Webpage published: 2011
We explain how the balance system works, causes of balance disorders, balance testing, and vestibular rehabilitation:
Your balance system is made up from what your eyes see, what your joints feel, and what is picked up by the balance part of your inner ear.
The inner ear is not only part of the hearing system but also sends signals to your brain about the direction and speed your head is moving (through sensors in the semi-circular canals) and detects when you move in a straight line (through the utricle and saccule, also known as the otolithic organs).
The inner ear is only one third of the balance system. It also includes inputs from the visual system, for example visual information is sent to the brain about the body’s position in relation to its surroundings. The third input is the musculoskeletal systems which send information from the muscles and joints of the feet and legs to maintain overall balance. The brain receives, interprets, and processes the information from these systems controls your balance.
What is a balance disorder?
It is a disturbance in your balance system which can cause you to feel: unsteady, giddy or have a sensation of spinning.
Symptoms of a balance disorder?
When you experience a balance disorder you will often have difficulty maintain your balance and you may experience a sensation which feels as though the room is spinning, you might stagger when you walk, or even be bedbound for a period of time. Some people also experience nausea and vomiting and fear and anxiety. The symptoms may appear and disappear over short periods of time or last for much longer periods depending upon the cause of the balance disorder.
After the initial symptoms if the balance part of your ear does not work correctly, you rely more on the information from your eyes and the joints and muscles in your body and you may feel dizzy. You may also find that certain movements make you feel dizzier, for example, turning your head quickly, bending down, or walking on uneven surfaces. Because of your dizziness, you might have stopped moving in ways that make your dizziness worse. But by stopping some movement your recovery will actually take longer. You might also experience neck stiffness, headaches, muscle stiffness or tiredness because you have stopped moving naturally.
Causes of a balance disorder?
Overall balance problems can be caused by one of four areas:
- Disturbances in the inner ear itself, this is known as a peripheral balance problem and may be down to viral or bacterial infections, blood circulation affecting the inner ear, certain medications and aging
- Changes in the connecting nerves of the inner ear and the way the brain receives the signals from the inner ear this can be caused by head injuries and disorders such as multiple sclerosis and migraines
- Systemic disorders of the body for example thyroid problems and the effects of diabetes
- Blood flow problems such as low blood pressure or cardiac arrhythmia
Common types of inner ear balance disorders?
(1) Benign Paroxysmal Positional Vertigo - BPPV
Benign Paroxysmal Positional Vertigo (BPPV) causes short episodes of vertigo or dizziness when moving your head in certain directions. Getting out of bed and rolling over in bed are two common "problem" motions. Also some people feel dizzy and unsteady when they tip their heads back to look up although symptoms can vary or come and go. Small crystals of calcium carbonate (sometimes called “ear rocks”) break loose from their correct position in the balance organ and collect as debris within another part. With head movements, these crystals move, sending false signals to the brain about how you are moving.
- About 20% of all dizziness is due to BPPV
- The most common cause of BPPV in people under age 50 is head injury
- About 50% of dizziness in older people is due to BPPV
- In half of all cases, there is no known reason for the onset of BPPV
Tests for BPPV are a form of positional testing where you are asked to lay flat on a clinical bench and the tester will observe your eyes for a phenomenon called nystagmus (which is an involuntary eye movement). Sometimes this also includes videonystagmography which is a test where a pair of video goggles records these eye movements.
Treatment is usually by returning the debris to its correct location with a particle-repositioning manoeuvre. These include the Epley and the Semont-liberatory manoeuvres and Brandt Daroff exercises.These are very effective in treating BPPV. Some are performed in hospital balance clinics and others as a set of home exercises.
If you have had an Epley manoeuvre performed you may feel tired in the evening, you may also feel a little unwell or unsteady. This is normal and will pass after a short period of time, but for this reason you should not drive yourself home from the hospital.
(2) Labyrinthitis or Vestibular Neuronitis with a lack of compensation
Labyrinthitis and vestibular neuritis are caused by an infection in the inner ear or the balance and hearing nerve. Inner ear infections are not the same as middle ear infections, which are the type of bacterial infections common in childhood that affects the area around the eardrum.
Symptoms may include:
- Labyrinthitis (inflammation of the labyrinth)
- Hearing loss
(3) Neuritis (or neuronitis) (inflammation of the nerve)
Infections of the inner ear are often caused by viruses and less commonly by bacterial infections. Although the symptoms may be similar, the treatments are very different, so correct diagnosis by a doctor is essential. An inner ear viral infection may be caused by a general viral illness or the infection may be just in the inner ear. Usually, only one ear is affected.
Symptoms can be mild or severe, ranging from mild dizziness to a violent spinning sensation. They may also include nausea, vomiting, unsteadiness and imbalance, difficulty with vision, and impaired concentration. Sometimes the symptoms can be so severe that they affect the ability to sit up, stand, or walk. Labyrinthitis may cause the same symptoms, together with tinnitus (ringing or noises in the ear) and/or hearing loss.
The onset of symptoms is usually very sudden, interrupting routine daily activities. After a period of gradual recovery over several weeks, some people are completely free of symptoms while others do not recover fully and continue to have chronic dizziness which is referred to as a lack of compensation.
No specific balance tests exist to diagnose vestibular neuritis or Labyrinthitis, however a test battery of videonystagmography, caloric testing and posturography can be helpful alongside a strong history.
Medications are often prescribed to control nausea and to improve dizziness during the severe stage. Other illnesses are usually ruled out and a diagnosis made as a result of symptoms. If treated promptly, many inner ear infections cause no permanent damage. In some cases, however, permanent loss of hearing or damage to the vestibular system can occur.
If symptoms of dizziness or imbalance continue for several months, vestibular rehabilitation exercises may be prescribed in order to teach the brain to adjust to the imbalance (known as compensation). An important part of a successful recovery is to keep moving, despite the symptoms.
(4) Meniere’s disease. Visit our Menieres page
Meniere’s disease is a condition of the inner ear affecting balance and hearing. It is thought to be caused by unusually large amounts of a fluid called endolymph creating a build up of pressure in the inner ear. This pressure can cause the inner ear to send abnormal messages to the brain resulting in dizziness, vomiting and dulled hearing. The exact cause of Meniere’s disease is not known but there may be links to circulation problems, viral infections, allergies, the immune system, migraines, or genetic factors.
- Around 15 people per 100,000 develop Meniere’s disease every year
- Of these, one third eventually develop the disease in the second ear as well
Attacks last from 20 minutes to 24 hours. They can be separated by weeks, months, or even years. The disease is difficult to predict making it difficult to tell how it might affect someone’s life in the future.
During an attack of early Meniere’s disease, the main symptoms are:
- Sudden, severe vertigo (which may include vomiting)
- Changes in hearing
- Fullness in the ear
- Tinnitus (noises in the ear)
During an attack you may also experience vomiting and following an attack, you may feel very tired and need to sleep a lot. The periods between attacks are often symptom-free.
Late Meniere’s disease refers to a slightly different set of symptoms:
- Hearing loss is greater and is less likely to change
- Tinnitus and or fullness in the ear may be stronger and last longer.
- Severe attacks of vertigo may be replaced by more constant struggles with vision and balance, including difficulty walking in the dark and occasional sudden loss of balance.
There is no cure but treatment aims to ease symptoms. Some people find that certain things can set off attacks; stress, overwork, fatigue, emotional distress, other illnesses, pressure changes, certain foods, and too much sodium (salt) in the diet.
The most traditional long-term treatments for Meniere’s disease may involve taking medication, a reduced salt diet and using diuretic medication (often called ‘water tablets’) to try to reduce inner ear fluid pressure. This may help to decrease the severity and frequency of attacks. During attacks medication can be used to control dizziness and sickness and is best taken as soon as an episode begins.
Vestibular rehabilitation exercises are sometimes used to help with any dizziness or imbalance between attacks but cannot help during the attack itself. If these are appropriate for you, it will be discussed at your assessment appointment.
For people diagnosed with Meniere's disease, dietary changes such as reducing intake of sodium may help. For some people, reducing alcohol, caffeine, and/or avoiding nicotine may be helpful.
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