By Marcello Cherchi, MD PhD
Disequilibrium is an extraordinarily common symptom. Every year, in the United States alone this symptom prompts millions of emergency room visits, and tens of millions of primary care visits (Cherchi 2013, Newman-Toker and Edlow 2015) — thus, internists, general practitioners, and emergency room physicians end up seeing the vast majority of these patients.
Despite how common disequilibrium is, there are very few medical practitioners who cultivate a specific interest in the population of patients suffering from disturbances of equilibrium.
Neurologists who have done extra fellowship training in diseases of equilibrium and hearing are called “oto-neurologists.” In some settings they may be referred to as “neuro-otologists,” but that designation is usually reserved for surgeons (see below). Oto-neurologists specialize is medically-managed causes of disequilibrium and auditory problems. Examples of medically-managed disorders of equilibrium include migraine associated vertigo. Examples of medically-managed disorders of hearing include autoimmune inner ear disease. Oto-neurologists do not currently have a unifying professional organization. As of this writing there are a few dozen such practitioners in the United States, and about 2 training programs.
Ear-nose-throat surgeons (otolaryngologists) who have done extra fellowship training in diseases of equilibrium and hearing are called “neuro-otologists,” and among their colleagues are often referred to as “skull base surgeons” because of the anatomical areas on which they operate. Given their training, their expertise is in diseases treated with surgery. Examples of surgically-managed disorders of equilibrium include vestibular schwannomas and superior semicircular canal dehiscence. Examples of surgically-managed disorders of hearing include otosclerosis and placement of cochlear implants. The American Neurotology Society is a professional organization that maintains a directory of these practitioners (https://ans.memberclicks.net/membership-directory#/, accessed 1/19/23). As of this writing there are a few hundred such practitioners in the United States, and about 25 training programs (https://www.americanneurotologysociety.com/neurotology-fellowship-program-information, accessed 1/19/23).
There is considerable overlap in the practice of neuro-otology and oto-neurology, and it is common for these specialists to collaborate. For example, a patient diagnosed with Meniere’s disease may initially be diagnosed and medically managed by an otoneurologist with dietary sodium restriction and medication; as the disease advances, the patient may eventually be referred to a neurotologist to be evaluated for a transtympanic gentamicin injection.
Allied fields
Since disorders of equilibrium and hearing can involve diseases of the ear and brain, and since the practice of medicine is increasingly subspecialized, it is understandable that the diagnosis and management of these patients is often an interdisciplinary enterprise. Beyond oto-neurology and neuro-otology, other relevant subspecialties include:
Audiology. Audiologists perform audiologic and vestibular tests. Many audiologists dispense hearing aids to help manage hearing loss.
Neuro-ophthalmology. Neuro-ophthalmologists are surgeons (ophthalmologists) who have done extra fellowship training in the neurological underpinnings of eye movements and visual processing. Neuro-ophthalmologists are often involved in the surgical management of strabismus (ocular misalignment).
Neuro-optometry. Neuro-optometrists are optometrists who have done extra training in disorders of ocular motility and vision processing. They are sometimes referred to as “developmental optometrists” because of their role in managing patients with strabismus (disorders of ocular alignment). Neuro-optometrists often manage patients with diagnoses such as visual vertigo, visual snow and anomalous retinal correspondence.
Neuro-surgery. Neurosurgeons are trained to perform surgery on all areas of the nervous system, including the brain, spinal cord and peripheral nerves. Some diseases (e.g., Chiari malformation) require surgery that can only be performed by a neurosurgeon. Some vestibular diseases (such as vestibular schwannoma and superior semicircular canal dehiscence) may require surgical intervention by both an otolaryngologist and a neurosurgeon working in tandem.
Vestibular rehabilitation therapy. Physical therapists who do extra training in vestibular disorders are sometimes called “vestibular physical therapists.” These practitioners play a crucial role in the management of some very common vestibular diseases, such as benign paroxysmal positional vertigo and vestibular neuritis.
The umbrella term “vestibular medicine” has been proposed to encompass the various subspecialties involved in the diagnosis and management of these patients (van de Berg, Murdin et al. 2022).
For pediatric patients
There are relatively few neuro-otologists, and very few oto-neurologists, who take care of adult patients with otologic and vestibular diseases. There are even fewer such practitioners who provide this care to pediatric vestibular patients. This is unfortunate, since symptoms of imbalance (Humphriss and Hall 2011; Niemensivu et al. 2006) and hearing deficits are not rare in children, the relative distribution of diagnoses is often different than in adults (Ferreira et al. 2025; Gioacchini et al. 2014), and responses to treatment may differ from that in adults (Gruber et al. 2012).
Despite the oft-repeated mantra that disequilibrium in children is more commonly due to central causes — typically migraine (Erbek et al. 2006) — and more commonly due to peripheral causes in adults, some studies instead report that most cases of “vertigo” in the pediatric population are attributable to peripheral causes (Balatsouras et al. 2007), including benign paroxysmal positional vertigo (Balzanelli et al. 2021).
Standardized questionnaires pertaining to vestibular symptoms need to be validated in the pediatric population. There has been some effort toward this, including the pediatric dizziness handicap inventory (McCaslin et al. 2015; Picciotti et al. 2023; Sommerfleck et al. 2023) and the Pediatric Vestibular Symptom Questionnaire (Rigal et al. 2024). Some investigators have attempted to algorithmize the questionnaire process by computer (Ravid et al. 2003).
As far as instrumented vestibular testing is concerned, the literature contains far more data regarding adults than children, both in terms of normative data and pathological results. The literature pertaining to pediatric vestibular testing is still emerging (Coudert et al. 2025; Janky and Rodriguez 2018; Martens et al. 2023; Valente 2011). Depending on the patient age, some instrumented tests may not be tolerated (Ciolek et al. 2018). Other instrumented tests may require modification (Wenzel et al. 2017). There are some published normative data for several instrumented vestibular tests, including cervical vestibular evoked myogenic potentials (Kelsch et al. 2006; Sheykholeslami et al. 2005), ocular vestibular evoked myogenic potentials (Kuhn et al. 2018), ocular motor testing (Kullmann et al. 2021; Levens 1988; Sinno et al. 2019), video head impulse testing (vHIT) (Bachmann et al. 2018) and rotatory chair testing (RCT) (Maes et al. 2008).
Clinic organization
A medical facility should be able to provide otoneurologic/neuro-otologic care in a timely fashion, and in such a way that evaluation (history, examination, diagnostic testing) and treatment occur in proximity, with iterative “course-corrections” as necessary. We have worked in several different settings, with varying equipment, and various combinations of practitioners. In our experience, greater diagnostic certainty, and more appropriately focused therapy, is more likely when the various components of this care can be delivered “under one roof” — colloquially referred to as “one-stop shopping” (Cook 2001, Mendis and Irving 2015). Such an arrangement facilitates communication among practitioners and affords internal quality control. Ideally such an arrangement would include adequate staffing (one or more otoneurologists, a neuro-otologist, an audiologist supported to otologic technicians, a vestibular physical therapist, a neuro-optometrist), infrastructure (appropriate equipment for each specialty), and adequate logistical support. Given the high prevalence of peripheral vestibular disorders such as benign paroxysmal positional vertigo (BPPV) and vestibular neuritis (VN), there is a case to be made for having vestibular physical therapists serve as the entry-point to vestibular care (Burrows et al. 2017; Kasbekar et al. 2014; Smith et al. 2024; Tank and Morrison 2024).
Why are there so few practitioners if there are so many patients?
In view of the economic tendencies governing supply and demand, it seems paradoxical that there are so many patients needing care for disorders of hearing and balance, yet so few practitioners to provide that care. The reasons for this supply-demand mismatch are unclear. In the author’s opinion there are probably several factors.
One factor is perhaps a byproduct of the interdisciplinary nature of the field. While the buzzword “interdisciplinary” may have positive connotations, it has a darker side as well. Specifically, if a medical problem straddles several subspecialties, then there is a risk that a practitioner in one subspecialty will feel uncomfortable taking on the care of a patient whose diagnosis they suspect might be better managed by a clinician in some other subspecialty.
A second factor is a consequence of lack of exposure during medical training. Because there are very few oto-neurologists and neuro-otologists, it is correspondingly uncommon for a medical trainee to come into contact with these practitioners during their education, so it may never even occur to a student that these disciplines exist as discrete fields.
A third factor is that, given that there are very few practitioners, there is no pressure in the design of medical educational curricula at the national level to make a clinical rotation a standard or mandatory component of a trainee’s exposure, since so few institutions would be able to meet such a requirement.
A fourth factor is the cost of setting up a clinic with adequate diagnostic capabilities. In November of 2022 we obtained the following quotes for the minimum new audiologic and vestibular equipment of an otoneurology clinic.
|
Type of test |
Specific model |
Company |
Price |
|
Binocular otomicroscopy |
OPMI Pico |
Zeiss |
$32,495.12 |
|
Video Frenzel goggles for doing videonystagmograms (without caloric testing) |
VisualEyes™️ 525b |
Micromedical by Interacoustics |
$37,183.00 |
|
Caloric irrigator |
Air Fx™️ and Aqua Stim™️ caloric irrigators |
Micromedical by Interacoustics |
$8,155.83 |
|
Video head impulse test |
VisualEyes™️ EyeSeeCam™️ |
Interacoustics |
$16,894.58 |
|
Rotatory chair test |
Orion™️ + VisualEyes™️ 525b |
Interacoustics |
$122,004.17 |
|
Rotatory chair test |
Dx Revolution Silver™️ |
Neurolign |
$110,000.00 |
|
Tympanometry and otoacoustic emissions |
Titan™️ |
Interacoustics |
$11,492.17 |
|
Otoacoustic emissions |
Duet |
Natus |
$9,675.00 |
|
Evoked potentials (for VEMP, BAER, ECoG) |
Eclipse™️ EP25 |
Interacoustics |
$31,447.13 |
|
Computerized dynamic posturography |
Bertec® CDP/IVR |
Bertec |
$164,315.00 |
|
Soundproof booth |
WhisperRoom™️ MDL 4872 S |
WhisperRoom |
$8,910.00 |
|
Audiometer |
Piano Plus™️ Clinical |
Invetis |
$7,500.00 |
|
Total |
$450,072.00 |
So as of this writing, a minimum audiologic and vestibular setup costs >$450k. This high up-front cost is a prohibitive barrier-to-entry for an independent medical practice, and will make a hospital system administrator pause when calculating how long the equipment will take to pay for itself. In short, the initial investment (just in equipment start-up costs) make it financially unattractive to establish an otoneurology practice.
References
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