A Balancing Act: Juggling Vestibular Evaluation Considerations and Effective Patient Care During a Pandemic

By Julie A. Honaker
November 23, 2020

COVID-19 and Vestibular Impairment—Is There a Link?

Coronavirus disease (COVID-19) quickly impacted every aspect of clinical care for patients and caregivers alike. COVID-19 is known to cause a variety of symptoms spanning respiratory, gastrointestinal, and even neurological presentations.  While not considered a primary symptom of COVID-19, few reports have documented dizziness, vertigo, and imbalance associated with COVID-19 (Malayala & Raza, 2020; Özçelik Korkmaz, Eğilmez, Özçelik, & Güven, 2020; Saniasiaya & Kulasegarah, 2020). Thus, it stands to reason that there could be viral effects on the vestibular system or a neuroinvasion leading to vestibular symptoms (Saniasiaya & Kulasegarah, 2020).  In a prospective, observational cohort study by Özçelik Korkmaz et al. (2020), out of 116 patients reviewed with a positive diagnosis of COVID-19, 31% had complaints of dizziness. Interestingly the rate of dizziness symptoms was higher in younger patients (<60 years) and females.

Often dizziness describes impaired or altered spatial orientation, which may be associated with numerous etiologies such as cardiovascular, neurologic, toxic, metabolic, psychiatric, and vestibular dysfunction. Indeed, symptoms of dizziness require careful questioning and a thorough assessment to determine the exact cause for proper management.  While there are limited data and high-level studies to determine a causal relationship between COVID-19 and impaired vestibular function, vestibular symptoms (e.g., dizziness, vertigo, imbalance) should be questioned in COVID-19 patients. Then, considerations for further vestibular consultation and objective testing can be determined to evaluate effects on vestibular function.  Additionally, there are speculations of ototoxic effects of experimental treatment (chloroquine and hydroxychloroquine) for COVID-19 (Prayuenyong, Kasbekar, & Baguley, 2020), further raising concern for long-term effects on the auditory and vestibular systems.

Best practice guidelines in a pandemic

More than ever, it is imperative to formulate an appropriate plan for seeing patients in the clinic, recognizing that time spent face-to-face puts more significant risk on both the patient and caregiver. This first begins with gathering as much information on symptoms to gear the evaluation toward possible answers. The use of questionnaires increases efficiency to categorize patient symptoms based on suspected diagnoses.  Virtual platforms are increasingly utilized as an initial first step to triage patients with suspected vestibular disorders to determine which patients should receive urgent versus outpatient care (Shaikh et al., 2020). These strategies can help with appointment planning to determine in-person versus virtual management needs for the patient.

Concerns from the pandemic have also led to an increase in emotional responses: anxiety, panic, and depression. These concerns may exacerbate effects from COVID-19, including any possible vestibular ramifications, and even contribute to problems of dizziness. Thus, clinicians must also be sensitive to listening and further probing for behavioral symptoms such as activity avoidance or restrictions that may be contributing to or causing the patient-reported problems. The use of screening tools can tease out avoidance behaviors, reinforcing the need for additional management options.

In addition to thorough case history, initial vestibular evaluation guides management, and further objective assessment considerations. A task force supported by the Society for Research in Cerebellum and Ataxia (Shaikh et al., 2020) outlined the feasibility of completing aspects of the typical oculomotor/vestibular screening examination virtually, without the need for additional equipment or supplies. Videoconferences platforms allow real-time or off-line evaluation of patient features, nystagmus patterns, oculomotor performance, vestibular-ocular reflex (VOR) function, and postural control and gait observation capabilities. Patients with high suspicion of vestibular impairment requiring further investigation may then warrant a vestibular and balance assessment. Still, the selection of services should be reserved to maximize diagnosis and treatment planning—ultimately minimizing face-to-face contact. The appropriately selected objective tests then aid in determining a peripheral or central cause for patient-reported symptoms. The American Balance Society Task Force (Rizk, Strange, Atallah, Massingale, & Clendaniel, 2020) presented an advisory document outlining safe vestibular assessment and rehabilitation practices to slow the spread of infection and keep patients and caregivers safe. For patients seen in the clinic for evaluation or management, vigilant hygiene rules should be followed using disposable equipment to the greatest extent possible.

The discussion above highlights the need for clinical planning to maximize efficiency during patient encounters and to ensure that clinicians only perform measures that are medically warranted to address the clinical question at the time of evaluation. My forthcoming book, Diagnostic Vestibular Pocket Guide: Evaluation of Dizziness, Imbalance, and Vertigo (Plural Publishing), offers a concise guide to all aspects of vestibular clinical care to support proficient planning and diagnostic evaluation considerations, which is ever more critical in our clinics today. Chapters outline the following:

Chapter 1. Vestibular Principles and Pathways Review

Chapter 2. Appointment Preparation and Case History

Chapter 3. Office Vestibular “Bedside” Examination

Chapter 4. Benign Paroxysmal Positional Vertigo (BPPV) Diagnosis and Treatment

Chapter 5. Electronystagmography (ENG)/Videonystagmography (VNG)

Chapter 6. Rotational Chair Test (RCT)

Chapter 7. Video Head Impulse test (VHIT)

Chapter 8. Vestibular Evoked Myogenic Potentials (VEMPs)

Chapter 9. Computerized Dynamic Posturography (CDP)

Chapter 10. Vestibular Care Path and Modifications to Standard Procedures Based on Patient Age

Chapter 11. Report Writing and Medical Referral Guide



Malayala, S. V., & Raza, A. (2020). A case of COVID-19-induced vestibular neuritis. Cureus, 12(6), e8918. https://doi.org/10.7759/cureus.8918

Özçelik Korkmaz, M., Eğilmez, O. K., Özçelik, M. A., & Güven, M. (2020). Otolaryngological manifestations of hospitalised patients with confirmed COVID-19 infection. European Archives of Oto-Rhino-Laryngology : Official Journal of the European Federation of Oto-Rhino-Laryngological Societies (EUFOS) : Affiliated with the German Society for Oto-Rhino-Laryngology - Head and Neck Surgery, pp. 1–11. Advance online publication. https://doi.org/10.1007/s00405-020-06396-8

Prayuenyong, P., Kasbekar, A. V., & Baguley, D. M. (2020). Clinical implications of chloroquine and hydroxychloroquine ototoxicity for COVID-19 treatment: A mini-review. Frontiers in Public Health, 8, 252. https://doi.org/10.3389/fpubh.2020.00252

Rizk, H. G., Strange, C., Atallah, S., Massingale, S., & Clendaniel, R. (2020). Coronavirus disease 2019 return to work guidance and recommendations for vestibular clinicians. Ear and Hearing, 41(4), 693–696. https://doi.org/10.1097/AUD.0000000000000903

Saniasiaya, J., & Kulasegarah, J. (2020). Dizziness and COVID-19. Ear, Nose, & ThroatJjournal, 145561320959573. Advance online publication. https://doi.org/10.1177/0145561320959573

Shaikh, A. G., Bronstein, A., Carmona, S., Cha, Y. H., Cho, C., Ghasia, F. F., … Kheradmand, A. (2020). Consensus on virtual management of vestibular disorders: Urgent versus expedited care. Cerebellum (London), pp. 1–5. Advance online publication. https://doi.org/10.1007/s12311-020-01178-8