Running the clinic
Workflow & protocols
The clinic's diagnostic power is the workflow, not the kit. A structured history, a fast bedside, instrumented testing on the same visit, and a weekly MDT — applied consistently — outperform any single technology.
Every patient takes the same path: history → bedside exam → targeted instrumented testing → diagnosis → treatment + rehab → follow-up. The order matters: a thorough history determines which tests are even needed.
Most peripheral diagnoses (BPPV, neuritis, Ménière's) can be reached in a single visit. Central diagnoses (vestibular migraine, posterior-circulation stroke, cerebellar ataxia) need a different pathway, often with neurology and urgent imaging.
The bedside HINTS battery is the single most important workflow node for the acute presentation: a central pattern (normal head impulse, direction-changing nystagmus, or skew deviation) is more sensitive than early DWI-MRI for posterior-circulation stroke when performed by a trained examiner.2,1
For the much commoner positional vertigo, the Dix-Hallpike with infrared video Frenzel goggles is the diagnostic standard, with the Epley delivered in the same visit when posterior-canal BPPV is identified.4
The bedside head impulse test remains the cleanest separator of peripheral vestibular failure from central causes;3 in the clinic it pairs with quantitative vHIT to confirm canal-specific gain reductions and detect covert saccades that the unaided eye misses.
Standardise everything that can be standardised: the same Dix-Hallpike technique, the same HIT speed and amplitude, the same VEMP montage, the same Epley variant. This reduces inter-clinician variance far more than equipment upgrades do, and it is what makes the MDT's case discussions productive.
Patient journey
Ten stations from referral to follow-up. The MDT node is the only one not in the patient path — it sits parallel as the audit and consistency engine. Note the dashed return arrow: the audit loop feeds back into how triage and protocols are written.
Standard protocols
- History: TiTrATE or SO STONED framework; capture timing, triggers, associated symptoms, targeted exam, evaluation.
- Bedside: HIT → spontaneous nystagmus → test of skew (HINTS) for acute; Dix-Hallpike + supine roll for episodic positional; Romberg + tandem gait + Fukuda for chronic.
- Instrumented: Audiometry + tympanometry on first visit for episodic and acute. VNG and vHIT same-visit when staffing permits; VEMP scheduled for SCDS or otolith-focused work-ups.
- Treatment: Same-visit Epley for PC-BPPV; Lempert/Gufoni for HC-BPPV; refer to vestibular physio within 72 hours for neuritis, bilateral vestibulopathy and PPPD.
- Documentation: Structured EMR fields for HIT, nystagmus, skew, DHI, VOR gain. Free-text notes prevent audit.