A balance disorder is a disturbance that causes an individual to feel unsteady, giddy, woozy, or have a sensation of movement, spinning, or floating. An organ in our inner ear, the labyrinth, is an important part of our vestibular (balance) system. The labyrinth interacts with other systems in the body, such as the visual (eyes) and skeletal (bones and joints) systems, to maintain the body's position. These systems, along with the brain and the nervous system, can be the source of balance problems.
Three structures of the labyrinth, the semicircular canals, let us know when we are in a rotary (circular) motion. The semicircular canals, the superior, posterior, and horizontal, are fluid-filled. Motion of the fluid tells us if we are moving. The semicircular canals and the visual and skeletal systems have specific functions that determine an individual's orientation. The vestibule is the region of the inner ear where the semicircular canals converge, close to the cochlea (the hearing organ). The vestibular system works with the visual system to keep objects in focus when the head is moving. Joint and muscle receptors also are important in maintaining balance. The brain receives, interprets, and processes the information from these systems that control our balance.
Some of the more common balance disorders are:
When balance is impaired, an individual has difficulty maintaining orientation. For example, an individual may experience the "room spinning" and may not be able to walk without staggering, or may not even be able to arise. Some of the symptoms a person with a balance disorder may experience are:
Some individuals may also experience nausea and vomiting, diarrhea, faintness, changes in heart rate and blood pressure, fear, anxiety, or panic. Some reactions to the symptoms are fatigue, depression, and decreased concentration. The symptoms may appear and disappear over short time periods or may last for a longer period of time.
Infections (viral or bacterial), head injury, disorders of blood circulation affecting the inner ear or brain, certain medications, and aging may change our balance system and result in a balance problem. Individuals who have illnesses, brain disorders, or injuries of the visual or skeletal systems, such as eye muscle imbalance and arthritis, may also experience balance difficulties. A conflict of signals to the brain about the sensation of movement can cause motion sickness (for instance, when an individual tries to read while riding in a car). Some symptoms of motion sickness are dizziness, sweating, nausea, vomiting, and generalized discomfort. Balance disorders can be due to problems in any of four areas:
Diagnosis of a balance disorder is complicated because there are many kinds of balance disorders and because other medical conditions--including ear infections, blood pressure changes, and some vision problems--and some medications may contribute to a balance disorder. A person experiencing dizziness should see a physician for an evaluation.
The primary physician should rule out some basic medical problems such as anxiety, migraine, diabetes and other medical problems. He may request the opinion of an otologist to help evaluate a balance problem. An otologist is a physician/surgeon who specializes in diseases and disorders of the ear with expertise in balance disorders. He or she will usually obtain a detailed medical history and perform a physical examination to start to sort out possible causes of the balance disorder. The physician may require tests to assess the cause and extent of the disruption of balance. The kinds of tests needed will vary based on the patient's symptoms and health status. Because there are so many variables, not all patients will require every test.
Some examples of diagnostic tests the otolaryngologist may request are a hearing examination, blood tests, an electronystagmogram (ENG--a test of the vestibular system), or imaging studies of the head and brain.
The caloric test may be performed as part of the ENG. In this test, each ear is flushed with warm and then cool usually one ear at a time; the amount of nystagmus resulting is measured. Weak nystagmus or the absence of nystagmus may indicate an inner ear disorder.
Another test of the vestibular system, posturography, requires the individual to stand on a special platform capable of movement within a controlled visual environment; body sway is recorded in response to movement of the platform and/or the visual environment.
There are various options for treating balance disorders. One option includes treatment for a disease or disorder that may be contributing to the balance problem, such as ear infection, stroke, or multiple sclerosis. Individual treatment will vary and will be based upon symptoms, medical history, general health, examination by a physician, and the results of medical tests.
Another treatment option includes balance retraining exercises (vestibular rehabilitation). The exercises include movements of the head and body specifically developed for the patient. This form of therapy is thought to promote compensation for the disorder. Vestibular retraining programs are administered by professionals with knowledge and understanding of the vestibular system and its relationship with other systems in the body.
For people diagnosed with Ménière'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. Multiple other medical and surgical treatments exist for Ménière's disease. A program of talk therapy and/or physical rehabilitation may be recommended for people with anxiety.
A program of talk therapy and/or physical rehabilitation may be recommended for people with anxiety.
You can take the following steps that may be helpful to your physician in determining a diagnosis and treatment plan.
Lastly, remember to write down any instructions or tips your doctor gives you.
Migraine is a type of headache (HA) characterized by throbbing pain limited to one side of the head and sometimes accompanied by nausea, vomiting and sensitivity to light and sound. Migraine headaches are one of the most common causes of dizziness. Dizziness in migraine may occur with the HA, prior to or after the HA or completely independent of the HA. It is common to have dizziness as the only symptom of a migraine HA. The dizziness may be vertigo (sensation of spinning), imbalance or sensitivity to motion. Ear fullness and tinnitus may also occur.
Migraines are more common in women than men, especially women of childbearing age. Approximately, one third of the migraine patients have dizziness. People who suffer from migraines with aura are more likely to have dizziness with the HA. Sensitivity to motion, as in car sickness, amusement park rides, fast moving objects, is reported in half of the patients with migraines and can be the only symptom of a migraine. In young children, typically younger than 4 years old, sudden brief episodes of loss of balance with vomiting, anxiety, and nystagmus occur that are thought to be migraine equivalents. About 50% of these children develop migraines later in life.
There are many theories and the exact cause is not know. People who are prone to migraines, when exposed to certain triggers, likely undergo changes in the brain associated with release of certain chemicals. These changes can cause dizziness along with HA.
A detailed history about the HAs, dizziness, triggers and many other factors along with a careful physical examination begin the diagnostic process. A hearing test is performed. Migraines may cause hearing loss and tinnitus (ringing of the ears) which also occurs in other ear conditions, and so a full diagnostic audiogram is required. Other diagnostic tests, electronystagmography(ENG) and electrocochleography(ECOG) and CDP may be performed. An MRI of the brain and inner ear is sometimes performed. A symptom diary, migraine diet and observation are sometimes performed as part of the diagnostic process.
The first step in the treatment is avoiding migraine triggers. Keeping a symptom diary helps to know your triggers. Certain foods are known migraine triggers and are listed below. There are many medications used to prevent migraine and they help prevent MAD. Vestibular and balance therapy is helpful to resolve the motion sensitivity associated with MAD. (link to balance therapy)
BEHAVIORAL PREVENTION
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Researches believe this condition is caused by an inflammation of the nerve of the inner ear. The nerve, called the vestibulocochlear nerve brings information from the balance system (vestibular) and the organ of hearing (cochlea) of the inner ear to the brain. Inflammation of the part of the nerve that supplies the balance system causes sudden onset of dizziness or vertigo known as vestibular neuritis. The lay persons’ term for this is labyrinthitis.
Viral infection is thought to be the cause, although there is still uncertainty. Viruses from the herpes family and reactivation of chicken pox virus are linked to VN.
VN is characterized by sudden onset of severe debilitating vertigo, which is the sensation of spinning of the head or the environment. Initially this is a constant sensation worsened by head or body movements. Associated with vertigo are severe imbalance, nausea, and vomiting. The symptoms decrease in severity from constant to episodic in nature over a period of days. About 15% of patients with VN develop BPPV.
Diagnosis is made after obtaining a detailed history of symptoms and performing a complete physical and neuro-otologic examination. A diagnostic hearing test is performed during the initial evaluation. Blood work is also ordered to check for infection. Electrophysiologic testing of the hearing and balance system and other tests are sometimes performed. done. An MRI is often ordered.
Vestibular neuritis is treated symptomatically. Medications are given for nausea, vomiting and dizziness. If onset of VN is recent then oral steroids may help to decrease the severity of dizziness. If vomiting is uncontrollable, admission into a hospital is required for intravenous rehydration. Vestibular rehabilitation exercises are very beneficial in the treatment of this conditions.
BPPV or Benign Paroxysmal Positional Vertigo is one of the most common disorders of the inner ear that results in vertigo. It is due to particles (crystals, otoliths,”ear rocks”) that have collected in the fluid filled balance canals of the inner ear. These particles, made of calcium, float in the fluid and will occasionally touch a sensitive area resulting in the sensation of vertigo. The name of this disorder is derived from the fact that BPPV is Benign (not life threatening), Paroxysmal (dizziness occurs suddenly and briefly), Positional (dizziness occurs with particular head positions) and causes Vertigo (sensation of spinning). BPPV is a common cause of dizziness. About 20% of all dizziness is due to BPPV. In older people, half of the patients with dizziness may have BPPV.
The symptoms can vary in each person and include dizziness or vertigo, lightheadedness, imbalance, and sometimes nausea and vomiting with head movements. The symptoms are almost always precipitated by a positional change of the head or body. Getting into or out of bed, or rolling over in bed are common “problem motions”. Some people will feel dizzy and unsteady when they tilt their heads back such as looking up, brushing their teeth, washing their hair, instilling eye drops, or checking the “blind spots” while driving. Although many people feel normal when not in a “problem” position, some do have a sensation of imbalance.
BPPV has often been described as “self-limited” because symptoms often subside or disappear within six months of onset. Symptoms tend to wax and wane. The symptoms can last for days or occasionally months.
The most common cause of BPPV in people under age 50 is head injury. It is more common in older people, commonly due to degeneration of the balance system of the inner ear. A viral upper respiratory infection or allergy flare up may also play a role. It also occurs commonly in people with Meniere’s disease and otosclerosis and after surgical and dental procedures. Minor stroke of the blood vessels supplying inner ear or a tumor of the inner ear are rare causes of BPPV. However, in perhaps half of all cases, BPPV is called “idiopathic”, which means it occurs for no known reason.
Your doctor will make the diagnosis based on your symptoms, physical examination and the results of your hearing and balance tests. During medical evaluation, Dix Hallpike test will be performed which helps to make the diagnosis of BPPV. During this test, the head is turned and the lies down quickly from a sitting position to hang the head at a 45 degree angle over the side of the table or bed. This is then repeated with the head turned to the other side. If there is a crystal, these movements cause a quick burst of nystagmus (jumping of the eyes) thus confirming the diagnosis of BPPV. Occasionally other tests may be required. A video nystagmography test (VNG) test may be needed to look for the characteristic eye movements and other possible causes of vertigo. An MRI scan would be performed if there is any possibility of a stroke or brain tumor. Although rare, it is possible to have BPPV in both ears, which may make the diagnosis and treatment more challenging.
Motion sickness medications (Meclizine, Dramamine, Bonine etc) are rarely effective and often worsen balance. These should be discontinued 48 hours prior to your doctor’s appointment for the evaluation of dizziness as they may interfere with the physical findings. Once the diagnosis of BPPV is confirmed, an in office treatment called an “Epley maneuver” is performed. This is effective in treating over 90% of cases. Other maneuvers exist to treat resistant or more complicated cases. A surgical procedure called “posterior semicircular canal occlusion” may be used to treat BPPV in the rare person where maneuvers fail.
The Epley maneuver (also called the particle repositioning or canalith repositioning procedure) involves sequential movement of the head through four positions while lying down. A hand held massager is applied to the bone behind the ear during these head movements. The procedure t moves the crystals from the balance canals back to their normal location where they do not cause any vertigo. The entire procedure takes about 10 minutes. It is best to have someone drive you to your appointment as you may feel dizzy after the maneuver. You will be given a cervical collar and certain instructions to follow that help in making this treatment a success. It is best to come to your appointment on an empty stomach. The maneuver can very rarely cause vertigo to worsen temporarily.
To increase the success of the Epley maneuver you will be asked to:
This treatment has a cure rate of 80% and repeat treatments may be necessary in the other 20% of the symptomatic patients. In rare cases, if repeat treatments fail, a surgical procedure called posterior semicircular canal occlusion can be performed.
Some people may feel lightheaded, imbalanced or “woozy” even after the treatment has been successful. These patients are put on a regimen of daily at home head and neck exercises for rehabilitation of the balance system. BPPV often recurs, in 30% within one year and 50% within five years.
Any vertigo accompanied by a change in hearing, blurring or double vision, severe headaches, numbness or tingling of body with difficulty speaking and swallowing, or loss of consciousness is an indication of a more serious medical condition and should be evaluated urgently.
