Episode Transcript
Rebecca: Hello and welcome to The Future is Sound, a partnership and hearing podcast brought to you by Oticon Canada. I'm your host, Becca Angel, and thanks for joining me on my first podcast journey where we will chat broadly about all things hearing. We will launch fun new episodes every month and if you have any suggestions or comments be sure to get in touch.
Let's get started. Okay, hi everyone. Good morning, Erica. Thank you so much for being here. Our guest today is Erica Zaia. She's an audiologist with over 25 years of experience in vestibular assessment and management. She's also the owner of an audio vestibular clinic here in Vancouver. From what I can see and find about you online and what I've seen in person is that you've dedicated much of your career to researching and learning about vestibular processes and taking that information and educating others with your wealth of knowledge and experience. Very, very excited to have her as a guest on the podcast today.
Erica: Good morning, Rebecca. Thank you so much. Yeah, it's such a joy to be here and talking about vestibular to more audiologists. That has been my main goal in life. It was just to address that other half of the inner ear.
Rebecca: That large other half that we tend to not think about nearly as much.
Erica: Yeah. It's harder to just do it all, I understand. I completely understand. I don't do hearing aids, for instance and I so respect and value my colleagues who do hearing aids. It's always nice to have that opportunity to share a little bit of what I do, what we do in vestibular with other colleagues and so we can have a better understanding of our clients, our patients and help more people in a more comprehensive way, so thank you for having me.
Rebecca: Yeah, you're very, very welcome. Is there anything that you would add there? How long have you had your clinic in Vancouver?
Erica: I opened it up in 2018. It was the first dedicated clinic for vestibular and I'm still the only one, I believe in Canada. Most of my colleagues do fit hearing aids and do other things. I do a little bit of tinnitus counseling and I do hearing tests, but it is a small minority of my patients. It is mostly for people who come to me primarily for a dissonance, vertical or balanced disorder I then do tinnitus counseling. I am probably the only one doing what I do without fitting hearing aids.
I do a lot of vestibular rehabilitation, which is not something that many audiologists venture into in Canada. In North America, there are more physiotherapists doing vestibular rehab. That's the part that I really love, not only providing diagnostic information to patients, but also telling them this is what we can do. That has been a huge part of my job and mostly the reason why I left the public system to be on my own and having my own clinics, then I could offer that kind of all in one, like one stop shop.
Rebecca: Yeah. I was at UBC when you spoke to our class during the audiology class about vestibular, but we get such a small snippet of that, and everybody always, like, loves that portion of the course. It's really interesting to everybody, but then I feel like it can sometimes be hard to really get that off the ground or really kind of decide, okay, this is what I'm going to focus on. I think we'll circle back to that at the end as to how we can kind of break down some of those barriers to learning more about vestibular at the end. I just wanted to say that, because I think everybody loves that part of the course. It's great that we have you sharing all of this information with us all the time.
Erica: Thank you. It is such a pleasure. Thank you.
Rebecca: I thought we could start with—for our listeners, just from your perspective and your knowledge, the relationship between the vestibular and the hearing system.
Erica: Yeah, stay tuned for the May Hearing Month Campaign by SAC because we are going to be focusing on that. The most important comorbidity with hearing loss is a vestibular issue, a vestibular loss. Again, it's that other half of the inner ear and as a mentor of mine would say, it's like duplex houses. They share the same electricity and plumbing system. It's the same innovation and the same blood supply. There is a lot of the physiology that it is the same between the hearing organ and the vestibular organs.
Every time there is a sensorineural hearing loss, we have to think about whether there could be some disorder of the vestibular organs. This is true for both adults and children. It is even more important for us audiologists to be on the lookout for those disorders, for the vestibular disorders in children, because kids are not going to tell us that they are dizzy, are they?
Rebecca: Yeah, that was definitely 1 of my questions. I'm sure it presents very differently in the pediatric population versus adults.
Erica: Absolutely yes. It is almost an obligation of the audiologist to think about it every time you identify a sensorineural hearing loss, take a step back and think, could there be a comorbid vestibular loss going on here. Of course, it does depend on the cause of that hearing loss, right? If you know it is for sure a noise exposure, noise induced hearing loss, there is a smaller chance that there's going to be a vestibular disorder. But say if it is a child who has been diagnosed with CMV, they actually have more vestibular loss than hearing loss.
The prevalence of vestibular loss in kids with CMV is higher than the prevalence of hearing loss. On those kids, when we find a hearing loss, you almost have to stop and search for the vestibular loss in order to offer that person a comprehensive, complete audiology service.
Rebecca: Yeah. I mean, I didn't know that about CMV. Is this new knowledge or is this old knowledge?
Erica: Well, this is relatively recent. There's been advances in diagnosing CMV and there's been more screening. There's been more like, okay, let's go back to that blood that was collected in hospital. We know, and it, it has been the past 5-10 years that we've known more about vestibular loss in kids. Here in Canada, I cannot speak about vestibular loss and hearing loss without mentioning Dr. Sharon Cushing from SickKids Toronto. She has been a force. She is an inspiration, one of the ENTs that respects audiology, and she's an amazing person.
Every time I meet her. I feel energized by her passion for vestibular and for hearing loss. We've learned a lot from research. The numbers are really shocking. You think about kids with hearing loss, up to 70% of them will have a vestibular loss. All those kids that have hearing aids, 70% of them will have some degree of hearing loss and 20 to 40% will have a severe vestibular loss, which can be bilateral.
Even kids with a unilateral hearing loss, chances are, there’s a high chance that they will have vestibular loss on that side too. This is something that must be on the radar of all the audiologists that’s dealing with the pediatric population. It's out there. It’s highly prevalent.
Rebecca: Yeah. From your experience, how does it present? Is it super variable or can it be really obvious? I'm sure a child isn't going to say, well, and they might say, I feel dizzy, but it's probably like, I walk into things a lot or something. I don't know how it presents definitely with kids.
Erica: That's a very, very good question. In very young kids, before school age, toddlers, you will see in the later motor development. You will see that this is a child that is 18 months old and might not be walking yet. It is a child that is a little bit older and is still walking and being wobbly and not necessarily running. It is a three or four year old who is not necessarily learning how to ride a bike or doesn't like the balance bike.
Then later in life, we will see, it's a child who is not very athletic, not inclined to sports. It's the shy, quiet kid who reads a lot, who is not socializing, not playing, not jumping and not doing a lot of more physical stuff. You can see that in how they move in the world, yes. But when a child is older and if they have a progressive, vestibular disorder, such is the case of CMV, they may start to articulate that they have dizziness.
I've seen cases as young as five, six years old, and they say, things are, what mommy, or why are things going around? They just stop and sit down because things are, things are moving. Why are things moving? They may say when they're older, but once again, for the younger crowd, you, the audiologist, the parent would notice in how they move and how they develop in terms of motor skills in the world.
Rebecca: Right. Makes sense.
Erica: There might be, again, depending if they are having, it's not say a stable vestibular loss that was safe, for instance, meningitis. It was a complete hearing loss and a complete vestibular loss, and that vestibular loss and hearing loss don't fluctuate. You will see just this delayed motor development and all those difficulties with playing sports and all of that, but CMV and/or enlarged vestibular aqueduct, and other types of inner ear malformations in which there can be a fluctuation in hearing.
You can expect that there can be a fluctuation in vestibular function and these kids may have episodes in which they are just falling off, and as you said, walking onto things Dr. Cushing has videos of little kids who are walkers are already walking and playing on the playground, and they try, and they veer and fall to the ground, and then kids are so resilient and that little girl stands up and tries again, and it is almost as if you see a force pulling her, pulling and then she falls again and she tries again.
Parents may see those episodes in which the child's balance is not as good as their usual and that should raise a concern. Again, for the audiologist to ask whenever there is a fluctuation in hearing, ask about this to parents.
Rebecca: Yeah. That's a good point. In clinic, and this is sort of like a pediatric podcast, but it is sort of broad. If we're thinking about pediatrics and in a clinic with kids, things that we can ask, that's a good example. If the hearing loss is fluctuating, then that's a good indicator that we should ask about, does the balance also fluctuate? Are there other things that we can look out for—sorry, not look out for, but other things that we can ask, or sort of things that we can maybe screen for quickly in the clinic that could give you some answers?
Erica: Yeah, and I would say both Rebecca. Those are excellent steps that unfortunately, we know that not many audiologists do. A few years back, there was a study that students from [inaudible 00:14:02] a colleague of mine in the university, they asked audiologists whether they asked their patients about falls, in the pediatric and in the adult population, and in the pediatric population, more than 60% of audiologists never asked about falls, never asked about balance.
We would hope for this to change that we as audiologists, again, embrace that other half of the inner ear and start asking the question, do you have any concerns about your child's balance? Do you have any concerns about your child's motor development? Ask about motor milestones. When do they start to sit? While sitting unassisted is not very vestibular, but it is already vestibular.
But then crawling and walking for sure, and then learning how to ride a bicycle and running. Is your child playing sports? Do they like it? How good are they? Are they feeling confident in that? Again, sometimes it is as simple as asking parents, are you concerned? Because parents are on the playground.
They are in the kid's birthday parties and they are noticing. Everyone is doing that, and climbing, and going, and my child isn't. Asking parents is the first thing, checking motor milestones, and then there are a few things that you can do for screening. One is, ask that child to stand on one leg, and it is as simple as that, and we can put a few, like a little table for your listeners somewhere on the website, just a screening tool there.
So, by five or six years old, they should be able to stand on one leg for more than a few seconds. If they are unable, that should raise your concern and say, why don't we pursue a balance and vestibular assessment for your kid and just see what comes up. I bet you, a lot is going to come up. You will notice that things are going to come from those parents.
It's just that they probably don't think about telling you that. They don't necessarily see this as we think the scope of practice of the audiologist, and if the audiologist doesn't ask, it becomes this gray area that nobody's touching, nobody's making—nobody's making that relationship between balance and hearing.
Rebecca: Yeah, if you don't—sometimes if you don't go looking for it, you won't find it, right?
Erica: That's a very good quote and I love it. You have to know what you're searching for in order for you to find it.
Rebecca: Yeah, so in BC with kids, and vestibular, and there is some concern, where do they go? I don’t know where we send them.
Erica: That's a tough one. I have heard a few things about a service being implemented at Children's Hospital, BC Children's Hospital. I do not know, I don't have any official information about that vestibular testing facility there in BC.
I would say that their new cardiologists should try and find it a colleague, an audiologist within their region. Right now, there are audiologists, myself in private and other people in private in the lower mainland doing vestibular, and any audiologist reaching out to us. We are going to try and be resourceful.
There are audiologists doing vestibular on the island privately. There's one up north. There's one in the near the interior. We are few and far in between, but seek the ones of us who are doing some work in vestibular, even if it is in the adult population, we wouldn't be more than happy to give you resources and try and find then people who could be doing vestibular rehabilitation for these kids.
The good thing is that we can test. It is not only hearing that we can test at young ages. We can also test the vestibular system at very young ages. We can adjust, it’s very similar to what we do in hearing tests that we adjust our testing battery according to the child's age and development. We do the same for vestibular testing.
We would address it. It is trickier in the public system. Yes. It is even for adults now the wait list is around a year for adults. A child does not have the luxury of waiting a year for assessment, unfortunately.
Rebecca: What are some of these sort of—I'm sure there's a lot of, as you mentioned, undiagnosed, the statistics of that, I'm sure are really high. Some of the negative implications of that down the road, kind of going undiagnosed.
Erica: Yeah. I think it all boils down to quality of life. These kids are already struggling because of their hearing loss. I'm not going to talk about it because it's well-known, all the impacts that hearing loss has in all aspects of a child's development, academically, emotionally, socially, all of that, when you add a vestibular disorder that is undiagnosed, it is an invisible burden there for that child and that family.
I think that we can draw from our experience with the pandemic and what is the anxiety of not knowing. When you don't know, when there is something that is wrong and you cannot put your finger on it, and sadly, it is very puzzling, and you would see these kids and these families just have moments where you go like, I did not know that. How didn't anyone tell me? It is hard, right?
Rebecca: Yeah, you can relate to that with anything. If there's something going on and you just don't know what it is, even if it's for a short period of time, it can be unsettling for sure. To go through that for years and years would take a real toll I think on a family as a whole
Erica: One hundred percent. I think that primarily it would add it to the overall quality of life. But then there is going to be some, of course, obvious, more obvious impact in sports performance and that child not being very good and not being the one chosen for the team, and not being very athletic. But what is interesting too, is that again, from SickKids in Toronto, there's been now a research looking into learning, learning in general.
What would a vestibular have to do with learning? Well, it has everything to do because spatial orientation has everything to do with learning. When a child has hearing loss and vestibular loss, their sense of where they are in space is developing completely different than their hearing peers.
We are now learning that this has an impact on several aspects of learning in attention, in memory, I mean, decoding cognitive abilities. We don't know yet how this is directed or indirectly related, and I will make the comparison with all the link between hearing loss and dementia, it might not be a direct link. It's not cause and effect necessarily, but we know that the vestibular system is one of the systems that is the bottom of the pyramid of learning in general.
It is not by chance that little kids play and just do pirouettes. It was interesting, I remember Christmas time, I went to VanDusen Gardens and there were two little girls and they were just spinning around and laughing, and spinning around and laughing, and one of the parents came and said, stop girls, you're going to be dizzy, you're going to fall off, and then they're just looking at each other and spinning and laughing, and they couldn't care less that the parents would say that they were going to be dizzy and fall off. They want to be dizzy.
It's part of experimenting, and growing, and learning, and learning about their bodies, and how their bodies move in space, and this is as I said, the bottom of the pyramid for many cognitive processes that are then impairing these kids. To an extent to that again, we don't even know yet, but we have inklings. We see that.
Rebecca: Besides SickKids, is there other kind of big facilities looking at vestibular in kids? Obviously maybe not Canada.
Erica: In the US. Yes. There is a large body of research coming from France in pediatric vestibular disorders. I believe Boys Town in the US is one that has a strong vestibular department. There are centers in children's hospitals and audiology centers in the US, and there's a large facility in France doing vestibular research, and in Canada for sure, Dr. Sharon Cushing and SickKids.
Rebecca: Okay, cool. This is probably maybe more related to the adult population, because that's a little bit of your domain with your clinic, but just a little bit about the rehabilitation process, just because I find that so interesting, if you could share just a couple of tidbits on that. I'm sure there is probably for everyone, every patient you see is probably very different. Do you have to tailor that process for everyone? What does that kind of look like?
Erica: Yeah, and I like that we as audiologists, because of the fact that we have more diagnostic tools in our toolbox, we are better, and it is within our wheelhouse. We are very comfortable diagnosing things and saying, yes, you have a hearing loss of that degree affecting those frequencies, and this is the mechanism by which say, if it's a conductive or sensory neural hearing loss, we like that physiopathological way of thinking and seeing things. When we apply that to the vestibular system, what I say to patients is that, well, let's try and reverse engineer your dizziness let's try and understand how your dizziness did come about.
In that, we tailor vestibular rehabilitation very much so. Again, I like to say that this is a privilege of the audiologist. It's an advantage point that we have, that is very unique and we should take more advantage of that as opposed to physiotherapists who are not that familiar with the inner ear and tend to approach vestibular rehabilitation from a symptomatic perspective.
They say, well, you get dizzy with head movements. Here, I'm just going to give you a bunch of head movement exercises in many different ways and many different directions, and we'll see what happens. That patient might not even understand, might never understand why was it that I was getting dizzy in the first place when I moved my head.
Whereas the audiologist will try to, okay, let me see, why is it that you're getting dizzy when you move your head? When we figure out why, then we tailor the management strategies to that particular patient. It might be that, say for instance, and I will say, we will use this example because it applies to both adult and pediatric population.
Vestibular migraine, dizziness that is related to migraine activity in the brain. One of the most common causes of dizziness in both adult and the pediatric population. Yes, the mechanism is really your brain being unable to process movement as well as it should, as well as you are non migraine-r peers.
When you understand that this is a brain processing issue, then you can teach those patients how to prevent migraine, give some activity on how to reduce migraine activity in the brain, as opposed to just let me try and exercise and see what happens. We can be more comprehensive. We can be more targeted. Hopefully, we have better chances at addressing and helping those patients. Yeah, as tailored as possible.
Rebecca: That's kind of a good full circle back to what I was saying at the beginning about it being kind of daunting, I guess, in a way to get involved or even to know where to begin, I think, can be challenging. How do we go about learning more about it?
Erica: Yes. I will direct the listener to an article that I wrote for the Canadian audiologist a while back where I proposed a tiered approach to vestibular disorders. Precisely thinking about how can an audiologist start dipping their tools into vestibular without the major uptaking of, I'm going to buy many thousands of dollars pieces of equipment. I don't even know if I have anyone who is going to be interested in that. I don't know if I'm going to have referrals. Is this something that I really want to do? How can you start dabbing into vestibular with very little investment?
What I would say to the audiologist who's interested in starting to incorporate some vestibular work in their practice is to start asking questions. In your case, history, as a way to start engaging. Are these people around me, would I have—do I have anyone to practice? Is there an interest in me doing any vestibular in my community? You will probably find that there is. Speaking of your community, start learning about in your community, who is doing vestibular.
Are there any physiotherapists who are really interested? Is there an ear, nose, and throat doctor who is interested, or a neurologist who is doing this in my community? Of course, you can start very little with equipment and you can just buy lenses that are frenzel glasses it's called.
It is not computerized, but it is just a way to start assessing simple things such as BPPV. It is a matter of starting slow and then you can build your practice from there, from the demand that you see in your community, from the interest that you would see these other professionals having, from these connections that you make with them.
Then of course, you're going to start seeking more training. Yes, there is more training now being offered in Canada, and I am very happy to see that manufacturers and even SAC and CAA, they are starting to offer and even universities are offering more vestibular content. Seeking people who are in clinic, who are doing vestibular, getting them as mentors, and then start building a practice. It doesn't have to be all or nothing, I think that's the main message that I have here for audiologists. You can start slowly and build your confidence in vestibular.
Rebecca: Yeah. Is there anything that you missed, or final thoughts, or notes that we didn't hit on?
Erica: Yeah, I think I will just take a step back because I found myself talking about balance and vestibular kind of interchangeably. I kind of want to talk a little bit more about what is what. When we talk about the vestibular system, it's really that forgotten half of the inner ear, as I say, right? We are talking about the semicircular canals, and utricle, and saccule, and their specific connections to the brainstem and other parts of the brain, and so the central nervous system projections of the inner ear sensors.
This is vestibular, [inaudible 00:32:14]. The vestibular system is the primary source of information for the brain for human balance. If you think about all the other mammals that are on four feet whereas humans are on two feet and how our balance is very specific and a very complex system.
The brain then gets information not only from the inner ear, from the vestibular system for balance, but it also gets information from vision, and from proprioception. All the sensation on the skin, muscles, joints. It's this tripod between inner ear, vision, and proprioception, all committed by the brain that we call balance.
Balance is bigger, balance is more or less the outcome. Balance is how well can I walk? Can I walk a straight line? Can I just do everything that I want to do and not feel dizzy versus vestibular, which is the inner ear sensors and their projections to the central nervous system. Again, it is within the scope of practice of the audiologist to assess the vestibular system as an essential part of balance.
I always say, we don't own balance, because again, balance involves the whole body, and physiotherapists, kinesiologists, occupational therapists, and all sorts of people who deal with movement will also have within their scope of practice to work with balance, but the vestibular system is our wheelhouse. All the magic starts there and that's where I always advocate for, again, as audiologists take that aim.
Rebecca: Yeah, that makes sense. I mean, I'm almost nine months pregnant right now and my balance is very much off. I tripped down the stairs yesterday and it was just like, oh my God, unrelated to the inner ear, perhaps to the vestibular. I don't know. But I'm definitely hitting things, hitting doorways or feeling off balanced which probably has more to do, I guess, with my center of gravity. But yeah, it's like the vestibular system incorporates balance, but does balance always incorporate the vestibular system?
Erica: That's a very good question. Balance always incorporate the vestibular system. Balance uses the vestibular system. But using our perfect example, you can have a balance disorder and the origin of it might not be vestibular at all. So chances are that your vestibular system is just fine with pregnancy, everything is okay. But now, your proprioception, it is your musculoskeletal system and your center of gravity has changed.
There's a lot more mass in your body. Everything is being pulled forward because of your big belly, because of your bump, because of your little human being that you're carrying there. It's heavy and it pulls you forward, and so adjusting. I always say, balance is this very complex, very quick dialogue between the body and the brain. All these parts of the body and the brain, and then readjusting the body.
What you're telling me is that as I'm growing, Erica, I'm going so large now that my brain isn't even able to catch up with how much more I'm being pulled forward and I am unable to readjust to that very quickly. That is part of the puzzle that I find very attractive in vestibular diagnostic. Having someone come and tell me what is going on with them and me playing detective and trying to troubleshoot the whole system, and try and understand, what is going on, and what could be causing that in order to just say, oh no, likely this is what is going on with you.
I have had actually patients who are pregnant and get a vestibular disorder. I would say, yes, right now, as you are eight and a half months pregnant, it's not a good idea for us to just do a lot of vestibular rehabilitation. It turned out that she was pregnant with twin babies. The twins were born two weeks after and then we started vestibular rehab. But as her body changed over growing a little bit more pregnant, and then having the babies, and then readjusting to having had a vestibular loss, that was quite the process for her.
There was a vestibular [inaudible 00:37:29] and the body that was changing, and it was quite a lot for her brain to process. But again, I find it fascinating. People can probably tell. That is one of the things, again, going back to audiologists being involved in vestibular, there is a learning curve, not only with regards to doing vestibular testing that as opposed to just doing our regular hearing tests or even electrophys that you look at the waveforms, you are looking at eyeball movements.
It can be daunting to just say, okay, I'm going to buy those VNG goggles, they’d be looking at eyeballs. What am I going to do here? Also, it can be a little bit daunting learning about human balance and all these other concepts. Central gravity, ankle strategy, hip strategy, why is it I feel a little bit like a physiotherapist. But once again, it is within our scope of practice, and it is a fun thing to do.
Rebecca: Yeah. Everyone's always interested in it, when you think, well I shouldn't say everyone, but my class was anyway.
Erica: Yeah, and I do feel that there will be more of an interest. I am seeing more people being involved and services starting to expand into not only hearing clinics, but hearing and balance clinics, or hearing and dizziness clinics where even within hearing you don't only offer hearing, but you’ll also offer tinnitus, and having hyperacusis, and other concerns, or auditory processing disorder services. I think that this broadening of the audiology is going to be welcomed by patients or clients. I think they will be interested in having us take care of more than one concern.
Rebecca: Yeah, absolutely. What's next for you? Do you have—you've got things, talks, and papers, or?
Erica: It's always good. There are always things cooking. I will be at the SAC May event. There is an event in Toronto, May 12 I want to say, and I will be giving a whole day of talks. The morning will be vestibular diagnostic, vestibular assessment, and then it is going to be my first vestibular rehabilitation talk the whole afternoon. I will go into detail of how it is that we in audiology can approach vestibular rehabilitation. I would love to see a lot of BC faces there in Toronto in May. I am working with Pacific Audiology Group on fundamentals of vestibular assessment course, and I should be doing some scripting and some shooting of that course. But that's coming down in…
Rebecca: Yeah. I was just talking with Chris yesterday actually.
Erica: Yes. I'm not doing so well with the scripting, but that is coming.
Rebecca: It's a lot of work I'm sure, to write all of that.
Erica: You wouldn't think, but yes, it is. When they explained to me, this is all you do, and I go like, oh, really? All those steps. It seems easy, but it isn't. I so appreciate and praise everyone at Pacific Audiology Group because the quality of this is going to be…
Rebecca: Yeah, that's so cool. People will be able to sign up for that course through Pacific Audiology Group?
Erica: Yeah.
Rebecca: Awesome.
Erica: That will give audiologists just the fundamentals. How can I get comfortable with the basic initial vestibular assessment? Then from there, hopefully, we can build on something else. There is going to be another event back East in June with Diatec which is representative for HR acoustics for equipment. Stay tuned for that too. It will come, so more training opportunities. It's going to be a busy first semester and I'm looking forward to all of that.
Rebecca: Great. Awesome. Thank you so much again for coming on and chatting.
Erica: Thank you.
Rebecca: We try to release episodes monthly, so there'll be like a little bit of a lag from when this one gets out, but it'll still be very much relevant for sure.
Erica: Perfect.
Rebecca: Okay. Thank you so much.
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