August 12, 2019
Gerard J. Gianoli, M.D.
While attending a wedding, MW, 35 years of age, tripped, hitting her head and lacerating her forehead. Blood was everywhere. She was brought to the ER where they sewed up her forehead and diagnosed her with a concussion. Her forehead wound healed. However, she was left with horrible imbalance, vertigo and dizziness. Her imbalance was so bad that it required her to use a walker to get around. Life was not easy for MW who was the mother of two young children at the time. She had vertigo spells once a week with associated vomiting, but the constant imbalance was her main disability. As one can imagine, this hampered her independence. She could not drive, and she could not participate in social activities as she would have liked.
She went from specialist to specialist at some of the best medical institutions in our country looking for help with her balance problem. Many of the doctors told her that her balance problem was unrelated to the fall and head injury. The ones that did think it was related to her concussion, told her that she injured the balance portion of her brain and that she would have to learn to live with this. She went through years of physical therapy and untold number of treatments that did not help her balance problem. Unfortunately, she would not receive any indication that she had an inner ear problem for 35 years…
MW’s experience, however unfortunate, is not unique. In the past, the diagnosis of concussion was often missed or mishandled. Of course, the recognition of a problem is a prerequisite for solving the problem. The increasing recognition of concussions by medical practitioners and the population at large is a huge advance for those of us who take care of head-injured patients.
Unfortunately, the recognition of a simultaneous inner ear problem was, and still is, routinely missed. Inner ear damage during a concussion is not only common, it is difficult or near impossible to have a concussion WITHOUT having an inner ear injury. After a car accident and a trip to the emergency room, broken bones get set and bleeding gets tended to, but the damage to your inner ear usually doesn’t get noticed.
There are several reasons for the under-recognition of inner ear problems for head-injured patients. First and foremost is something called a “distracting injury”. When a patient comes in the emergency room after a motor vehicle accident complaining of arm and shoulder pain (due to a fracture), it can be easy to miss the cervical spine injury that is not causing so much pain. Similarly, when someone has lost consciousness after a head injury, attention is directed most appropriately to the evaluation of intracranial problems. For most of us, treating a brain injury takes priority over other parts of the body. Everyone gets “distracted” by the seriousness of a brain injury. However, after the acute assessment is complete, there is no longer any reason to be distracted from looking for other injuries.
Second, the understanding of vestibular (inner ear balance) disorders among the general public and among medical personnel is limited. Very few medical professionals are trained to diagnose and treat inner ear problems. Ear nose and throat doctors (Otolaryngologists) receive some training about inner ear disorders during residency, but from a practical standpoint, the vast majority do not treat inner ear disorders during their career. Some Otolaryngologists will undertake fellowship training in Neurotology and Skull Base Surgery. Neurotologists are the only physicians with any extensive training for inner ear problems. However, there are only about 250 board-certified Neurotologists in the U.S. This is not nearly enough to be able to take care of the estimated 2 million concussions each year.
However, even if there were enough Neurotologists to care for all the concussion patients each year, there are two factors dissuading them from evaluating and treating post-concussive dizziness. The two factors are 1.) reimbursement and 2.) adequate testing equipment. Post-concussive dizzy patients are some of the most complex patients and require a lot of time and testing to be able to appropriately diagnose and treat. The current reimbursement environment dissuades physicians from treating inner ear patients.
For example, Medicare, Medicaid and the private insurance companies will pay Neurotologists about the same amount of money for spending an hour doing a thorough evaluation of a dizzy patient as they would pay for 2 minutes cleaning wax out of a patient’s ear. This disparity drives Neurotologists to spend their time elsewhere. In fact, if they are employed by a hospital (like more and more doctors these days), they may have no choice in the matter.
Vestibular testing is essential to the appropriate evaluation of the post-concussive dizzy patient. However, reimbursement for vestibular testing has been falling for years. In fact, the cost to do thorough vestibular testing is higher than the reimbursement for such testing by Medicare, Medicaid or the private insurance companies. So, providing thorough vestibular testing to patients who have post-concussive dizziness will lose money for the providers every time. The only answer is to “shrink” the test – meaning reduce what is done (i.e. reduce quality) – in order to not lose money, or to simply not offer the testing at all. As a result, fewer and fewer clinicians offer robust vestibular testing to their dizzy patients.
Due to these factors, many post-concussive dizzy patients will have persistent problems indefinitely due to inadequate evaluation and inappropriate treatment.
What can Neurotologists do to address these problems? The answer to the above problems of inadequate evaluation and inappropriate treatment is to tear up the contracts to Medicare, Medicaid and private insurance – and charge a reasonable cash price. If there were appropriate reimbursement (payment) for the expertise, time and equipment involved, more Neurotologists would be interested in evaluating the post-concussive dizzy patient.
This is exactly what we at the Ear and Balance Institute did in 2005. Since 2005, we have had no contracts with any insurance company. We charge a reasonable price in order to not lose money. Because of this, we can provide a full and thorough evaluation by a board-certified Neurotologist with decades of experience in treating dizzy patients and provide all the appropriate vestibular testing. As a result, we can provide more expeditious evaluation and recovery for our patients. Our fees are reasonable because we are paid what we charge, as opposed to those physicians who are contracted with insurance companies who have exorbitant “charges” but only receive a small fraction of those charges (unless you are paying cash, then you get charged a fortune!). We charge a fraction of the fees charged by those with insurance contracts.
There are some “red flag” symptoms that may identify post-concussive dizzy patients for in-depth vestibular testing. These include fluctuating hearing loss, fluctuating tinnitus, pressure/fullness sensation in the ear (especially if the hearing loss, tinnitus or fullness are in just one ear), and episodes of spinning vertigo. Dizziness that is made worse with noise, straining or positional changes are also highly suspect for an unstable inner ear problem that requires further evaluation and treatment beyond vestibular rehabilitation.
…after 35 years of suffering, MW came to see me. She underwent a full hour-long history and physical examination as well as 2 days of thorough vestibular testing. She was diagnosed with BPPV and perilymph fistula secondary to her head injury. With appropriate treatment, she was free of vertigo and dizziness within 6 weeks. She was able to get rid of her walker and went back to driving. She is now 6 years from treatment and is still free of vertigo and dizziness. Did she have a concussion? Yes. But she also had injured her inner ear – a problem that had been untreated or inappropriately treated for 35 years.
Unfortunately, there are untold numbers of post-concussive dizzy patients who have never had appropriate evaluation for inner ear problems and continue to have life-altering symptoms. One thing to keep in mind is that there are no rules that say you can only have one problem. Many patients who have had brain damage also have inner ear damage. And there are means to evaluate and successfully treat these patients with inner ear damage.
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Dr. Gerard J. Gianoli
Dr. Gianoli is a Neurotologist at the Ear and Balance Institute in Covington, Louisiana and a Clinical Associate Professor at Tulane University School of Medicine in New Orleans, Louisiana. He is Board Certified in Otolaryngology-Head and Neck Surgery and Board Certified in Neurotology. Dr. Gianoli is one of less than 200 Board Certified Neurotologists in the country.