Dizziness, vertigo, and imbalance can wreak havoc on lives. For Balance Awareness Week this week (14-20 September 2025), HPA asks four practitioners who specialise in vestibular disorders for an update on the field and how to bring a vestibular clinic to life.
Sydney audiologist Dr Celene McNeill, who has worked in the vestibular field for more than 30 years, believes every audiologist can become proficient in vestibular care if they have the interest and commitment.
“Vestibular knowledge isn’t exclusive or unreachable – it’s just a matter of training and curiosity,” she says.
“I strongly believe the vestibular field has been overlooked in Australia in favour of hearing rehabilitation. There’s a large gap between the number of people experiencing dizziness and the number of clinicians trained to assess and treat vestibular issues.”
Dr McNeill says many patients are misdiagnosed or dismissed before reaching a clinic like hers. “I would absolutely encourage audiologists to consider further training in this area; it’s intellectually stimulating and incredibly rewarding. With the right mindset and preparation, audiologists are uniquely positioned to lead in vestibular diagnostics and care,” she says.
In 2024, an Australian study of people aged 55 and over found dizziness/vertigo was a frequent and detrimental symptom in the community. Cumulative 10-year incidence of dizziness/vertigo, vestibular vertigo and non-vestibular vertigo were 39%, 27%, and 11%, respectively.
Other Australian research estimates 10%-30% of older community-living people report dizziness often leading to functional disability and psychological distress.
Dizziness is often caused by problems of the inner ear with common causes including benign paroxysmal positional vertigo (BPPV), migraine and vestibular neuritis.
In Dr McNeill’s clinic, BPPV is possibly the most common but she also sees many Ménière’s disease cases, one of her key areas of interest.
“Differential diagnosis is essential, especially in distinguishing Ménière’s from conditions such as vestibular migraine, vestibular neuritis, labyrinthitis, persistent postural-perceptual dizziness (PPPD), and other chronic balance disorders,” she adds.
Increase in cases
There does seem to be an increase in cases, she says, likely due to greater awareness and improved diagnostic capabilities. More patients are seeking help earlier, possibly driven by online information and word-of-mouth.
Dr McNeill has noticed an increase in word-of-mouth and self-referrals. She also receives referrals from ENT specialists, neurologists, GPs, physiotherapists, and fellow audiologists, which have remained steady over the clinic’s 20-plus-year history.
Her interest in the field began early in her career in Brazil, where there’s a strong tradition of research into vestibular diagnostics and rehabilitation. “When I arrived in Australia, my first position was as chief audiologist at St Vincent’s Private Hospital’s Hearing Research and Diagnostic Clinic, which at the time was the only private audiology clinic in Sydney offering vestibular testing,” she recalls.
She received further training at the Royal Prince Alfred Hospital balance clinic under neurologist Professor Michael Halmagyi, a global leader in vestibular disorders. When she opened her practice in Bondi Junction in 2003, she included a comprehensive vestibular service.
Dr McNeill offers audio-vestibular assessments, interprets results, explains findings, and creates individualised management plans. “We provide in-house vestibular rehabilitation and refer for medical evaluation when red flags appear,” she adds.
“Education and counselling are central to what I do; helping patients understand their diagnosis and prognosis is just as important as testing.”
She recalls major diagnostic advances over the past two decades including development of ocular/cervical vestibular-evoked myogenic potentials (VEMPs) and video Head Impulse Testing (vHIT) which has allowed more precise assessment of individual otolith and semicircular canals function.
“Infrared video goggles also have made BPPV diagnosis more accurate and accessible,” she adds. In treatment, vestibular rehabilitation has gained traction, and there’s growing recognition of psychological aspects of dizziness, particularly its relationship with anxiety.
“Virtual reality is an emerging tool for rehabilitation which is promising and I’ve explored.”
Wearable tech, including mobile phone cameras for monitoring nystagmus, along with mobile apps and AI-supported diagnostics, are starting to play an important role, she says.
Setting up a vestibular clinic requires clinical expertise and strategic planning, she adds, especially because equipment is costly. This can be a barrier for small independent clinics but she started by buying second-hand machines and upgrading as the clinic grew.
“When I founded Healthy Hearing & Balance Care, my goal was to create a full-scope audiology clinic. I had extensive experience in vestibular testing and CPD has always been a priority – I attend conferences and seminars to stay current,” she says.
“Vestibular rehabilitation was a natural progression after diagnosis. There are many manoeuvres and targeted vestibular exercises that fall well within an audiologist’s scope.”
Lack of Medicare funding
Dr McNeill believes funding remains a significant barrier to expanding vestibular services. Since Medicare doesn’t allow audiologists to bill vestibular tests, medical oversight is needed from an ENT, neurologist or neuro-otologist.
“A key issue is Medicare’s lack of recognition of audiologists’ expertise. We’re not allowed to bill vestibular tests under our own Medicare provider numbers,” she says. “Only hearing tests qualify. In contrast, ENTs, neurologists, and even GPs can bill vestibular tests, often performed by audiologists, nurses, or physiotherapists on their behalf.
“To provide Medicare rebates, I must work under the ‘supervision’ of a medical specialist who is responsible for the test results. This is not only unfair to audiologists but also places an unnecessary burden on already busy specialists and increases patient costs by involving two professionals where one would suffice.”
Patients can claim up to $636.06 in rebates when vestibular tests are billed through a specialist’s provider number but receive no rebate if billed through an audiologist.
She says another frustrating discrepancy is that hearing tests billed under a medical specialist’s Medicare number attract a fee 20% higher than those billed by audiologists despite the fact most specialists don’t perform the tests. “Audiologists, with master’s level training, are the qualified providers, yet the current system allows unqualified personnel to bill under a specialist’s number,” she says. “This urgently needs reform.”
In 2020, the Medicare system was reviewed and Melbourne vestibular audiologist Dr Jessica Vitkovic helped describe vestibular items for bulk billing. Her treatment is provided under medical oversight of neuro-otologist Dr John Waterston.
“Medicare allows us to provide those services on his behalf. He doesn’t have to physically see every patient but guidelines stipulate he has input into the patient’s care and writes reports,” Dr Vitkovic says. “We’ll see the patient, prepare the draft report, provide management recommendations, and he is like a second pair of eyes and may recommend additional management.”
A vestibular audiologist with 24 years’ experience in the field, Dr Vitkovic says the reason she established her vestibular practice in 2022 was that patients with dizziness, vertigo or imbalance often did not know where to go for help.
Many experienced lengthy delays and costs in getting an accurate diagnosis and she wanted to provide a quicker pathway to diagnosis and treatment. She named her Mount Waverley practice Dizzology so people with these symptoms could easily find it by googling.
Post graduation, Dr Vitkovic worked at the Royal Victorian Eye and Ear Hospital (Eye and Ear), and later ran the balance unit there. She was also an academic at The University of Melbourne for 19 years, in charge of vestibular research and the audiology masters course.
She enjoys troubleshooting and diagnosis. “There’s always something new coming out in this space that helps with diagnosis or understanding pathologies,” she says. “A lot of it involves empowering the patient. Patients want to know what they can do about their symptoms and we get to address that in a two-hour session where we build rapport, trust, and educate them on what will be beneficial across their journey.”
The top three conditions she sees are BPPV, vestibular migraine and PPPD.
“In BPPV, otoconia migrate from one part of the balance organ into the wrong part and in a series of manoeuvres we perform, gravity migrates the crystals out of the wrong part,” she says. “It’s very treatable, and the patients love you because you can fix them with one or two manoeuvres. It’s really satisfying. Other pathologies are more complex.”
If treatment is required outside her expertise she refers to physiotherapists, neurologists or ENTs who specialise in the conditions.
Anxiety is a common comorbidity Dr Vitkovic can assist with due to cognitive behavioural therapy and acceptance commitment therapy training. “Sometimes people worry, ‘Will I have this forever?’ and ‘I’m dizzy, I’m not going to be able to do this’. There’s such a big, dizzy-anxious cycle,” she says.
Having vestibular migraine herself is reassuring for patients. “Some arrive in tears, feeling alone, but leave feeling understood, hopeful, and equipped with tools from someone who truly gets what they’re going through,” she says.
Knowledge of protocols and billing systems from her previous roles assisted in setting up her practice, and she chose a geographic area without a similar service.
While still working, she eased herself into her new business, initially renting a room part time in a busy vestibular physiotherapy practice. Once she was working there four days, she moved to her own premises. Business has flourished and she has taken on two vestibular audiologists.
Outlay for equipment was substantial so she initially bought the basics and has bought more as the business has grown. She says vestibular equipment and assessment keeps advancing especially with lighter VNG cameras facilitating the development of the video head impulse test. Testing is becoming more automated and even portable now, she adds.
Popular bootcamps
As an Audiology Australia director, Dr Vitkovic has helped arrange popular vestibular boot camps at its Sound Exchange events as vestibular testing has grown from a caloric test, ABR and a hearing test, to include CVEMP, OVEMP and VHIT.
Dr Vitkovic’s teaching at university inspired her student Jessica Blakeley to specialise in vestibular audiology. Blakeley set up her own Melbourne clinic, Ears in Balance Dizziness and Vertigo Clinic in Chelsea, ten years ago.
“She’s the reason I love vestibular audiology; she was a real mentor to me starting out and setting up,” Blakeley says. “We collaborate quite a lot, have meetings with our staff members, and share resources – even a vestibular audiologist!”
After graduating, Blakeley got a job doing vestibular function testing at The University of Melbourne hearing clinic along with research. She loved it but long distances to work took its toll.
“My mum had done careers coaching and we worked out I wanted to work in a vestibular clinic. Since there wasn’t one close to home, she joked, ‘Why don’t you start one?’” she says. “We created a spreadsheet of what we’d have to do to achieve it and started ticking things off. I set my goal, and it happened.”
Blakeley started working two days a week in her practice as she was still working part time at the university and for a neurologist. “I had three jobs but as the business grew, I got to focus solely on it,” she says.
“Now I have vestibular audiologist employees and we’ve just refurbished the clinic. We’ve got three clinical rooms with equipment which allows us to see multiple patients in a day because we’re so busy.”
Like Dr Vitkovic, Blakeley initially rented a room part-time in a physiotherapy practice, and later in an audiology clinic where the audiologist concentrated on hearing aids and she focused on vestibular issues. That relationship continues today as she refers to both and they refer patients to her.
She says equipment is a big cost in setting up and it’s important to pick a manufacturer with support behind it, training modules and who you can reach out to about equipment. Before setup, she used a computer-based 3D room designer to create where equipment would go and how it would fit in rooms.
Neuro otologist Dr Luke Chen who specialises in vestibular disorders has medical oversight.
“I wanted the service to be accessible to everyone so we bulk bill for everything,” Blakeley says. “Luke looks at every report, he’s on call if we have any questions, and he’ll see our urgent patients, such as those with acute vestibular dysfunction, red flags or sudden onset symptoms for the first time, which is great.”
Creating more awareness
BPPV is the most common condition she sees. “I’m hoping we are creating more awareness,” she adds.
“Our local doctors are getting more switched on and some are sending patients straight to us which I hope cuts down that bouncing around to practitioners that many patients experience.
“Doctors are also sending a lot to physios which is good – they get the more complex ones – but we see a lot too. We also get people who’ve been to a hospital ED and are often misdiagnosed with vertigo.”
Her patients come from a wide catchment from Mornington Peninsula to Brighton and she has even had interstate clients. “Usually, they only have to see us once as if it’s BPPV, we’re ideally treating them in one session, but I’ll always recommend they follow up with a physio.
“If symptoms recur, they may need another go to reposition all calcium carbonate crystals.”
Accurate diagnosis for other conditions means treatment or referral to other specialists and addressing contributing lifestyle factors.
“Some patients are very frustrated. They’ve spent a lot of money and had blood tests and sometimes, it’s a process of elimination, so validating that and helping them through the process is important,” she says.
“One of my favourite things is that look of relief – ‘Oh, I’m not going crazy’ – because they’re often invisible symptoms that don’t show up on blood tests or scans. To give them that validation that what they’re feeling is real, and then how we can work towards feeling better is vital.”
With more awareness, comes more demand for these tests and clinics, she says. “We do need more vestibular audiologists and the more, the merrier,” Blakeley says.
Complex balance disorders
At the forefront of treating and researching complex balance disorders in Australia is Associate Professor David Szmulewicz, a neurologist and neuro-otologist at the Eye and Ear and head of the NeuroMovement Laboratory at The Bionics Institute.
The hospital’s balance disorders and ataxia service includes a vestibular clinic, complex balance disorders clinic, injecting clinic for vestibular migraine, and a vestibular audiology service.
At the heart of his work is the Complex Balance Disorders and Ataxia Service (COMBDAS), a unique, multidisciplinary clinic set up in response to an increasing need for treatment.
A/Prof Szmulewicz says it’s the only clinic of its type in Australia dedicated to patients with complex balance disorders such as combinations of peripheral and central vestibular disorders, peripheral sensory and other impairments.
“Patients seen in this clinic often don’t fit neatly into a single diagnosis. Their presentations are complex, so assessments must be equally comprehensive,” he adds.
COMBDAS opened two years ago after earlier operation elsewhere. Its status as a US National Ataxia Foundation Centre of Excellence reflects its national and international recognition.
It conducts extended vestibular and ocular motor objective assessment, detailed MRI brain and full spine scans, an ataxia protocol neurophysiology panel including large and small fibre nerve conduction studies, autonomic nervous system assessment, and central sensory evoked potentials.
“The clinic’s been a great success; it has seen more than 400 patients and continues to receive referrals weekly nationwide from audiologists, ENT specialists, neurologists, GPs, and physiotherapists,” A/Prof Szmulewicz says.
Audiologist referrals
Audiologist referrals to the standard vestibular clinic are via GPs to satisfy Medicare hospital referral requirements and are for patients with vestibular disorders.
If vestibular function testing raises suspicion of central vestibular pathology, they can refer patients to the complex balance disorders clinic.
“In many cases, audiologists play a central role, not only in identifying peripheral vestibular deficits but also in referring onward when central pathologies are suspected,” he says.
The COMBDAS clinic is also a research hub and his team was involved in a rehabilitation trial for central and combined central and peripheral vestibular disorders. It also discovered the two most common inherited complex balance disorders including spinocerebellar ataxia type 27b (SCA27b), the most common inherited central vestibular disease.
A/Prof Szmulewicz says more recent testing in the vestibular space includes routine 6-canal VHIT to assess superior and inferior branches of the vestibular nerve; expanded VEMP protocols for better detection of superior semicircular canal dehiscence (SSCD); and VHIT-caloric dissociation to differentiate between vestibular migraine and Menière’s disease.
Treatment of nystagmus and its effect on destabilising vision, in particular downbeat nystagmus, is with 4-aminopyridine. This partly relates to the
“Treatment depends on the patient’s condition but is multidisciplinary and involves specialised balance physiotherapy, speech and swallow therapy, occupational therapy, and medications. Additionally, optometrist management – for example, prisms – may be useful where there is double vision in a squint.”
The COMBDAS clinic is also a research hub and his team was involved in a rehabilitation trial for central and combined central and peripheral vestibular disorders. It also discovered the two most common inherited complex balance disorders including spinocerebellar ataxia type 27b (SCA27b), the most common inherited central vestibular disease.
A/Prof Szmulewicz says more recent testing in the vestibular space includes routine 6-canal VHIT to assess superior and inferior branches of the vestibular nerve; expanded VEMP protocols for better detection of superior semicircular canal dehiscence (SSCD); and VHIT-caloric dissociation to differentiate between vestibular migraine and Menière’s disease.
Treatment of nystagmus and its effect on destabilising vision, in particular downbeat nystagmus, is with 4-aminopyridine. This partly relates to the discovery of SCA27b.
Other innovations include the Epley Omniax Positioning System to assess and treat BPPV in patients with physical limitations or complex presentations, some of whom need neurosurgery. This major piece of equipment was funded by a Gandel Foundation Major Grant.
“Our audiologists perform the Dix-Hallpike test for assessment of BPPV and management manoeuvres where required,” A/Prof Szmulewicz says. “It is my view that any audiologist can be readily trained to do this and enjoy the satisfaction of curing this condition on the spot.”
The clinic has instrumented wearable devices to assess ataxia and imbalance including the Ataxia Instrumented Measurement System. There are 150 inherited cerebellar or central vestibular diseases and Machado-Joseph Disease (MJD/SCA3) is one.
The world’s highest prevalence of MJD occurs in the Northern Territory and through collaboration with the MJD Foundation, A/Prof Szmulewicz and his team conduct outreach clinics four times a year. “Before we began, fewer than 10% had seen a neurologist. That’s now 97%,” he says.
He also discovered the second most common inherited ataxia – cerebellar ataxia, neuropathy and vestibular areflexia syndrome (CANVAS) – and with collaborators at the Murdoch Children’s Research Institute and Walter and Eliza Hall Institute of Medical Research, its genetic cause, RFC1.
“Audiologists and ENT surgeons see this condition, particularly for the presence of bilateral vestibular hypofunction,” he says. “Hearing for this condition is unaffected. We also developed diagnostic guidelines.”
Additionally, the clinic pioneered a “VHIT on arrival” protocol, ensuring all new patients undergo video head impulse testing before their first medical consultation which streamlines diagnosis and improves clinical efficiency. With Dr Hamish MacDougall from the Bionics Institute, the team also developed the video VVOR test, a sensitive ocular motor assessment for detecting combined central and peripheral vestibular dysfunction.
With its pioneering research, patient-focused innovation, and interdisciplinary approach, COMBDAS offers a glimpse into the future of vestibular care, one where audiologists are key partners in diagnosis, referral, and treatment. More audiologists going down the vestibular path in future will also help improve access and outcomes for the dizzy patient.
