Vestibular testing and the big E.

Inability to perceive the big E on a Snellen eye chart indicates very poor vision. It is the standard of practice for ophthalmologists to test a patient's vision prior to eye surgery and of otologists to obtain an audiogram for pure tones and speech discrimination before doing ear surgery.

While patients with vision or hearing problems might be able to identify the organ where their difficulties originate, those with vertigo cannot identify which vestibular labyrinth, or which of any other part of the vestibular system, is involved and producing symptoms of vertigo. Without doing an objective vestibular test, there is no way a physician can accurately identify the site of the lesion.

Ken Brookler, in the Vestibulology Clinic of this month's Ear, Nose & Throat Journal, describes a tragic case involving a woman whose only functioning vestibular labyrinth was iatrogenically destroyed. Proper pretreatment vestibular testing would very likely have detected the complete vestibular loss in the ear that was not to be treated and would have shown that destruction of the remaining functioning vestibular end-organ in that ear was contraindicated. All knowledgeable neurotologists know that patients sometimes have total loss of hearing with normal vestibular function in one ear, and total loss of vestibular function with normal hearing in the opposite ear. Measles or mumps in childhood, or trauma or surgery to the head or ears, can account for these pathologic findings.

In retrospect, for the woman whose case Dr. Brookler describes, conservative treatment with the Semont or Epley positioning maneuvers or, if necessary, surgical ablation of the involved semicircular canal would have been more appropriate treatment. This month's Vestibulology Clinic should be read and remembered by anyone who treats patients with vertigo.

JACK L. PULEC

Editor-in-Chief