FRCS (ORL-HNS) · SECTION 1 SBA

Bilateral vestibulopathy interpretation

A patient reports oscillopsia while walking and imbalance worse in darkness. Video head-impulse testing shows bilaterally reduced horizontal canal gain; calorics are bilaterally weak. MRI is normal. What is the best management principle after excluding a remediable cause?

CHOOSE ONE ANSWER

Best of five

  1. A. Repeated Epley manoeuvres
  2. B. Long-term vestibular suppressants
  3. C. Individualised vestibular rehabilitation emphasizing gaze and postural substitution
  4. D. Endolymphatic sac surgery
  5. E. Reassure because MRI is normal
ANSWER AND REASONING

C. Individualised vestibular rehabilitation emphasizing gaze and postural substitution

The symptoms and concordant bilateral vestibulo-ocular reflex loss support bilateral vestibulopathy; rehabilitation uses adaptation and substitution while falls risk, vision, proprioception and ototoxic exposure are addressed.

Why every option is right or wrong

A. Repeated Epley manoeuvres: Canalith repositioning treats positional canalithiasis, not persistent bilateral hypofunction.

B. Long-term vestibular suppressants: Suppressants can impede central compensation and worsen imbalance.

C. Individualised vestibular rehabilitation emphasizing gaze and postural substitution: The symptoms and concordant bilateral vestibulo-ocular reflex loss support bilateral vestibulopathy; rehabilitation uses adaptation and substitution while falls risk, vision, proprioception and ototoxic exposure are addressed.

D. Endolymphatic sac surgery: There is no episodic unilateral hydropic syndrome to target.

E. Reassure because MRI is normal: MRI excludes some structural causes but does not negate physiological bilateral vestibular loss.

What if the scenario changed?

If head-impulse testing were normal and attacks lasted seconds only with a positive Dix–Hallpike test, canalith repositioning would be appropriate.

EDUCATIONAL USE

Independent Clinora educational material; not official JCIE content, an accredited programme, clinical advice, or a substitute for local policy and specialist judgement.

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