The incidence of a disorder or condition refers to the number of new cases identified in a specified time period. Prevalence refers to the number of individuals who are living with the disorder or condition in a given time period.

Approximately 36.8 million adults in the United States report a dizziness or balance problem during the past 12 months (Mitchell & Bhattacharyya, 2023). The true incidence and prevalence of balance system disorders in adults and children are unknown. This may be due, in part, to the wide range of symptoms attributable to balance disorders, the underlying cause(s), the length or frequency of the disorder, and the varied diagnostic techniques used for detection. However, epidemiological data provide estimates across different populations and specific disorders.

Adults

Research suggests that symptoms of balance disorders, such as dizziness and vertigo, affect between 15% and 35% of the general population at some point in their lives (Neuhauser, 2016). The lifetime prevalence estimates of significant dizziness range between 17% and 30% in adults (Murdin & Schilder, 2015). In the United States, the prevalence of reported balance problems in a year increased to 15.5% of adults in 2016 compared to 11.1% in 2008 (Mitchell & Bhattacharyya, 2023).

Studies show that the rate of vestibular dysfunction increases with age (Agrawal et al., 2009; Murdin & Schilder, 2015; Neuhauser, 2016), and women are more likely to experience dizziness and vertigo symptoms than men (Hung et al., 2023; Murdin & Schilder, 2015; Neuhauser, 2016). Nearly 28% of adults over the age of 65 years reported falling at least once in the past 12 months (Kakara et al., 2023).

Statistics for balance system disorders can vary by type of disorder. Common vestibular diagnoses include benign paroxysmal positional vertigo (BPPV), Ménière’s disease, vestibular migraine, unilateral vestibular hypofunction, vestibular neuritis, and other psychogenic disorders (Parker et al., 2019). Estimates for some balance disorders include the following:

• BPPV: An estimated 6.6 million Americans have characteristics of BPPV (Kerber et al., 2017). The lifetime prevalence in the general population is 2.4%, with an estimated incidence of six cases per 1,000 people per year (von Brevern et al., 2007).
• Ménière’s disease: Prevalence estimates indicate that more than 615,000 Americans show characteristics of Ménière’s disease (National Institute on Deafness and Other Communication Disorders, 2024). Approximately 13% of patients in dizziness clinics present with Ménière’s disease (Parker et al., 2019).
• Vestibular migraine: The 1-year prevalence of vestibular migraine is estimated to be 2.9%; however, vestibular migraine is thought to be underdiagnosed (Kang et al., 2023).
• Vestibular neuritis: Estimated to be the third most common cause of peripheral vertigo (Strupp et al., 2023), vestibular neuritis has an approximate annual incidence of 3.5–15.5 per 100,000 people (Adamec et al., 2015; Sekitani et al., 1993). It represents about 7.9% of cases evaluated in vertigo specialty clinics (Brandt et al., 2005).

Pediatrics

Dizziness and balance disorders can also occur in children (Lee et al., 2017; Li et al., 2016; Wiener-Vacher et al., 2018). Reponses to the 2016 Balance Supplement to the U.S. National Health Interview Survey for children revealed dizziness or imbalance symptoms in 5.6% of children ages 3–17 years, of which 40% had visited a health care provider to evaluate their symptoms (Brodsky et al., 2020). In adolescents, dizziness and vertigo symptoms are reported at rates similar to levels reported by adults (Langhagen et al., 2015; Li et al., 2016). Children with hearing difficulties demonstrate a significantly higher rate (20.9%) of experiencing dizziness and balance problems, compared to children without hearing difficulty (4.9%; Li et al., 2016). Those with profound hearing loss show an even higher rate (approximately 50%; Cushing et al., 2013; Jacot et al., 2009). After adjusting for sociodemographic and other factors, children with hearing loss show 2.4 times more risk for dizziness and balance problems (Li et al., 2016). In children with sensorineural hearing loss, 23% had at least one abnormal vestibular test on both sides, indicating bilateral vestibular hypofunction (Loos et al., 2025). Common vestibular diagnoses in children include vestibular migraine (35%), BPPV (21.6%), primary dysautonomia (15.7%), anxiety disorder (13.5%), and persistent postural-perceptual dizziness (PPPD; 11.2%). Additionally, pediatric patients who experience dizziness may be diagnosed with multiple conditions concurrently (Wang et al., 2021).

Signs and symptoms of balance system disorders vary due to a wide range of underlying causes. Signs and symptoms may be episodic, acute, or chronic and may include the following:

• confusion/disorientation
• difficulty concentrating
• falls/near falls
• fatigue
• gross motor and/or reflex delays
• headache
• imbalance/disequilibrium/unsteadiness
• impaired mobility/gait abnormality
• lightheadedness/feeling faint
• motion intolerance/motion sickness
• nausea/vomiting
• nystagmus
• vertigo
• visual disturbances (e.g., oscillopsia)

Accompanying auditory symptoms may include the following:

• aural fullness
• autophony (i.e., hearing one’s own voice or other self-generated noises as unusually loud)
• hearing loss
• hyperacusis
• sound-induced dizziness
• tinnitus

Functional modifications that may be observed include the following:

• limiting head movement
• requiring assistance in activities of daily living
• using an assistive mobility device (e.g., a walker or a cane)
• walking slowly and deliberately

Pediatrics

Identifying children with balance disorders, vestibular deficits, or dizziness can pose additional challenges when compared to adults. The process of acquiring information from a pediatric patient will be different, as will the testing strategies. Often, children will not report symptoms and may be incapable of verbalizing the abnormal sensations that they are experiencing (McCaslin et al., 2011; Wiener-Vacher, 2008). Distinct differences may exist in symptoms of dizziness and balance disorders in the pediatric population as compared with adults. Vestibular system impairments in children may present as developmental (e.g., gross motor and postural) delays in activities such as sitting upright, crawling, and walking. Some balance diagnoses, such as bilateral vestibular hypofunction, may also increase the risk for falls, internal cochlear implant device failure, fatigue, learning disabilities, and cognitive deficits in children (Loos et al., 2025). Working with this population requires specialized education and training.

The underlying causes of balance disorders and the resulting symptoms are many and varied. They include causes related to the vestibular system and causes related to other body systems and conditions. Conditions and events resulting in imbalance and/or dizziness may resolve spontaneously or may become chronic.

Causes of balance system disorders may include, but not be limited to, the following:

• acute injury to the vestibular system
• aging vestibular system
• alcohol and/or recreational drug use
• anatomic brain changes
• autoimmune inner ear disease
• benign paroxysmal positional vertigo (BPPV)
• circulatory or cardiovascular conditions
• cochlear implant surgery
• congenital cytomegalovirus (CMV)
• enlarged vestibular aqueduct syndrome
• genetic disorders
• infectious disease (viral or bacterial)
• inflammatory process of the inner ear
• mal de débarquement syndrome
• medication side effects
• Ménière’s disease
• metabolic disorders
• musculoskeletal conditions
• neck injury
• nervous system disorders (i.e., dysautonomia)
• neurological impairment/event/disease
• otosclerosis
• ototoxicity
• peripheral neuropathy
• persistent postural-perceptual dizziness (PPPD; see ASHA’s Evidence Map on Functional Neurologic Disorder)
• psychological disorders
• lesions of the auditory nerve
• superior semicircular canal dehiscence
• temporal bone fracture
• traumatic brain injury (see ASHA’s Practice Portal pages on Traumatic Brain Injury in Adults and Pediatric Traumatic Brain Injury)
• vestibular migraine and other migraine variants

Pediatrics

A review of current literature indicates that the most common causes of dizziness in children are recurrent vertigo of childhood (also referred to as benign paroxysmal vertigo of childhood), migraine headache, head trauma, vestibular neuritis, and otitis media (Gioacchini et al., 2014; O’Reilly et al., 2010; van de Berg et al., 2021). Numerous reports have detailed common disorders, illnesses, and injuries that cause vertigo and imbalance in children (Balatsouras et al., 2007; Blayney & Colman, 1984; Jahn et al., 2011; Master et al., 2020; McCaslin et al., 2011; Russell & Abu-Arafeh, 1999; Szirmai, 2010; Wiener-Vacher, 2008).

Roles and Responsibilities of Audiologists

Audiologists play a role in the screening, assessment, diagnosis, and management of people with balance system disorders, often within a collaborative and interprofessional team. Professional roles and activities in audiology include clinical services (diagnosis, assessment, planning, and management); prevention and advocacy; and education, administration, and research. See ASHA’s Scope of Practice in Audiology (ASHA, 2018).

The following roles and responsibilities are appropriate for audiologists.

Education and Advocacy

• Maintain knowledge of the anatomy, physiology, and pathophysiology of the balance system, including the peripheral and central vestibular, visual, and somatosensory systems as well as interactions among these systems.
• Maintain knowledge of various conditions and events that may affect the balance system.
• Provide counseling and education to patients, their families, and other care team members (e.g., teachers, other specialists) regarding the diagnosis and functional impacts of balance system disorders.

Screening and Assessment

• Ensure that all equipment used in the assessment and management of patients with dizziness and/or balance disorders is properly calibrated and functioning according to manufacturer standards—including required calibration, maintenance, and performance checks.
• Participate in multidisciplinary team consultation for assessment and management of patients with dizziness and/or balance disorders.
• Administer and appropriately alter vestibular test protocols for diagnostic and rehabilitative assessment of dizziness and/or balance disorders.
• Utilize patient-report tools to determine the functional impact of dizziness and/or balance disorders.
• Interpret and integrate vestibular and balance test results and related data to establish the baseline function to be used for outcome measures in future rehabilitation and/or management.
• Identify benign paroxysmal positional vertigo (BPPV)—including posterior, lateral, and anterior semicircular canal variants—through clinical assessment of symptom-provoking maneuvers and determine whether the presentation reflects canalithiasis or cupulolithiasis.
• Determine patient candidacy for vestibular and balance rehabilitation based on the integration of information from patient history, test results, functional assessment, and collaboration with other professionals.

Intervention and Support

• Maintain an understanding of management options for dizziness and balance disorders (e.g., medical, surgical).
• Maintain knowledge of medical conditions that may impact or contraindicate the assessment and management of balance disorders.
• Perform canalith repositioning procedures on patients with benign paroxysmal positional vertigo (BPPV) as indicated.
• Make referrals as appropriate.
• Consult on the design and implementation of an individualized vestibular rehabilitation program in collaboration with an interprofessional team.
• Develop and use outcome measures to determine the efficacy of vestibular rehabilitation provided.
• Accurately document all information collected from the patient, tests performed, results and recommendations stemming from assessment and/or management of the patient, and patient condition during all stages of assessment and/or management (including any adverse reactions).

As indicated in the ASHA Code of Ethics (ASHA, 2023), audiologists who serve this population should be specifically educated and appropriately trained to do so.

Roles and Responsibilities of Speech-Language Pathologists

Speech-language pathologists may encounter individuals with reports of dizziness and/or imbalance within the populations they serve. See ASHA’s Scope of Practice in Speech-Language Pathology (ASHA, 2016).

Appropriate roles and responsibilities for speech-language pathologists include providing referrals for patients who report dizziness and/or balance disorders.

The assessment of a patient with dizziness and/or imbalance complaints includes aspects of the central and peripheral vestibular systems as well as sensory and motor balance components. Balance system assessment is an interprofessional endeavor, with audiologists serving as experts in hearing and vestibular function testing. Balance system evaluation by an audiologist may be prompted by results of a case history and/or a medical referral.

The process (whether in a screening or a comprehensive assessment) always begins with a thorough case history.

Case History

Case history information may indicate a need for modification of screening or evaluation procedures. Because the term “dizziness” can describe varying symptoms and each patient may have a different idea of what dizziness means, a thorough case history is vital (Dye, 2008).

A case history specific to balance may include the following:

• collection of results from other health professionals
• fall risk information (number of previous falls, gait patterns, mentation, reaction time, vision)
• medical history, including
• general health (e.g., blood pressure and other vitals);
• history of hearing loss;
• history of dizziness, balance problems, or falls;
• family history of hearing loss and/or balance disorders;
• medication use (prescriptions and/or over-the-counter medications);
• complementary and alternative medicine use; and
• presence of comorbidities
• nature of dizziness and/or imbalance symptoms, including
• aggravating factors (e.g., motion, positional, diet);
• alleviating factors;
• associated symptoms (e.g., auditory [hearing loss, tinnitus, aural fullness] and neurological [headache, numbness/tingling of the face, diplopia, dysarthria, dysphagia, oscillopsia, photophobia, visual aura]);
• duration;
• frequency;
• initial onset and any concurrent event(s);
• pattern (e.g., time of day, activity); and
• quality and character (spinning, imbalance, disorientation)
• patient and/or family questionnaire(s) on dizziness and the impact of balance problems on quality of life and activities of daily living

Pediatric case histories may differ in the type of information gathered as well as in the strategies used to obtain the information. Documenting the age at which developmental milestones are reached and making note of a child’s performance on gross and fine motor tasks are important. Children who are deaf or hard of hearing may exhibit certain predictive factors of a co-occurring vestibular loss, including not sitting independently by 7.25 months, not walking by 14.5 months, and/or parental concerns for balance (Janky et al., 2018). Information regarding these factors can be used to identify children who may benefit from an age-appropriate vestibular evaluation.

For information regarding gathering a case history, see ASHA’s Practice Portal page on Cultural Responsiveness.

Vestibular and Balance Screening

Performing appropriate screening measures may determine the need for further assessment, referrals, and/or a management plan. Screening a patient with balance complaints can assist in triaging, ruling out emergencies, and determining the probability of a central (brain/brainstem) versus a peripheral (vestibular labyrinth, eighth cranial nerve) origin. Vestibular and balance screening may be performed by audiologists as well as other trained medical professionals, such as physical therapists. Screening measures may be affected by the patient’s understanding of the task(s), their eye muscle function and visual acuity, and their current levels of fatigue and attention.

Screening of vestibular function and vestibular ocular reflexes (VORs) may be completed at a patient’s bedside or in an office setting with little or no equipment.

A vestibular and balance screening may include observation of nystagmus using static and dynamic measures, tests to differentiate between peripheral and central causes of acute vestibular syndrome (i.e., Head Impulse–Nystagmus–Test of Skew [HINTS]), and various “bedside” or non-instrumented versions of other vestibular assessments (e.g., head thrust test/head impulse test, dynamic visual acuity test, oculomotor tests, and positioning tests). For more detailed information on these tests and measures, see the Comprehensive Assessment section.

Screening measures may be accompanied by postural and/or gait observations (Cohen et al., 2019). Such observations may be obtained using tools that include—but are not limited to—the Romberg test, the Fukuda Stepping Test, the Modified Clinical Test of Sensory Interaction in Balance, and the single-leg stance test.

Observation of Nystagmus

Reflexive eye movements in response to head movement and position involve input from peripheral vestibular organs. These organs include the semicircular canals (lateral, anterior, and posterior) and the otolith organs (utricle and saccule). Nystagmus is a reflexive eye movement characterized by two components: the slow phase, in which the eyes drift away from center, and the fast phase, in which the eyes quickly move back toward center. Nystagmus can be observed under various conditions (normal [physiologic] and abnormal [pathophysiologic]), which are named accordingly: spontaneous, positional, evoked, congenital, and gaze. Some level of spontaneous nystagmus may be seen in healthy individuals (Levo et al., 2004).

The presence and direction of nystagmus as well as the response to visual fixation may provide important information for differentiating between a peripheral and a central etiology of vertigo. In general, “nystagmus of peripheral origin is horizontal, and direction fixed . . . and decreases with visual fixation . . .. Central signs include direction-changing nystagmus, pure vertical or torsional nystagmus and/or enhancement with fixation” (Slattery et al., 2011, p. 145).

Screening of nystagmus may include noninstrumented tests, such as direct observation using a penlight or an otoscope. The specificity of these findings will likely be reduced in comparison to those obtained with instrumented measures, such as videonystagmography (VNG) or electronystagmography (ENG; Guidetti et al., 2006).

Screening for Differentiation of Acute Stroke

One screening objective is to differentiate between peripheral causes (e.g., vestibular neuritis) and central causes (e.g., acute cerebellar stroke) when a patient presents with acute vestibular syndrome—a term used to describe the presence of “severe vertigo, nausea and vomiting, spontaneous nystagmus, and postural instability” (Hotson & Baloh, 1998, p. 680). One review of the literature determined that peripheral or central vestibular diagnoses were given to 74% of patients with acute vestibular syndrome, whereas 26% of patients had nonspecific causes. Stroke was the second most common cause of acute vestibular syndrome at 21% of patients (Coban & Tarnutzer, 2026).

HINTS, which can be helpful in this differentiation, is a three-step oculomotor/VOR test protocol that includes (a) the Head Impulse test, (b) interpretation of Nystagmus, and (c) Test of Skew (Kattah et al., 2009). Skew deviation is a vertical misalignment of the eyes that can be tested by covering the patient’s eyes, one at a time, while they focus on a fixed target.

Screening Considerations

When screening for dizziness and/or imbalance, the following considerations are important:

• Conditions such as orthostatic hypotension or visual deficits may impact balance screening results.
• Some assessment techniques for vestibular function that require equipment or instrumentation may also be considered bedside-appropriate if the clinician has access to the technology (e.g., Frenzel glasses, VNG, video head impulse test [vHIT], vestibular evoked myogenic potential [VEMP]).
• Sensitivity and specificity of bedside vestibular screening measures will vary (Cohen et al., 2014; Herdman et al., 1998; Jacobson et al., 1990; Kattah et al., 2009; Zamysłowska-Szmytke et al., 2015), whether taken individually or collectively.
• Screening tests in combination may provide more specific results; however, interpretation of findings by the examiner requires in-depth knowledge and understanding.

Comprehensive Assessment

Accurate differential diagnosis of balance system disorders relies partly on the audiologist’s interpretation of a test battery within the context of the individual’s medical history. Comprehensive assessment of dizziness and/or balance complaints will include a case history (as outlined above), results from any number of screening tests (described above), an audiologic assessment, in-depth vestibular assessments (described below), and information from outside referrals or sources (as part of an interprofessional collaborative team).

Audiometry

Comprehensive assessment of a patient with dizziness, vertigo, or imbalance includes an audiometric assessment. There is a close relationship between hearing and balance in relation to inner ear organs. Some patients with dizziness and imbalance symptoms will have coexisting auditory symptoms. For example, the combination of vertigo and sensorineural hearing loss is a classic presentation in a patient with labyrinthitis and may also be seen in patients after they experience head trauma. Audiologic assessment can provide information about possible retrocochlear or middle ear pathologies that may need to be addressed prior to further vestibular testing and follow-up.

Audiometric and electrophysiological assessments in a patient with dizziness, vertigo, or imbalance complaints may include but not be limited to

• acoustic reflex thresholds and acoustic reflex decay testing,
• auditory brainstem response,
• electrocochleography (ECochG),
• immittance testing,
• otoacoustic emissions,
• otoscopy,
• pure-tone testing, and
• speech audiometry in quiet and noise.

See the Assessment sections of ASHA’s Practice Portal pages on Hearing Loss in Children and Hearing Loss in Adults for detailed information on audiologic assessment.

Balance System Testing

A comprehensive balance system evaluation will include a combination of tests. Results and combinations of results from vestibular tests require complex interpretation and can indicate various deficits. The audiologist’s goal is differential diagnosis, identification of a peripheral or central pathology, and differentiation of unilateral versus bilateral vestibular disorders.

Depending on the age of a pediatric patient, the maturation of the vestibular and related systems, and their levels of cooperation and comprehension, it may not be possible to complete a comprehensive balance function examination. However, as with pediatric hearing assessment, experts in the assessment of pediatric dizziness have the skills necessary to adjust testing methods to collect useful information regarding the status of a child’s vestibular function and overall balance.

In interprofessional practice (IPP) settings, vital signs such as blood pressure and oxygen saturation may be measured prior to patients receiving a full balance assessment (Dye, 2008). These measurements are important because symptoms of dizziness stem from a variety of etiologies and may be multifactorial.

Videonystagmography (VNG)/Electronystagmography (ENG)

Videonystagmography (VNG) and electronystagmography (ENG) are techniques used to measure and record a patient’s eye movements, including nystagmus, during a variety of tasks and conditions. Both VNG and ENG include computer analysis of eye movements. ENG is a process of recording eye movement indirectly through the electrical potential difference between the front and back of the eye. Electrodes are placed around the eyes during ENG. VNG, which has become standard in balance assessment, uses infrared video technology to record eye movement.

VNG and ENG technologies enable enhanced assessment and recording of nystagmus (e.g., gaze-evoked, spontaneous) and allow for measurement of nystagmus intensity and direction. Measurements of nystagmus may be taken without fixation (i.e., in complete darkness), thus minimizing the possibility that nystagmus will be suppressed by visual fixation.

VNG and ENG technology may be used when conducting oculomotor tests, positional and positioning tests, and/or caloric tests.

Oculomotor tests measure eye movement and can be useful in identifying abnormalities of the VOR and/or the presence of spontaneous nystagmus. Significant abnormalities in these functions may indicate a referral to neurology or neuro-ophthalmology for assessment of the central nervous system. An oculomotor test battery may include tests of the following:

• gaze stability, or maintenance on a specific target (i.e., center, left, right, up, down) while keeping the head in a primary position
• saccades, which are the voluntary and reflexive rapid eye movements of varying amplitude that abruptly change a point of fixation and are used to bring a target object into the center line of sight
• smooth pursuit tracking, referring to continuous voluntary eye movements following a moving target across the visual field while the head remains stationary
• optokinetic nystagmus, which is the normal reflexive response of the eyes when confronted with large-scale movement in the visual field

Static and dynamic positional tests are used to observe the vestibular system response to a change in head and/or body position as compared with neutral head and/or body position. Measurements can be taken with or without fixation. The examiner considers the presence or absence of nystagmus and/or changes in nystagmus as well as the patient’s subjective report of symptoms.

Positioning tests (e.g., the Dix–Hallpike maneuver) are most often used to elicit signs and symptoms of benign paroxysmal positional vertigo (BPPV), such as nystagmus and vertigo, and to aid in diagnosing this disorder. Symptoms of BPPV occur when otoconia move into one of the semicircular canals. Movement of a patient from one position to another elicits or exacerbates these symptoms. Nystagmus caused by BPPV is usually transient. The observation of nystagmus during positioning tests—direction, intensity, latency, and duration—helps in diagnosing BPPV and in determining which ear and which semicircular canal is impacted. Abnormal results may indicate the need for canalith repositioning procedures.

BPPV most commonly affects the posterior canal (R. Bhandari et al., 2023). Less common lateral canal BPPV may be assessed using the supine roll test, the bow and lean test, or the upright head roll test (A. Bhandari et al., 2022; Choung et al., 2006; Malara et al., 2020).

Caloric tests stimulate the vestibular system in the ear by creating a temperature difference relative to body temperature. Methods used to create a temperature change include heated or cooled air introduced into the ear canal, heated or cooled water introduced directly into the ear canal (open-loop), and heated or cooled water introduced into the ear canal inside of a balloon (closed-loop). The examiner measures the presence, strength, and direction of any nystagmus that exists during and following the introduction of each stimulus.

Considerations with caloric testing include the following:

• Responses to cool and warm stimuli will differ. Warm irrigations produce an excitatory response that causes the fast phase of nystagmus to beat toward the stimulated ear. Cool irrigations produce an inhibitory response that causes the fast phase of nystagmus to beat away from the stimulated ear. Warm irrigations tend to evoke a stronger nystagmus response than cool irrigations.
• Providing appropriate alerting tasks to distract the patient during caloric testing is important so that the resulting nystagmus is not affected by central suppression. Formby et al. (1992) provided a comparison and ranking of several different alerting tasks used during observation of caloric-induced nystagmus.
• When standard procedures for caloric testing do not elicit a response in an individual, ice water caloric testing may be introduced as appropriate.
• Visual fixation can be assessed following the response to caloric stimulation and should reduce the intensity of nystagmus. Failure of fixation suppression may indicate a central deficit.
• Some patients will not tolerate caloric testing (e.g., pediatric patients).
• Open-loop water irrigation is contraindicated if the patient has a perforated tympanic membrane or has pressure-equalizing tubes in place.
• Caloric testing should not be performed on any patient with cerumen obstruction of either or both ear canals.
• Caution should be used when performing and/or interpreting caloric responses on patients with a history of ear surgery in which the anatomy of the temporal bone has been altered (e.g., mastoidectomy).

Other tests that can be included in a VNG battery or an ENG battery are hyperventilation testing, vibration testing, and head-shake testing.

• Hyperventilation testing requires the patient to take deep, rapid breaths for 30–60 seconds. The examiner observes any nystagmus during this state of hyperventilation and then observes any changes in the presence or intensity of nystagmus after hyperventilation concludes.
• Vibration testing involves placing a handheld vibrating instrument on the left and right mastoid bone and on the left and right posterior sternocleidomastoid (SCM) muscle and then observing changes in the presence or intensity of nystagmus. The results may be abnormal in patients with superior semicircular canal dehiscence or unilateral vestibular hypofunction.
• Head-shake testing involves the patient tilting their head down slightly and then the patient or examiner shaking the head quickly left to right at a rate of 120 beats per minute (often with fixation removed) for 10–20 seconds—with some clinical variability possible—or for 20–30 full cycles of head shakes. The eyes are then examined for the presence or absence of nystagmus. The presence of horizontal head-shake nystagmus may indicate asymmetric peripheral vestibular function (e.g., semicircular canal function), whereas vertical or torsional nystagmus may indicate central vestibular dysfunction.

Rotary Chair Testing

Rotary chair testing can be helpful in detecting bilateral and uncompensated unilateral vestibular disorders. Results may be more accurate when used in conjunction with VNG or ENG. Rotary chair testing involves whole-body rotation, with the patient seated and restrained in a motorized rotary chair. Eye movements are recorded in darkness using electrodes, as in ENG, or video-oculography goggles, as in VNG. The patient’s head is properly secured so that the chair and head movements correspond. It is important to record baseline spontaneous nystagmus and gaze nystagmus prior to rotary chair testing. A rotary chair test battery may include sinusoidal harmonic acceleration tests, visual–vestibular interaction tests (i.e., visual–vestibular ocular reflex and visual–vestibular fixation), and step velocity tests, as follows:

• Sinusoidal harmonic acceleration tests involve rotating or oscillating the patient in alternating directions, rightward (clockwise) and leftward (counterclockwise), at varying harmonic frequencies. Measurements of gain (eye movement in relation to head movement), phase (timing relationship between eye movement and head movement), and symmetry (nystagmus from rightward vs. leftward rotations) are derived from the eye movement recordings.
• Visual–vestibular interaction tests assess whether the addition of visual cues results in changes in VOR gain.
• visual–vestibular ocular reflex testing involves the patient viewing objects on the wall as the chair turns rightward and leftward. This typically results in an increase in VOR gain compared with VOR gain measured in darkness.
• visual–vestibular fixation or suppression testing involves the patient fixating on a visual target that moves along with the rotary chair. This typically results in a decrease in VOR gain compared with VOR gain measured in darkness.
• Step velocity tests involve (a) rapid acceleration of the chair in one direction, (b) rotation at a constant speed for about 1 minute, and (c) abrupt deceleration of the chair. The examiner measures the time it takes for the nystagmus to decay in each direction of rotation or the peak nystagmus response.

Rotary chair testing assesses both ears simultaneously rather than independently. A natural stimulus allows for VOR measurements to be taken during physiologically relevant stimulation (i.e., head rotation) at a variety of frequencies. Rotational testing provides important information about residual vestibular function in individuals with bilateral vestibular weakness on caloric testing. This information is critical in selecting appropriate rehabilitative strategies.

Computerized Dynamic Posturography (CDP)

Computerized dynamic posturography (CDP) is a method of assessing an individual’s functional balance and the contribution of visual, vestibular, and somatosensory inputs. CDP does not provide information regarding the possible location of lesions or the possible etiology of balance disorders. The equipment required for CDP includes a movable support surface (a force platform) within a movable enclosure.

Subtests include the following:

• The sensory organization test (SOT) involves measuring an individual’s postural stability or sway under varied circumstances, such as stable support surface versus moving support surface and with eyes open versus with eyes closed. On the basis of postural control performance in each circumstance, a pattern is generated, which can be associated with functional impairments. Reduced performance scores on the SOT have been documented in individuals with a history of multiple falls as compared with individuals with a history of one or no falls (Whitney et al., 2006).
• The motor control test (MCT) involves disturbing the individual’s postural control with unexpected linear movements of the support surface and then observing and measuring their response to and recovery from these disturbances. This measure of sensory input and motor output is important in interpreting the SOT and predicting future falls.
• The adaptation test involves unpredictable movement of the support surface in either the toes-up or the toes-down position, which is meant to simulate irregular walking surfaces. An individual’s ability to reduce sway and overcome instability is assessed.

Vestibular Evoked Myogenic Potential (VEMP)

A vestibular evoked myogenic potential (VEMP) offers an electrophysiological method of testing otolith (saccule and utricle) function and potentially both branches of the vestibular nerve. VEMP testing involves measuring a motor response to sound stimulation of the otolith organs.

There are two types of VEMP testing. The cervical VEMP (cVEMP) measures an inhibitory response in the sternocleidomastoid (SCM) muscle coincident with the presentation of sound or vibration. Electrodes are placed in a specified configuration on the SCM muscle and on the forehead. Because the cVEMP is an inhibitory response, the SCM muscle must be activated (contracted) either unilaterally or bilaterally through intentional head positioning by the patient. The ocular VEMP (oVEMP) uses electrode placement under the eyes and on the forehead and measures an activation response from those muscles. For both types of VEMP testing, clicks and/or tone bursts are introduced via earphones or a bone-conduction oscillator. Recordings of waveforms are taken, and asymmetries can be identified between responses generated by stimulating the right and left ears.

Results of VEMP testing may provide insight into pathologies that affect balance and/or cause dizziness, such as superior semicircular canal dehiscence and vestibular neuritis. The use of one of these tests as opposed to the other (i.e., oVEMP or cVEMP) may be preferred for certain patients and/or situations. As with any vestibular test, VEMP results must be interpreted by a knowledgeable clinician and in the context of the patient’s personal history and characteristics. For example, patient age may impact VEMP results (Janky & Shepard, 2009; Ochi & Ohashi, 2003).

In addition to VEMP testing, another assessment available to measure otolith function is the subjective visual vertical (SVV) test. When performing the SVV test, the patient is asked to adjust an illuminated straight line on a blank background until it looks completely vertical to them. Abnormalities in this test may reflect the presence of utricle dysfunction but can also be abnormal with central lesions.

Computerized Dynamic Visual Acuity Test

The dynamic visual acuity test assesses the VOR by having the patient read a Snellen eye chart first in a static position and then while the head is rotated left to right at a rate of two cycles per second or 240 beats per minute. The lowest line on the eye chart in which the patient correctly identifies 50% of the characters correctly may be used to compare static versus dynamic visual acuity results. The possibility of a VOR deficit depends on how many lines are lost in this comparison. When the difference between static and dynamic visual acuity is greater than two lines of separation, this may be suggestive of peripheral vestibular loss as related to gaze stabilization.

Computerized systems are available for the measurement of dynamic visual acuity (Chen et al., 2023). The patient is seated at a specific distance from a computer screen and wears a device that measures head movements in various dimensions during the testing.

Electrocochleography (ECochG)

Electrocochleography (ECochG) is an electrophysiologic measurement of electrical potentials of the inner ear and auditory nerve in response to sound. ECochG is a valuable component of the vestibular diagnostic battery, particularly for the diagnosis of conditions associated with endolymphatic hydrops (e.g., Ménière’s disease). ECochG recordings capture the cochlear microphonic (CM), summating potential (SP), and compound action potential (AP), with clinical interpretation centered on the SP/AP ratio.

ECochG is limited by relatively low sensitivity and specificity across methodologies (Kaf et al., 2015). Test outcomes may be influenced by the degree of hearing loss, the stage of Ménière’s disease, the symptom status at the time of testing, and the inherently high variability of SP and AP amplitudes in the ears of individuals with and without Ménière’s disease (Ferraro, 2010; Ferraro & Durrant, 2006; Gibson, 2017; Margolis et al., 1992).

Although ECochG alone demonstrates variable sensitivity and specificity across recording techniques, evidence indicates that its diagnostic value increases when combined with complementary vestibular assessments such as VEMPs, caloric testing, and magnetic resonance imaging (MRI; Ayub et al., 2019; Huang et al., 2025; Lu et al., 2025).

Video Head Impulse Test (vHIT)

The video head impulse test (vHIT)—also referred to as the head thrust test—assesses the VOR. It involves observing whether the patient can maintain visual fixation on a target after brief and rapid head thrusts in the planes of the semicircular canals. When dysfunctional, the patient requires corrective saccadic eye movements to regain eye contact with the target, which may indicate semicircular canal dysfunction. Results of this test, taken in context, may give an indication of abnormal peripheral function versus abnormal central nervous system function.

The vHIT is an instrumented version of the head impulse test using infrared video recording of eye movements in response to short, brisk head turns or impulses in the planes of the semicircular canals. Recordings may be obtained with a camera inside of goggles or with a hands-free recording focusing on the patient’s face. This allows for objective measurement of eye movements rather than subjective clinician observations. The vHIT also enables the evaluation of each semicircular canal independently (Hougaard & Abrahamsen, 2019). The patient is instructed to maintain visual contact on a stationary target during head impulses. Eye movements are analyzed to determine whether the eyes (a) moved in the same direction as the head during impulses and then made a corrective refixation back to the target (abnormal) or (b) moved in the opposite direction of the head during impulses and maintained fixation on the target (normal). Results may demonstrate a problem with semicircular canal function on the same side to which the head was turned prior to the corrective refixation response. This procedure is noninvasive, is relatively short, and utilizes stimuli in the physiological range of everyday head movement.

Goggle-worn video recording systems must fit tightly on the face to prevent slippage during the head impulse test. They will not fit and/or may not be tolerated by all pediatric patients. Alternatively, the clinician may use a remote camera recording system on infants, starting when the infant is around 6 months of age, as well as on patients of all ages and developmental levels.

Balance Assessment Modifications for the Pediatric Population

A careful and thorough case history, assessment, and diagnostic approach is vital in achieving optimal treatment outcomes (Dasgupta et al., 2025). When assessing a child with dizziness or vertigo, clinicians should recognize that several vestibular tests commonly used in adults lack established pediatric norms—particularly for infants and toddlers (e.g., caloric irrigation responses, vestibular autorotation testing, gaze stability measures, and certain rotary chair protocols). The American Academy of Audiology’s clinical consensus statement on pediatric vestibular function assessment [PDF] provides information and guidance on this population (Lavender et al., 2025).

Considerations when assessing the pediatric population may include the following:

• Select age-appropriate and developmentally-appropriate tests.
• Use alternative equipment for accurate results—for example, appropriately sized test goggles or remote camera vHIT technology.
• Use tests that have age-appropriate normative data.
• When needed, adjust the child’s positioning during VEMP and vHIT testing. For example, conduct these tests while having the patient lying supine or while using passive head support on the patient.
• Use age-appropriate visual target test stimuli to help maintain attention for longer periods of time.
• Prioritize which tests to perform first, keeping in mind variability in the child’s focus duration.
• Monitor and document electromyography (EMG) activity during cVEMP assessment; pediatric patients may have variable SCM muscle contractions.

Referral/Interprofessional Practice (IPP)

Interprofessional practice (IPP) occurs when two or more professions collaborate with each other to improve health outcomes for a patient. This approach is vital in the assessment and management of balance and vestibular disorders. In addition to undergoing tests and services offered by a trained audiologist, the patient may require input from other medical professionals both to (a) complete a comprehensive evaluation and (b) conduct management planning. For example, the patient may require medical imaging studies, a gait assessment by a vestibular physical therapist, or a review of medications by their primary care physician. See ASHA’s resources on interprofessional education/interprofessional practice (IPE/IPP) for more information on this topic.

Management of balance and vestibular disorders may include medical, surgical, and/or rehabilitative approaches. Interprofessional collaborative practice is a vital part of the management process. Coordination and communication between and among balance professionals will assist the patient in achieving the best outcomes. Professionals involved may include an audiologist, a physical and/or an occupational therapist with balance expertise, a primary care physician, an otolaryngologist, a neurologist, mental health professionals, and other medical professionals.

State practice laws vary, and not every state explicitly addresses vestibular or balance system disorders in their audiology scope of practice. However, the absence of explicit language regarding given services does not necessarily mean such services are prohibited. Clinicians should consult their state licensure board to understand how their scope of practice is interpreted and review insurance provider requirements, which may differ from state licensure rules and, in some cases, are more restrictive.

Medical Management

Depending on the etiology of the patient’s vestibular disorder and/or the underlying cause(s) of their balance symptoms, a variety of medical and surgical options may be recommended by appropriate medical professionals. Medications may be provided to temporarily suppress the vestibular symptoms or to treat the underlying pathology (e.g., migraine, multiple sclerosis). Dietary and/or lifestyle changes may be suggested. Surgical intervention may be considered in specific cases (e.g., excision of vestibular schwannoma [benign tumor]).

Vestibular Management and Rehabilitation

Vestibular rehabilitation involves activities specific to the diagnosis and individual needs of each patient. This therapy promotes the central nervous system’s natural compensation process to reduce or eliminate problematic symptoms that come with chronic balance disorders and/or dizziness.

Goals of vestibular rehabilitation may include

• promoting the compensation process of the central vestibular system,
• reducing the patient’s sensitivity to symptom-provoking movements or visual motion,
• reducing fall risk by improving static and dynamic balance and gait,
• maintaining the compensation process, and
• improving the patient’s quality of life.

Adaptation/Gaze Stabilization Exercises

Adaptation and/or gaze stabilization exercises target the vestibular ocular reflexes (VORs) and involve the patient performing specific head movements while keeping a visual target in focus. The clinician carefully monitors the patient’s performance for accuracy and for appropriateness of progression in difficulty. Variations are made to patient positioning, distance from target, and speed of movement. A typical adaptation exercise program may last between 6 and 8 weeks (Dye, 2008).

Habituation Exercises

The goal of habituation exercises is long-term reduction of negative responses (e.g., dizziness) to particular stimuli (e.g., motion) by repeated controlled exposure to those stimuli. The patient will be guided to perform specific symptom-inducing movements repeatedly. Monitored progression of habituation exercises may be appropriate for a patient who has dizziness or other vestibular symptoms caused by motion or visual field sensitivity.

Substitution Exercises

In substitution exercises, the patient learns to replace and actively control eye movements during head movement with the goal of reducing vestibular symptoms. For example, smooth pursuit and/or corrective saccades may be used to reduce dizziness. A patient can master substitution skills by engaging in repetitive exercises using visual targets.

Balance, Strength, and Conditioning Exercises

Exercises that focus on balance, strength, and conditioning challenge the patient by removing or disturbing visual input or using uneven surfaces. These exercises can focus on static and/or dynamic balance. An exercise program focusing on balance may be appropriate for a person experiencing symptoms from general vestibular hypofunction.

In some cases, muscle weakness may be a contributing factor to a patient’s balance difficulties. These patients may benefit from traditional strength and conditioning exercises. This aspect of vestibular rehabilitation will require input and collaboration with a physical and/or an occupational therapist.

Functional Activities

In addition to exercise programs, the balance management team also considers the patient’s functional performance. For example, an occupational therapist may do a home assessment to help reduce fall risk, a physical therapist may recommend gait activities, or an audiologist may provide education on how specific vestibular and balance disorders can impact daily activities.

Canalith Repositioning Procedures

Canalith repositioning procedures are maneuvers used to manage benign paroxysmal positional vertigo (BPPV). BPPV is caused by otoconia detaching from the utricle and/or saccule and collecting in the semicircular canals. Typical symptoms of BPPV include episodic dizziness, vertigo, imbalance, and nausea. The goal of repositioning maneuvers is to move otoconia out of the semicircular canals to reduce dizziness and/or other vestibular symptoms. Canalith repositioning procedures involve specific sequences of head and body movements guided by a trained professional. Eye movements are monitored during each guided head and body movement sequence.

Patients may be instructed to follow limitations and restrictions (e.g., posture, head movements, activities) for some time after the maneuver. However, use of post-maneuver restrictions generally does not improve the efficacy of the procedure or the patient outcomes (Casqueiro et al., 2008; Hunt et al., 2012; McGinnis et al., 2009; Roberts et al., 2005).

Posterior Semicircular Canal BPPV Management Maneuvers

One management option for posterior semicircular canal BPPV is the Epley maneuver, which assists in the migration of otoconia (Epley, 1992). Medication may be given to reduce nausea during the procedure.

The Semont maneuver, also called the liberatory maneuver, manages BPPV in conditions with free-floating otoconia (known as canalithiasis) and—more commonly—in conditions with otoconia that are attached to the cupula in the posterior semicircular canal (known as cupulolithiasis). The Semont maneuver requires quicker positional changes than the Epley maneuver with the intention of dislodging otoconia from the semicircular canal walls.

Lateral Semicircular Canal BPPV Management Maneuvers

Techniques such as the “barbeque roll,” the Lempert maneuver, and the Gufoni maneuver all target the lateral semicircular canal variant of BPPV. These techniques involve variations of rotating and tilting movements performed by the patient.

Anterior Semicircular Canal BPPV Management Maneuvers

Anterior semicircular canal BPPV is rare and is sometimes diagnosed after a head injury or recovery from surgical procedures. Less information is available on effective management. In some cases, the Epley maneuver or the Semont maneuver may be helpful. Another technique called the forced prolonged position procedure has been described (Crevits, 2004).

Counseling and Patient Education

Each patient with dizziness and/or imbalance concerns will require education and counseling specific to the etiology, symptomology, and characteristics of their disorder. Ensuring a patient’s health literacy regarding their diagnosis and management options will allow them to make informed decisions and to be a participant in their care. A patient with chronic balance issues can use a variety of strategies to remain active, reduce fall risk, and cope with symptoms. See ASHA’s Practice Portal page on Counseling in Audiology and Speech-Language Pathology for more information on this topic.

Management Considerations

Pediatrics

Untreated vestibular system dysfunction or hypofunction in children can lead to problems with coordination, delays in developmental milestones, fatigue, academic concerns, and cognitive deficits (Loos et al., 2025; Rine et al., 2004). Once a child has had a medical evaluation by a physician (e.g., pediatrician, neurologist, otolaryngologist) and has received a thorough diagnostic assessment, an effective management plan can be developed. Outcome measures may include (a) the use of tools that address dizziness-related quality of life and dizziness symptoms (McCaslin et al., 2015) as well as (b) the administration of age-specific gross motor and developmental questionnaires.

Management Limitations

Factors that may limit the success of vestibular rehabilitation include

• cerebellar dysfunction (e.g., stroke),
• cognitive deficits,
• excessive nausea,
• fluctuating etiologies (e.g., Ménière’s disease, perilymph fistula),
• the level of patient involvement,
• mental health conditions (e.g., anxiety, depression),
• polypharmacy,
• reduced proprioception, and
• reduced vision.

Contraindications for canalith repositioning maneuvers include

• acute bone fractures,
• a history of back or neck problems,
• medical conditions (e.g., unstable heart disease),
• reduced mobility or flexibility, and
• retinal detachment.

ASHA Resources

• Audiology Information Series: Dizziness and Balance [PDF]
• Audiology Information Series: Preventing Falls [PDF]
• Audiology Information Series: Benign Paroxysmal Positional Vertigo (BPPV) [PDF]
• Billing and Reimbursement
• Health Literacy
• Hearing-Related Topics: Terminology Guidance
• Infection Control Resources for Audiologists and Speech-Language Pathologists
• International Classification of Functioning, Disability, and Health (ICF)
• Interprofessional Education/Interprofessional Practice (IPE/IPP)
• The Value of Audiologists in the Assessment and Treatment of Balance and Dizziness [PDF]
• Vestibular Impairments in the Pediatric Population

Other Resources

This list of resources is not exhaustive, and the inclusion of any specific resource does not imply endorsement from ASHA.

• American Academy of Audiology Clinical Consensus Statement: Assessment of Vestibular Function in the Pediatric Population [PDF]
• The American Institute of Balance
• The Bárány Society
• Centers for Disease Control and Prevention: Algorithm for Fall Risk Screening, Assessment, and Intervention [PDF]
• Centers for Disease Control and Prevention: STEADI – Older Adult Fall Prevention
• International Pediatric Balance Network
• National Institute on Deafness and Other Communication Disorders: Balance Disorders
• Vanderbilt Pediatric Dizziness Handicap Inventory [PDF]
• Vestibular Disorders Association
• Vestibular Neuritis Fact Sheet [PDF]

Adamec, I., Krbot Skorić, M., Handžić, J., & Habek, M. (2015). Incidence, seasonality and comorbidity in vestibular neuritis. Neurological Sciences, 36(1), 91–95. https://doi.org/10.1007/s10072-014-1912-4

Agrawal, Y., Carey, J. P., Della Santina, C. C., Schubert, M. C., & Minor L. B. (2009). Disorders of balance and vestibular function in US adults: Data from the National Health and Nutrition Examination Survey, 2001–2004. Archives of Internal Medicine, 169(10), 938–944. https://doi.org/10.1001/archinternmed.2009.66

American Speech-Language-Hearing Association. (2016). Scope of practice in speech-language pathology [Scope of practice]. https://www.asha.org/policy/

American Speech-Language-Hearing Association. (2018). Scope of practice in audiology [Scope of practice]. https://www.asha.org/policy/

American Speech-Language-Hearing Association. (2023). Code of ethics [Ethics]. https://www.asha.org/policy/

Ayub, A., Qi, L., & Nunez, D. A. (2019). A systematic review and meta-analysis of extratympanic electrocochleography in Ménière’s disease diagnosis. International Journal of Audiology, 58(9), 533–540. https://doi.org/10.1080/14992027.2019.1606947

Balatsouras, D. G., Kaberos, A., Assimakopoulos, D., Katotomichelakis, M., Economou, N. C., & Korres, S. G. (2007). Etiology of vertigo in children. International Journal of Pediatric Otorhinolaryngology, 71(3), 487–494. https://doi.org/10.1016/j.ijporl.2006.11.024

Bhandari, A., Bhandari, R., Kingma, H., & Strupp, M. (2022). Modified interpretations of the supine roll test in horizontal canal BPPV based on simulations: How the initial position of the debris in the canal and the sequence of testing affects the direction of the nystagmus and the diagnosis. Frontiers in Neurology, 13, Article 881156. https://doi.org/10.3389/fneur.2022.881156

Bhandari, R., Bhandari, A., Hsieh, Y.-H., Edlow, J., & Omron, R. (2023). Prevalence of horizontal canal variant in 3,975 patients with benign paroxysmal positional vertigo: A cross-sectional study. Neurology: Clinical Practice, 13(5), Article e200191. https://doi.org/10.1212/CPJ.0000000000200191

Blayney, A. W., & Colman, B. H. (1984). Dizziness in childhood. Clinical Otolaryngology & Allied Sciences, 9(2), 77–85. https://doi.org/10.1111/j.1365-2273.1984.tb01477.x

Brandt, T., Dieterich, M., & Strupp, M. (2005). Vertigo and dizziness: Common complaints. Springer.

Brodsky, J. R., Lipson, S., & Bhattacharyya, N. (2020). Prevalence of pediatric dizziness and imbalance in the United States. Otolaryngology—Head and Neck Surgery, 162(2), 241–247. https://doi.org/10.1177/0194599819887375

Casqueiro, J. C., Ayala, A., & Monedero, G. (2008). No more postural restrictions in posterior canal benign paroxysmal positional vertigo. Otology & Neurotology, 29(5), 706–709. https://doi.org/10.1097/MAO.0b013e31817d01e8

Chen, G., Zhang, J., Qiao, Q., Zhou, L., Li, Y., Yang, J., Wu, J., & Huangfu, H. (2023). Advances in dynamic visual acuity test research. Frontiers in Neurology, 13, Article 1047876. https://doi.org/10.3389/fneur.2022.1047876

Choung, Y.-H., Shin, Y. R., Kahng, H., Park, K., & Choi, S. J. (2006). ‘Bow and lean test’ to determine the affected ear of horizontal canal benign paroxysmal positional vertigo. The Laryngoscope, 116(10), 1776–1781. https://doi.org/10.1097/01.mlg.0000231291.44818.be

Coban, F. A., & Tarnutzer, A. A. (2026). The epidemiology and clinical presentation of acute vestibular syndromes: A systematic review of the literature. Journal of Neurology, 273(3), Article 173. https://doi.org/10.1007/s00415-026-13720-5

Cohen, H. S., Mulavara, A. P., Stitz, J., Sangi-Haghpeykar, H., Williams, S. P., Peters, B. T., & Bloomberg, J. J. (2019). Screening for vestibular disorders using the modified clinical test of sensory interaction and balance and tandem walking with eyes closed. Otology & Neurotology, 40(5), 658–665. https://doi.org/10.1097/MAO.0000000000002173

Cohen, H. S., Sangi-Haghpeykar, H., Ricci, N. A., Kampangkaew, J., & Williamson, R. A. (2014). Utility of stepping, walking, and head impulses for screening patients for vestibular impairments. Otolaryngology—Head and Neck Surgery, 151(1), 131–136. https://doi.org/10.1177/0194599814527724

Crevits, L. (2004). Treatment of anterior canal benign paroxysmal positional vertigo by a prolonged forced position procedure. Journal of Neurology, Neurosurgery & Psychiatry, 75(5), 779–781. https://doi.org/10.1136/jnnp.2003.025478

Cushing, S. L., Gordon, K. A., Rutka, J. A., James, A. L., & Papsin, B. C. (2013). Vestibular end-organ dysfunction in children with sensorineural hearing loss and cochlear implants: An expanded cohort and etiologic assessment. Otology & Neurotology, 34(3), 422–428. https://doi.org/10.1097/MAO.0b013e31827b4ba0

Dasgupta, S., Brodsky, J., & Widdershoven, J. (2025). Paediatric vestibular disorders—A focussed diagnostic approach for best management outcomes. Frontiers in Neurology, 15, Article 1532327. https://doi.org/10.3389/fneur.2024.1532327

Dye, D. (2008, July/August). Vestibular rehabilitation: Rehabilitation options for patients with dizziness and imbalance. ASHA Access Audiology, 7. https://www.asha.org/articles/vestibular-rehabilitation/

Epley, J. M. (1992). The Canalith Repositioning Procedure: For treatment of benign paroxysmal positional vertigo. Otolaryngology—Head and Neck Surgery, 107(3), 399–404. https://doi.org/10.1177/019459989210700310

Ferraro, J. A. (2010). Electrocochleography: A review of recording approaches, clinical applications, and new findings in adults and children. Journal of the American Academy of Audiology, 21(3), 145–152. https://doi.org/10.3766/jaaa.21.3.2

Ferraro, J. A., & Durrant, J. D. (2006). Electrocochleography in the evaluation of patients with Ménière’s disease/endolymphatic hydrops. Journal of the American Academy of Audiology, 17(1), 45–68. https://doi.org/10.3766/jaaa.17.1.6

Formby, C., Kuntz, L. A., Rivera-Taylor, I. M., Rivera-Mraz, N., Weesner, D. R., Butler-Young, N. E., & Ahlers, A. E. (1992). Measurement, analysis, and modelling of the caloric response. 2.: Evaluation of mental alerting tasks for measurement of caloric-induced nystagmus. Acta Oto-Laryngologica, 112(Suppl. 498), 19–29. https://doi.org/10.3109/00016489209136855

Gibson, W. P. (2017). The clinical uses of electrocochleography. Frontiers in Neuroscience, 11, Article 274. https://doi.org/10.3389/fnins.2017.00274

Gioacchini, F. M., Alicandri-Ciufelli, M., Kaleci, S., Magliulo, G., & Re, M. (2014). Prevalence and diagnosis of vestibular disorders in children: A review. International Journal of Pediatric Otorhinolaryngology, 78(5), 718–724. https://doi.org/10.1016/j.ijporl.2014.02.009

Graafmans, W. C., Ooms, M. E., Hofstee, H. M. A., Bezemer, P. D., Bouter, L. M., & Lips, P. (1996). Falls in the elderly: A prospective study of risk factors and risk profiles. American Journal of Epidemiology, 143(11), 1129–1136. https://doi.org/10.1093/oxfordjournals.aje.a008690

Guidetti, G., Monzani, D., & Rovatti, V. (2006). Clinical examination of labyrinthine-defective patients out of the vertigo attack: Sensitivity and specificity of three low-cost methods. Acta Otorhinolaryngologica Italica, 26(2), 96–101.

Herdman, S. J., Tusa, R. J., Blatt, P., Suzuki, A., Venuto, P. J., & Roberts, D. (1998). Computerized dynamic visual acuity test in the assessment of vestibular deficits. Otology & Neurotology, 19(6), 790–796.

Hotson, J. R., & Baloh, R. W. (1998). Acute vestibular syndrome. The New England Journal of Medicine, 339(10), 680–685. https://doi.org/10.1056/NEJM199809033391007

Hougaard, D. D., & Abrahamsen, E. R. (2019). Testing of all six semicircular canals with video head impulse test systems. Journal of Visualized Experiments, 146, Article e59012. https://doi.org/10.3791/59012

Huang, M., Wang, X., & Chen, M. (2025). Optimizing staging of Meniere’s disease: Integrating electrocochleography with vestibular tests. Frontiers in Neuroscience, 19, Article 1600665. https://doi.org/10.3389/fnins.2025.1600665

Hung, S.-H., Xirasagar, S., Dang, L. H., Chen, Y.-C., Cheng, Y.-F., Lin, H.-C., & Chen, C.-S. (2023). Trends in the incidence of peripheral vestibular disorders: A nationwide population-based study. Frontiers in Neurology, 14, Article 1322199. https://doi.org/10.3389/fneur.2023.1322199

Hunt, W. T., Zimmerman, E. F., & Hilton, M. P. (2012). Modifications of the Epley (canalith repositioning) manoeuvre for posterior canal benign paroxysmal positional vertigo (BPPV). Cochrane Database of Systematic Reviews. https://doi.org/10.1002/14651858.CD008675.pub2

Jacobson, G. P., Newman, C. W., & Safadi, I. (1990). Sensitivity and specificity of the head-shaking test for detecting vestibular system abnormalities. Annals of Otology, Rhinology & Laryngology, 99(7), 539–542. https://doi.org/10.1177/000348949009900708

Jacot, E., Van Den Abbeele, T., Debre, H. R., & Wiener-Vacher, S. R. (2009). Vestibular impairments pre- and post-cochlear implant in children. International Journal of Pediatric Otorhinolaryngology, 73(2), 209–217. https://doi.org/10.1016/j.ijporl.2008.10.024

Jahn, K., Langhagen, T., Schroeder, A. S., & Heinen, F. (2011). Vertigo and dizziness in childhood—Update on diagnosis and treatment. Neuropediatrics, 42(4), 129–134. https://doi.org/10.1055/s-0031-1283158

Janky, K. L., & Shepard, N. (2009). Vestibular evoked myogenic potential (VEMP) testing: Normative threshold response curves and effects of age. Journal of the American Academy of Audiology, 20(8), 514–522. https://doi.org/10.3766/jaaa.20.8.6

Janky, K. L., Thomas, M. L. A., High, R. R., Schmid, K. K., & Ogun, O. A. (2018). Predictive factors for vestibular loss in children with hearing loss. American Journal of Audiology, 27(1), 137–146. https://doi.org/10.1044/2017_AJA-17-0058

Kaf, W. A., Abdelhakiem, M. K., Zahirsha, Z., & Lichtenhan, J. T. (2015). Ménière’s disease: Current and potential new objective measures using electrocochleography. Perspectives on Hearing and Hearing Disorders: Research and Diagnostics, 19(2), 44–54.

Kakara, R., Bergen, G., Burns, E., & Stevens, M. (2023). Nonfatal and fatal falls among adults aged ≥65 years—United States, 2020–2021. Morbidity and Mortality Weekly Report, 72(35), 938–943. http://dx.doi.org/10.15585/mmwr.mm7235a1

Kang, B. C., Kim, T., & Kwon, J. K. (2023). Prevalence of vestibular migraine in an otolaryngologic clinic: Preliminary clinical diagnosis versus diagnosis according to the strictly applied Bárány criteria. Journal of Vestibular Research, 33(2), 137–142. https://doi.org/10.3233/VES-220112

Kattah, J. C., Talkad, A. V., Wang, D. Z., Hsieh, Y.-H., & Newman-Toker, D. E. (2009). HINTS to diagnose stroke in the acute vestibular syndrome: Three-step bedside oculomotor examination more sensitive than early MRI diffusion-weighted imaging. Stroke, 40(11), 3504–3510. https://doi.org/10.1161/STROKEAHA.109.551234

Kerber, K. A., Callaghan, B. C., Telian, S. A., Meurer, W. J., Skolarus, L. E., Carender, W., & Burke, J. F. (2017). Dizziness symptom type prevalence and overlap: A US nationally representative survey. The American Journal of Medicine, 130(12), 1465.E1–1465.E9. https://doi.org/10.1016/j.amjmed.2017.05.048

Langhagen, T., Albers, L., Heinen, F., Straube, A., Filippopulos, F., Landgraf, M. N., Gerstl, L., Jahn, K., & von Kries, R. (2015). Period prevalence of dizziness and vertigo in adolescents. PLOS ONE, 10(9), Article e0136512. https://doi.org/10.1371/journal.pone.0136512

Lavender, V., Janky, K., Bachmann, K., Caine, M., Castiglione, M., & Zhou, G. (2025). American Academy of Audiology clinical consensus statement: Assessment of vestibular function in the pediatric population. Journal of the American Academy of Audiology, 36(3), 196–229. https://doi.org/10.3766/jaaa.24250301

Lee, J. D., Kim, C.-H., Hong, S. M., Kim, S. H., Suh, M.-W., Kim, M.-B., Shim, D. B., Chu, H., Lee, N. H., Kim, M., Hong, S. K., & Seo, J.-H. (2017). Prevalence of vestibular and balance disorders in children and adolescents according to age: A multi-center study. International Journal of Pediatric Otorhinolaryngology, 94, 36–39. https://doi.org/10.1016/j.ijporl.2017.01.012

Levo, H., Aalto, H., & Petteri Hirvonen, T. (2004). Nystagmus measured with video-oculography: Methodological aspects and normative data. ORL: Journal for Oto-Rhino-Laryngology and Its Related Specialties, 66(3), 101–104. https://doi.org/10.1159/000079327

Li, C.-M., Hoffman, H. J., Ward, B. K., Cohen, H. S., & Rine, R. M. (2016). Epidemiology of dizziness and balance problems in children in the United States: A population-based study. The Journal of Pediatrics, 171, 240.E3–247.E3. https://doi.org/10.1016/j.jpeds.2015.12.002

Loos, E., Gerdsen, M., Hazen, M., Cushing, S. L., Gordon, K. A., Perez-Fornos, A., Verhaert, N., Desloovere, C., Van de Berg, R., & Widdershoven, J. (2025). Bilateral vestibular hypofunction in children. International Journal of Pediatric Otorhinolaryngology, 196, Article 112506. https://doi.org/10.1016/j.ijporl.2025.112506

Lu, Y., Gao, F., Zhu, Y., Wang, J., Li, S., Gao, B., Pan, X., & Wei, X. (2025). The diagnostic significance and value of vestibular function testing combined with MRI in Meniere’s disease. Head & Face Medicine, 21(1), Article 89. https://doi.org/10.1186/s13005-025-00568-9

Malara, P., Castellucci, A., & Martellucci, S. (2020). Upright head roll test: A new contribution for the diagnosis of lateral semicircular canal benign paroxysmal positional vertigo. Audiology Research, 10(1), Article 236. https://doi.org/10.4081/audiores.2020.236

Margolis, R. H., Levine, S. C., Foamier, E. M., Hunter, L. L., Smith, S. L., & Lilly, D. J. (1992). Tympanic electrocochleography: Normal and abnormal patterns of response. Audiology, 31(1), 8–24. https://doi.org/10.3109/00206099209072898

Master, C. L., Curry, A. E., Pfeiffer, M. R., Metzger, K. B., Kessler, R. S., Haarbauer-Krupa, J., DePadilla, L., Greenspan, A., Breiding, M. J., & Arbogast, K. B. (2020). Characteristics of concussion in elementary school-aged children: Implications for clinical management. The Journal of Pediatrics, 223, 128–135. https://doi.org/10.1016/j.jpeds.2020.04.001

McCaslin, D. L., Jacobson, G. P., & Gruenwald, J. M. (2011). The predominant forms of vertigo in children and their associated findings on balance function testing. Otolaryngologic Clinics of North America, 44(2), 291–307. https://doi.org/10.1016/j.otc.2011.01.003

McCaslin, D. L., Jacobson, G. P., Lambert, W., English, L. N., & Kemph, A. J. (2015). The development of the vanderbilt pediatric dizziness handicap inventory for patient caregivers (DHI-PC). International Journal of Pediatric Otorhinolaryngology, 79(10), 1662–1666. https://doi.org/10.1016/j.ijporl.2015.07.017

McGinnis, P. Q., Nebbia, M., Saez, L., & Rudolph, K. (2009). Retrospective comparison of outcomes for patients with benign paroxysmal positional vertigo based on length of postural restrictions. Journal of Geriatric Physical Therapy, 32(4), 168–173. https://doi.org/10.1519/00139143-200932040-00005

Mitchell, M. B., & Bhattacharyya, N. (2023). Balance disorder trends in US adults 2008‐2016: Epidemiology and functional impact. OTO Open, 7(2), Article e58. https://doi.org/10.1002/oto2.58

Murdin, L., & Schilder, A. G. M. (2015). Epidemiology of balance symptoms and disorders in the community: A systematic review. Otology & Neurotology, 36(3), 387–392. https://doi.org/10.1097/MAO.0000000000000691

National Institute on Deafness and Other Communication Disorders. (2024). Ménière’s disease (NIH Publication No. 10-3404). U.S. Department of Health and Human Services.

Neuhauser, H. K. (2016). The epidemiology of dizziness and vertigo. In J. M. Furman & T. Lempert (Eds.), Handbook of clinical neurology (Vol. 137, pp. 67–82). https://doi.org/10.1016/B978-0-444-63437-5.00005-4

Ochi, K., & Ohashi, T. (2003). Age-related changes in the vestibular-evoked myogenic potentials. Otolaryngology—Head and Neck Surgery, 129(6), 655–659. https://doi.org/10.1016/S0194-59980301578-X

O’Loughlin, J. L., Boivin, J.-F., Robitaille, Y., & Suissa, S. (1994). Falls among the elderly: Distinguishing indoor and outdoor risk factors in Canada. Journal of Epidemiology & Community Health, 48(5), 488–489. https://doi.org/10.1136/jech.48.5.488

O’Reilly, R. C., Morlet, T., Nicholas, B. D., Josephson, G., Horlbeck, D., Lundy, L., & Mercado, A. (2010). Prevalence of vestibular and balance disorders in children. Otology & Neurotology, 31(9), 1441–1444. https://doi.org/10.1097/MAO.0b013e3181f20673

Parker, I. G., Hartel, G., Paratz, J., Choy, N. L., & Rahmann, A. (2019). A systematic review of the reported proportions of diagnoses for dizziness and vertigo. Otology & Neurotology, 40(1), 6–15. https://doi.org/10.1097/MAO.0000000000002044

Rine, R. M., Braswell, J., Fisher, D., Joyce, K., Kalar, K., & Shaffer, M. (2004). Improvement of motor development and postural control following intervention in children with sensorineural hearing loss and vestibular impairment. International Journal of Pediatric Otorhinolaryngology, 68(9), 1141–1148. https://doi.org/10.1016/j.ijporl.2004.04.007

Roberts, R. A., Gans, R. E., DeBoodt, J. L., & Lister, J. J. (2005). Treatment of benign paroxysmal positional vertigo: Necessity of postmaneuver patient restrictions. Journal of the American Academy of Audiology, 16(6), 357–366. https://doi.org/10.3766/jaaa.16.6.4

Rubenstein, L. Z. (2006). Falls in older people: Epidemiology, risk factors and strategies for prevention. Age and Ageing, 35(Suppl. 2), ii37–ii41. https://doi.org/10.1093/ageing/afl084

Russell, G., & Abu-Arafeh, I. (1999). Paroxysmal vertigo in children—An epidemiological study. International Journal of Pediatric Otorhinolaryngology, 49(Suppl. 1), S105–S107. https://doi.org/10.1016/S0165-5876(99)00143-3

Sekitani, T., Imate, Y., Noguchi, T., & Inokuma, T. (1993). Vestibular neuronitis: Epidemiological survey by questionnaire in Japan. Acta Oto-Laryngologica, 113(Suppl. 503), 9–12. https://doi.org/10.3109/00016489309128061

Slattery, E. L., Sinks, B. C., & Goebel, J. A. (2011). Vestibular tests for rehabilitation: Applications and interpretation. NeuroRehabilitation, 29(2), 143–151. https://doi.org/10.3233/NRE-2011-0688

Strupp, M., Brandt, T., & Dieterich, M. (2023). Vertigo and dizziness: Common complaints (3rd ed.). Springer.

Szirmai, A. (2010). Vestibular disorders in childhood and adolescents. European Archives of Oto-Rhino-Laryngology, 267(11), 1801–1804. https://doi.org/10.1007/s00405-010-1283-2

Ten Voorde, M., van der Zaag-Loonen, H. J., & van Leeuwen, R. B. (2012). Dizziness impairs health-related quality of life. Quality of Life Research, 21(6), 961–966. https://doi.org/10.1007/s11136-011-0001-x

van de Berg, R., Widdershoven, J., Bisdorff, A., Evers, S., Wiener-Vacher, S., Cushing, S. L., Mack, K. J., Kim, J. S., Jahn, K., Strupp, M., & Lempert, T. (2021). Vestibular migraine and recurrent vertigo of childhood: Diagnostic criteria consensus document of the classification committee of vestibular disorders of the Bárány Society and the International Headache Society. Journal of Vestibular Research, 31(1), 1–9. https://doi.org/10.3233/VES-200003

von Brevern, M., Radtke, A., Lezius, F., Feldmann, M., Ziese, T., Lempert, T., & Neuhauser, H. (2007). Epidemiology of benign paroxysmal positional vertigo: A population based study. Journal of Neurology, Neurosurgery & Psychiatry, 78(7), 710–715. https://doi.org/10.1136/jnnp.2006.100420

Wang, A., Zhou, G., Lipson, S., Kawai, K., Corcoran, M., & Brodsky, J. R. (2021). Multifactorial characteristics of pediatric dizziness and imbalance. The Laryngoscope, 131(4), E1308–E1314. https://doi.org/10.1002/lary.29024

Whitney, S. L., Marchetti, G. F., & Schade, A. I. (2006). The relationship between falls history and computerized dynamic posturography in persons with balance and vestibular disorders. Archives of Physical Medicine and Rehabilitation, 87(3), 402–407. https://doi.org/10.1016/j.apmr.2005.11.002

Wiener-Vacher, S. R. (2008). Vestibular disorders in children. International Journal of Audiology, 47(9), 578–583. https://doi.org/10.1080/14992020802334358

Wiener-Vacher, S. R., Quarez, J., & Le Priol, A. (2018). Epidemiology of vestibular impairments in a pediatric population. Seminars in Hearing, 39(3), 229–242. https://doi.org/10.1055/s-0038-1666815

Zamysłowska-Szmytke, E., Szostek-Rogula, S., & Śliwińska-Kowalska, M. (2015). Bedside examination for vestibular screening in occupational medicine. International Journal of Occupational Medicine and Environmental Health, 28(2), 379–387. https://doi.org/10.13075/ijomeh.1896.00514

Acknowledgments

Content for ASHA’s Practice Portal is developed through a comprehensive process that includes multiple rounds of subject-matter expert input and review. ASHA extends its gratitude to the following subject-matter experts who were involved in the development of the Balance System Disorders page.

Primary Version

• Margot Beckerman, AuD, CCC-A
• Robin Criter, AuD, CCC-A
• Deanna Dye, PhD, PT
• Tucker Gleason, PhD, CCC-A
• Jaynee Handelsman, PhD, CCC-A
• Julie Honaker, PhD, CCC-A
• Kristen Janky, PhD, CCC-A
• Devin McCaslin, PhD, CCC-A
• Belinda Sinks, AuD, CCC-A
• Christopher Zalewski, PhD, CCC-A

Secondary Versions

• Melissa Caine, AuD, CCC-A
• Megan Cherry, AuD, CCC-A
• Ingrid Edwards, AuD, CCC-A
• Karen Hendrick, AuD, CCC-A

ASHA seeks input from subject-matter experts representing differing perspectives and backgrounds. At times, a subject-matter expert may request to have their name removed from our acknowledgment. We continue to appreciate their work.

Citing Practice Portal Pages

The recommended citation for the Practice Portal page is as follows:

American Speech-Language-Hearing Association. (n.d.). Balance system disorders [Practice portal]. https://www.asha.org/Practice-Portal/Clinical-Topics/Balance-System-Disorders/