Understanding Vestibular Disorders Across The Lifespan with Dr. Julie Honaker & Dr. Violette Lavender

In this insightful episode of empowEAR Audiology,  I am joined by two experts in vestibular and balance care. Dr. Julie Honaker and Dr. Violette Lavender shed light on the complexities of vestibular disorders in children and adults. Representing care across the lifespan, they discuss the impact of these conditions on daily life, advancements in diagnosis and treatment, and the vital role audiologists play in managing balance and hearing health.  

Dr. Honaker is the Director of the Vestibular and Balance Disorders Program within the Head and Neck Institute at Cleveland Clinic Foundation. She specializes in assessing and managing dizziness, imbalance, and fall risks while advancing clinical research focused on fall prevention across the lifespan. Dr. Violette Lavender is at Cincinnati Children’s Hospital, a pediatric audiologist specializing in hearing and balance disorders. She is passionate about making vestibular testing accessible to young children and advancing research in pediatric balance assessment. 

Whether you’re an audiologist, a healthcare professional, or someone curious about vestibular health, this episode provides valuable takeaways for understanding and addressing these often-overlooked conditions. Don’t miss this opportunity to deepen your understanding of vestibular health and how it impacts people of all ages. Subscribe, rate, and review to stay updated on future episodes!

For more information about Dr. Carrie Spangler- check out her Linktree at https://linktr.ee/carrie.spangler.

For transcripts of this episode- visit the podcast website at: https://empowearaudiology.buzzsprout.com

Transcript

Announcer: [00:00:00] Welcome to episode 72 of empowEAR Audiology with Dr Carrie Spangler.

Carrie: [00:00:14] Welcome to the empowEAR Audiology podcast, a production of the 3C Digital Media Network. I am your host, Dr Carrie Spangler, a passionate, deaf and hard of hearing audiologist. Each episode will bring an empowering message surrounding audiology and beyond. Thank you for spending time with me today, and let's get started with today's episode.

Carrie: [00:00:41] All right. I am excited to have two guests with me today on the empowEAR Audiology podcast. I have Dr Julie Honaker. She is currently the director of the Vestibular and Balance Disorders Program within the Head and Neck Institute at the Cleveland Clinic Foundation. Dr Honaker is an audiologist specializing in state of the art assessment and management planning for all patients with dizziness, imbalance, and falling risk concerns. In addition to patient care, she engages in clinical research pertaining to patients across the lifespan with vestibular disorders, with an emphasis on risk of falling assessment and prevention. Dr Honaker completed her PhD at the University of Cincinnati and her post-doctoral fellowship fellowship at the Mayo Clinic in Rochester. I also have today with me, Dr Violette Lavender, and she is a pediatric audiologist with Cincinnati Children's Hospital. She attended Purdue University, where she earned both her bachelor's of communication Disorders and Masters of Audiology. She graduated from the University of Florida with her AuD. She specializes in both hearing and balance disorders and has published and presented in the areas of pediatric balance assessment. Violette is interested in translational research and strives to make the vestibular test battery accessible for young children. So Dr Lavender and Dr Honaker, thank you for joining me on the audiology podcast.

Violette: [00:02:23] Thank you for having us.

Carrie: [00:02:25] Thank you. Well, um, one of the things that I always like to ask first, when I have professionals and audiologists on the podcast, is how did you find your way to audiology and then your niche in vestibular disorders. So, um, Julie, do you want to go first?

Julie: [00:02:43] Sure, I'll go first. Well, I think my story is probably like many others. In college, I started off in one direction. I actually was interested in special education and my minor was Communication sciences and disorders. And from there I took an intro to audiology course at Ohio State, and I just fell in love with it. And I just was fascinated with the ear. And I made a transfer to University of Cincinnati and just switched everything over to speech and hearing sciences for my undergrad. And I can remember in undergrad, I did a project where we made a life size traveling wave, and that was just the the most exciting thing for me to to do that. And from there, I went into grad school and it was really my first class in vestibular, where I fell in love with it. And I had a lot of friends at the University of Cincinnati who were in med school. And I would talk about physiology, and they were seeing the other end of the spectrum of pathophysiology, and it just really broadened my horizon. And ever since then, I've been hooked. That's my story and decided to go on to my PhD because I had more questions than answers in my program.

Carrie: [00:03:56] Well, good.

Violette: [00:03:56] My story is not that dissimilar. No it's not. It's not very dissimilar at all. It's, um. I was interested in speech therapy and teaching, and I went into those classes, but I really craved the science portion. And so when audiology was introduced, it was it was definitely more heavily science based. So I really loved that. And I knew that I wasn't cut out to be a speech therapist, to plan sessions. I wanted to go in there and do some evaluations and some testing, and that's where audiology kind of fell into my lap. Um, my uncle was an audiologist, and in our little town he had a rotary chair. And that was a very big deal because it was a rotary chair in this small town that was the only one in a big area. So it was really fun for me to see that, that how different it was from regular audiology and grad school at the time. And so I started really developing this interest in vestibular sciences. And then I sought out a fellowship at the University of Michigan because I knew they had a strong vestibular program. So I trained with them, and I was fortunate enough when I came to Cincinnati to meet Julie, and Julie partnered with us at Cincinnati Children's. She was so kind to let us partner with her so that we could really develop a pediatric vestibular program. It was something that wasn't really heard of. There may have been only one other program in the country, 1 or 2 other programs in the country, and she was kind enough to let us, you know, use equipment for a couple of months, for a few months and really get our feet wet learning how to do a vestibular program for kids. So thank you, Julie. It's good to it's good to work with you on this capacity again.

Julie: [00:05:45] We're all friends in audiology.

Violette: [00:05:47] Yes, exactly.

Julie: [00:05:48] That's the beauty of it.

Carrie: [00:05:49] I love how the circles kind of connect. And that is so, um, interesting too. And I am excited because I have not done a podcast for our listeners about vestibular disorders and function and balance and orientation. So this would be a great way to really have our listeners get a taste of some of the this other aspect of audiology and why it is so important to to look at. But before we get started, would one of you want to just give the audience more of like a 360 degree view of like, what vestibular, um, function looks like and disorders and how that really can impact.

Violette: [00:06:35] I can start and I can start and give it to you from the pediatric approach and how we look at the development of the vestibular system. And maybe, Julie, you want to pick up and talk about how we carry over into the lifetime. Um, but when we look at vestibular disorders in children, the number one thing families tell us is that their child might have a motor delay. They might also have some hypotonia. And I think for years when children had delays and they had hearing loss, particularly, um, the thought was that children who have hearing loss also have concurrent comorbidities. So they have these other, um, delays going on. And I don't think the vestibular system was really looked at in the past as a cause for some of these delays, per se. And now we know that, you know, through research, um, you know, Kristen Janke did a great paper in 2018 on predictive factors showing that, you know, if your child with hearing loss that is greater than 66dB and for your pure tone average. So really a moderately severe hearing loss that really puts you at greater risk for having a vestibular delay. And what that might show up as is that you're sitting is delayed. You're walking is delayed. Um, a lot of parents tell me that they notice from birth that their moro reflex may be delayed.

Violette: [00:07:54] And that's the reflex that you notice with your baby at home, where if you're holding them and you tip them back, they naturally put their hands out quickly. It's almost like a primitive reflex to almost catch yourself. Or some doctors call it the parachute reflex. And so parents will tell us that they don't even see it in some of their children with severe or profound hearing loss. And that continues, like I said, we'll see. Delayed sitting, delayed walking. And what we also know from literature now is that children with vestibular loss left untreated often never catch up to the levels of their peers. They never completely make that switch over to look exactly like their. Their typical hearing peers, um, functionally. So maybe they're the kiddos who are not the most graceful on the soccer field or the most athletic. Or they might have a difficult time learning how to ride a bike or roller skate, or do some of those activities that kids love to do. So those are things we look out for when children have hearing loss particularly, and what things to look out for when we suspect they may have a vestibular loss too.

Carrie: [00:09:00] Okay, so Julie, what happens as they get older. And it's something that is a later onset.

Julie: [00:09:09] Well, I'll just kind of I'll give everybody like the the 360 view of the vestibular system. It's part of our balance system which is a sensory motor system. So we utilize our vision. We have touch sensors throughout our body, in particular important sensors within our ankles that help us understand externally where we are in space. Our vestibular system is that internal gyroscope that lets us know where we are internally, where we're moving with respect to the world around us. The vestibular system helps us with gaze stability when we're in motion or performing activities of daily living. It helps us orient where we are in space. So our perception of true north vertical as well as the horizon. And then it also helps us with postural control. And as Violette was saying, many of those reflexive, um, pathways that happen to keep us upright when everything's working well, we don't even think about our vestibular system. And our vestibular system doesn't have really primary pathways to a cortex. So it is all behind the scenes work that's being done and reflexive work that's happening just to keep us moving and grooving throughout the day. And it's not until things break down that we really have an appreciation for this sense, which is, in essence, kind of our sixth sense that helps us where we are.

Julie: [00:10:29] Um, as we mature in age, we have declined to all of our sensory systems. And that, um, includes what we know with our hearing apparatus as well as our vestibular system, where we can have a breakdown in, um, the neural pathways, the functionality of the sensory systems, even hair cells within these organs that help to transfer electrical signals to help us with these reflexive movements that can all start to break down and that can lead to debilitating symptoms of dizziness, vertigo, unsteadiness a feeling that your world, what you're seeing visually, is bobbing when you're in motion. And then it also increases falls. And that's really what we see on the other end when we have a decline of our sensory structures, how those sensory structures interact with each other, and then also a decline in the motor output that helps with those quick reflexive responses. So we can see clearly, keep us upright, know where we are in space and prevent falls that can all start to decline with age.

Carrie: [00:11:34] Yeah. Well thank you both for that big, big view. And like what you said, Julie, this is probably something that you don't think about until it impacts you. And then what are some of those common reasons, some from an adult perspective, that may contribute to vestibular? I know you said aging in general, just because our senses start to kind of break down, but what else?

Julie: [00:12:03] Well, I'll say dizziness and imbalance is a very common reason that adults will present to their primary care providers with concerns. And we so often think of dizziness as having the caveat of, oh, it's an inner ear, it's a vestibular thing. But there are so a multitude of reasons why somebody may be presenting with dizziness. And dizziness itself is a descriptor, but it can have very many different characteristics. So we have to get creative and we have to help our patients articulate what they're feeling so that we can best pinpoint what could be the cause for this. I think it's estimated and prevalence for dizziness of anywhere from 11 to like 16% of the population, but that increases as we advance in our age. For individuals, as they mature in age, if we're thinking just inner ear disorders, there's very common disorders. The most common one is called benign paroxysmal positional vertigo. And that's where part of our sensory vestibular system that is gravity sensitive and has little crystals within it. These crystals can branch off with age, and they can free float into parts of the inner ear that's fluid filled where they don't belong. And that can cause transient episodes of vertigo, even imbalance. In particular, when patients or individuals are rolling in bed, tipping their head back to put eye drops in, pulling something off the grocery shelf, or even getting their hair done and being reclined back, that can trigger these very short lived but debilitating symptoms of vertigo. That's probably the most common reason. But for symptoms of dizziness, it can span from medication interaction or side effects. It could be something that's more visual, where maybe they're getting acclimated to new progressive lenses that can throw off somebody's balance and their perception of the world. We have cardiovascular causes, heart related causes, neurologic causes, even psychosomatic causes, anxiety, depression, panic that all can have secondary effects of, um, symptoms of imbalance, swaying, dizziness, vertigo, what have you. And it's really our job as vestibular audiologists and part of the interprofessional team that works with patients with these symptoms to try to decipher what's going on.

Carrie: [00:14:26] Yeah, that sounds like, um, a very thorough case history and assessment to determine what that actual cause is, because, as you said earlier, it's dizziness can mean a lot of things. And getting to the core of what that looks like is important. So Violette, from a more pediatric perspective, can you just share maybe some of those common symptoms or causes for vestibular loss?

Carrie: [00:14:53] Sure.

Violette: [00:14:54] So in the pediatric world, what we notice most is that they don't necessarily present with complaints of dizziness. So especially in the kids under ten, a lot of times if they've been experiencing vertigo, they may not share that with their parents because they may think it's normal, because they've been experiencing it for a long enough time, that it may have become normal to them. And often they don't even have the vocabulary to describe that something is different. So when parents present to us with their child who is having vertigo attacks, it's usually because they're experiencing episodes of vomiting. They may be experiencing times where they feel like they can't go to school and their child feels off. Um, some of the kids tell us they feel like they're floating or they're flying or, um, they may not be able to describe it the way an adult can describe it. Um, and especially true with our kiddos who have hearing loss. So in the chances that they might have a bilateral vestibular loss from birth, those kids don't know anything is different or off about their vestibular system, because that's how they've always functioned. And they wouldn't feel dizziness. Instead, they may have, like I said, that motor delay and again, that could feel very normal to them. Um, and that's where we come in as audiologists, because we're going to offer some help or some opportunities for them to improve their balance when they may have not noticed anything was was different. Um, back to the Vertigo piece. For our kids who experience vertigo. The most common cause is often variations of migraine.

Violette: [00:16:29] Um, sometimes we have kids who have something called recurrent vertigo of childhood. Um, that's the latest terminology that I think most of the neurologists. Neurologists are using recurrent vertigo of childhood, that is, spells of vertigo where they are having clear and cut spells, where it turns on and it turns off and they feel dizzy and they really don't. They might not have any other symptoms, so there may be vomiting. There may not be. They may have a headache like actual head pain, but they may not. But it's just clear. Clear cut spells of vertigo attributed to no other cause. Um, and sometimes they outgrow it. Sometimes as they get older, the children can outgrow that, and they may have a period where they have nothing for a while. So a lot of times we'll see kids come in, um, at age three, four, five, and then they kind of drop off for a while. So they're almost cured. And the parents get very excited. So they have nothing from ages eight, nine, ten. But then as the hormones shift in their body and they start to enter puberty, all of a sudden that kind of kicks back up. And it doesn't happen to all the kiddos, but sometimes they may go into a more traditional Migraine as a teenager. Um, so those are the things we typically watch for in our kids who have migraine. Migraine is vertigo. Um, we also see psychosomatic, just like Julie does. We also will see, um, kiddos who have hypermobility spectrum disorder. So this is very interesting for us. I think for years we saw kids who had symptoms that looked like Pots, postural orthostatic tachycardia syndrome, where they stood up and had blackening of their vision or feeling of vertigo or feeling lightheaded.

Violette: [00:18:11] A lot of times that hit in the teenage years. Um, and for years we were seeing these kids. They might also have dysautonomia where they were getting dizzy from working too hard or being active or normal things that you and I would do, which would be like, get up, move around, go pack your lunch, go get your backpack. But that would fatigue them or make them feel more dizzy. Um, and what we started noticing is that there was a connection with their, um, their joints. And so we now know that with hypermobility, even if it's not full blown. Ehlers-Danlos syndrome, even if they're on the spectrum of hypermobility, they often experience dysautonomia. So we are we are getting children, um, with that diagnosis now. And we're starting to ask about it more often. And a lot of times that does run in families. And it's very easy to ask a parent and they'll say, oh, I've been dealing with that for years. And so even the parents who have dealt with it their whole life might not think it's different. Um, yeah. So those are our usual causes. We don't have a lot of bppv in the little kids that are ten or under. We don't get a lot of neuritis. We often don't have even Meniere's disease in this population, so very different than adults. Um, but yes, we are still getting children who come in with vertigo.

Carrie: [00:19:25] Yeah. So either other disorders that give you kind of red flags, I mean, you mentioned hearing loss as one, but are there other things that you're like, okay, if they have this disorder or syndrome or whatever, like a red flag? Like we need to make sure that they have a vestibular assessment too.

Violette: [00:19:49] Yes. That's a great question. Let me circle back to hearing loss first. So amongst kids with hearing loss, I know I already have shared that Kristen Janke predictive factor was having a moderately severe or worse hearing loss predisposed you more often to have a vestibular disorder. But amongst kids who had hearing loss, we know that there are certain genetic factors that can cause them to more likely have a vestibular loss. So things like enlarged vestibular aqueduct syndrome, they can have fluctuating vestibular input. Kids with cytomegalovirus. We're starting to learn a lot more about these children just because of advances in newborn screenings for cytomegalovirus. And we now know that kids can have no hearing loss sometimes and still have a vestibular disorder, or they can have a vestibular loss on one side and a hearing loss on the other side. So it doesn't always match up perfectly just because they have hearing loss with CMV. Um, but sometimes that does affect their vestibular system. We know kids who have Usher syndrome are often born, especially type one are born without a vestibular system, and children who have charge association. Those children are often born without any type of vestibular apparatus, so they don't even have oftentimes any semicircular canals. Um, those are our our big heavy hitters. Kids with Waardenburg syndrome often have vestibular loss as well. But those are our our main ones. But certainly there are plenty of other syndromes and inner ear malformations that can cause vestibular loss as well. Um, in terms of other disorders that may cause vestibular loss, I had already shared, you know, our hypermobile kids can be at risk. Um, and then Julie also shared cardiology. So if there's any cardiac concerns, we can have that as well. Um, we often look at children who have mental health disorders because they are more often likely to have vestibular loss. And those are our main ones, I would say.

Carrie: [00:21:42] Okay.

Carrie: [00:21:43] Julie, are there any more? For adults, I know you had mentioned BPV as one thing, but is there anything else that's kind of a red flag for adults to be seen for vestibular workout?

Julie: [00:21:57] I'll just piggyback on Violette's comment about migraines. We see that commonly in our adult population, and oftentimes when they make their way to myself or one of my team members at the Cleveland Clinic, our goal is to rule in or rule out a peripheral cause as a source. And sometimes patients will present with vertigo secondary to their migraine events. And we'll be looking at function, whether or not this is causing any dysfunction or whether or not we can pinpoint that. It's maybe another condition that's causing these Vertigo episodes.

Carrie: [00:22:32] Um.

Julie: [00:22:33] Kind of other vestibular disorders that impact adults. Um, many have heard of Meniere's disease. So this has a triad of symptoms of vertigo episodes with fluctuations in hearing, typically one ear, uh, unilateral tinnitus and that involved ear as well as a fullness feeling in that ear that is very brief in duration for these episodes on the order of minutes to hours, not more than a day. Um, but they're very debilitating, and they can progress over time, and eventually it can cause dysfunction of the other ear. Sometimes there's an overlap between migraines and Meniere's disease. So individuals can have both conditions. One condition. And we have to really decipher what is the most appropriate management option for these individuals. Um, there's involvement of tumors. You can have schwannomas. So small benign tumors that arise on the, eighth cranial nerve, which is involves both hearing and balance. Um individuals can have vascular issues. Strokes can be common in older adults. There's many spinocerebellar dysfunctions and disorders that can impact the balance system as a whole. Ms. can be as a secondary symptom. Individuals can have dizziness. They can have vertigo. They can even have subsequent um bppv because of that condition. And then there's just other things that can go across any age, any stage. Head injury can cause dizziness and vestibular problems. Um, neck injuries can cause issues of dizziness and imbalance. So there's there's lots of lots of different disorders to think about.

Carrie: [00:24:17] Yeah. So with all of that, I mean, like you said, there's lots of different disorders to kind of think about. And it goes beyond hearing as well. How do people get to you? I mean, what is that referral process? Are family physician saying, hey, you need to go for a vestibular workup. What is kind of that mechanism if they have these symptoms of vestibular disorders?

Julie: [00:24:48] From an adult perspective, I think patients can come many different ways. And I'll just speak to how it is at the Cleveland Clinic. So we have some patients who again, knowing that their primary care provider is there, their home base, they will be referred to perhaps an ear, nose and throat specialist to evaluate if there's common hearing and, um, vertigo or maybe balance dysfunction, um, from ENT. They'll make a referral for us for evaluation. Um, we have dizzy clinics at the Cleveland Clinic and that involves, um, audiology working alongside um, providers and otology. So ear specialists and non-medical audiology providers evaluating hearing and balance function and patients come for these visits all in one day. They have a multitude of visits and then they're able to get their evaluation and management in one stop shop. Um, other patients, it kind of depends. Sometimes they'll make a route and go to neurology, and perhaps from there they'll be sent to physical therapy for management of their symptoms. And when they're not progressing in physical therapy, they'll then see us to make some determinations of what what is the true cause for their symptoms, and how do they need to make some changes in their management pathways. So I would say there's lots of resources and there are a multitude of interdisciplinary clinics, not only at Cleveland Clinic, I assume also at Children's Hospital in Cincinnati. Um, but there's lots of pathways for patients to get in. It's getting the word out of how we can all work together. And when patients are meeting targets with with therapy or other management to then have other resources for evaluation and to know that we're here to help really make that determination of whether or not it is truly an inner ear problem, and to what extent.

Carrie: [00:26:41] All right. Yeah. Similar to.

Violette: [00:26:45] Yes. So similar. Um, usually I would feel like the primary care doctors are the the usual referral sources. Ear, nose and throat. That's our second. That's ENT is probably our largest referral source than primary care doctors. Um, like Julie said, just getting the word out and letting people know there are probably only 20 or less dedicated pediatric vestibular centers across the United States, and we're scattered amongst the United States. So there's not a lot of places for people to go to get tested or comprehensively tested for their child. It's getting the word out, letting other audiologists know that they can do this work as well. Um, actually, I'm speaking ahead of AAA. They're going to be publishing a, um, I think in the next couple of months, there will be a guideline published on how to test children. And there's a nice graphic in that document showing that if you have a child that is 0 to 2 years old, for example, um, how would you test them as an audiologist or, um, you know, the different age groups showing that there are different tests you could do in your clinic even if you don't have pediatric adapted, um, goggles or you don't have, um, all the fancy equipment to be able to test children. There's lots of bedside tests that you can do for children. So just getting that word out, letting other audiologists know in their communities that they can also do this test, um, I would say a referral source for us that's kind of come about in the last few years might be hematology oncology. So, um, children who are undergoing cancer treatments, sometimes it affects their vestibular system as well. So sometimes we're getting children come through that process. Um, Those are our main referral sources in general. Carrie.

Carrie: [00:28:28] Okay.

Carrie: [00:28:29] Yeah. And like you said, Violette, like only having 20 dedicated centers in the US and knowing the prevalence is high, I would assume. And, you know, making sure that kids and adults get the care that they need. Is that pretty common, too? Julie. For adult populations, as far as vestibular centers, I would think it would be a little more. But is it still kind of we need more?

Julie: [00:29:00] I would say we need more. Number one, I don't I don't know, off the top of my head the number of centers we have. And I think it can be broken down into major medical centers that may have access to more equipment versus, um, ent outpatient centers or, you know, facilities where they have maybe one provider who's able to perform the testing and maybe more limited equipment. It just depends. But I would say there's probably more opportunity in adults, but probably there's still a real need in audiology to have more providers. Just knowing, um, with our aging population, there's going to be more more patients who need our services and more answers that we have to give the managing providers to better understand what could be the cause.

Carrie: [00:29:48] Which is, I think, a good segue into diagnosing vestibular disorders. Can you just give maybe Julie, from an adult perspective, what does that look like as far as maybe the testing and and the sequence? I know you can't get into details, but just from a bigger view. If they're coming to see you for a whole day, like what are the different pinpoints along the way? Sure.

Julie: [00:30:17] Carrie, we Violette and I feel that I can talk your ear off for hours on end about this. It's our passion. But I'll give you a synopsis of it. So I think I alluded to it a little bit earlier that, um, we are well, we're we're clinician scientists, and as scientists, we have to put on our, our clinical questioning hat to develop hypotheses of what could be going on. And first and foremost, we have to have an appreciation for the patient symptoms and the signs that they've been dealing with. And I would say the bulk of our work for any provider dealing with patients with dizziness and balance or vertigo is to have a thorough case history to let the patient talk, because they have the answers that can help us pinpoint what could be the cause. Um, where we come in and I don't know how you feel about this, but sometimes testing is not necessary for some conditions and disorders. Um, we help to clarify function of the vestibular system. We help to clarify the status of a person recovering from vestibular onset. Um, we can help to appreciate what structures or site of lesion are involved. But we're not necessarily a key in many aspects of the diagnosis. But we're vital. We're a vital part of this.

Julie: [00:31:31] But I would say case history is is the number one thing from there, from case history, we can get a good appreciation for both physiology. So the function of the system with many of our tests and we can look like a hearing test. We can look across the vestibular spectrum like a frequency spectrum, where we have some testing that will pinpoint very low frequency responses, such as, um, what happens maybe when you're standing very still, just as the vestibular system is, is sending information to help keep us upright and keep our vision stable so we can see the world clearly to very much, um, when the vestibular system is activated, when we're performing more activities of daily living, which is more of a high frequency response, so we can look across the spectrum with our testing and we can add tests into the mix that can help us answer particular questions that are stemming from our detective work and looking at case history, maybe even some bedside investigations at the beginning, or office examination and even functional examination of a person's posture, their gait, their their head orientation. That can give us good clues into whether or not this is a vestibular problem or not. I'll turn it over to you.

Carrie: [00:32:47] Yes. What about these kids that are.

Carrie: [00:32:50] Probably a little more challenging to to test.

Carrie: [00:32:55] Sometimes?

Violette: [00:32:56] Yes, but so much fun and so rewarding. Truly. Um, like Julie said, some some kids just really don't necessarily need testing. And especially when they are presenting with concerns. And in our world, um, a 14 year old girl who, when she stands up, gets a little lightheaded. Originally when people thought we had a vestibular clinic, they wanted to send all of those kiddos over to us, and we felt like they would do better with the cardiology referral, um, and, and whatnot. And sometimes, like the hypermobility clinic whatnot, those were those were the better places to send those kiddos. But like Julie also said, we are a, um, answer the question type of test, type of test battery. So we're looking to see what is the question the family has and how we can answer it for them. I think when I first started out as a clinician, I was very test based, and so I knew I had all these tests in my toolbox, and I wanted to go in and perform all those tests and get all of the answers. And as I have grown as a clinician, I have realized you don't need every test necessarily. We need to answer the question. And so if I have a child, for example, who comes in with hearing loss or cochlear implants, and I already know that they're delayed in walking, I need to tell the physical therapist, number one, how much vestibular loss they have.

Violette: [00:34:18] Is it both sides? Is it one side only? Is it a total wipeout that they don't have any vestibular function? Or do they have partial vestibular function that they can really utilize in vestibular rehab to uptrain to help this kiddo? So those are the questions I'm answering when I have a child coming in with hearing loss. When I have a child coming in who has normal hearing and has vertigo complaints, I really need to let the doctors know. Is there any chance this could be attributed to an inner ear disorder? And so I have a collection of tests that I would run specifically to look at inner ear function, and then that way I can really give them a clean bill of health so they can move on with their process of finding out the diagnosis. And sometimes I'm surprised. Sometimes they might have a little inner ear, something going on, and we can feed that back to the physicians as well. What's always interesting to me is whenever we have a child who will come in with cochlear implants on, and I feel very strongly that their vertigo is going to show me that they have an asymmetric, asymmetrical vestibular system or some sort of active process going on. And in what we find out is that they have totally normal inner ear function on both sides.

Violette: [00:35:27] And really, when I've obtained the case history further and listening to their complaints, we realize that they are also having a migrainous disorder going on as well. So it's such a it's always a rewarding day because in vestibular, because you never know what you're going to get. Every every time we see a patient, it's impossible often to predict what we're going to be looking at. And I think one of the diagnoses that we're getting a lot more often is 3PD on some of these children. Um, I'm Julie might be able to talk about that a little bit more from the, you know, the functional aspect of it. But especially after Covid, the Covid 19 pandemic, we often had kiddos who got really sick. And when they came out of it, they would have this daily headache where they had a headache chronically every day. And in addition to that, they were dizzy every day, chronically dizzy. Um, and so that took that took on a new level for us. It wasn't just the Covid pandemic. Sometimes children have a event such as, um, I'll say neuritis. Maybe a teenager comes in with neuritis, and after the neuritis, they're having a really hard time compensating. They're kind of stuck in compensation. And so we really have to use this like multi disciplinary approach to helping these children.

Violette: [00:36:49] I know Carrie will probably ask that in a little bit about treatment options. Um, but certainly I think with our with our kids I know I'm getting off topic here. Um, but certainly with our kids, I think we have to really think of it as like a multidisciplinary approach when we're looking at their at their diagnosis as well. And the last thing I'll say regarding diagnosis is working with kids is, Is always interesting. So when I have a six month old baby come in, I really have to get the parents on board. I really have to make sure that the parents understand exactly what we're doing so that they feel comfortable, because the children always take their cues from their mom and dad. If the mom is stressed out, or if the mom is worried, then the child feeds right off of that. So I often call the parents ahead of time and let them know what we're going to do exactly, and that there's nothing that hurts the children, that we're going to be putting electrodes on, or that we're going to be watching their eyes in the dark, and that they get to sit with them the entire test. Um, but a lot of the success of our testing comes from their caregiver that comes with them, um, and just letting them know that the caregiver is comfortable so that if they're comfortable, then the child is comfortable.

Violette: [00:37:59] We also, um, give our weights worth in prizes. Um, we definitely need lots of stickers and toys and all kinds of cute surprises to keep them motivated. So sometimes with a four year old, It's all about, okay, we have this challenge, and after this we get to pick our next prize. And now we're going to do this challenge. And after that, we're picking another prize. So there's lots of fun ways that we keep the kids engaged and motivated. We use TV a lot. We use, um, like an iPod to watch a little video, especially when doing things like, Ovemps or Evemps, um, and kids love, you know, especially in the 2 to 3 year old range. As soon as you put on Miss Rachel or, um, cocomelon or something like that, they get really excited to watch and, and maybe some of the kids don't have a lot of TV at home, so this is like a special treat for them that they get to watch a show. So there's lots of ways we test children, but I would say that it's always about answering the question and not having to perform tests that are not necessary because we don't. We only have their attention span for a very short time.

Carrie: [00:39:06] All right.

Julie: [00:39:07] Chime in and just say really quickly that I, um, I appreciate your comments about, you know, and having a calming environment and involving the family. And that's very much the same for adults. We have adults who may be very anxious about their symptoms, anxious that we could reproduce their symptoms with our testing. And we have to be very mindful of that throughout our evaluation and, and have that same, you know, nurturing, calming, soothing nature and also being able to pivot with our test battery the same as you would for a younger patient who may not be able to tolerate all aspects of testing. We have to do the same for our adult patients as well. And that's where it really is. Having that, you know, moving away from everyone getting the same tests. Um, we really have to pivot it to what are we trying to answer and what would make the most sense for this particular patient? We don't have as many prizes in the adult world, but I probably motivate just as much as you do, especially for like my after lunch time patients that come in, they're sleepy and I'm sleepy and we're in the dark the whole time. I'm very much a cheerleader, and I have my same set of jokes I do with all my patients just for setup that my students want.

Carrie: [00:40:20] But, you know.

Julie: [00:40:21] It's always a hit that I try to get the patients to get on board and get through the test as much as they can.

Carrie: [00:40:27] Huh

Carrie: [00:40:27] Well, yeah. So it sounds like having a good toolbox and knowing which tools to use, depending on what the patient or the family is telling you the symptoms are and kind of moving a little bit forward, because I do want to be mindful of our time, too. Uh, I once you diagnosed, you both have talked a little bit about interprofessional teams and how important that is. And, um, you talked a little bit on that management piece with maybe some physical therapy, but I know it probably depends on what you find out from all of your questioning and your testing. Is there a common treatment plan or is it really just dependent all the time?

Julie: [00:41:20] I think in the adult world, and I can only assume it's the same in the kiddo world too. It really just depends on what we find with our investigation. Working closely because we're non-medical providers, working closely with our medical providers to formulate those next step plans, and having our thought process as far as what recommendations a patient might best benefit from. We look at it from the adult world of what do we need to do to help the patient functionally. So is this something that's, um, having an ill effect on their state, where we mean to be mindful of behavioral health for the individual and coping strategies and grounding strategies that help them as they're trying to matriculate through maybe a medical management program or a therapeutic program. Um, we'll often make recommendations if appropriate, for physical therapy in addition to occupational therapy, just to help these individuals with their activities of daily living and getting back to recovering and compensating and doing things that they once did before. Um, from a medical management side, I don't want to speak out of turn because I'm not a medical provider, but I think it really depends on if there's something conservative that's more a medical medication management. Although long term use of medications is often ill advised for patients as they're going through a compensation process, but there are some conditions where they have to be on medications to help control these cycles, such as migraines or such as Méniere's disease, something that's going to help keep and ward off these episodes from reoccurring so that they can have more success with other management.

Julie: [00:42:58] Um, and I think as patients change in age, we have to be mindful of other professionals that we want to refer them to for management, having colleagues and close connection with neurology to ensure that we're not missing anything that could be with the diagnosis. Thinking about their vision and how that plays into a balanced system, and having good ties and ensuring that they're getting corrective vision and taking care of visual problems if necessary. Excuse me if necessary, there could be cardiovascular concerns that we talked about. So that might be managing more in the medical side for that. Um, and then also just thinking about, you know, going back to kind of some of my work with falls and just having that as part of the management plan. And one thing we do with all our patients is we inform them of falling risk, and we help direct them to falling management. Um, if we feel that they're at higher risk for falls.

Carrie: [00:43:55] Yeah. So that quality of life piece is really a critical piece of that treatment management process to be Violette anything more to add on that pediatric side?

Violette: [00:44:07] Sure. Um, I think for pediatrics, the primary treatment plan is often physical therapy in approach, especially the first level of treatment. Um, most of the parents do not want to jump to migraine medicine in children under ten. I know neurologists are also a little more hesitant to prescribe a prophylactic treatment unless it is obviously very, um, disruptive to their daily life than they might. Um, I think our patients, because PT is our number one treatment option, we offer a child when they come in through the vestibular clinic, they're getting a combined evaluation. So they see audiology and physical therapy. And if it's feasible, we try to do it on the same day so that they can get both. Usually there's like a lunch break in between or a time to eat in between. Ours is usually first the audiology one is first, and the physical therapy one is often second. Sometimes they don't come in on the same day, especially if they live close by and they don't want to dedicate that amount of time to being here at children's. Um, but we, we try to give them both. And the reason for that is sometimes in our diagnostic approach, we will see a totally normal evaluation. And especially if they have migraine, our eval often is quite normal. And then they'll go to physical therapy. And they have tools that look at what makes the child dizzy. Um, they have a scale, for example, called the motion sensitivity quotient, where they look to see which motions specifically bring out the dizziness. And it's very interesting because our physical therapist has kind of adapted it for pediatrics for even very young pediatrics, um, even using the scale, the pain scale with the faces, um, as a representation of how much their vertigo increases as they are put in those different positions.

Violette: [00:45:58] And she'll develop a treatment plan based on that. And what we have found is that there's a very high correlation in our migraine patients with an increased level of motion sensitivity, and that helps her design a treatment plan of habituation. Um, we have done a study that actually shows that the kids who have vestibular migraine when they go through the vestibular therapy process, it hasn't always been popular to necessarily treat people with vestibular migraine with physical therapy. Um, but in our pediatric literature and our pediatric evidence that we've collected and published, we actually show that children with vestibular migraine do improve their motion sensitivity when they go through the habituation program that is targeted at the motions that they, that they have that provoke their symptoms. Um, yeah. So I would say in general it's physical therapy. We do involve the team. So in the cases, for example, that I brought up earlier of kids with 3PD, sometimes we have to bring in cognitive behavioral therapy. Sometimes we have to bring in medical management. Um, maybe neurology, maybe psychiatry. Um, so sometimes there is a medical piece like a, like a medication piece specifically that we have to add to their treatment program to really break them out of that chronic headache, chronic daily dizziness. Um, but in general, it's usually physical therapy.

Carrie: [00:47:18] Okay. And how long.

Carrie: [00:47:20] Does that typically a patient involved in a treatment plan. Is it for life. Is it you know, is it kind of an estimate.

Violette: [00:47:30] For children I would say usually on the order of 3 to 6 months, the children are usually free of their symptoms or their symptoms have greatly improved. Um, and that would be them participating in a home exercise program as well. So it's not just done weekly in therapy or even every other week in therapy. It's done through home exercises that the parents would help them work on at home as well, to help reduce that those symptoms. Um, for children who have bilateral vestibular loss from birth, We have a really unique approach. A lot of times the parents will come in in spurts, so they may come in in the beginning to help them learn to walk. And once they've mastered walking, they may take some time off and and enjoy their their free life without having to come for physical therapy. But then maybe around age seven, the children really want to learn to ride a bike. But the parents are struggling, teaching their child with a bilateral vestibular loss how to get their balance on a bicycle. And so our physical therapist really works with them on things like up training, the proprioceptive and the visual cues, because that's what they do have. So basically using substitution to learn to ride a bike so they may pop in then and get some some skills there, and then they may fall off for a while and then maybe around 11 or 12, they want to learn how to, um, be able to crouch down at the line on a football game and not fall over because they're perched on their toes and on a couple of fingers. Or maybe they want to learn how to hit a baseball and then drop the bat in turn, and then run successfully to first base without falling over. Um, and so there often are life skills that present themselves through the, the lifetime that oftentimes as parents, we are just not equipped. We don't have the instruction manual on how to teach a child how to how to do these things without a vestibular system. So oftentimes they'll pop back in for certain skills they want to work on.

Carrie: [00:49:23] That makes sense.

Carrie: [00:49:25] Julie. Is it kind of a I don't know, estimate for treatment?

Julie: [00:49:31] Yeah, I would say for somebody with, let's say a unilateral or asymmetrical vestibular dysfunction, those individuals may go through a therapy program that could be on the order of 6 to 8 weeks for them to start feeling better, but it's always as part of these therapy processes. And something that we try to counsel patients is that it's lifelong, where you want to maintain a level of activity you can decompensate, you can decondition if you're not keeping up with your balance system. And we want these individuals to be maintaining active movements, head movements, body movements as much as possible so that the balance system can recognize this and pick up on any error messages and help to correct for that. So I think it really depends on the individual. It depends on whether or not they have something like a bilateral loss like Violette was describing or unilateral loss. Or maybe it's something that's many sensory systems that need to be better integrated, that can have a more challenging therapeutic prognosis, where individuals may take longer just to start to have symptom relief.

Carrie: [00:50:45] Well, I think we've talked about a lot today, which is exciting from just a 360 degree view to just really what are some of those common reason why people present with vestibular disorders and and the next steps for diagnosing and treating. Is there anything that I didn't ask you that you think would be important for listeners to know? Either one of you, from the parent or from the child side, pediatric side to the adult side. I guess if you're thinking about our listeners who maybe might not be connected with a big center like Cincinnati or Cleveland Clinic.

Julie: [00:51:34] I'll just say one thing. There are wonderful resources on the web. So if, um, patients or parents want to go to vestibular. Org, there's a lot of information on there as far as what are common vestibular conditions. Um, there's even descriptions of therapy and some of the testing, and it also has resources on that particular website for support groups as well as how to find a provider. And they do a lot in the fall, they have a Balance Awareness Week to help raise awareness for these conditions that are not overt, their internal that patients deal with across the lifespan.

Carrie: [00:52:17] And I can definitely link that in the show notes. So people can go directly to vestibular. Org and get more information to be alerted. Anything that you wanted to add.

Violette: [00:52:30] I might just add that the number one thing an audiologist could do for a patient in the pediatric world would be do a hearing test, um, if they're under ten years old, in our in our own data that we've collected, it's unlikely that if they don't have hearing loss and it doesn't, it's not perfect. But in general, if they don't have hearing loss, typically, it isn't usually inner ear. And that's not true for the adult world. I know because things like bppv and and neuritis not do not necessarily have anything to do with hearing. But in the pediatric world, usually our data shows that the kids who have hearing loss are more likely to have inner ear related vestibular loss. And the kids who have normal hearing often have more central nervous system related vestibular problems. So that's just a generalized, you know, rule of thumb. It's not perfect. It doesn't work every time. And especially in the cases special cases of like CMV for example, doesn't work every time. But yeah, that's just a good way to to start, just get your hearing tested if you suspect vertigo in your child.

Carrie: [00:53:39] All right.

Carrie: [00:53:40] Good advice. And I just want to thank both of you for being part of the EmpowEAR Audiology podcast. I think our listeners are really going to enjoy this conversation. If anyone would have more questions. Are they able to reach out to you in any way? And I can link your information if you're willing, in the show notes as well.

Violette: [00:54:03] I would be happy to. Yes, I will share.

Julie: [00:54:05] Absolutely.

Carrie: [00:54:07] Okay.

Carrie: [00:54:08] Well, thank you both for being guests today. I really enjoyed this conversation. I think I could have had a hundred more questions. Um, but I'm not sure if we would have. Maybe we can have a part two someday, and we can really dive a little bit deeper into some of the, uh, more details of vestibular.

Carrie: [00:54:29] So thank you guys for being.

Carrie: [00:54:31] A guest today, I appreciate it.

Carrie: [00:54:34] Thank you so much, Carrie.

Announcer: [00:54:36] Thank you for listening. This has been a production of the 3C Digital Media Network.