"I HAVE NOT DONE A CALORIC TEST FOR YEARS"

Analogy: If you take your car to the garage because something is wrong with
the steering mechanism, e.g. pulling to the right ...

Do you take it for granted that the mechanic will check the wheels for size,
inflation, and that the wheels on the left and on the right are the same size?
... and take it for a test drive!?!

Similarly, if you as a licensed specialist, do not perform a basic check on
the two balance organs, e.g. Romberg, Unterberger (Fukuda), tandem walking,
minimal caloric test ... but do study the CPT-4 book, or employ a special
person to do the billing...

Example: A patient may have had an episode of viral vestibular neuritis some
time ago (off balance for many days) and forgot about it.

Then a BPPV develops, or a secondary Meni•re... imagine this is your long case
for the final exam for whatever degree or diploma applies: if you did not do a
simple caloric test, you should be given the privilege to come back a few
months later.

The caloric test is quick and effective: Tap water (usually 15 - 18 degrees)
into the ear canal for 8 - 10 seconds, and observe the nystagmus (preferably
with Frenzel's glasses) is all that is necessary.

If the water is colder, irrigate for 5 seconds.

A thermometer is cheap and should always be in the otologists' office, a
headlight and an ear speculum is available, a kidney dish is available, a
towel is available, a disposable 20 ml or 50 ml syringe is available, a
plastic baby feeding tube 6 FG (cut short) fits on the syringe, Frenzel
glasses is mandatory in any otologists's office (otherwise he should not drive
a new car).

Then do the other side after 5 minutes.

Any consulting room (office) should have an examination couch in a separate
room (for someone who does not feel well, to rest a bit after an otolith
repositioning manoeuver had been done) - or have more than one chair in which
the patients sits.

At the MEEI in Boston, Schuknecht's private office had 3 rooms with a chair in
each, and a minimal caloric with tap water was done as a routine (when
indicated), without rescheduling the patient).

If the test reveals abnormality, then do a bithermal at 30 and 44 degrees, at
some other time, preferably using an infrared videonystagmoscope (which is
best for observing BPPV) or ENG (I seldom use mine).

Ice water calorics is seldom necessary - in any case, have somebody put
icewater into you ears first, then you will see what I mean.

Remember: You as a specialist should not be influenced by "mismanaged care", a
full waiting room, pressure by politicians, etc.

The patient regards you as a specialist otologist, who is up to date with the
new developments, and not a saleman who has to have a big turnover to make
ends meet (this is what the politicians and "wealthcare" manipulators try to
make of the doctors).

Specialist should set an example, should lead, not follow...

If you do not like to see dizzy patients, put up a notice to that effect, and
divert them to someone else.

Herman Hamersma
Florida Park
South Africa

Author: The Caloric Test. An Electronystagmographical Study. Amsterdam, 1957.

hamersma@global.co.za

The specialist sets the example, leads, and does not follow.