Patients presenting to the emergency department with acute vertigo pose a diagnostic challenge. While ‘benign’ peripheral vestibulopathy is the most common cause, the possibility of a posterior circulation stroke is paradoxically the most feared and missed diagnosis in the emergency department.

This review will attempt to cover the significant advances in the ability to diagnose acute vertigo that have occurred in the last two decades. The review discusses the role of neurological examinations, imaging and specific oculomotor examinations. The review then discusses the relative attributes of the Head Impulse-Nystagmus-Test of Skew plus hearing (‘HINTS+’) examination, the timing, triggers and targeted bedside eye examinations (‘TiTrATE’), the associated symptoms, timing and triggers, examination signs and testing (‘ATTEST’) algorithm, and the spontaneous nystagmus, direction, head impulse testing and standing (‘STANDING’) algorithm. The most recent technological advancements in video-oculography guided care are discussed, as well as other potential advances for clinicians to look out for.

Balance dysfunction and vestibular conditions are major problems requiring significant resources. There is significant national and international variation in management pathways for such patients.

This paper outlines a collaborative project run by the ENT department and two vestibular rehabilitation trained physiotherapists to establish a clinic to manage patients referred to ENT with vestibular and/or balance complaints. As part of a six-month pilot, two physiotherapy-led balance clinics were provided per week.

A total of 159 new patients were seen, with only 15 needing ENT consultant input. This led to the successful creation of substantive posts; the clinic has seen 698 patients in its first two years.

Patient outcomes and experience have been positive, and accompanied by reduced waiting and in-service times. The authors discuss some of the pitfalls, challenges and opportunities of developing this type of clinic.

This pilot study aimed to evaluate a training programme for primary care physiotherapists focused on the assessment and management of benign paroxysmal positional vertigo.

A six-month training programme and toolkit utilising the revised Standards for Quality Improvement Reporting Excellence (‘SQUIRE 2.0’) guidelines was developed to facilitate the learning of new knowledge and skills in the assessment and management of benign paroxysmal positional vertigo following Gagne's model of instructional design. A pre- and post-training knowledge and confidence questionnaire evaluated the impact of the training programme.

Eleven participants started the training programme and five completed it. On average, knowledge increased by 54 per cent (range, 41–95 per cent) and confidence increased by 45 per cent (range, 31–76 per cent). A 73 per cent improvement in practical skills acquisition was demonstrated after the initial training session.

A structured approach to learning demonstrates improvements in knowledge, skills and confidence of physiotherapists in the evidence-based management of benign paroxysmal positional vertigo.

To examine the newly established role of a primary contact physiotherapist in an ENT clinic, in an Australian cohort and context, over two phases of development.

A retrospective cohort study was conducted with data collected from a medical record audit. Over the study duration, the primary contact physiotherapist completed initial appointments with patients; follow-up appointments were subsequently conducted by medical staff.

There was a 46 per cent reduction in patients with suggested vestibulopathy requiring an ENT medical review. This reduction could hypothetically increase to 71 per cent with follow-up primary contact physiotherapist appointments. Improvements in the service delivery model and a primary contact physiotherapist arranging diagnostic assessments could improve waitlist times and facilitate better utilisation of medical staff time.

The primary contact physiotherapist can help in the management of patients with suspected vestibulopathy on an ENT waitlist. This is achieved through: a reduction of patients requiring ENT review, improvements to waitlist time and improved utilisation of medical specialists’ time.

Persistent postural-perceptual dizziness classifies patients with chronic dizziness, often triggered by an acute episode of vestibular dysfunction or threat to balance. Unsteadiness and spatial disorientation vary in intensity but persist for over three months, exacerbated by complex visual environments.

Literature suggests diagnosis relies on a clinical history of persistent subjective dizziness and normal vestibular and neurological examination findings. Behavioural diagnostic biomarkers have been proposed, to facilitate diagnosis.

Research has focused on understanding the neural mechanisms that underpin this perceptual disorder, with imaging data supporting altered connectivity between neural brain networks that process vision, motion and emotion. Behavioural research identified the perceptual and motor responses to a heightened perception of imbalance.

Management utilises head and body motion detection, and downregulation of visual motion excitability, reducing postural hypervigilance and anxiety. Combinations of physical and cognitive therapies, with antidepressant medications, help if the condition is associated with mood disorder.

Differential diagnosis of acute vertigo syndrome is challenging given the similarities between clinical presentations of posterior circulation stroke and peripheral vestibular dysfunction. The Head Impulse, Nystagmus, Test of Skew (‘HINTS’) assessment is a clinical bedside test used to aid diagnosis.

Comprehensive training on use of the Head Impulse, Nystagmus, Test of Skew assessment was provided to one stroke consultant, and the effectiveness of the test in that setting was assessed. Further education was completed with more members of the stroke and emergency department multi-disciplinary team. Quality improvement measures including magnetic resonance imaging use and bed utilisation were explored.

Following training of one stroke consultant, the Head Impulse, Nystagmus, Test of Skew assessment was found to be a feasible, accurate bedside test within this acute stroke service. Further training for the multi-disciplinary team was completed, but outcome measures were not explored because of the coronavirus disease 2019 pandemic and maternity leave.

There is a role for trained members of the multi-disciplinary team to successfully use the Head Impulse, Nystagmus, Test of Skew assessment in hyperacute stroke settings, to aid diagnosis in acute vertigo syndrome.

Driving capacity is affected by vestibular disorders and the medications used to treat them. Driving is not considered during medical consultations, with 92 per cent of patients attending a centre for dizziness not discussing it with the doctor.

To investigate if medical record prompts facilitate dizziness and driving conversations in ENT balance clinics.

A questionnaire was designed to reflect the current standards of practice and advice given regarding driving and dizziness during balance clinic consultations.

Medical record prompts facilitated the improved frequency and recording of shared decision-making conversations about driving and dizziness in 98 per cent of consultations.

This study highlights the benefits of medical record prompts for documented and accurate shared decision-making conversations surrounding dizziness, vertigo, vestibular conditions and driving. This potentially improves safety for all road users, and protects the patient and clinician in the event of road traffic accidents and medico-legal investigations.

Using Otoplan software, it is possible to measure the cochlea before cochlear implant surgery. Until now, computed tomography (CT) of the cochlea has been necessary for this purpose. The aim of this study was to find out whether measuring the cochlea with magnetic resonance imaging (MRI) using Otoplan is possible with the same accuracy.

The cochlea of 44 patients of the local cochlear implant centre was measured by Otoplan using high-resolution CT-bone and MRI images, and the determined lengths were compared.

No significant difference was found between the cochlear lengths measured, regardless of whether the length measurement was based on a CT or an MRI data set.

For the determination of cochlear length prior to cochlear implant surgery, MRI images are just as suitable as CT images, therefore CT is not mandatory for length measurement by Otoplan, which could reduce the patient's radiation exposure.

The study aimed to compare ipsilateral and contralateral electrically evoked stapedial reflex thresholds in children with a unilateral cochlear implant surgically implanted either through Veria or posterior tympanotomy approaches.

Forty-nine children using cochlear implants were studied, of whom 27 underwent the Veria approach and 22 underwent the posterior tympanotomy approach. The electrically evoked stapedius reflex thresholds were measured ipsilaterally and contralaterally by stimulating four equally spaced electrodes.

The ipsilateral electrically evoked stapedius reflex threshold was absent in all four electrodes in the children implanted using the Veria approach. However, the ipsilateral electrically evoked stapedius reflex threshold was present in 70 per cent of the children implanted using the posterior tympanotomy approach. The contralateral electrically evoked stapedius reflex threshold was present in most of the children for both surgical approaches.

The presence of the ipsilateral electrically evoked stapedius reflex threshold varies depending on the surgical technique used for cochlear implantation. However, contralateral reflexes are present in the majority of children using cochlear implants, irrespective of the surgical approach.

There have been many studies linking falls and benign paroxysmal positional vertigo. This article collates those studies, and demonstrates how a community falls service fast-tracked patients with benign paroxysmal positional vertigo by implementing validated screening tools and recognised guidance.

This study aimed to explore whether routine screening of referrals to a community falls service can identify those with benign paroxysmal positional vertigo, for fast-tracked management.

Patients referred to a community falls service were screened for possible benign paroxysmal positional vertigo using the Dizziness Handicap Inventory, and triaged to a physiotherapy-led falls and benign paroxysmal positional vertigo assessment service.

Twenty-five per cent of patients were fast-tracked to a falls and benign paroxysmal positional vertigo assessment service for management. The community falls service waiting list reduced by 25 per cent.

The data support incorporating assessment and treatment of benign paroxysmal positional vertigo into routine practice within all falls services.

Vestibular migraine is a newly recognised and debilitating condition. This article aims to provide an overview of what is known of vestibular migraine, delineating its diagnostic criteria and presenting some initial management strategies to aid ENT professionals in delivering optimal care when patients first present to the otolaryngology clinic.

Although traditionally underdiagnosed, there are now clearly defined diagnostic criteria to aid accurate diagnosis of vestibular migraine.

A detailed history and clinical examination are the cornerstone of the diagnostic process, but supportive evidence is required from appropriate audio-vestibular tests and imaging.

This is a unique condition that commonly initially presents to ENT. This article provides a summary of diagnostic and management strategies to facilitate early diagnosis and first-line treatment that can be employed in general ENT settings, which may be particularly useful given the limited availability of specialist audio-vestibular medicine and neuro-otology services.

There is a high prevalence of dizziness, vertigo and balance symptoms in the general population. Symptoms can be generated by many inner-ear vestibular disorders and there are several diagnostic tests available that can help identify the site of the vestibular lesion. There is little consensus on what diagnostic tests are appropriate, with diagnostics either not completed or minimally performed, leading to missed diagnosis, unsatisfactory results for patients and costs to healthcare systems.

This study explored the literature for different neuro-vestibular diagnostic tests not currently considered in the traditional standard vestibular test battery, and examined how they fit effectively into a patient care pathway to help quickly and succinctly identify vestibular function.

A vestibular patient care pathway is presented for acute and subacute presentation of vestibular disorders.

An accurate diagnosis following a rigorous anamnesis and vestibular testing is paramount for successful management and favourable outcomes.

The hidden cochlear implant concept has two data transmission methods: Bluetooth low energy and transtympanic optical data transfer systems. This study aimed to present the hidden cochlear implant and compare the test results with the existing fully implanted cochlear implant.

The Bluetooth low energy module was implanted into the implant bed. For the transtympanic optical data transfer tests, a receiver was passed through the posterior tympanotomy, and the transmitter was placed in the ear canal.

The Bluetooth low energy module range was 5.2–17.5 m. Transtympanic optical data transfer reached a rate of 1 Mbit/s and had 99.22 per cent accuracy. Despite various obstacles, the accuracy of the transtympanic optical data transfer was more than 99 per cent with a 250 Kbit/s rate. The average power consumption was 310 mW for the implanted Bluetooth low energy module and 41 mW for the transtympanic optical data transfer receiver.

Bluetooth low energy is suitable to be used transcutaneously. Transtympanic optical data transfer is an effective and promising technology. Hidden use cochlear implants aim to have the aesthetics of a fully implantable cochlear implant with higher reliability and a magnet-free design with smart device integration.

This article presents the case of an adolescent with asymptomatic coronavirus disease 2019 infection who had vestibular neuronitis symptoms.

The new coronavirus disease 2019 demonstrates neurotropic properties, apart from airway symptoms. Early in the pandemic, coronavirus disease 2019 infection had been associated with olfactory disturbances. Accumulative evidence supports that both the infection with coronavirus disease 2019 and the vaccination against the virus may induce a condition of vestibular hypofunction, known as vestibular neuronitis. Coronavirus disease 2019 may directly affect the vestibular organs and ganglia, or indirectly damage them via immune-mediated mechanisms. In most cases, complete recovery is achieved with the typical therapeutic approaches for vestibular neuronitis, consisting of supportive measures and corticosteroids.

Physicians may expect an increased incidence of vestibular neuronitis during the coronavirus disease 2019 pandemic. Conversely, coronavirus disease 2019 infection should be considered in patients with sudden vestibular symptoms.

There are currently no guidelines for simultaneous vestibular schwannoma surgery and cochlear implantation. This paper therefore provides our experience and our results regarding predictive parameters of good hearing.

Morphological appearance of the cochlear nerve after tumour resection was used as the main criterion for implantation in the case series. Patients were then divided into responders and non-responders to cochlear implantation, and potential outcome predicting factors were evaluated in the two groups.

Nine of the 16 patients showed a response to cochlear implantation. Pre-surgery serviceable hearing was significantly more common in the responder group, while no difference was found in the two groups for other variables.

This study highlights how the morphological appearance of the cochlear nerve can be useful to predict the hearing outcome and indicates that satisfactory hearing results are closely related to pre-surgery serviceable hearing.

To determine the short- and long-term outcomes of triple semicircular canal occlusion as a potential alternative for patients with intractable Ménière's disease.

A retrospective case series was performed in university settings, enrolling patients with intractable Ménière's disease with previous maximum treatment, who underwent transmastoid, triple semicircular canal occlusion. The study documented: pre- and post-operative Dizziness Handicap Inventory scores at six weeks and one year post-treatment, pure tone audiometry, and surgical aspects.

Two female patients, aged 42 and 65 years, underwent unilateral three-semicircular-canal occlusion. Their respective Dizziness Handicap Inventory scores improved from 88 to 68 and 54 to 30 at six weeks post-operatively, with scores of 66 and 0 at one year post-treatment. The one patient with pre-existing functional hearing maintained her hearing threshold post-operatively.

Triple semicircular canal occlusion is a safe, hearing-preserving, extracranial alternative technique that can control rotatory vertigo in patients with intractable Ménière's disease, when other measures have failed.

To summarise published research investigating maximal temperatures associated with endoscopes used in otology. Possible thermal issues surrounding the use of endoscopes in middle-ear surgery are discussed, and recommendations regarding the safest ways to use endoscopes in endoscopic ear surgery are made.

A non-systematic review of the relevant literature was conducted, with descriptive analysis and presentation of the results.

There are currently no reports of any temperature-related deleterious effects in patients having undergone endoscopic ear surgery. There is debate regarding heat issues in endoscopic ear surgery, with a limited body of work documenting potential negative impacts of middle-ear heat exposure from endoscopes. The diameter of endoscope, type of light source used, distance from endoscope tip and duration of exposure are highlighted potential factors for high temperatures in endoscopic ear surgery.

There is a trend towards endoscopes being used routinely in ear surgery. Simple practice points are recommended to minimise potential thermal risks.

Histopathological anomalies of inner-ear structures in individuals with Down syndrome have been well documented; however, few studies have examined the radiological features.

A retrospective study was conducted of temporal bone computed tomography images in 38 individuals (75 ears) with Down syndrome to evaluate the prevalence of inner-ear abnormalities and assess vestibular aqueduct widths.

Inner-ear anomalies were identified in 20 of the 38 individuals (52.6 per cent). Seven of the 75 temporal bones (9.3 per cent) were found to have higher than previously reported. A dilated internal auditory canal and vestibule were more common among the present study group, while prior studies have demonstrated internal auditory canal stenosis and decreased vestibule size.

Down syndrome patients exhibit a high prevalence of dysplastic inner-ear features that confer substantial risk of sensorineural hearing loss. Computed tomography is a useful screening aid to detect inner-ear abnormalities, particularly enlarged vestibular aqueducts, which cause preventable sensorineural hearing loss in this population.