Development and Validation of A Neuro-Otology Telehealth Service

Affecting between 15-35% of the general population in their lifetime, dizziness is a common cause for consultation in the emergency department (ED). Between 14% and 22% of patients leave the ED without a diagnosis.

Among those diagnosed with peripheral vestibular disease, 81% are misclassified, with a mere 4% of BPPV patients receiving correct treatment. 35% of stroke patients with vertigo are initially missed.

Rapid and accurate diagnosis of vestibular stroke is imperative to enable time-critical interventions that dramatically affect patient morbidity and survival.

Crucial in this detection is the HINTS examination (Head Impulse test – gaze evoked Nystagmus - Test of Skew): this battery of 3 clinical tests allows for the accurate exclusion of stroke with a high sensitivity of 100% and specificity of 96% rivaling that of an MRI. However, this clinical exam is highly dependent on the examiner’s experience (risk of stroke misclassification).

Availability of modern quantitative tests (video-nystagmography to replace inspection of the eyes, video head impulse testing in place of bedside HIT by an expert and video recording of skew) offers the opportunity of accurate HINTS assessments by non-experts (emergency medics). However, precise quantitative HINTS testing in remote settings is currently not available.

The global Covid-19 pandemic with its social distancing measures and prolonged lockdowns has led to a substantial increase in video-conferencing and the remote exchange of information.

Assessment of dizzy patients is well suited to telemedicine as it requires structured history taking, examination of distinctive eye-movement characteristics (nystagmus, pursuit, saccades, skew deviation) and quantitative tests (hearing, video head-impulse testing, nystagmography), exams normally undertaken by specialist neurologists and otorhinolaryngologists.

These tests could be conducted by non-specialists using modern devices including webcams and video-glasses.

Video-oculography (using vision denied video-goggles) would provide robust quantitative data on the presence/absence and direction/waveform of nystagmus interpretable by a remote expert.

Aim: To implement and evaluate telehealth as a means of providing a timely and accurate assessment of vertiginous patients.

I will develop a structured history, examination management tool and laboratory testing protocol usable by non-expert healthcare professionals and test these against expert diagnosis.Methods: I will conduct two studies: 1) Develop a structured history, examination protocol and patient management tool (decision tree) for use by non-expert primary care physicians to diagnose and treat 50 patients with vertigo and compare outcomes to expert care. 2) Implement remote VOG technology in local primary care clinics with telehealth link to an expert neuro-otology clinic and compare diagnostic and treatment outcomes in 50 patients to expert care.Patients will be seen initially by the general practitioner and then by the neuro-otology expert (the Post Doc Mobility candidate) within 72 hours.

These telehealth tools will be evaluated for accuracy (sensitivity, specificity) as well as ease of implementation, time commitment and quality of video recordings.

They will provide important data to inform subsequent clinical trials planned for both the Australian and Swiss research groups.Expected results and their impact in the field: 1) A validated telehealth suite usable by non-expert physicians. 2) A prototype outreach service that unites otoneurologists with clinicians in primary care.3) Timely and accurate assessment of the dizzy patient in remote settings. 4) Reduced healthcare costs.