DISTANCE FROM THE TOP:
initial

Referring Physicians

Thank you for referring your patient to the Balance and Falls Center at UCSF. Our goal is to provide high quality, comprehensive care for patients with vestibular disorders. We also want to make the referral process as quick and as painless as possible! The aim of this section is to explain the different components of the Balance and Falls Center, with the hope of clarifying certain aspects of the referral process.

Referral to the Balance and Falls Center

This is a referral for vestibular testing. We offer several forms of vestibular testing, including VNG (videonystagmography), vHIT (video head impulse testing), rotary chair testing, and VEMPs (vestibular evoked myogenic potentials). Please go to the page for each test to learn more about them. If you only place this referral, you will get vestibular testing done, and a report explaining the testing in detail. This is best for qualified professionals (usually neurologists or otolaryngologists) who wish to manage patients themselves, but wish to have testing done in order to help with that.

In terms of testing, you can either specify which testing you would like to have done, or just get the standard battery. If you do not specify in the referral, you will get a VNG and rotary chair testing. If you do specify, you can have any combination of tests you prefer, including VNG, rotary chair, VEMPs, and vHIT.

  • VNG: Provides information about eye movements (smooth pursuit, saccades, optokinetic nystagmus), and caloric testing (horizontal canal function). This test is useful for suspected cases of labyrinthine weakness. Each ear is stimulated separately (unlike a rotary chair test), so laterality of disease can be established. It is abnormal in cases of unilateral and bilateral loss of function, brainstem and cerebellar diseases affecting oculomotor control mechanisms, and frequently abnormal with Meniere’s disease. This test involves low frequency stimulation of the inner ear.
  • Rotary chair testing: information is provided regarding eye movements (optokinetic nystagmus), and the response of the horizontal canal to whole body rotations. This test is widely considered to be the gold standard for bilateral vestibular loss of function. It is not good at establishing laterality of disease. This test involves mid-frequency stimulation of the inner ear.
  • vHIT testing: information is provided regarding the function of all six semicircular canals. Each is studied separately, by a physiologic stimulation with a quick head movement. This test is abnormal in cases of unilateral and bilateral vestibular loss of function. It involves high frequency stimulation of the inner ear.
  • VEMPs: This involves stimulating the utricle (ocular VEMP) and saccule (cervical VEMP) with sound, and then looking for evoked potentials in the neck muscles (cVEMP) or eye muscles (oVEMP). This test is the single best test (better than CT scan) for the diagnosis of superior canal dehiscence syndrome.

Referral to Otolaryngology - Head and Neck Surgery

This referral will mean that the patient will see a provider in the OHNS clinic who is a specialist in dizziness. The list of providers is shown here. We recommend this in cases of suspected peripheral vestibular disease, such as Meniere’s disease, BPPV, vestibular weakness, or superior canal dehiscence syndrome. We also recommend this if a patient has recurrent or chronic dizziness and previously seen a neurologist, and no central cause for the dizziness was found. Our usual policy is to require some testing to be done prior to a new patient visit. This includes:

  • Audiogram (Needed for evaluation of Meniere’s disease, superior canal dehiscence syndrome, inner ear disorders, and the frequent otologic complaints that accompany dizziness, like hearing loss, aural fullness, and tinnitus). Since some patients will have a low frequency hearing loss on testing without being aware that they have a hearing loss, we do ask for testing in all patients. If they have a recent audiogram (within 1 year if they feel their hearing is stable, within 1 month if there are recent changes in hearing), that is ok.
  • Vestibular testing (referral to the Balance and Falls center).
  • We do not routinely require imaging prior to an evaluation. If they patient has a history of surgery on the ears, then a temporal bone CT without contrast will be needed prior to evaluation. If the patient has a history of brain surgery or vestibular schwannoma, then MRI of the brain and IAC will be needed. If the patient has had any relevant imaging studies (Brain MRI, IAC MRI, Temporal bone CT), then they need to bring a CD with the images to their appointment, as a backup in case the images are not transferred to our system ahead of time.

Referral to Neurology

This referral will mean that the patient will see a provider in the general neurology clinic who is a specialist in dizziness. The list of providers is shown here. We recommend this in cases of suspected central causes of dizziness, such as cerebellar, brainstem, or neurovascular disease. It should be noted that there are several relevant neurology clinics at UCSF. General neurology is usually the right place to start. The headache clinic is recommended for patients with a history of migraines, or with chronic headaches in addition to dizziness. If a movement disorder like Parkinson’s disease is suspected, then the referral should be to them. Finally, in cases of stroke or neurovascular disease, we recommend referral to the stroke clinic. We also recommend this if a patient has recurrent or chronic dizziness and previously seen an otolaryngologist, and no peripheral cause for the dizziness was found.

Referral to Physical Therapy

This referral indicates that the patient will be seen by a physical therapist who has subspecialty training in vestibular and neurologic disorders. We recommend this for

  • Unilateral vestibular loss
  • Bilateral vestibular loss
  • BPPV (does not need a referral to a physician as well in clear cases of BPPV)
  • Post-operative dizziness
  • Chronic dizziness of unclear etiology
  • History of falls
  • Impaired gait
  • Multifactorial dizziness
  • Deconditioning
  • Mal de Debarquement syndrome
  • Vestibular migraine
  • In addition, in any case of dizziness or unsteadiness not improving with medical therapy, vestibular physical therapy should be prescribed.

General advice in the care of dizzy patients

  • BPPV is the easiest to diagnose and easiest to treat form of dizziness. If possible, we recommend always screening for this by performing a Dix Hallpike maneuver, and treating it with an Epley maneuver. Please see the section on BPPV to learn more.
  • Physical therapy is effective for many different types of dizziness. In cases of recurrent or chronic dizziness that are not improving with medical care, it should almost always be prescribed. It is also effective for fall risk reduction, so if there is a history of falls, or risk factors for a fall, it should be prescribed.
  • Psychiatric conditions are very common in patients with chronic dizziness. Therefore, it’s recommended that if a patient has anxiety, panic attacks, depression, or any other psychiatric condition, this be treated concurrently with a qualified mental health professional.
  • Certain medical conditions, like orthostatic hypotension, polypharmacy, and cardiac arrhythmias can produce dizziness. The Balance and Falls center is focused on vestibular causes of dizziness (OHNS), and central causes of dizziness (Neurology). Therefore, we recommend that you screen and treat for any correctable medical conditions prior to referral. If the dizziness is most prominent when getting up quickly, then orthostasis can be suspected. The CDC has recommendation for measurement of vital signs, they can be found here. If dizziness is associated with syncope, then the cause is likely to be cardiac or vascular in nature.
  • Neuroimaging (MRI of the brain with contrast) is recommended in cases with an abnormal neurologic exam.
  • CT scanning is generally not helpful in cases of dizziness, there are rare exceptions to this rule (CT temporal bones to evaluate for superior canal dehiscence syndrome).
  • Migraine is the most common and also the most under appreciated cause of dizziness in the United States. If your patient has a history of migraine headaches, and currently has dizziness without another clear explanation; or if they have dizziness with migrainous features such as photophobia or phonophobia or head pressure, it’s likely that migraine is the cause.

CPT Codes

For a list of CPT codes, please click here (PDF).