Report by: Alex Bennett, Consultant ENT Surgeon, Honorary Senior Lecturer, University of Edinburgh, UK.
I was fortunate to be awarded one of the Matthew Yung and Chris Raine Travelling Scholarships to shadow Professor Goebel at Washington University, St. Louis, Missouri. The Center for Advanced Medicine Department of Otolaryngology serves a population of 3.5 million. There are approximately 20 attending physicians (consultants) of whom five are neuro-otologists. During the two weeks I was there I was able to observe clinics and surgery, attend lectures and discuss research.
Prof Goebel has an international reputation for his expertise in balance medicine and receives referrals from all over America. As you would expect his clinic has full access to all the latest vestibular equipment, however, it was his clinical skills which impressed me the most. All patients seeking to attend the clinic must complete and return a balance questionnaire before receiving an appointment. This ensures a low ‘did not attend’ (DNA) rate and gives him a good idea of the diagnosis before the patient is even seen. All computer interaction is done in a separate room so as not to interfere with the consultation.
Although Prof Goebel has a general otology workload most of his patients present with balance problems. In contrast to our balance clinic in Edinburgh a much higher proportion of his patients had central vestibular pathology: brainstem strokes, cerebellar degeneration, Parkinson’s and suspected multiple sclerosis (MS). We also saw a good range of peripheral vestibular disorders including recurrent benign paroxysmal positional vertigo (BPPV), Meniere’s, superior canal dehiscence syndrome (SCDS) and acoustic neuromas. For me, as important as the opportunity to discuss management, was seeing the way Prof Goebel interacted with the patients.
While I was there I saw re-runs of ‘Late night with David Letterman’. A regular feature was a summary of the week’s events entitled the ‘Top 10 list’ so here are mine:
- Pre-visit balance questionnaire.
- Use balance pads.
- Consider using a mastoid vibrator in BPPV patients resistant to repositioning manoeuvres.
- Have a lower threshold for post semi-circular canal obliteration in recurrent BPPV.
- Consider vestibular neuritis as Bell’s Palsy of the vestibular nerve.
- Consider vitamin B2 and magnesium supplements for vestibular migraine.
- Meniere’s and migraine is frequently an overlapping diagnosis.
- Get 256Hz tuning fork for testing diplacusis and hyperacusis in Meniere’s patients.
- Have a lower threshold for treating Meniere’s with intra-tympanic steroids.
- Consider four-hour delayed contrast MRI to predict contralateral Meniere’s before clinical signs become apparent.
It is exactly a decade since I did my fellowship, so I have thoroughly enjoyed this unique opportunity to be a student again. I am incredibly grateful to Mr Yung and Professor Raine for sponsoring and arranging this scholarship and Prof Goebel for being a wonderful host and giving me his time and expertise.