Audiovestibular Education and Services via Telemedicine Technologies

ABSTRACT

Delivery of health care to populations with limited access has been an ongoing issue. Access to hearing and balance services frequently is limited to larger cities and metropolitan areas. Patients with dizziness and/or balance disorders are disadvantaged in that access issues are magnified by travel concerns. One answer is to provide education and services to rural and remote areas through telemedicine. This project developed a system to provide interactive, Web-based education of healthcare professionals, services, and research in hearing and balance. The project demonstrated teaching of clinical skills and service provision via telecommunication. Using the hub-and-spoke model, base and remote sites were established. Procedures were developed and evaluated for training personnel by telecommunication and providing clinical services in hearing and balance. Optimal communication systems and strategies were determined. The result was an educational Web site, distance clinical education and services, and a model for establishing balance screening services. The program is applicable for civilian and military populations.

Audiology - telemedicine - balance - dizziness - tele-education - distance learning

REFERENCES

• 1 National Institutes of Health .1994-95 National Strategic Research Plan. National Institute of Deafness, Communication Disorders and Stroke. Washington, DC; NIH 97-3217 1994: 77-110
• 2 Spindel J. Understanding vestibular physiology, testing and treatment. Paper presented at the American Academy of Audiology Annual Convention. March 15-19, 2000 Chicago, IL;
• 3 Yates J T, Harmer S D, Campbell K, Viirre E, Kau D. Module 6. Case Study: Audiology and Balance. University of Hawaii Telemedicine. Available at: http://www.uhtelemed.hawaii.edu/curriculum. Accessed 2001
• 4 Saltman D, Jacobs J, Burgess L. University of Hawaii Curriculum Site Module 7. Available at: http://www.uhtelemed.hawaii.edu/curriculum/module7. Accessed 2001
• 5 Huhta D, Saiki S. University of Hawaii Curriculum Site Module 2, Telemedicine Technology and Environment. University of Hawaii Telemedicine Curriculum. Available at: http://www.uhtelemed.hawaii.edu/curriculum/module2 Accessed 2001
• 6 Brown J. A systematic approach to the dizzy patient.  Neurol Clin. 1990;  8 209-224

APPENDIX A

University of Hawaii

John A. Burns School of Medicine

Audio-Vestibular Laboratory

Frear Hall - 2569 Dole Street

Honolulu, HI 96822

OFF-SITE TEST PROTOCOLS

TEST: INFRARED VIDEO FRENZEL (RealEyes)

PURPOSE

Infrared video Frenzels (RealEyes) will be used as a vehicle to detect nystagmus while screening patients with complaints of disequilibrium from a remote site. This is a time and cost-effective means to expedite patient care in areas where medical and audiologic care is not immediately available.

EQUIPMENT

1. Micro-medical Technologies Real Eyes TV/VCR (remote site)

2. Micro-medical Technologies VisualEyes system (base clinic site)

3. Communication line(s)

METHOD

1. Trained technical staff at a remote site will perform the testing. The audiologist at the base clinic will conduct interpretation of the screening and recommendation for further diagnostic assessment.

2. The RealEyes system will allow transmission of the real time video display to the base clinic at the University of Hawaii Audio-Vestibular Laboratory for review and consultation.

   • Prepare the Patient for Testing

     BEFORE TESTING ANYONE USING POSITIONING OR POSITIONAL MANEUVERS, QUESTION THE PATIENT REGARDING ANY NECK OR BACK INJURIES/ABNORMALITIES, WHICH WILL PRECLUDE THEM FROM TAKING THAT PORTION OF THE TEST.

   • SCAN Test

     i. SCAN with Vision-The test will be performed with vision (camera over one eye and pivot cap not occluding the other eye) with the patient in a sitting position. Position yourself in front of the patient. Using a pen light instruct the patient.

     Instruction to the patient:

     Keep your eyes open and follow the light as it moves in front of you. Please keep your head still and just move the eyes with the light.

     ii. SCAN without Vision-The test will be performed without vision this time (camera over one eye and pivot cap occluding the other eye). The patient remains in the seated position.

     Instruction to the patient:

     This time I'm going to cover your eye and you will be doing the same task, but I will guide your hand through the positions. I want you to imagine that you can clearly see and track your finger moving from one position to the next.

     

   • Positional Testing

     This test should be conducted by moving the head/body slowly from one position to the next. This is a test of head and body position rather than head/body movement. Each position is held for at least 40 seconds. The patient should be kept alert through this procedure.

     Instruction to the patient:

     1. You are going to be tested in 6 different head and body positions. The positions are: on your back facing the ceiling, head turned to the right, head turned to the left, on your back with head hanging, body turned to the right and body turned to the left. You will be in each position for approximately 40 seconds. I will give you some mental tasks to perform out loud while you are in each position. Listen carefully and do the best you can.

     2. Now I want you to slowly lie on your back. Remember to keep your eyes open throughout this testing. (Begin positional.)

   • Dix-Hallpike Maneuver

     This test is used to identify torsional nystagmus brought on by fast changes of the body position. It is of significance in assessing a patient for Benign Paroxysmal Positional Vertigo (BPPV). The testing will be performed in the head right and head left positions. Position the patient in a seated position making sure that when they lie down, the head will be hanging over the end of the exam bed.

     Instruction to the patient:

     1. I am going to turn your head to the right at approximately 45 degrees. Next I will help you lie back with your head hanging over the edge of the bed. You will be in this position for approximately 60 seconds before getting up. Remember: Keep your eyes open! (Put patient down.)

     2. Observe and record eye movement for approximately 60 seconds.

     3. Have patient fixate on the green LED in the camera (goggles).

     4. Bring the patient to a seated position.

     5. Allow for a few minutes rest and repeat testing with head rotated to the left.

   • Videotape All Procedures

     Start the VCR for the first test. The recorder may be paused between tests. The following tests will be conducted with eyes open under goggles and infrared camera over the “better” eye. When video taping, announce each subtest prior to recording to appropriately assess each

     • SCAN test (with and without vision)

     • Positional tests

       • Supine

       • Head right

       • Head left

       • Head hanging

       • Right lateral

       • Left lateral

     • Dix-Hallpike right

     • Dix-Hallpike left