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Microsoft word - vng consent _03-2007_.doc

INFORMED CONSENT
Visualnystagmography (VNG): Evaluating Dizziness VNG is a test to evaluate the possible etiology of your dizziness. This test takes approximately one hour.
You should schedule this evaluation on a day that you can have time to rest after the test as it does typically
induce some fatigue. By having this evaluation completed, we can often determine potential causes of your
symptoms and plan a course of treatment.
Description of the test: During your VNG, you will be wearing a set of goggles containing infrared
cameras that will be recording the movement of your eyes. During parts of the test, the goggles will be
capped and you will be in the dark.
The VNG is divided into three parts:
1. Ocular-Motor Evaluation: This part of the test evaluates your eye muscles and central nervous system. You will be asked to follow a red light during different tasks over a period of 10-15 minutes. The light moves vertically and horizontally at variable speeds. 2. Positional Evaluation: This part of the test evaluates both your central nervous system and the balance organs of your inner ear. You will be asked to sit, lie down, turn your head, and to lie on your side. Part of this test involves a rapid change in position from a sitting to lying down position and is modifiable if necessary due to back and or neck disorders. Most of this portion of the test takes place with the goggles capped and lasts approximately 10 minutes. 3. Caloric Evaluation: This part of the test evaluates the function of the balance organs of the inner ear. During the test, you will be lying comfortably on your back while wearing the capped goggles. Cool and then warm air will be introduced into each ear canal for approximately 2 minutes at a time. This change in the temperature of the ear canal will induce some dizziness. After the two minutes are up, the cap will be removed from the goggles and you will be asked to stare at a point on the ceiling. During this fixation period, the dizziness will subside. You will be allowed to rest for approximately 3-5 minutes between each portion of the evaluation. It is important to remember that, while you may feel dizzy during the test, you should feel better by the time you leave. If you are concerned about the lasting effects of nausea, you are encouraged to bring a friend or family member with you to drive you home.
Important things to remember:

1. No sedatives, tranquilizers, vestibular suppressants (including meclizine, Bonine and Antivert), or other
medications that make you sleepy for 48 hours prior to the test. Scolpamine patches must be discontinued 5 days prior to evaluation. Please call us if you are unsure about a medication. 2. No alcohol for 48 hours prior to the test. No Benedryl or PM medications (Tylenol/Advil PM) 3. No makeup, face lotion, or sunscreen on the face the day of the test (This includes all eye makeup). 4. Please wear comfortable clothing. 5. Avoid eating a heavy meal at least 2 hours prior to testing. This is to prevent nausea. 6. Please bring a case/solution if you wear contact lenses as they cannot be worn (or wear glasses). 7. A CO-PAY MAY BE CHARGED FOR DIAGNOSTIC TESTING IN ADDITION TO THE CO-PAY CHARGED FOR THE CONSULTATION WITH OUR DOCTORS. THIS VARIES BY INSURANCE PLAN. IF THERE IS A SECOND CO-PAY THIS WILL BE DUE ON THE DATE OF SERVICE. Common aftereffects of the test include: Headache, fatigue, minor earache, residual nausea and mild vertigo lasting a few hours. Other possible complications*: Tympanic membrane perforation, anxiety, spinal injury, persistent vertigo/ nausea, cardiac arrest *While these complications have been reported in the literature, please remember that these are very rare. _____________________________________

Source: http://carlsonent.com/wp-content/uploads/VNG_Consent_03_2011.pdf

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