Special imaging of the middle ear bones may be in order. If the bulla appears abnormal, the ear may require surgical drainage. The problem is that radiography is often not sensitive enough to pick up damage in the middle ear and a normal set of films does not rule out disease. If a middle ear infection is present but is not known to be present, a routine cleaning of the external ear can lead to a flare up of vestibular symptoms. This is often unavoidable in long standing ear infections.
Brain tumors can be a cause of vestibular disease if the signs fit with a central lesion.
In these cases, special imaging as mentioned above is needed to make the diagnosis. Such tumors may be treatable depending on their location.