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Vestibular Testing: Uncovering the Root of Balance Problems

April 16th, 2024 | 5 min. read

By Mark Nichols, MD

Vestibular Testing

The vestibular system maintains our sense of balance and spatial orientation. It consists of a complex network of structures in the inner ear, including the semicircular canals and otolith organs. These structures help us perceive and interpret movements and changes in our head position. When the vestibular system is not functioning properly, it can result in dizziness, vertigo, and problems with balance.

Understanding the Vestibular System

By understanding how the vestibular system works, healthcare professionals can better diagnose and treat balance problems. Vestibular testing plays a crucial role in this process, as it helps identify any abnormalities or dysfunctions in the vestibular system.

Common Balance Disorders

  • Benign Paroxysmal Positional Vertigo (BPPV): This is one of the most common balance disorders. It occurs when tiny calcium crystals (otoconia) in the inner ear become dislodged and enter the semicircular canals. Sudden head movements cause these crystals to move, sending incorrect signals to the brain and resulting in brief but intense vertigo episodes.

  • Meniere's Disease: This chronic inner ear disorder causes recurrent vertigo episodes that can last minutes to hours. It also involves fluctuating hearing loss, tinnitus (ringing in the ears), and a feeling of fullness or pressure in the affected ear. The exact cause of Meniere's is unknown, but it's thought to involve fluid buildup in the inner ear.

  • Vestibular Migraine: These are migraine headaches accompanied by dizziness, vertigo, or balance problems. These vestibular migraines are a subcategory of migraine that are not typically associated with headaches.

  • Labyrinthitis: This refers to inflammation of the inner ear labyrinth, usually caused by a viral infection. It results in sudden onset of vertigo, dizziness, nausea, and sometimes hearing loss. Symptoms usually improve within a few weeks but can occasionally linger.

  • Vestibular Neuritis: This condition involves inflammation of the vestibular nerve, which connects the inner ear to the brain. It often follows a viral illness and causes sudden, severe vertigo, nausea, and unsteadiness. Similar to labyrinthitis, symptoms tend to subside gradually over weeks as the brain compensates for the nerve dysfunction.

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How Vestibular Testing Helps

Each of these conditions produces slightly different patterns of symptoms and responds best to specific treatments. Vestibular testing is invaluable in distinguishing between them:

  • BPPV: Positional testing during VNG will often show characteristic eye movements (nystagmus) triggered by head position changes.

  • Meniere's Disease: Audiometry testing will likely demonstrate hearing loss, while an EcochG can sometimes detect excess fluid pressure in the inner ear.

  • Vestibular Migraine: Diagnosis depends on a combination of symptom history and ruling out other causes through vestibular tests.

  • Labyrinthitis and Vestibular Neuritis: VNG caloric tests may indicate decreased function on the affected side, and ABR testing can assess if hearing nerve pathways are also impacted.

Importance of Accurate Diagnosis

Getting a precise diagnosis through vestibular testing is crucial because:

  • Targeted treatment: BPPV responds to repositioning maneuvers, Meniere's Disease can be managed with medications and dietary changes, and vestibular migraines might require preventive medications.

  • Reassurance: Differentiating between temporary conditions like labyrinthitis and long-term disorders like Meniere's Disease reduces anxiety.

  • Proactive management: Knowing the specific disorder better prepares individuals and healthcare providers to manage symptoms and prevent complications.

Several common balance disorders can be diagnosed through vestibular testing. One example is benign paroxysmal positional vertigo (BPPV), characterized by brief episodes of vertigo triggered by specific head movements. Another common balance disorder is Meniere's disease, which causes recurring episodes of vertigo, hearing loss, and tinnitus. Other balance disorders include vestibular migraine, labyrinthitis, and vestibular neuritis.

Identifying the specific balance disorder is essential for developing an appropriate treatment plan. Vestibular testing helps healthcare professionals determine the underlying cause of the balance problem and tailor treatment accordingly.

Types of Vestibular Tests


Videonystagmography (VNG)

  • Purpose: VNG provides a comprehensive evaluation of the vestibular system's function and its interaction with the central nervous system. It is the most widely used vestibular test.

  • Procedure:
    • Oculomotor Tests: The patient follows a moving light with their eyes while wearing specialized goggles that track eye movements.

    • Positional Tests: The patient's head is moved into different positions, and the goggles record any involuntary eye movements (nystagmus), helping pinpoint Benign Paroxysmal Positional Vertigo (BPPV).

    • Caloric Tests: Warm and cool air or water is gently introduced into each ear canal. The goggles record how the eyes respond, assessing if both sides of the vestibular system are functioning equally.

  • Diagnoses Aided: BPPV, vestibular neuritis, labyrinthitis, Meniere's disease, central nervous system disorders affecting balance.

Rotary Chair Test

  • Purpose: This test measures how well the vestibulo-ocular reflex (VOR) functions. The VOR allows you to maintain stable vision while your head is moving.

  • Procedure: The patient sits in a computerized chair that rotates at varying speeds in a darkened room. Eye movements are recorded to assess the VOR and detect any weaknesses in the vestibular system on one side or the other.

  • Diagnoses Aided: Bilateral vestibular weakness (weakness on both sides), central nervous system disorders, compensation levels after vestibular damage.

Auditory Brainstem Response (ABR)

  • Purpose: ABR primarily evaluates the auditory nerve and brainstem pathways involved in hearing. However, it can also provide some information about vestibular nerve function.

  • Procedure: Electrodes are placed on the head, and clicking sounds are delivered through earphones. The electrodes measure the brain's electrical response to these sounds.

  • Diagnoses Aided: Hearing loss, auditory nerve tumors (acoustic neuromas), brainstem lesions, and sometimes used to assess vestibular nerve function in conditions like vestibular neuritis.

Electrocochleography (ECochG)

  • Purpose: ECochG directly measures the electrical activity of the inner ear (cochlea), providing information about its function. This helps differentiate between inner ear and hearing nerve problems.
  • Procedure: A small electrode is placed either through the eardrum onto the inner ear or inside the ear canal. Clicking sounds are presented, and the electrical responses of the inner ear are recorded.
  • Diagnoses Aided: Meniere's disease (helps assess fluid buildup in the inner ear), hearing loss caused by inner ear issues, and can sometimes give insights into vestibular function.

Vestibular Evoked Myogenic Potentials (VEMP)

  • Purpose: VEMP tests specifically assess the function of the otolith organs (utricle and saccule) within the vestibular system and related nerve pathways. These organs sense gravity and linear movement.

  • Procedure: Electrodes are placed on neck muscles (cVEMP test) or around the eyes (oVEMP test), and loud clicks or tones are delivered. The electrodes measure muscle reflexes triggered by the sound stimulation.

  • Diagnoses Aided: Superior canal dehiscence (a hole in the bone of the inner ear), vestibular neuritis, Meniere's disease, and other disorders affecting the otolith organs.

Benefits of Early Detection and Treatment

  • Improved Treatment Outcomes: When balance problems are caught early, treatment is often more effective. Conditions like BPPV and vestibular neuritis often respond very well to specific therapies if addressed promptly. Early diagnosis gives the best chance of minimizing symptom severity and restoring balance function.

  • Reduced Risk of Long-Term Complications: Untreated balance disorders can lead to further complications over time. For example:

    • Unmanaged dizziness and vertigo can worsen, significantly impacting daily life.
    • Constant balance issues increase the risk of falls and injuries, especially in older adults.
    • Some conditions, if left untreated, can cause permanent damage to the vestibular system.
  • Preservation of Independence: Balance problems can severely limit mobility and independence. Early intervention allows for treatments like Vestibular Rehabilitation Therapy (VRT), helping individuals regain balance and confidence. This can make a huge difference in maintaining an active lifestyle.

  • Prevention of Secondary Issues: Balance disorders often lead to secondary problems due to the way they impact functioning:

    • People may reduce activity levels due to fear of falls, leading to muscle weakness and further balance decline.
    • Dizziness and disorientation can cause anxiety or depression, impacting overall well-being.
  • Better Quality of Life: The constant struggle with dizziness, instability, and potential falls creates significant stress. Early diagnosis and treatment help restore a sense of control, lessening anxiety and allowing people to participate fully in activities they enjoy.

The Importance of Not Ignoring Symptoms

Many people dismiss dizziness or unsteadiness as a normal part of aging or "just being clumsy." However, these symptoms shouldn't be ignored. Prompt evaluation with vestibular testing can determine if there's an underlying, treatable condition. Often, even seemingly minor balance issues can be significantly improved with the right intervention, preventing them from becoming a major life disruption.

In conclusion, vestibular testing is crucial in uncovering the root causes of balance problems. By understanding the vestibular system, identifying common balance disorders, emphasizing the importance of vestibular testing, explaining the different types of vestibular tests, and highlighting the benefits of early detection and treatment, individuals can better understand how vestibular testing can help address their balance issues and improve their overall well-being.

Mark Nichols, MD

Mark Lynn Nichols, M.D., received his Bachelor of Science degree with Honors in Pharmacy in 1983, prior to his entering the University of Texas Medical Branch, Galveston, Texas, where he received the degree of Doctor of Medicine with Highest Honors. Following his Internship in General Surgery, and Residency in Otolaryngology at UTMB, Dr. Nichols did a Fellowship in Otology-Neurotology at the Ear Research Foundation, in Sarasota, Florida. He is a member of several professional associations, and is a Diplomat of the American Board of Otolaryngology.