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CLINICAL EXAMINATION OF THE EAR AND HEARING
100
Air–bone gap dB
100
Figure 3.3 Subtotal perforation with visible middle ear contents.
80
60
40
20
5101520
Figure 3.3.1 A comparison of the sensitivity and specicity of the 256 Hz fork using a loudness
comparison method against the 512 Hz fork using a threshold method, in detecting air–bone gaps
of various magnitudes. Redrawn with permission from Browning et al. Clinical role of informal
tests of hearing. J Laryngol Otol 1989; 103: 7–11.
25 30 35 40
% specicity
% sensitivity
256 Hz loud
512 Hz loud
80
60
40
20
Clinical Assessment of Hearing
Clinical assessment of the hearing in each ear should be done in all patients presenting with
ear problems irrespective of whether hearing impairment is a symptom. Free-eld speech
testing is reliable
2
(Table 3.1) and can act as a screening tool to determine whether pure-tone
audiometry is required.
General Technique of Free-Field Speech Testing
e examiner explains to the patient that a combination of letters and numbers are going to
be whispered or spoken and the patient’s task is to try and repeat them. A number-letter combination is chosen as this has a reasonable mix of consonants that allows a relatively broad
range of frequencies to be tested. For less experienced testers, a list of these to read from allows
18 e Ear
CLINICAL EXAMINATION OF THE EAR AND HEARING
Table 3.1 Comparison of free-eld voice thresholds and pure-tone
average (PTA) over 0.5, 1, 2 and 4kHz
Source: From Swan IRC, Browning GG. The whispered voice as a
screening test for hearing loss. J R Coll Gen Pract 1985; 35: 197.
a more consistent voice level to be produced. e examiner then positions themselves behind
the patient so t hat the subject cannot lip-read and in a loud voice conrms that they understand
the task by saying very recognisable numbers such as ‘99.’ e non-test ear can be masked by
tragal rubbing where the tragus is positioned over the canal and rubbed; this produces a masking level of around 40 dBA. When standing behind at arm’s length, if the subject cannot repeat
more than 50% of the words spoken in a whispered voice they will have a hearing impairment
of at least 25 dB hearing loss (HL) in that ear. Varying the distance from 60 to 15 cm and the
voice level can thereaer determine the likely degree of hearing impairment.
Tuning Fork Tests
ese are of minimal value when accurate pure-tone audiometry, with both air and bone
conduction, is available. e most commonly used forks are the 256 and 512 Hz with the
former giving more reliable results. ey are best activated by striking them gently on the
elbow giving a sound of ~70 dBA when presented to the ear.
Rinne Test
With the tuning fork activated, the patient is asked to say which of the following sounds
louder: the fork placed within 2 cm of the external auditory canal (air conduction [AC])
or placed rmly on the at bone of the mastoid behind the pinna (bone conduction [BC]).
To aid bone contact with the tuning fork, the patient’s head is held with the other hand to
prevent it from moving. In normal ears and those with a pure sensorineural impairment,
AC will be reported as louder than BC. When this is not the case, then a conductive defect is
suggested. BC can also be louder than AC due to a severe-profound HL in the test ear, with
BC being detected in the contralateral better-hearing ear.
If the ear is otoscopically normal and there is a hearing impairment, the Rinne tuning
fork test is insuciently sensitive to diagnose otosclerosis with an air-bone gap of less than
30–40 dB
2
(Table 3.2). It will only suggest a conductive loss in ears with a 20-dB air-bone gap
in ~50% of ears.
Weber Test
is is only applicable to those with unilateral or asymmetric hearing. An activated tuning
fork base is rmly placed in the midline over the forehead, incisor teeth, or skull vertex.
e patient is asked to report where in the head the sound is loudest. If heard in the ‘betterhearing’ ear there is a sensorineural impairment in the contralateral ear. If heard in the
poorer ear then it has a conductive impairment. e Weber test has a low sensitivity and
specicity and is marginally better than chance at determining whether a HL is sensorineural or conductive in nature.
e Ear 19
PSYCHOACOUSTIC AND OBJECTIVE ASSESSMENT OF HEARING
Table 3.2 Size of air-bone gap (dB) which would be correctly identied
by Rinne test on various percentages of occasions. (See Scott-Brown’s
Otorhinolaryngology, 8th edition, Chapter 73, for full references)
KEY POINTS
• Otoscopy is best performed backed up by microscopic-aided suction to improve
visualisation of all areas including the attic and surgical defects.
• The largest speculum available should be used to visualise the tympanic membrane; an
oval one is better than a round one.
• Free-eld speech tests with a whispered voice at 60 cm from the ear can be used as a
screening test for a hearing impairment if audiometry is not available.
• If the tympanic membrane is normal the Rinne tuning fork test will only detect an air-
bone gap of 20 dB in 50% of cases.
• If otoscopy suggests the possibility of a conductive impairment, full audiometry is
required to assess the magnitude of the air-bone gap if any.
Further Reading
1. Wormald PJ, Browning GG, Otoscopy: A Structured Approach. 1996, London: Hodder
Arnold.
2. Browning GG, Swan IRC, Chew KK, Clinical role of informal tests of hearing Journal
of Laryngology and Otology, 1989, 103, 7–11.
4. PSYCHOACOUSTIC AND OBJECTIVE ASSESSMENT OF HEARING
Psychoacoustic Audiometry
Audiometry is the measurement of hearing detection levels for pure tones in each ear across
frequencies. Results indicate the type and degree of hearing loss and give a basic indication
of the impact of ear pathology on hearing.
Audiometry results are recorded on a chart called the pure-tone audiogram (PTA).
1
Sound
levels are represented on the y-axis of the PTA in decibels (dBs). e number of decibels
is 20 times the logarithm of the ratio of two sound pressure levels (SPLs). A logarithmic
20 e Ear
PSYCHOACOUSTIC AND OBJECTIVE ASSESSMENT OF HEARING
Right
Uncomfortable loudness level
L
L
Hearing level (dB HL)
Left
8000
Conductive
dB HL
Frequency in Hz
Frequency in Hz
Frequency in Hz
Sensorineural
Mixed
Masked BC
–10
0
10
20
30
40
50
60
70
80
90
100
110
120
125 8000400020001000
500250
Frequency (Hz)
–10
0
10
20
30
40
50
60
70
80
90
100
Hearing level (dB HL)
110
120
125
500250
Frequency (Hz)
400020001000
RightLeft
Air conduction (masked or not)
Bone conduction (not masked)
Bone conduction (masked)
o
x
∆
∆
[
]
Figure 4.1 Audiogram chart and symbols used in clinical audiometry.
unit is used due to the wide dynamic range of human hearing (120 dB). e unit ‘dB hearing level’ or dB HL is used for ease of reading, as the normal hearing threshold varies
across frequencies when measured in SPL. e 0 dB HL line on the PTA represents average thresholds for otologically normal young adults at each frequency. e higher up the
chart the better are the HLs. Negative numbers indicate that thresholds are better than
average. Pure tones are used to measure HLs as they are easily characterised in terms of
frequency and level. e x-axis displays the frequencies of pure-tone signals typically at
octave intervals and encompasses a range important for speech understanding (250, 500,
1000, 2000, 4000 and 8000 Hz). e name of the patient, date, tester, and audiometer are
recorded. e convention for symbols used to record the outcomes of audiometry are
shown in Figure 4.1.
e procedures and calibration of audiometry equipment are specied by international and
national standards. e characteristics of the test environment are dened to reduce external
and internal competing noise sources.
Testing of absolute thresholds is done using air conduction (AC), using headphones or insert
earphones, and bone conduction (BC), using a transducer placed on the mastoid. e sensitivity for detecting mechanical vibrations produced in BC testing depends largely on the
inner ear with reduced inuence of the outer and middle ears.
Figure 4.2 Types of hearing loss.
–20
0
20
40
60
80
100
120
250500 1000 2000 4000 8000
–20
0
20
40
60
dB HL
80
100
120
250 500 1000 2000 4000 8000
–20
dB HL
100
120
0
20
40
60
80
250 500 1000 2000 4000 8000
Right ear
e Ear 21
PSYCHOACOUSTIC AND OBJECTIVE ASSESSMENT OF HEARING
Following otoscopic examination, headphones or insert earphones are positioned on the
ears. Patients are asked if they have had exposure to loud sounds in the last 24 hours, and
whether they have tinnitus, in which case the sound signal can be changed to warble tones to
make it easier to distinguish from tinnitus.
Patients respond by pressing a button or raising a nger for the duration of the presented
tone. e order of testing is typically started at 1000 Hz in the better-hearing ear, followed by 2000, 4000, 8000, 500, and 250 Hz. e rst frequency is repeated at the end of
testing of the rst ear to ensure test-retest consistency of 5 dB or less. e second ear is
then tested.
Starting at an easily audible level, the signals are systematically reduced in volume in
10-dB steps until the signal is inaudible. When the patient no longer responds, the signal is
increased in steps of 5 dB until the patient responds again. is is a bracketing technique,
which is also called the ‘10 dB-down, 5 dB-up technique’. e ‘absolute threshold’ is dened
as the lowest sound level that a person responds to on two out of three presentations and it
is used to quantify the degree of hearing loss, which can be mild (21–40 dB HL), moderate
(41–70 dB HL), severe (71–95 dB HL), or profound (above 95 dB HL). Dierences of 10 dB or
greater across tests are considered signicant.
Next, BC thresholds are tested at frequencies from 500, 1000, 2000, and 4000 Hz. e bone
transducer is placed to avoid it touching the pinna and hair. e test-retest reliability of
BC thresholds is poorer than that for AC. In moderate-to-profound hearing loss, some
low-frequency BC signals may be felt as vibration, giving the impression of a conductive
component of hearing loss in low frequencies. e type of hearing loss is dened as either
sensorineural (AC and BC loss dier by less than 20 dB, known as air-bone gap [ABG]), conductive (AC loss greater than BC loss by 20 dB or more), or mixed.
ere are occasions when the test signal may be perceived in the non-test or contralateral ear
through transcranial transmission (via BC). In AC, this tends to occur when there is an interaural dierence of 40 dB or more, in thresholds derived with supra-aural headphones, or over
55 dB with insert earphones. Ear-specic thresholds are obtained by ‘masking’ the non-test
ear by presenting a continuous narrow band of noise centred around the test signal frequency
(Table 4.1). Masking noise is calibrated in the decibel-eective masking level (dB EML). e
Table 4.1 Rules for the use of clinical masking
‘Rule’ Situation What to do
1 The not-masked AC thresholds differ by
10dB or more when using supra-or
circum-aural headphones, or by 55dB
when using insert earphones.
2 The not-masked BC threshold of one ear
is better than the AC threshold of
either ear by 10dB or more.
3 Rule 1 was bit applicable, but the BC
threshold of one ear (ear A) is 40 dB
(for supra- or circum-aural headphones)
or 55dB (for insertion earphones)
better than the not masked AC
threshold for the other ear (ear B).
22 e Ear
Retest the AC threshold of the worse ear
masking the contralateral ear.
Retest the BC threshold of the ear with the
worse AC threshold masking the
contralateral ear.
Use clinical judgement. Is it critical to
diagnosis to apply this rule (e.g. when there
are only small BC thresholds)?
If the masked BC threshold has changed little
(i.e. up to 10dB), it may be necessary to
retest the BC threshold of the ear with better
AC threshold masking the contralateral ear.
Retest the AC threshold of ear B masking
ear A.
PSYCHOACOUSTIC AND OBJECTIVE ASSESSMENT OF HEARING
100
0102030405060708090100 dB HL
%
AB
90
80
70
60
50
40
30
20
10
0
Figure 4.3 Example of speech discrimination score curves. Curve A represents normal hearing
and Curve B is typical of a conductive hearing loss, whereas the pattern in Curve C may be seen
with a retrocochlear hearing loss.
C
level of the masking noise is increased in 10-dB steps and the threshold for the pure-tone
signal is re-evaluated. e hearing threshold is recorded as the level at which the threshold
remains unchanged across three 10-dB step increments of masking. It is not always possible
to derive masked thresholds in case of severe conductive hearing loss due to constraints in
masking levels. For BC, unmasked thresholds indicate detection levels in the better-hearing
cochlea, so masking is generally recommended whenever quantication of ABG is needed.
ere are known distortions that occur in auditory perception for people with cochlear
impairment and reduced HLs, for example, loudness recruitment (an abnormal increase in
loudness perception between the detection level and maximum comfort level of sound), or
loss of frequency selectivity, among others. ese are not tested in PTA. us, people with
similar PTAs may have a very dierent experience of hearing in everyday life.
Speech-Perception Testing
To understand the impact of hearing loss on communication, speech audiometry is required.
Testing using real words at a range of intensities in each ear provides the performance intensity function. e optimum discrimination score (ODS) gives a measure of speech discrimination and the cochlear reserve in a mixed hearing loss. A lack of improvement with
increasing intensity may indicate impaired cochlear function. A marked rollover (worsening
speech recognition with increased intensity, Figure 4.3, Curve C) is usually indicative of
vestibular schwannoma or other neural pathology.
Objective Assessment of the Ears and Hearing
Tympanometry
Tympanometry is used to assess middle ear function. e test is conducted by placing a
probe in the ear canal, which is surrounded by a so tip. e probe is composed of a loudspeaker, a microphone, and a pump. e so tip should seal the ear canal so that the pump
introduces controlled variations of the air pressure in the ear canal. e loudspeaker delivers
a tone, usually 226 Hz, and the microphone monitors the sound level in the ear canal. With
this probe, the compliance (or admittance) of the middle ear is measured as a function of the
air pressure in the ear canal.
e result is shown on a chart called a tympanogram, which includes parameters of middle
ear compliance/pressure, and the ear canal volume (ECV). e norms for compliance peak
are values of 0.3 (or 0.2 for children) to 1.6 cm3 for adults. Low compliance indicates abnormal stiness of the middle ear (i.e. otosclerosis or malleus xation). Abnormally high compliance may indicate ossicular discontinuity or atrophic scarring of the eardrum. Dierent
e Ear 23
PSYCHOACOUSTIC AND OBJECTIVE ASSESSMENT OF HEARING
Figure 4.4 Different types of tympanogram traces. Normal middle ear pressure values are
between ±50 daPa in adults (Type A tympanogram). Values around –200 daPa indicate signicant
Eustachian tube dysfunction (negative middle ear pressure: Type C tympanogram). If the trace is
at (Type B tympanogram), the test conrms the presence of middle ear effusion if the ear canal
volume (ECV) is normal (between 0.6 and 2.5 cm3 for adults and between 0.4 and 1 cm3 for children). It is important to consider the ECV: a at trace with a small ECV may indicate that the probe
was blocked, and a value that is large may indicate a tympanic perforation.
types of tympanogram traces are shown in Figure 4.4. Additional testing through the use of
tympanometry includes long time-based tympanometry (Chapter 8) and the acoustic stapedial reex. e latter is elicited by brief pure tones or noise bursts. e lowest intensity of
sound that triggers the reex is the acoustic reex threshold (ART). An absent or abnormal
stapedial reex with normal middle ear pressure occurs in otosclerosis.
OAEs
Otoacoustic emissions (OAEs) are low-level sounds that reect the active mechanism of the
outer hair cells (OHCs) in the cochlea. ey can be recorded in the ear canal. OEAs can be
spontaneous or evoked. Evoked OAEs with clinical relevance are classied into the following:
Transient evoked OAEs (TEOAEs): ese are evoked by a transient stimulus (click or
•
burst) and recorded in the ear canal aer a short delay. e outcomes are assessed in
terms of reproducibility, level, and signal-to-noise ratio. TEOAEs are typically absent
or abnormal with cochlear hearing losses above 30 dB HL.
Distortion-product OAEs (DPOAEs): ese are evoked by the simultaneous presenta-
•
tion of two pure tones (called ‘primaries’ with frequencies f1 and f2). If f1 and f2 are
close in frequency, they lead to the production of distortion products in ears with a
healthy basilar membrane. e highest amplitude distortion product is usually 2f1-f2;
therefore, it is assessed clinically. DPOAEs are typically absent or abnormal with
cochlear hearing losses above 40–50 dB HL.
It is advised that the measurement of OAEs is combined with tympanometry, especially in
cases where OAEs are absent, because middle ear problems can interfere with the recording
of OAEs. A key application of OAEs is the diagnosis of auditory neuropathy (Chapter 16).
e newborn hearing screening programme (NHSP) uses automated OAE recordings in
babies together with automated auditory brainstem responses (ABRs).
Auditory Evoked Potentials (AEPs) Sound stimuli result in activation of the auditory path-
way, and this electrical activity can be recorded from the scalp. An analysis of response
characteristics, such as latency and amplitude of the resulting waveform, gives important
24 e Ear
PSYCHOACOUSTIC AND OBJECTIVE ASSESSMENT OF HEARING
diagnostic information about the integrity of the peripheral and central auditory system.
Recordings are performed with a minimum of three electrodes: an active electrode, a reference electrode, and a ground electrode. Biological and electric noise are reduced by averaging
responses to repeated stimulation. While noise occurs randomly, the auditory evoked potential (AEP) occurs at a constant latency to the stimulus onset. Signal processing techniques
including ltering are typically also used to reduce noise. Common sound stimuli are clicks
(square wave pulses) and tone bursts (sinusoidal).
Cochlear Microphonics (CM) CM is a pre-neural response from cochlear OHCs that mirrors
the waveform of the stimulus. It is oen measured in children, as part of the auditory neuropathy test battery. Similar to OAEs, the CM indicates OHC function. However, the CM is
less vulnerable to the eect of a conductive hearing loss than OAEs.
Electrocochleography (ECOG) ECOG is a technique of assessing cochlear and auditory nerve
function. e active electrode is placed on the tympanic membrane, through the tympanic
membrane on the promontory or in the cochlea. e response has several components
including (1) the CM; (2) the summating potential (SP), which is a direct current response
from hair cells; and (3) the auditory nerve action potential (AP). A high SP:AP ratio is associated with Meniere’s disease. AP measurements can also be used to indicate the presence of a
functioning auditory nerve prior to cochlear implantation.
Auditory Brainstem Response (ABR) e ABR arises from the auditory nerve and low brain-
stem within 10 ms from the onset of the click stimulus and comprises ve waves, labeled
from I to V. e generators of each wave are thought to be for I the distal portion of the auditory nerve, for II the proximal portion of the auditory nerve, for III the cochlear nucleus, for
IV the superior olivary complex and lateral lemniscus, and for V the lateral lemniscus and
possibly the inferior colliculus.
By measuring the lowest sound signal at which the ABR response can be detected, the hearing threshold can be estimated for dierent frequencies for both air and bone conduction.
It must be noted that the 95% condence intervals for estimated HLs are fairly large (up to
30 dB at low frequencies). However, the great advantage of ABR is that a robust response can
be measured even during sleep or general anaesthesia. is makes it particularly suitable for
hearing-threshold estimation for patients in whom behavioural audiometry is not possible.
ABRs are important in the diagnosis of auditory neuropathy, which is characterised by normal OAE/CM but absent or abnormal suprathreshold ABRs.
Auditory Late Response (ALR) e ALR is cortical in origin and the neural generator is
thought to include Heschl’s gyrus. e response is recorded at a latency of approximately
50–290 ms aer stimulus onset. ALRs assess the auditory pathway at the level of the auditory
cortex and are less susceptible to muscle activity compared with ABR. ey are typically
used for hearing threshold estimation in adults with suspected non-organic hearing loss
and to indicate whether young children with hearing loss are obtaining benet from their
hearing aids.
KEY POINTS
• Performance on a PTA relies on sound detection; therefore, it does not characterise
other decits that have a signicant impact on hearing for speech.
• Speech audiometry is essential in the assessment of the impact of hearing loss on
communication.
• AEP can be used to assess the peripheral and central auditory pathways.
• Patients who are difcult to test by behavioural audiometry can have their hearing
thresholds quantied using the threshold ABR.
e Ear 25
EVALUATION OF BALANCE
Further Reading
1. British Society of Audiology. Pure-Tone Air-Conduction and Bone-Conduction
reshold Audiometry with and without Masking. British Society of Audiology
Recommended Procedures and Publications. Reading, UK: British Society of
Audiology; 2011.
2. British Society of Audiology. Recommended Procedure for Tympanometry. Reading,
UK: British Society of Audiology; 2013.
3. Katz J, Medwetsky L, Burkhard R, et al. (eds). Handbook of Clinical Audiology. 6th ed.
Baltimore: Lippincott, Williams & Wilkins; 2009.
4. Musiek F, Josey A, Glass cock M. Auditory bra instem response : interwave measure ments
in acoustic neuroma. Ear Hear. 1986;7:100–105.
5. EVALUATION OF BALANCE
Symptoms in Balance Disorders
Vertigo and Dizziness
Dizziness, vertigo, and unsteadiness accounts for one-h of referrals to ear, nose, and
throat (ENT) and neurology clinics, and the rise in the ageing population will increase
this further. Despite many developments in vestibular science, nothing replaces a good
clinical history.
Vertigo is a reliable vestibular symptom, but lesions can be anywhere from the semicircular
canals to vestibular cortex. Additional symptoms allow localisation (Table 5.1). Duration
is indicative, lasting seconds in benign paroxysmal positional vertigo (BPPV); minutes to
Table 5.1 Additional symptoms helpful in the topographical diagnosis of balance disorders
Site of lesion Symptom Comment
Peripheral
(labyrinth or VIII nerve)
Special cases
- Labyrinthine Ear fullness Meniere’s disease
- Cerebellopontine angle V, VI, and VII cranial nerves Extra-canalicular growth
- VII + VIII neuritis External auditory canal vesicles + VII Ramsay Hunt syndrome
Brainstem Diplopia (III, IV, VI, or skew deviation*)
*
Skew deviation (elevation of one eye and depression of the other) is caused by unilateral lesion in
brainstem vestibular structures.
Note: AICA, anterior inferior cerebellar artery, from where the labyrinthine artery branches off.
26 e Ear
Tinnitus
Hearing loss
(herpes zoster oticus)
Facial numbness (V) weakness (VII)
Difculty swallowing, choking (IX, X)
Slurred speech (XII, cerebellum)
Uni-bilateral numbness, weakness,
ataxia (long tracts, cerebellum)
Unilateral deafness (+ ataxia) AICA infarct
EVALUATION OF BALANCE
Table 5.2 Some non-vestibular causes of dizziness
Type Possible causes
Endocrine Hypoglycaemia, adrenal failure, pheochromocytoma
Cardiovascular Vasovagal syncope, orthostatic hypotension, embolic disease, cardiac
dysrhythmias
Haematological Hyperviscosity syndromes, anaemias
Psychological Anxiety, phobias, panic attacks, PPPD
Note: PPPD, persistent perceptual postural dizziness, is a common functional balance disorder.
many hours in migraine-associated vertigo (vestibular migraine); a few hours in Meniere’s
disease; and days in acute vestibular neuritis and stroke.
Non-rotational ‘dizziness’, rocking sensations, light-headedness, and feeling detached can be
vestibular or non-vestibular (Table 5.2). Some patients are ‘unsteady’ or ‘o-balance’ but ‘not
dizzy in the head’ or feeling ne if seated or lying down; indeed, patients with a neurological
gait disorder perceive their own disequilibrium and can report it as dizziness.
Vertigo Presentations
e three m ain presentations of vert igo are single episo de (acute vert igo), recur rent (episodic),
or chronic dizziness (Bronstein and Lempert 2017).
Acute vertigo is severe and disabling, with autonomic symptoms such as nausea, vomiting,
pallor, and sweating. e key syndromes are
1 Acute vestibulopathy/neuritis (no hearing or neurological symptoms),
2 A vascular or inammatory disorder of the VIII nerve or labyrinth (hearing loss),
and
3 A cerebellar-brainstem stroke (central nervous system [CNS] symptoms) (Table 5.3).
Dierentiate positional increase of vertigo (as in conditions above) from truly positional
vertigo where vertigo stops, if motionless.
Inquire actively about additional hearing or cerebellar-brainstem symptoms as they may
not be volunteered. Distinguishing peripheral and central acute vertigo is crucial because a
stroke requires urgent treatment, hence the ‘red ags’ are described in Box 5.1.
Table 5.3 Vertigo presentations: episodic or recurrent vertigo, accompanying features
Accompanying feature Possible cause
Positional
Postural
Paroxysmal Vestibular paroxysmia
Migraine features (headache, photophobia) Vestibular and basilar migraine
Hearing disorder Meniere’s syndrome or hydrops
Ataxia Episodic ataxias
Brainstem symptoms Transient ischaemic attacks (TIA)
Autonomic-anxiety-avoidance Panic attacks
Faintness Heart disease, vasovagal syncope
No accompanying features Benign recurrent vertigo*
*
Benign recurrent vertigo, recurrent peripheral vestibular disorder, or vestibular Meniere’s disease
are names given to patients with recurrent peripheral vertigo that do not fall into well-dened
categories such as Meniere’s disease or migraine.
Source: Modied from Bronstein and Lempert (2017) (see further reading).
Benign paroxysmal positional vertigo (on lying or
turning in bed)
Orthostatic hypotension (on standing)
e Ear 27
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