Vestibular Disorder

Vestibular disorders affect millions of people worldwide, disrupting the delicate balance system that allows us to move confidently through daily life. These conditions can transform simple activities like grocery shopping or walking into challenging obstacles, leaving many feeling dizzy, unsteady, and struggling to maintain their quality of life.

Table of contents

• What Are Vestibular Disorders?
• Associated Anatomy
• Types of Vestibular Disorders
• Symptoms
• Causes
• Diagnosis
• Treatment Options
• Living with a Vestibular Disorder

What Are Vestibular Disorders?

Vestibular disorders involve problems with your vestibular system, which is the body system that includes structures in your inner ear and brain that help you maintain your sense of balance^[1]. When this system doesn’t work properly, it leads to vestibular dysfunction, which means your body has difficulty maintaining balance^[1].

A vestibular disorder occurs when a disease, condition, or injury interferes with your body’s balance system. A link between your inner ear and your brain helps you keep your balance when you get out of bed or walk over rough ground^[2]. The vestibular system is central to a person’s core functioning, so a damaged or diseased vestibular system affects not only how you feel, but how you are able to perform day-to-day activities^[6].

Vestibular disorders affect more people than you might realize. Some studies suggest that up to 35% of adults over the age of 40 have experienced some form of vestibular dysfunction^[5]. Up to 50% of people with a history of traumatic brain injury experience vestibular impairments^[6].

Associated Anatomy

• Inner ear (vestibular labyrinth)
• Semicircular canals
• Otolith organs
• Vestibular nerve
• Brain (central nervous system)
• Brainstem
• Cerebellum

The vestibular system includes the parts of the inner ear and brain that process the sensory information involved with controlling balance and eye movements^[3]. The sensory organ structures are located in the inner ear and contain different tubes, called canals, that are filled with fluid and hair cells. Each sensory organ has three canals—lateral, superior, and posterior semicircular canals—to help the body move in all directions^[6].

Your sense of balance relies on the relationship between your central nervous system (brain) and your sensory system. Your vestibular labyrinth in your inner ear includes your semicircular canals, which react when you turn your head, and otolith organs that react to gravity and movement^[11]. When your body moves, it puts pressure on your tissues, and your tissues send signals to your brain, telling it where your body is in relation to space^[11].

Types of Vestibular Disorders

Experts classify vestibular disorders based on where the breakdown is within your vestibular system^[1]:

Peripheral vestibular disorders (PVD) are conditions that impact your inner ear or the nerve that carries balance signals to your brain (vestibular nerve)^[1].

Central vestibular disorders (CVD) are conditions that impact parts of your brain that process balance signals from your peripheral vestibular system^[1].

The most common vestibular disorders are^[1]:

• Benign paroxysmal positional vertigo (BPPV)
• Ménière’s disease
• Vestibular neuritis
• Labyrinthitis

Benign paroxysmal positional vertigo (BPPV) is the most common cause of positional vertigo and the most common form of acute peripheral vestibular dysfunction^[2][4]. It happens when tiny calcium crystals in one part of your ear move into an area where they shouldn’t be. This causes your inner ear to tell your brain you’re moving when you’re not^[2].

Labyrinthitis is an inner ear infection that happens when a fragile structure deep inside your ear, known as the labyrinth, gets inflamed. This affects not just your balance and hearing, but you also may have ear pain, pressure, pus or fluid coming from your ear, nausea, and a high fever^[2].

Vestibular neuritis is the third most common peripheral vestibular disorder after benign paroxysmal positional vertigo and Ménière disease^[12]. A viral infection somewhere else in your body, such as chickenpox or measles, can bring on this disorder that affects the nerve that sends sound and balance information from your inner ear to your brain. The most common symptoms are sudden dizziness, nausea, vomiting, and trouble walking^[2].

Ménière’s disease is a chronic inner ear disorder where people have sudden attacks of vertigo, tinnitus (a ringing, buzzing, or roaring sound in their ears), hearing loss, and a feeling of fullness in the affected ear. This may be a result of too much fluid in the inner ear, caused by a virus, allergy, or autoimmune reaction^[2].

Other vestibular conditions include^[1]:

• Acoustic neuroma
• Autoimmune inner ear disease
• Enlarged vestibular aqueducts
• Mal de débarquement syndrome
• Otosclerosis
• Perilymphatic fistula
• Persistent postural-perceptual dizziness
• Presbyvestibulopathy
• Secondary endolymphatic hydrops
• Superior semicircular canal dehiscence syndrome
• Vascular vertigo
• Vertebrobasilar insufficiency
• Vestibular ataxia
• Vestibular migraines
• Vestibular hypofunction
• Vestibular paroxysmia

Symptoms

The most common symptoms of a vestibular issue are^[1]:

• Dizziness (feeling disoriented or “woozy”)
• Vertigo (feeling as if you’re spinning or the room is spinning around you)

Vertigo is the sensation of self-motion of the head or body when no self-motion is occurring or the sensation of distorted self-motion during an otherwise normal head movement^[12]. Vertigo is often used to describe complaints of feeling lightheaded, dizzy, and off-balance^[6].

Symptoms of vestibular dysfunction include a variety of complaints that typically consist of vertigo, nausea and vomiting, intolerance to head motion, unsteady gait, and postural instability, with nystagmus (uncontrollable, irregular eye movements) often clinically apparent as well^[4].

Other symptoms depend on the specific condition or balance issues you’re having. They include^[1]:

• Trouble standing or sitting upright
• Trouble walking in a steady pattern
• Hearing loss or ringing in your ears (tinnitus)
• Blurred vision
• Nausea and vomiting
• Difficulty concentrating

Many people with a vestibular disorder also find it hard to focus on objects, especially when moving. Seeing bright lights and focusing on objects or perceiving them moving can be very stressing^[18].

The symptoms of vestibular neuritis and labyrinthitis are very similar. However, if your hearing is affected, then labyrinthitis is the cause. This is because inflammation of the labyrinth affects hearing, while inflammation of the vestibular nerve does not^[8].

Causes

If disease or injury damages the processing areas of the vestibular system, vestibular disorders can result. Vestibular disorders can also result from or be worsened by genetic or environmental conditions, or occur for unknown reasons^[3].

Causes of vestibular dysfunction include^[1]:

Aging: The structures within your inner ear that receive and send balance signals to your brain can deteriorate as you age^[1].

Head injuries: Trauma from a head injury can damage your inner ear or parts of your brain involved in your vestibular system^[1]. A brain injury can often cause damage to one or more of the parts that make up the vestibular system^[6].

Exposure to toxins: Ototoxicity is when a medicine you’re taking damages your inner ear. It’s one of the most common causes of vestibular dysfunction. Chemicals in the environment (like lead) can also damage your inner ear^[1].

Inflammation: Inflammation can damage the organs and nerves in your inner ear involved in balance. Sometimes, the inflammation results from a viral or bacterial infection^[1]. Labyrinthitis or vestibular neuritis is usually caused by a viral infection, such as a cold or flu^[8].

Problems with inner ear fluid (endolymph): Fluid inside your inner ear shifts in response to your head movements. The shifting activates nerves that communicate information about your position to your brain. Problems with the fluid can disrupt the signal, causing vestibular system problems^[1].

Tumors: Growths, including tumors, can impact the nerves that help you maintain your balance^[1]. Acoustic neuroma is a serious but nonmalignant tumor that develops on the sheath of inner ear’s vestibulo-cochlear nerve. As an acoustic neuroma grows, it compresses the nerve, usually causing hearing loss, tinnitus, and dizziness or loss of balance^[3].

Autoimmune diseases: Although it’s rare, an autoimmune disease can cause your immune system to attack your inner ear^[1]. When the immune system malfunctions and attacks the ear itself, this is known as autoimmune inner ear disease^[3].

Neurological conditions: Conditions that impact your nerves and central nervous system can disrupt your balance. Stroke is the most common cause of severe central vestibular dysfunction, and acute ischemic stroke accounts for up to 25% of patients who present with central vestibular dysfunction^[4].

Diagnosis

A complete history and physical examination is the best way to differentiate peripheral from central vestibular dysfunction^[4]. To determine if your symptoms are caused by problems in the balance function in your inner ear, your doctor is likely to recommend tests^[16].

Your doctor will start by reviewing your medical history and conducting a physical and neurological examination^[16]. You may need to work with an ear, nose, and throat specialist (ENT or otolaryngologist)^[7]. After your health history is reviewed, you may need the following tests^[7]:

Hearing exam: Difficulties with hearing are frequently associated with balance problems^[16].

Vision exam: Part of the diagnosis may include vision testing^[7].

Blood tests: Blood work may be ordered to rule out other causes^[7].

Imaging tests: Imaging tests of the head and brain, such as MRI and CT scans, can help determine whether an underlying condition is causing balance problems^[7][16].

Posturography test: This test looks at your posture and movement. Wearing a safety harness, you try to remain standing on a moving platform. A posturography test indicates which parts of your balance system you rely on most^[16].

ENG (electronystagmography) and VNG (videonystagmography): These are tests that record eye movements. They can help your healthcare provider find the cause of your disorder. Your vision system is a major part of your sense of balance. The ENG uses electrodes to watch eye movement. The VNG uses video cameras^[7].

Rotary chair test: Your eye movements are analyzed while you sit in a computer-controlled chair that moves slowly in a circle^[16].

Dix-Hallpike maneuver: Your doctor carefully turns your head in different positions while watching your eye movements to determine whether you have a false sense of motion or spinning^[16].

Vestibular evoked myogenic potential test: Sensor pads attached to your neck and forehead and under your eyes measure tiny changes in muscle contractions in reaction to sounds^[16].

State-of-the-art vestibular testing centers may include videonystagmography, rotatory chair testing, vestibular-evoked myogenic potential testing, video head impulse testing, electrocochleography, and platform testing^[14].

Treatment Options

Treatment will depend on the cause of your balance disorder^[7]. A team of doctors trained in balance disorders works with each patient to develop an individualized treatment plan based on that person’s specific condition^[14].

Vestibular Rehabilitation Therapy

Vestibular rehabilitation therapy (VRT) involves exercises that help you manage dizziness and balance issues. This therapy may help people cope with the symptoms of conditions such as vertigo and labyrinthitis^[11]. Vestibular rehabilitation is a specialized form of exercise-based therapy designed to alleviate both primary and secondary symptoms of vestibular disorders^[13].

VRT uses specific head, body, and eye exercises designed to retrain the brain to recognize and process signals from the vestibular system and coordinate them with information from vision and proprioception. The choice and form of VRT exercises will differ from person to person^[13].

Therapy may include these exercises^[11]:

• Eye movement control
• Balance retraining
• Stretching and strengthening

Evidence suggests that early treatment of inner ear problems is helpful in decreasing dizziness. Not all inner ear problems are the same and so not everyone will do every exercise. Your physical therapist will determine which exercises will help you the most on the basis of your dizziness and balance concerns^[10].

Canalith Repositioning Procedure

For benign paroxysmal positional vertigo, treatment can be done through a series of head movements your doctor guides you through, called the Epley maneuver. Doing that helps put the crystals back where they’re supposed to be^[2]. These are specialized maneuvers performed to treat BPPV, involving a series of specifically patterned head and trunk movements to move tiny displaced otoliths to a place in the inner ear where they can’t cause symptoms^[13].

Medications

If you have labyrinthitis or vestibular neuritis, a doctor may prescribe antihistamines or motion sickness tablets for up to 3 days. Do not take them for any longer, as they can slow down your recovery^[8]. Labyrinthitis or vestibular neuritis is usually caused by a viral infection, so antibiotics will not help. But a doctor may prescribe antibiotics if they think your infection is bacterial^[8].

To treat vestibular neuritis, your doctor may give you medicine to wipe out the virus that’s causing it^[2]. For patients with Ménière’s disease, migrainous vertigo, or psychiatric disorders, medications can help manage balance problems^[14].

Diet and Lifestyle Changes

For patients with Ménière’s disease, reducing salt intake can help symptoms. Some people with migraine-related dizziness might also benefit by reducing caffeine, alcohol, nicotine, and chocolate. Patients who experience drops in blood pressure when standing might need to drink more fluids, wear compressive stockings, or undergo postural conditioning^[14].

Some vestibular disorders can cause a migraine, associated with dizziness. Meniere’s disease or secondary endolymphatic hydrops can be managed in some ways through dietary modifications. Stay hydrated, avoid foods high in salt or sugar, avoid stress-inducing beverages like caffeine to avoid migraines. Limit or eliminate alcohol consumption. Eliminate smoking due to the ability of nicotine to increase symptoms by decreasing blood supply to the inner ear^[18].

Surgery

When medical treatment isn’t effective in controlling vertigo and other symptoms caused by vestibular system dysfunction, surgery may be considered. The type of surgery performed depends upon each individual’s diagnosis and physical condition. Surgical procedures for peripheral vestibular disorders are either corrective or destructive. The goal of corrective surgery is to repair or stabilize inner ear function. The goal of destructive surgery is to stop the production of sensory information or prevent its transmission from the inner ear to the brain^[13].

Surgery can help repair perilymph fistulas. Openings or tears can be plugged with tissue taken from the outer part of your ear^[2]. An acoustic neuroma can be taken out with surgery, or your doctor might treat it with radiation to stop it from growing^[2].

Living with a Vestibular Disorder

Living with a vestibular disorder affects a person’s life in many ways. Many things you used to be able to do easily are a struggle, or impossible. Going to the mall, grocery shopping, attending a play, visiting with family—these everyday activities are like mountains you have to climb. And because your symptoms are invisible, your friends, family and coworkers don’t understand, and may even question whether your symptoms are real^[17].

Managing Fatigue

Fatigue is a common and distressing symptom that affects many people with vestibular disorders^[22]. People with vestibular disorders have to concentrate harder and use more energy just to figure out where they are in space, leaving them with less energy to perform daily activities^[22]. When someone is suffering from repeated or prolonged episodes of stress, which is certainly the case for many people with vertigo, dizziness and balance issues, the body enters a state of chronic stress^[22].

Safety at Home

Several modifications can help you stay safe at home^[21]:

• Install a grab bar near your bathtub and toilet
• Use a chair or a grab bar in the shower
• Use non-skid mats on slippery surfaces
• Use nightlights when walking at nighttime
• Clear out clutter in your home
• Place items you need on low shelves
• Use a chair for cooking, doing the dishes, or any other household tasks

Safety Outside

When leaving the house^[21]:

• Use walking devices such as walking sticks, canes, or walkers
• Wear supportive, non-slip shoes that offer plenty of traction
• Take lots of breaks and go slow
• Use a chair to exercise for extra stability

Coping with Challenging Environments

Crowded and noisy environments can easily produce fatigue in people with a vestibular disorder. Bright lights, rapid movements, and altitude changes can all play against a person’s balance^[18]. For many people with a vestibular disorder, a trip to the grocery store can turn into a battle with dizziness. The lights, rows of shelves, and crowds of people can trigger symptoms such as dizziness, nausea, and light-headedness^[17].

Recommendations include wearing sunglasses to assist with the light and your movement, leaving a small stool or folding chair in the trunk of your car for you to sit down at outdoor events, sitting in a location where you do not have to move your head every minute, avoiding rush hour, loud background music and looking directly into fluorescent lights^[18].

Communicating with Loved Ones

Sharing your symptoms and feelings with loved ones is essential. Let them know how they can support you during your dizziness to keep you safe. Ask them to help with chores around the house, help with errands like groceries and shopping, help with taking care of kids or pets, and have them drive you to appointments or any other needed place^[21].

Remember that avoidances and lifestyle modifications should only be temporary. You should be working to get back to a normal life again^[21]. Staying active is very important and moving your head, even if it makes you dizzy, is one of the best ways to recover from your inner ear problem^[10].