Wobbler vesitublar testing layperson layman patients view staggering gentamicin

The purpose of this page is to present a patient's view of the tests given to determine amount of damage done by gentamicin.
NOTE: This info is not a substitute for medical advice or professional guidance.

Balance and Hearing Center N.W.
Otology Neuro-otology
F. Owen Black, M.D., F.A.C.S., P.C.

Interview answers to questions by Fran, Dr. Blacks Nurse

1. Listing of medicines and poor responses.
2. Light-headedness increases with change of position
3. Have light-headedness 90% of the time
4. Vision seems to snap when I turn head left or right
5. Sensitive to peripheral movements.
6. Tinnitus increases bilaterally in the daytime.
7. Tinnitus very distracting in left ear.
8. Most difficult time of day is later afternoon, exhaustion

Interview with Dr. Black

1. Dr. observed boney protrusions in both hears. It is seen frequently in those who swam in cold water. It is not occluding his ears.
2. Balance part of ear mainly impacted by gentamicin
3. Will do baseline testing today.
4. If patient recovers they will see recovery within a year.
5. He said we could contact Senators and remove antitrust controls on insurance companies.
6. Gave Dave an option to participate in a NASA research project.
7. Specific instructions to Dave:
   • No step stool use
   • No ladder use
   • Hold onto bannisters on stairs
   • Don't carry objects up or down stairs
   • Stay away from water
   • Use life jacket whenever around water

Judith Palmer provided the following notes. During the day of testing she was told:

The purpose of all this testing is to show what amount of function the individual does have. It will be used to form a treatment plan.
The treatment plan will include diet, vestibular rehab and gait retraining.
The purpose of the individualized treatment plan is to improve life and decrease symptoms.

"There are treatments for every inner ear disorder"

#1 Balance Test with EquiTest Machine (Posturography testing )

Colette is the technician

Test shows how three areas work together. The areas are visual, inner ear and muscles and joints. Patient stands in a 3-sided "telephone" booth. The booth walls and floor can move independently of each other. Patient has a vest connected to overhead straps. There is no chance of falling. The patient is not supposed to wobble, become unbalanced or lurch.

• 1st test: eyes open, booth/floor steady, Dave able to be still and quiet, then with eyes closed Dave listed to front, then to left and front to back and then to back.
• 2nd test: walls moving, eyes open. Dave kept balance by jerky movements forward and backward and appeared to be fighting backward moves. Then with eyes closed jerking movement forward and back, when foot platforms are moving. He also leaned back slowly.
• 3rd test: a motor control test with the foot platforms moving back and forth. Dave leans forward when platform moves back. When platform moves forward Dave moved back and to the left and lifted and moved his left foot.
• 4th test: an adaptation test, front of foot platforms front tip up. Dave had to be supported by Colette and he moved backwards. When the platform tilted down Dave lunged forward and caught himself by bending his knees, and he needed support from Colette at least 2 to 3 times. One time he bent his knees and moved backwards .

#2 Eye Tests

Charts

Similar if not the same as given during an eyeglass exam. First part is reading a standard eye chart and then reading another chart which has a lower contrast.

Then an attempt is made to read the same charts and report the letters read as the head is moved from side to side. This test is repeated with vertical head movement.

Special Glasses

Red (r), green (l) lenses and a chart with color coded X's and O's. Tests binocular vision.

Polarized glasses and booklet to see 'standing' or 'floating' objects.

Dave did poorly on the head movement part of the chart test. He was unable to read a line of text, except through memorization, reading and memorizing a letter as the head moved in one direction or another.

Dave lacks binocular vision and the special glasses test was not useful.

#3 VEMP (Vestibular Evoked Miogenic Potential)

Test is to measure neck muscle at the same time the tester is vibrating the inner ear. It reflects how readily your neck muscles are responding for what is received in the inner ears. One side of the neck is tested at a time. A probe is put into the ear canal. The probe emits a clicking sound. The saculo function is tested. The clicking sounds will vibrate little otolets. This test is also known as ECOG (electrocochleography).

Each ear is tested 4 times. The test involves turning the head as far as possible in a direction opposite of the ear being tested. (Testing the left ear, turn head right.)

In this test connections are made to the patients forehead and neck muscles as well as the probe. The output of the test is recorded by computer attached devices.

#4 Dynamic Visual Acuity Test, known as a Visualr Vestibular Ocular Reflex test (VVOR)

This test is a computer driven test of the previous manual acuity test (test #2).

The patient wears a computer attached headband. The headband has a ball, on top, which contains a sensor that records how the head accelerates and stops. The patient looks like a clown wearing a small bouncing ball for a hat.

• 1st test (static): The computer screen quickly displays eye test "E" characters (of decreasing size) and the patient reports the direction by saying : "Up, Down, Left or Right" to report what is seen. The technician records the results. The patient's head does not move, it is static.
• Initially Dave had trouble. The initial size of the "E" was incorrectly established. Once it was corrected Dave had no trouble. When the size of the "E" reached a small size Dave could no longer recognize the correct orientation.
• 2nd test (dynamic): This tests vision when the head turns from one of four predetermined positions and stops at the screen and the patient reports the direction - but the image is displayed for a very short period of time. As the characters size is reduced the test is repeated a number of times in each position.
• This test starts by testing movement from the right to the left, then left to the right, then from head up to center, and then from head down to center.

This was a difficult test for Dave. The larger characters were easy to read. As the size decreased it became difficult to recognize the orientation of the letter "E".

#5 Hearing Testing.

Testing is done with patient in dark, soundproof room. Headphones are used.

#6 VAT (Vestibular Auto-rotation Test)

This test measures vestibular ocular reflex (VOR). The VOR stabilizes images when we move. Normally when you turn your head your eyes move the same number of degrees in the opposite direction. This is how we accommodate movement. The VAT measures high frequencies of VOR. During this test the movement approaches 5-6 hertz.

Electrodes are placed on the forehead and around the eye.

Using the sensors the computer can interpolate the 3 neuron (brain, ear and eye) signals as the patient moves the head (in time with a prerecorded sound) while attempting to keep the eye focused on a dot on the wall.

Repetitive head movement can be horizontal (left to right) or vertical (top to bottom). In either case the amount of the movement is reduced over time. The speed of the movement increases from slow (wide movement) to very rapid (narrow movement).

The test measures distance and timing (degree) of eye movement and head movement. When the head is moved the brain sends a message to the eyes and ears. The test starts with slow side to side movements and progresses to quicker and shorter movements, and ends with very tiny movements back and forth.

Dave did 4 repetitions in the horizontal and vertical plane and both were repeated once to collect more data.

#7 Test for ENG Electronystagmography.

This multiple step test checks for the amount of involuntary eye movements.

The patient wears a goggle like device. The goggles are attached to a computer and VCR and TV display. The goggles have an infrared (IR) camera. The camera captures the eyeball. The patient looks out through reflective glass and can see normally.

A projector is used to display items on the wall in front of the patient. The tests involve calibration, tracking, positional and caloric components.

Calibration:

• 1st: The patient follows a little yellow light, then the light swings back and forth, then the light randomly hops around.

Tracking

• Then while focusing in the center vertical stripes march across the field of view, first to the Left and then to the Right. Patient has to stay focused and can't follow the stripes.
• Then the speed of the movement is increased. Again the patient is asked to stay focused and not follow the stripes or let them break into narrower stripes (optical illusion).

Positional

• 2nd: The goggles are covered. The patient sees black only. Sitting on the cot the patient will be assisted in reclining to the right and reclining to the left while letting the head hang over the cot. The patient is asked to keep the eyes focused on the center of the goggle.
• 3rd: Goggles still covered. Patient is flat, the turns head to right and then to left.
• 4th: Goggles still covered. Turn on right side with head down, turn on left side with head down.

Caloric

• 5th: Then in a reclining (30 degree) position, wearing the same covered goggles the patient undergoes tests which include heating and cooling the inner ear. This is an artificial stimulation test. A very small probe with a balloon is filled with cool or warm water, allowing 4 tests (cool temperatures in right and then left ear and warm temperature in the right and then left ear). Once a probe is inserted it heats or cools the ear drum for 45 seconds. Then the balloon at the end of the probe is deflated. The patient is engaged in conversation while keeping the eye focused (inside the goggle). Then a small round image appears momentarily and the patient is asked to focus on it. During all this the IR camera tracks the movement of the eye. The test looks for horizontal canal function and how much independent function there is in each ear. It also commpares the functioning of each ear in relationship to the other and whether or not it is functioning.

During Dave's tests:

• During 4th step, Dave's eyes were not looking straight ahead. In response he state "I thought I was looking straight aahead, I don't know where straight ahead is."
• Cool right ear: Noted eye movements side to side in short jerks while conversing.
• Cool left ear: Noted eye pulls to right then eye moves to a more central position and there were some eye jerks side to side during conversation.
• Warm right ear: Side to side short jerks, eye tends to pull to the right. Dave notes a pulsating/throbbing light sensation.
• Warn left ear: Less eye movement to the right and fewer short jerks of the eye. There was some up and down eye movement. Dave doesn't sense the same warm temperature as the right ear.