Online Health Chat with Julie Honaker, PhD
October 11, 2017
Dizziness is defined as feelings of unsteadiness, wooziness and lightheadedness; and sensations of moving, spinning, floating, swaying, tilting or whirling (sensations known as vertigo). These sensations occur even when standing still or lying down. More than four out of 10 people experience an episode of dizziness significant enough to send them to a doctor. Dizziness changes your sense of balance and can increase your risk of falling.
Dizziness is generally not serious. However, it may result from problems associated with the inner ear, brain or heart. It can also be the result of medications.
If you have suffered dizziness that does not go away, please join Cleveland Clinic vestibular and balance specialist Julie Honaker, PhD in a free online chat. She will answer your questions about dizziness and balance disorders.
About the Speaker
Julie Honaker, PhD is the director of the Vestibular and Balance Disorders Laboratories within the Head & Neck Institute. She was previously an assistant professor in the Department of Special Education and Communication Disorders at University of Nebraska-Lincoln where she taught graduate courses on vestibular and balance disorder assessment and management. She received her master’s training and PhD in audiology from the University of Cincinnati. She completed a post-doctorate fellowship at the Mayo Clinic in Rochester, MN. Dr. Honaker has a passion for the clinical assessment and rehabilitation of balance disorder patients, and this is the focus of her clinical research endeavors.
Let’s Chat About Dizziness and Balance Disorders
johnspol: A viral inner ear infection following Bell's palsy left me with permanent dizziness, vertigo and deafness in my right ear, as well as four destroyed facial nerves.
Julie_Honaker_PhD,_CCC-A: I’m sorry to hear that. In cases of dizziness, there are measures to improve your symptoms following viral infection. Vestibular rehabilitation helps to restore your balance and reduce symptoms. Also, you may find benefit in speaking with an audiologist regarding your hearing loss.
cwadsl: In 2014, I turned over in bed with my eyes open and experienced a severe bout of room-spinning vertigo. My dresser appeared to be flying over my head in a perfect circle, as if I was looking through a kaleidoscope. This lasted about five minutes, but I was terribly ill the rest of the day and suffered from severe dizziness 24 hours a day over the next eight weeks. I visited many specialists and had many tests, which found nothing. Canalith repositioning maneuvers for BPPV did not work. Doctors suspected Meniere's disease or a vestibular infection or disorder. The only thing that seemed to lessen the symptoms was steroids. After about six weeks, the dizziness finally began to subside in the evenings, then earlier and earlier in the day until it was gone about three weeks later. Nothing has happened since then except that I feel a bit more sensitive to motion.
Do you have any recommendations for what my plan of attack should be if this happens again? Thank you.
Julie_Honaker_PhD,_CCC-A: I'm sorry to hear about your episode of true spinning vertigo. While I may not be able to provide clarity on if/when this may happen again, I can give you tips on what to document to help your physician/other specialists better identify the cause. 1) Try to note what brought on the symptoms (e.g., rolling over in bed, sitting up too quickly in bed, etc.) 2) Try to note how long the symptoms last (seconds then go away if sitting very still, minutes, hours, etc.) 3) Try to document any associated symptoms (headache, double vision, changes in speech, etc.) This will help your physician or other specialist better identify if this is truly an inner ear disorder or perhaps another reason (headache, migraine, viral infection) for your symptoms.
Cecelia: I have the same symptoms as cwadsley. It has now been eight months. My current symptoms include a spinning sensation when rolling over in bed at night or first thing in the morning and dizziness when looking up. The more movement I do, the more unsteady I feel. I am becoming more active but by two or three p.m., but I begin to fatigue and morning light, noise or other stimuli increase fatigue and dizziness. I have been getting vestibular therapy, but the therapist is finding I am not responding to it. A neurologist diagnosed vestibular neuronitis. I am currently on 8 mg twice a day of beta-histamine, which seems to help. Any further suggestions would be SO appreciated.
Julie_Honaker_PhD,_CCC-A: I'm sorry to hear about your ongoing symptoms. It may be a good idea to have a thorough vestibular evaluation with an audiologist to determine how your vestibular system is functioning or if there is another cause for your ongoing symptoms since you have not responded to therapy. The beta-histamine helps with symptom relief, but is not a cure.
Suereed43: Does getting dizzy often have anything to do with heart disease?
Julie_Honaker_PhD,_CCC-A: Good question. There are many causes of dizziness, and heart disease is actually a common cause. Sometimes, this has to do with problems with blood pressure or the medications that are used to control heart-related problems. Patients with heart disease may even experience problems with balance and are often at greater risk of falling. It is important to speak with the doctor who is managing your heart-related condition to discuss your concerns of dizziness and see if it is related to the condition or a possible side effect of medication.
Jode9297: Can thrombocytosis cause vertigo? I was diagnosed about 30 years ago.
How about the medication Agrelyn (anagrelide)? Thanks.
Julie_Honaker_PhD,_CCC-A: Thank you for your question. Your symptoms may be related to your disease, as well as a side effect of the medication. I would suggest discussing these symptoms with your primary care physician who can review your medications and possibly refer you to a specialist regarding your condition.
pilatesgirl: How do concussions from the past affect long term balance?
Julie_Honaker_PhD,_CCC-A: We are learning more and more about concussions and their effect on the balance system. There are known cases/research to support long-term effects on balance. If you are noticing problems with your balance, it is recommended that you discuss this with your primary care physician who can then refer you to a specialist to evaluate your balance and make appropriate recommendations to improve your balance and keep you safe from falls.
MineOrYours2: Hi. I get dizzy every now and then. I also feel spinny. I work out almost daily and am fine doing that. I don't know why I would get dizzy when not exercising. Would a lack of a daily dose of water cause dizziness?
Julie_Honaker_PhD,_CCC-A: There are numerous causes for symptoms of dizziness. Sometimes, dehydration can cause symptoms of lightheadedness or dizziness. This may be a good first factor to check. Also, it is always a good idea to discuss these concerns with your primary care physician, as medication and diet changes can also cause symptoms.
MarL: Good Afternoon. Do you have any data on how dizziness and balance might have an effect on lupus patients?
Julie_Honaker_PhD,_CCC-A: I do not have data on hand, but there are known medication side effects, as well as possible consequences of the disease on your peripheral nervous system that can result in symptoms of dizziness, imbalance and even blurred vision. If you are experiencing these symptoms, it would be good to discuss this with your managing physician to first rule out medication effects and then explore other causes for the symptoms.
derekl: Can migraines cause dizziness?
Julie_Honaker_PhD,_CCC-A: Good question. Dizziness, vertigo, imbalance, blurred vision, etc. are all consequences of migraines. There are even variants of migraines that can cause vertigo or dizziness without migraine head pain. If you think you are experiencing any of these symptoms and have a diagnosis of migraine, it would be important to discuss this with your physician. There are criteria that your physician would need to determine if migraines are the cause of your symptoms.
TimboBear: Could thyroid medication or it not being on the right dose affect dizziness, lightheadedness and feeling off balance?
Julie_Honaker_PhD,_CCC-A: I cannot comment on medication doses, but symptoms of dizziness, lightheadedness and feeling off balance may result in other disorders, including problems with the thyroid. It would be best to discuss these concerns with your managing physician to better determine if this is related to your condition or another possible cause.
sbdav: I have a problem with lightheadedness due to blood pressure medications, but have much more of the problem when walking in large expanses like a mall parking lot. I feel very unstable and out of balance. I have to walk looking down at the ground because looking up or turning my head makes me feel even more unbalanced. Is this something you've heard of?
Julie_Honaker_PhD,_CCC-A: It is not uncommon for people with balance problems to experience visually provoked symptoms such as those described in your question. If you have already worked with your physician to adjust your blood pressure medications, then you may want to have a more thorough evaluation to determine if you have a balance problem causing your symptoms when in large spaces, looking up, etc.
internetkat01: I'm about to have back surgery because there is a cyst on my spine. While the doctor is in there, he will be putting a screw in the two lower bones of my spine to hold them together because they are moving and there is no cartilage left in between the bones. I've stopped taking my steroids weeks before the surgery. He doesn't want me starting my steroids for 12 weeks after the surgery. If I start before, he says the steroid will weaken my bones and the screw will not hold. Do you have any advice on how to not lose the cartilage between your bones?
cerim: Would inner ear issues cause balance to be thrown off upon standing?
Julie_Honaker_PhD,_CCC-A: Good question. Yes, an inner ear balance disorder could cause your balance to be thrown off when standing. In cases of inner ear problems, imbalance is very common, and when we move we are activating our inner ear balance system. If this is not working properly, you could experience strange symptoms when moving in different positions such as standing.
clihea2: Quite a few years ago I lost hearing in one ear almost completely overnight and that has affected my balance as well. Eventually, I was told that I blocked my internal auditory artery. I still can't be fitted for a hearing aid and I still can't do things such as stand on one leg much. I do a few exercises a few times a week, but it doesn't keep me from being twirly headed when I look up or make a turn other than very slowly. Do you have any suggestions? Thanks Le Ann.
Julie_Honaker_PhD,_CCC-A: Sorry to hear about your sudden hearing loss. Some patients who suddenly lose their hearing on one side may also have the other part of the ear involved (vestibular system). Do to this, you may be experiencing symptoms related to loss of inner ear function (hearing and balance) on one side. It may be beneficial to meet with an audiologist and vestibular rehab therapist to discuss additional exercises to perform to help with your balance concerns, as well as newer options for single-sided hearing loss.
weya: How can you get rid of fluid on the ears, which causes my dizziness?
Julie_Honaker_PhD,_CCC-A: Thank you for your question. It would depend on the problem with the fluid. We have fluid in our inner ear that is important for our sense of hearing and balance. In cases of disease, where there is an overabundance of fluid (for example, Meniere’s disease), conservative treatment of a low-salt diet and water pills to reduce water retention may be of benefit. Some individuals have fluid in other parts of the ear (for example, in the middle ear space, which is normally air filled), and this can cause symptoms of imbalance and sometimes even dizziness. In these cases, it would be important to try to remove the fluid in that part of the ear. In either case, it is important to speak with a health care professional, ear, nose and throat specialist and perhaps an audiologist (hearing specialists) to determine where the fluid is located to help determine the best management option.
SDsummer: I have Meniere's disease. Is there anything I can do to help keep this from progressing? I was told I could eventually have hearing loss. My sense of balance is affected at random times, with bouts of dizziness and balance issues. Also, I’m wondering if years of dental work and TMJ issues are related since the jaw is near the ears? Thank you.
Julie_Honaker_PhD,_CCC-A: Thank you for your question. There is no cure for Meniere’s disease, but there is treatment available to manage the symptoms and sometimes reduce how often and severe the attacks are. The most common treatment option is a low-sodium diet and water pills to reduce water retention. If this approach is not beneficial, steroid injections are another option to reduce severity and number of attacks. Vestibular rehabilitation is also of benefit to help with symptoms of dizziness/imbalance between attacks. It would be best to have an expert evaluate any additional symptoms (TMJ issues) to see if there are other causes of symptoms (hearing related/tinnitus) contributing to your symptoms of dizziness.
MarL: What is Meniere's disease, and how does it affect you?
Julie_Honaker_PhD,_CCC-A: Good question. Meniere's disease is an inner ear disorder that causes spontaneous episodes of decreased hearing, vertigo, tinnitus and even a fullness feeling in one ear (sometimes both ears). It is believed to be due to an overabundance of fluid in the inner ear. This disease can be very debilitating for patients, as it can come on without warning. There are treatment options if you or someone else believes you have this condition.
SDsummer: I have Meniere's disease and struggle with bouts of dizziness. Can this lead to eventual hearing loss? What is the root cause of the disease? I've had a lot of orthodontic work over the years since early childhood. Could that be related?
Julie_Honaker_PhD,_CCC-A: It would be best to have an expert evaluate additional symptoms, (specifically dental issues) to see if there are other causes of symptoms (hearing related/tinnitus) contributing to your symptoms of dizziness. As far as I know, there are no credible studies that link Meniere's with multiple dental procedures.
Thoughts on Treatment
sbdav: Would a cane or walking poles help with a balance problem?
Julie_Honaker_PhD,_CCC-A: A cane or walking poles provide extra support (widen the base of support on which you are standing) and may assist with your balance. It is always recommended that you meet with a specialist (for example, a physical therapist) to discuss assistive mobility options such as a cane to ensure that you are using the correct device.
colo157: I've been diagnosed with BPPV. I received much benefit from the Epley treatments early on, but now the symptoms come back within two weeks after a maneuver, no matter how careful I am. Is there any reason for this?
Julie_Honaker_PhD,_CCC-A: I'm glad you received benefit with the Epley maneuver. It is not uncommon for symptoms to return, as the Epley is not a cure but a treatment for the problem. Given that you are experiencing your symptoms so frequently, it may be of benefit to look into other reasons aside from the BPPV for your symptom to return. It may be beneficial to have a comprehensive vestibular assessment to better identify why this is returning so frequently. I recommend discussing this with your primary care physician and asking about a referral to a vestibular therapist or audiologist for a more thorough evaluation.
Happy70: What are the treatment options if no reason is found for the dizziness? I have had hearing tests, VG and VEMP, which ruled out an inner ear problem. I’ve also had an ophthalmologic checkup, MRI and MRA of the brain to check for blood flow and tumor, and physical therapy. Is there anything I can do to help control the dizziness and help prevent a fall?
Julie_Honaker_PhD,_CCC-A: Treatment options would really depend on the cause for your symptoms of dizziness. There are numerous causes including inner ear disorders, but this does not sound like the case, as you have had normal tests of inner ear function. You may benefit from further evaluation of other causes (not inner ear-related causes, but mediation, anxiety, neurological conditions) for your dizziness. You should discuss this with your primary care physician. Fall prevention tips can be found on the Centers for Disease Control and Prevention (CDC) website. These include ways to keep you safe in and around your home, as well as group exercise programs that can help with your balance.
Gail Ann: Are there any techniques, exercises, medications or supplements to help with an off balance issue? What role, if any, does stress play? I never experience dizziness, only a continuous off balance feeling in my head accompanied by a headache. Thank you for answering my question.
Julie_Honaker_PhD,_CCC-A: Good question. There are options to help with your balance if we better understand the cause. It appears that you are experiencing your symptoms with a headache. This may indicate that further investigation and possible treatment is needed for the underlying headache. I would recommend following up with your primary care physician to discuss your balance concerns/headache and to determine if a medication would benefit you or perhaps balance therapy to keep you safe from falling.
Chrysanthemum: What is the most accurate way of getting a proper diagnosis? There are so many variables, even conditions, that overlap, and sometimes it feels that each doctor feels the problem falls under his or her particular specialty. Sometimes, treatments contradict one another. In the meantime, years have passed and I'm still afflicted and greatly limited in life. Thank you.
Julie_Honaker_PhD,_CCC-A: You are correct that it can be very challenging to get an accurate diagnosis. There are many overlapping conditions and professionals that may need to be involved to get the most correct diagnosis. The Cleveland Clinic Head and Neck institute now offers a Dizziness and Imbalance Shared Medical Appointment. (To schedule an appointment, call 216.444.8500.) In this group visit with other patients, two providers evaluate the patients in a group and private setting to help sort out the many causes for dizziness and come up with a proper diagnosis and management plan.
Ed95: If you've never had an episode of serious dizziness or the feeling of almost passing out, what are the first things a person should check if this happens, blood pressure, O2 levels, heart rate, etc.? I recently experienced the feeling of almost passing out after some strenuous activity. I'm a 62-year-old male and wonder what could have caused this. It’s never happened before and hasn't happened since. Thanks.
Julie_Honaker_PhD,_CCC-A: Thank you for your question. It is always best to first discuss your concerns of almost passing out with your primary care physician, as this may be related to issues described above such as blood pressure changes or heart related conditions. If this is ruled out, then we need to look into changes in medication as the cause. Finally, if those are all ruled out, other causes including inner ear-related problems will need to be evaluated.
Jode9297: With so many people suffering with vertigo, why is there no cure?
Julie_Honaker_PhD,_CCC-A: It can be frustrating both for the patient as well as the clinician to determine the cause of vertigo/dizziness. There are many reasons for vertigo: medications, cardiovascular issues, neurological issues, anxiety, depression and inner ear problems to just name a few. Medications often are not beneficial and only mask the real problem. It may be beneficial to speak with your primary care physician and see about referral to a vestibular specialist (audiologist, physical therapist or physician) to better evaluate and determine the cause of the vertigo.
Jode9297: In addition to my right ear feeling full, a few seconds before a vertigo episode, always to the right, I hear what I can only describe as a "rubbing "sound in my right ear. What might this indicate?
Julie_Honaker_PhD,_CCC-A: Both symptoms relate to a possible ear-related cause to the symptoms. It would be best to be evaluated by an ear specialist (ear, nose and throat physician and audiologist) to evaluate your symptoms and hearing to better determine the ear-related condition.
Voices on Vertigo
Nanat426: Once you get vertigo, are you prone to getting it again? Why does it last so long and is not just a quick day-long thing? Mine have been going on for three weeks. I was given medication and am now trying physical therapy.
Julie_Honaker_PhD,_CCC-A: It really depends on the cause for the vertigo. Sometimes, vertigo can be related to a common inner ear disorder, such as something called benign paroxysmal positional vertigo or BPPV. This condition causes brief episodes of vertigo when changing positions (bending over, rolling over in bed). The best course of treatment for this is exercises that can be provided by a physical therapist, audiologist or physician. Medication is often not the cure, but helps to reduce symptoms. It is best to wean off of medications and treat vertigo with other management solutions such as rehabilitation exercises.
pollyjohnsey: A viral inner ear infection following Bell's palsy left me with total deafness in my right ear, destruction of four facial nerves and permanent vertigo. The distortion of my facial features never returned to normal. I have been told that medication will not help the condition, and I am wondering if research has shown any indication of help for the vertigo.
Julie_Honaker_PhD,_CCC-A: Provided your left inner ear balance system (since your viral infection was on the right) is working properly, and you do not have any other problems with your balance system, you should be a good candidate for a vestibular rehabilitation program to help promote the brain's "recalibrating" from your viral infection. This will help reduce your symptoms of vertigo, improve your balance and maintain activities of daily living.
Jode9297: My vertigo episodes come on unpredictably when I’m sitting, standing, sleeping and at various times of the day. All the tests came back inconclusive. Do you have any suggestions on what to do next?
Julie_Honaker_PhD,_CCC-A: I'm sorry to hear that. It would depend on which tests you have had, and also how long your symptoms last when they come on spontaneously. I would start tracking patterns and having this conversation with your physician to better identify the cause or other avenues to explore to determine why you are experiencing these symptoms.
Xomue: I've had BPPV in the past, so I am familiar with the feeling of waking up turning my head and feeling the room spin briefly. It stops after 10 to 15 seconds. This has happened to me every few years for the past 20 years. Yesterday, I woke up and experienced the same spinning when I turned my head in both directions. In the past, I was told that in order to get rid of it, I can have the Epley procedure or I can practice the positions that make your head spin a little, that is lying down, turning the head to one side and holding it for 30 seconds. Since it's so hard to get an appointment in my area with a doctor for a non-emergent condition, I would like to try the "home method." I am putting my head in the positions that cause dizziness and holding it for 30 seconds? I don't want to overdo and make it worse. My question is: Is it possible to make it worse by overdoing? It usually clears up in a week or so. Do you have any suggestions on how to prevent BPPV?
Julie_Honaker_PhD,_CCC-A: I am not concerned with you overdoing it, but rather displacing the crystals (what is causing the BPPV) to be moved into other parts of your inner ear system (other semi-circular canals), which can make it more challenging to treat. There are home treatment options that you can try if you know exactly what type of BPPV you have. You may want to go to vestibular.org as a resource to help you find a specialist near you. Choose the "find a specialist tab" to see if you can get in with someone sooner to be evaluated and treated properly.
pilatesgirl: What does it mean when your balance is OK with your eyes open, but is much harder to impossible when your eyes are closed? I was told it is related to the temporal lobe.
Julie_Honaker_PhD,_CCC-A: Good question. We use three sensory systems to help us with our balance: vision, inner ear balance organs/vestibular system and prioprioception. When we have our eyes open and are standing on a firm surface, we use our vision and prioprioception to help maintain our balance. When our eyes are closed, we must rely on our vestibular system to keep us upright. This system is not as strong as the other systems when trying to stand still. This is why it is important to utilize our sensory systems together to help us maintain our balance.
Lois Johnson: I have issues with my vision, dizziness, etc. I have been told it involves vestibular-ocular reflex (VOR). Would you please explain the VOR?
Julie_Honaker_PhD,_CCC-A: I’m happy to discuss the VOR. The vestibular-ocular reflex is a reflex between the inner ear vestibular system and the muscles that control eye movements. These muscles help us maintain stable vision when our head/body is in motion. For example, when I turn my head to the right, the VOR moves my eyes to the left so I am able to see clearly.
keroppi: I had extensive workups (ENT, neurology, vision-vestibular, etc.), and no official cause of the constant lightheadedness/dizziness I’ve had for decades has been found. It’s been chalked up to underlying condition of dysautonomia/POTS. Vestibular rehab and medicines like meclizine haven't worked. I also get episodes of true vertigo for hours, after which my baseline level of dizziness/floatiness increases for a long time. I’m currently going on two months since my last episode. Is there anything one can do to try to "reset" back to the former "dizziness baseline" at least? I used to try some vestibular exercises and Ativan, and sometimes I've gotten it down to two weeks, but this time nothing is working. Also, this year, months before this last vertigo episode, I developed a chronic stuffiness in my left ear that never goes away. The ENT just said it was a "fluid imbalance/endolymphatic hydrops," probably due to dysautonomia, and lowering salt intake didn’t help. Does this ever resolve on its own? Is there anything else noninvasive to be tried (my brain MRI was negative)?
Julie_Honaker_PhD,_CCC-A: You are not alone in experiencing symptoms of dizziness, and it is very frustrating when you do not have a clear answer as to the cause. As for how to “reset” back to the former dizziness baseline, it would depend on the reason for the dizziness in the first place and how your system is responding at the moment. It may be beneficial to have a comprehensive vestibular evaluation with an audiologist to better understand your current symptoms and reasons for the longstanding dizziness. You may want to speak with your primary care physician regarding your questions and a possible referral for vestibular assessment with an audiologist. For more information on services at Cleveland Clinic, you may call 216.444.8500.
Chrysanthemum: With aging and having a host of issues, it seems each specialist sees my dizziness/imbalance from their own area of expertise and they don't always agree. Can there be multiple causes for dizziness at the same time?
Julie_Honaker_PhD,_CCC-A: Good question/concern. To answer your question, yes. There can be multiple causes for dizziness. With that said, each specialist may be focused on a specific area that may be a cause for the symptoms.
F94jL63: Apart from issues/symptoms related to ear dysfunctions, can vertigo be triggered by visual disturbances? My episode of extreme dizziness was preceded by distorted vision in one eye, where images appeared wavy and moving rather than being in a fixed and focused orientation. That anomaly eventually subsided, but dizziness remained for several hours.
Julie_Honaker_PhD,_CCC-A: Yes. There are visual causes for dizziness. Our visual system is an important part of our balance system; if this is off, you may experience symptoms of dizziness or imbalance. And, if you have an underlying vestibular/ear dysfunction, it is not uncommon to have visually provoked symptoms. Sometimes, patients will experience symptoms when walking down a grocery store aisle, reading on a phone or computer, etc. Vestibular therapy is of help to reduce some of the visually provoked symptoms.
Allison0502: Hello. Thank you for hosting this chat. I have tinnitus and have heard that certain hearing aids can be helpful in coping with this issue. Which brands or kinds of hearing aids do you typically recommend?
Julie_Honaker_PhD,_CCC-A: Thank you for your question. We are actually having a web chat on October 18 regarding hearing loss during which two specialists will be discussing management options for tinnitus.
Julie_Honaker_PhD,_CCC-A: Thank you for participating in the Cleveland Clinic dizziness web chat.
That is all the time we have for questions today. Thank you, Dr. Honaker, for taking time to educate us about dizziness and balance disorders.
On behalf of Cleveland Clinic, we want to thank you for attending our online health chat. We hope you found it to be helpful and informative. If you would like to learn more about the benefits of choosing Cleveland Clinic for your health concerns, please visit us online at http://my.clevelandclinic.org.
To make an appointment with Julie Honaker, PhD or any of the other specialists in Cleveland Clinic’s Head & Neck Institute, please call 216.444.8500, toll-free at 800.223.2273 (extension 48500) or visit us at clevelandclinic.org/headandneck for more information.
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The Section of Vestibular and Balance Disorders provides laboratory diagnosis, medical neurotology and vestibular rehabilitation of patients with dizziness, disequilibrium and imbalance. An outpatient clinic manages self-referred patients and those referred from Otolaryngology, Neurology, Internal Medicine and other departments. Residents rotate through the Section of Vestibular and Balance Disorders to learn about test administration and interpretation.
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