The assessment of the patient with a neuro-otological problem is not a complex task if approached in a logical manner. It is best addressed by taking a comprehensive history, by a physical examination that is directed towards detecting abnormalities of eye movements and abnormalities of gait, and also towards identifying any associated otological or neurological problems. This examination needs to be mindful of the factors that can compromise the value of the signs elicited, and the range of investigative techniques available. The majority of patients that present with neuro-otological symptoms do not have a space occupying lesion and the over reliance on imaging techniques is likely to miss more common conditions, such as benign paroxysmal positional vertigo (BPPV), or the failure to compensate following an acute unilateral labyrinthine event.

The role of the neuro-otologist is to identify the site of the lesion, gather information that may lead to an aetiological diagnosis, and from there, to formulate a management plan.

BACKGROUND

Balance is maintained through the integration at the brainstem level of information from the vestibular end organs, and the visual and proprioceptive sensory modalities. This processing takes place in the vestibular nuclei, with modulating influences from higher centres including the cerebellum, the extrapyramidal system, the cerebral cortex, and the contiguous reticular formation (fig 1). Therefore any derangement of the structure or function of the sensory inputs, the central vestibular structures or the effector pathways—that is, the oculomotor and vestibulo-spinal pathways—is likely to result in a balance disorder.

Many conditions will elude diagnosis if balance is equated purely with a disorder of vestibular function. Drachman and Hart¹ have emphasised the importance of multi-sensory dizziness, particularly in …