inventory (DHI): In addition to the appointment letter the patient will also be sent the DHI which is used to quantify the patient perception of their balance problems and how they are impacting on the daily life. Page 6 of 17

7 3. A full explanation of the development of the DHI can be found in Jacobson and Newman s 1990 paper The development of the Dizziness Handicap Inventory 4. Briefing - Patient to be given full explanation of the treatment / procedure involved including advice on benefits & risks of proposed treatment / procedure and the implications of not having treatment including alternative options. 5. Involvement of Others - Patients in care should have an escort from their place of residence. 6. Patient Instruction Patients to be fully informed of examination and treatment procedures in order to make informed consent. Clear instructions must be given to all patients at each stage of any procedure to ensure maximum patient co-operation. 7. Patient Debriefing Patients will be provided with verbal confirmation of results where possible on day of testing as well as being sent written conformation. This conformation will include test results and further management plans. This written report will also be provided to the referring clinican and the patients GP. Appointment Introduction: Clinicians introduce themselves and check the patient s details. Check the patient understands the nature of the appointment Explain purposed of appointment and obtain patient consent to treatment. Make the patient as comfortable and relaxed as possible. History Taking: Extensive Vestibular / Balance history completed using Salford Royal Foundation Trust Audiology Vestibular questionnaire Page 7 of 17

8 Otoscopy and tympanometry: Perform otoscopy and tympanometry in accordance with recommended procedures to ensure no contraindications are present. (BSa Recommended procedure for ear examination, 2010) (BSA Recommended Procedure for Tympanometry, 2013) Current Vestibular Diagnositic testing provided Videonystagmography (VNG) Electronystagmography (ENG) VNG/ENG is an assessment of the vestibular ocular reflex and is carried out in accordance with the BSa Recommended Procedures Vestibular assessment eye movement recordings 2013 and may include: o Saccades: o Tracking: o Gaze Right / left / Central: o Dix-Hallpike (with VNG Googles in place) o Positional Testing (As indicated from history) o Halmaygi Head Thrust Test (HHTT) o Head Shake Test It is primarily used to differentiate between peripheral and central sites of lesion. Bi-Thermal and Ice Caloric Test Caloric testing is carried out in accordance with the BSa Recommended Procedures- The Caloric test Routinely performed to differentiate between normal vestibular output and abnormally reduced or increased output. It establishes this for only the lateral semi-circular canals and superior portion of the vestibular nerves. Ice Caloric testing is available to assess for any residual peripheral function Cervical Vestibular Evoked Myogenic Potential Measurements (c-vemps) c-vemps are completed in accordance with the BSa Information documentation Cervical Vestibular Evoked Myogenic Potential Measurements 2012 and the manufactures guidelines for the equipment being used. The test can provide information about the function and integrity of the saccules and inferior portion of the vestibular nerves. Can be used to aid the diagnosis of superior semi-circular canal dehiscence (SSCD) and large vestibular aqueduct syndrome. Page 8 of 17

9 Electrocochleography (ECochG) ECochG testing is an non-invasive assessment for the diagnosis of endolymphatic hydrops /Meniere s disease. There is currently no nationaly recognised recommended procedure for the completion of EcochG testing. The department currently uses the process outlined by the manufacturer of the test equipment. Contraindications Staff performing the test should be aware of these contraindications and the Specific relevant specialist should be contacted for advice on individual patients. Contraindications for ENG/VNG and caloric testing: It is the responsibility of both the referring physician and specialist audiologist to ensure that the patient is fit to undergo the test before it is conducted. It is inappropriate to conduct the caloric test if any of the following are present: History of hypertension (uncontrolled, acute or de-compensated phase) History of cardiac problems (arrhythmias especially bradycardia or Stokes- Adams attack; acute or de-compensated phase) e.g. if someone has unstable angina, a recent myocardial infarction (within last 3-6 months) or is undergoing cardiac investigations Psychotic/neurotic disorders (acute or de-compensated phase) Epilepsy (acute or de-compensated phase) Eye surgery (within the previous 3 months) Ear surgery (within the previous 6 months) If the patient has taken any Vestibular Suppressent Medication 48 hours prior to the test If the patient has consumed Alcohol 48 hours prior to the test If the patient plans to drive home following the test Significant sight conditions The next list shows the second level of contraindications / special precautions which should be checked for compliance at the time of the appointment by the tester as well as by the referring physician and which also may contraindicate performance of the caloric test: Page 9 of 17

10 Significant degree of space occupying wax Otitis externa Middle ear fluid / Effusion Hypermobile or atrophic tympanic membrane - care should be taken for severe hyper-mobility and a second medical opinion obtained Tympanic membrane perforation (may be suitable for air calorics) Patients with mastoid cavities may be considered for air calorics, but interpretation should be carried out with caution. Use of water as a stimulus should also be avoided in patients whose immune systems are compromised. Contraindications for c-vemps Subjects with cervical spine problems should be carefully assessed to ensure that they are able to maintain adequate Sternocleidomastoid (SCM) contraction without causing any pain or discomfort. The response is often abolished by a modest conductive hearing loss caused by middle ear problems such as middle ear effusion, perforations or otosclerosis, since the loss attenuates the stimulus reaching the inner ear. However the c-vemp will be present in a conductive hearing loss of nonmiddle ear origin e.g. with abnormal third window effects such as SSCD and widened vestibular aqueduct syndrome. Thus c-vemps can be performed in conductive hearing losses where there is a normal tympanogram and acoustic reflexes are present. Given the high level of the acoustic stimulus, care should be taken with subjects with tinnitus or hyperacusis. Contraindications for Electrocochleography (ECochG) testing: It is the responsibility of both the referring physician and specialist audiologist to ensure that the patient is fit to undergo the test before it is conducted. It is inappropriate to conduct the ECochG test if any of the following are present: Ear surgery (within the previous 6 months) Perforated Tympanic Membrane Vestibular Rehabilitation There are many reasonable indications for vestibular rehabilitation: Specific interventions for BPPV (Benign Paroxysmal Positional Vertigo): The Epley manoeuvre The Brandt-Daroff exercises Page 10 of 17

11 Log roll exercises (for lateral canal BPPV) Semont manoeuvre General interventions for vestibular loss: Unilateral loss, such as for vestibular neuritis or acoustic neuroma Bilateral loss, such as for gentamicin toxicity and related conditions. Persons with fluctuating vestibular problems, not necessarily dizzy at the time of the therapy. Meniere's syndrome Perilymphatic fistula Empirical treatment for situations where the diagnosis is unclear Post-traumatic vertigo Multifactorial disequilibrium of the elderly Psychogenic vertigo for desensitization Brandt-Daroff exercises for phobic postural vertigo Other situations where there is irrational fear of situations in which balance is challenged Recent evidence: Two Cochrane reviews in 2009 and 2011 have proven the overall benefit of vestibular rehabilitation for patient with vestibular weakness. Minimal evidence is available for the use of vestibular suppressants as a treatment for vestibular weakness Early intervention through the use of vestibular rehabilitation can have a significant impact in the reduction of falls, anxiety, depression and reduced quality of life. Assessment and treatment process First assessment: Full clinical assessment of balance problems including Rombergs, Unterbergers, Dix-Hallpike, head thrust and gait assessment Advanced Practitioner within department may also complete full cardiovascular, respiratory upper and lower neurological assessment and MSK assessments as required Counselling on care plan options and benefits of vestibular rehabilitation Page 11 of 17

12 Treatment Options provided on first assessment Detailed customised vestibular rehabilitation exercises dependent on the patient ability and requirements Repositioning manoeuvres Epley, Semont and Lempert or Roll manoeuvers can be completed (with and without vibration as required) Counselling on associated anxiety related to balance problems Referral to Physiotherapy lead group exercise class as required Vestibular Rehabilitation follow up (Completed dependent on the patient s problems) Further Counselling as required Follow up DHI completed Provision and adjustments of exercises as required Further follow up appointments will be arranged dependent on the patient s progress and requirement for support. Reporting of results All vestibular assessments will be reported using the trust document policy and template within 24 hours of the assessment appointment. A copy of the report will be sent to the requesting physician, the patients general practictioner and a copy will be forwarded directly to the patient. In the case of patient who are referred from Salford Royal ENT service a copy of the patient notes will be added to the sunrise system on the day of assessment in order to aid efficient reporting. Ice Caloric testing The department will support the Salford Royal ENT gentimycin injection service or patient with acostic neuromas with the provision of pre treatment caloric testing and post treatment ice caloric testing. Following a referral being reviced from the ENT service patient will have two appointments arranged the first to complete full vestibular function testing including bi-thermal caloric testing. The second five weeks later following the initial three gentimycin injections for completion of an ice caloric to assess for any residual vestibular function. The bi-thermal caloric testing and ice caloric will be completed in accordance with the BSa recommended procedure for completing caloric testing. Page 12 of 17

13 If there is no vestibular function recorded on the initial assessment caloric testing the follow up ice caloric test will be cancelled. See Appdendix 1 for Acoustic Neuroma Pathway Advanced Practitioner Assessment Advanced Audiological Practitioners based within the Audiology Service they will complete any additional systems assessments as required from patients attending the vestibular service and provided onward referrals as appropriate in keeping with national guidelines and trust protocols. Band 6 Audiologist can arrange 30 minute appointments with the Advanced Practitioners to complete extended assessments once the full vestibular assessments has been completed. Band 6 Audiologist will discuss the case prior to arranging the appointment in order to assess its suitablilty. Standards Linked to the following Salford Royal Foundation Trust Objectives: Improving Quality and Productivity Transforming Service Delivery Integrating Care Improving Health and Wellbeing Linked to the following national policies: BSa Recommended Procedures for Otoscopy (2010) BSaRecommended Procedure for Positioning Tests (2015) BSa Vibration-Induced Nystagmus (2013) BSa Vestibular Rehabilitation on a shoe string (2013) BSa Information Document Performing Cervical Vestibular Evoked Myogenic Potential Measurements (2012) BSa Vestibular Assessment Eye movement Recordings (2014) BSa The caloric test (2010) BSa Recommended procedure for Hallpike manoeuvre (2001) Explanation of terms & Definitions Terms explained in document also refer to Salford Royal Foundation Trust Audiology Abbreviations document Page 13 of 17

14 References and Supporting Documents Supporting references and links to other resources should be included here. This includes other Trust policies and guidelines. Department of Health (2009). Provision of Adult Balance Services: A Good Practice Guide Hiller, S.L., McDonnell, M. (2011) Vestibular Rehabilitation For Unilateral Peripheral Dysfunction (Review) The Cochrane Collaboration. The Cochrane Library Issue 2 Holmes, S., Padgham, N.D. (2011) A Review of the Burden of Vertigo. Journal of Clinical Nursing 20 ( ) Blackwell Publishing Ltd Jacobson, G.P., Newman, C.W. (1990) The development of the Dizziness Handicap Inventory. Arch Otolaryngol Head Neck Surg. 1990; 116: 424 Menant, J.C., Wong, A., Sturnieks, D.L., Close, J.C.T., Delbaere, K., Sachdev, P.S., Brodaty, H., Lord, S.R. (2013) Pain and Anxiety Mediae the Relationship Between Dizziness and Falls in Older People. Journal of the American Geriatrics Society March Vol 61 (No 3). Nazareth, I., Yardley, L. (2002) A Clinical Approach to Dizziness. Journal of Clinical Outcomes in Medicine 9 ( ) Neuhauser, H.K., Radtke, A., Von Brevern, M., Lezius, F., Feldmann, M., Lempert, T. (2008) Burden of Dizziness and Vertigo in the Community. Arch Intern Med Vol 168 (No 19) NHS Improvements (2011) Audiology Improvement Programme, Pushing the Boundaries: Evidence to Support the delivery of Good Practice in Audiology Pyburn, R., Greene, E., (2007) Sure Footed IN Salford: Salford Strategy for st (2014) Annual Plan University College London (2012) Guide to History taking and examination Roles and responsibilities Staff groups covered by this policy: Specialist Audiologist (Band 6 or above) specially trained for all of the above Any staff completing these procedures should hold an approved qualification / in house competencies in the specific procedures within their CPD Audiology staff have a responsibility to: Ensure they read and understand this document Ensure they adhere to the procedures outlined and seek help or guidance from the Audiology manager if they do not understand or can not comply with the procedures for whatever reason. Ensure that no breach of this document occurs from their actions. Page 14 of 17

15 Bring to the attention of their manager any area that could be more effectively managed, or risk minimised by a further review of this policy Page 15 of 17

16 Appendices Appendix 1 Acoutsic Neuroma Pathway Page 16 of 17

17 Page 17 of 17