Dizziness Caused by Vestibular Disorders
Balance and dizziness disorders are often caused by a problem with one of the three major parts of the balance system that sends information to the brain: vestibular system (inner ear); proprioception (reaction of muscles and joints) and vision. Or the problem could be with the brain's processing or integration of these three systems. Dizziness affecting the vestibular system can be grouped into types by the component of the balance system that is not working properly:
Inner Ear Dizziness
Half of the inner ear is used for hearing (the cochlea) and the other half is used for balance (vestibular system). Vestibular symptoms and imbalance can result if the vestibular system or the nerve that connects it to the brain is malfunctioning. These maladies of the inner ear are also known as peripheral vestibular disorders and include:
- Age-related Imbalance (Prebystases)
In general, dizziness is not considered to be a normal part of aging. However, as with many other organs, there is evidence that some inner ear degeneration occurs with age. Some individuals develop imbalance or vestibular dysfunction with age for which the exact reasons are not well misunderstood. In some cases, the very small blood vessels supplying in inner ear or balance centres in the brain may change. Although dizziness may be minimal, some people have a high risk of falling. Rehabilitation, education and prevention strategies can address the dizziness and reduce the risk of falling.
- Acoustic Neuromas
Also called vestibular schwannomas, these are benign tumours of the balance nerve. They can cause unsteadiness, hearing loss, and tinnitus. Surgery is the most effective treatment for an acoustic neuroma. Depending on the size a watch and wait approach is actually the recommended choice.
- Autoimmune Inner Ear Disease
Diseases of the immune system may cause hearing impairment, dizziness or both. The diagnosis is based on the symptoms and blood test results. Treatment with cortisone or autoimmune drugs may prevent further hearing loss and usually relieves dizziness. Long-term drug therapy may be necessary.
- Benign Paroxysmal Positional Vertigo (BPPV)
BPPV is the most common inner ear balance problem. It is defined as sudden attacks of vertigo (spinning sensation) that last for less than a minute and are always triggered by certain head movements. Read more about BPPV
- Bilateral Vestibular Loss
Rarely, people can suffer from loss of vestibular function on both sides simultaneously. This may occur due to autoimmune disease, after certain medications (such as Gentamicin), or without known cause. Unsteadiness and falls are a primary concern. A perception of things bouncing in the field of vision when moving (oscillopsia) is one of the most common symptoms. Education is important to prevent falls and vestibular rehabilitation will address the visual blurring and imbalance.
A benign cyst in the middle ear behind the eardrum. It may be caused by repeated middle ear infections or a poorly functioning Eustachian tube. Symptoms may include pain or pressure, hearing loss and dizziness. As it grows it can erode the balance sensors in the inner ear, causing dysfunction and dizziness/balance symptoms.
- Enlarged Vestibular Aqueduct
Some people are born with inner ear abnormalities, such as children who are born with an abnormal connection between their brain and ear, a so-called “enlarged vestibular aqueduct.” This can sometimes be detected on a CT (computerized tomography) scan and may lead to fluctuating hearing loss as well as dizziness.
A condition in which the vestibular nerve becomes inflamed, resulting in dizziness or vertigo as well sudden hearing loss.
- Ménière’s Disease (Endolymphatic Hydrops)
In Ménière’s disease, the endolymphatic sac fails to absorb fluid properly. This change in inner ear fluid pressure results in dizziness and hearing loss.
These changes may be caused by excess inner ear sodium (salt). In addition to dizziness, which usually lasts hours, patients may have fluctuating hearing, tinnitus, and a feeling of fullness in the affected ear. It can occasionally affect both ears.
The cause of this disorder is not known and may vary from person to person. The spells can sometimes be induced by excess salt intake, stress, weather changes, allergies or other dietetic triggers.
Treatment usually includes restriction of salt (sodium) intake and the use of a diuretic (water pill). Betahistine is the medication of choice for Ménière’s disease. Sometimes, anti-dizziness medication like Antivert or Valium can decrease the severity of the acute spells, but they do not cure the disease or help with symptoms that are present between attacks. Antivert (meclizine) is not available in Canada anymore. Benzodiazepines such as Valium are not exactly anti-dizziness medications. When used during a dizziness episode, the desired effect of benzodiazepines is sedation – to help the person through the episode.
Vestibular rehabilitation may help with dizziness, blurred vision and imbalance related to Ménière’s disease, but rehabilitation cannot prevent future attacks. Classically, these patients are not good candidates for rehabilitation until there is stable damage to the inner ear organs (burn out stage)
In severe cases of Ménière’s disease, surgery may be needed. Fortunately, there are many surgical options. Of all these options, only sac decompression surgery attempts to improve function of the inner ear. The remaining options attempt to selectively ablate (remove or destroy) the malfunctioning balance (vestibular) nerve, and sometimes the hearing nerve as well. However, surgery is very rarely recommended these days. The most effective treatment currently for Ménière’s disease is intra-tympanic steroid injections. They are thought to reduce possible underlying inflammatory processes, improving hearing and speech discrimination and reducing frequency and severity of attacks.
It is very rare, but it can happen that the otosclerosis process affects the balance sensors; other times dizziness occurs as a complication post otosclerosis surgery (fistula like).
- Perilymph Fistula
The inner ear is a fluid-filled space within the temporal bone of the skull. If a fluid leaks from this space, dizziness and hearing loss may occur. The leak usually occurs in or near the natural structures of the inner ear, such as the oval and round membranous windows. The leak may occur naturally, with heavy straining, or after trauma. With rest, inner ear leaks may heal on their own. In some cases, minor surgery is required to plug the leak. Some people have on-going symptoms that require rehabilitation or to learn new strategies to avoid symptoms.
- Ramsay Hunt Syndrome
Also known as herpes zoster oticus. A rare complication of shingles (herpes zoster) in which the varicella-zoster virus reactivates and attacks the facial nerve near one of your ears. Symptoms include dizziness, hearing loss and tinnitus (ringing in your ears).
- Secondary Endolymphatic Hydrops (SEH)
Secondary endolymphatic hydrops is a pathologic finding of the inner ear resulting in episodic vertigo and intermittent hearing loss. Recent investigation of secondary endolymphatic hydrops has brought attention to traumatic and inflammatory insults as causes for secondary endolymphatic hydrops. Such etiologies, including postsurgical effects of cochlear implantation and endolymphatic sac ablation; otosclerosis and its operative intervention(s); acoustic and mechanical trauma; medications; and systemic inflammatory and viral processes, have been determined as causes of secondary lymphatic hydrops.
- Superior Semicircular Canal Dehiscence
Superior Semicircular Canal Dehiscence occurs when the temporal bone overlying the superior semicircular canal is unusually thin or absent. It is a clinical condition that results in a constellation of auditory and vestibular symptoms, such as sound- and/or pressure-induced vertigo and nystagmus, hearing loss, and/or autophony (hearing one’s own body sounds at an abnormally high sound level).Treatment options are surgical or conservative/management, involving avoidance of triggers and amplification (hearing aid) in cases where hearing loss is present.
- Vestibular Neuritis
Neuritis (inflammation of a nerve), usually due to a virus, may affect the vestibular nerve. When this happens the balance centres of the brain are over-stimulated, which results in severe dizziness and vertigo. Fortunately, vestibular neuritis usually subsides with time and it does not normally recur. Certain medications such as steroids and/or antivirals may help in the acute phase to decrease the severe symptoms or improve the long-term outcome. Many people heal naturally. However, some people have long-term weakness (or paresis) of this nerve. If this occurs, exercises (vestibular and balance rehabilitation) can speed-up recovery or treat symptoms such as dizziness, blurred vision and imbalance. Also called vestibular neuronitis.
- Vestibular Migraine
Originates in the inner ear and therefore can be considered peripheral migraine. It is sometimes referred to as migraine-associated vertigo, migraine-associated dizziness, migraine-related vestibulopathy and migrainous vertigo. Read more.
Central or neurological dizziness refers to problems in the balance centres of the brain. Anytime these areas are not working properly, dizziness and imbalance can occur. Symptoms may include dizziness, vertigo, light-headedness, disorientation, imbalance and sometimes even blacking out. Treatment usually involves dealing with the underlying brain problem. This varies from person to person, but may include medications, changes in lifestyle or vestibular rehabilitation. Causes of central dizziness include:
- Concussion and Other Head Injuries
A concussion is a mild traumatic brain injury (TBI) caused by a direct or indirect blow to the head. Signs of a concussion may include dizziness and balance problems.
- Cerebellar Degeneration
- Deformities of the Upper Spine and Back of the Brain
- Low blood sugar (hypoglycemia)
Low blood-sugar (glucose) levels can make you feel light-headed and dizzy and at risk of falling. This is most common in individuals with diabetes.
- Low blood pressure to the brain (orthostatic hypotension)
- Mal de Débarquement (mDd) Syndrome
MdD is a rare disorder in which the person has persistent feelings of dizziness or body sway after being exposed to an unstable surface for an extended period (usually more than 72 hours). Most commonly this happens after a cruise, but it can occur after other activities such as a long car trip.
- Motion Sickness
A portion of the population experiences sensations of dizziness or nausea with motion of either the person or the surroundings. This may not necessarily be a medical disorder but more likely represents a sensitive or hyperactive balance system. However, some people develop these sensations for the first time after a new vestibular disorder. Medication, rehabilitation (exercises or desensitization), and coping strategies can be helpful.
- Multiple Sclerosis (MS)
A stroke occurs when a blood vessel that carries oxygen and nutrient to the brain is either blocked by a clot or ruptures. Stroke symptoms can include dizziness and loss of balance and coordination. This condition is a medical emergency – call 911.
- Transient Ischemic Attack (TIA)
- Also known as mini-strokes, TIAs occurs when there is a sudden lack of blood flow to your brain for a short period of time. A common sign is poor balance. This condition is a medical emergency – call 911
Tumors and cysts that sit on areas of the brain that control coordination and movement can cause dizziness and imbalance.
- Vascular Vertigo
Dizziness is caused by problems with blood supply to the inner ear or balance centres of the brain. It can occur in people who suffer from migraine, are overweight, smoke, have high blood pressure or do not get enough exercise.
- Migraine with Brainstem Aura
Also known as central migraine with dizziness. By definition, needs to be fully reversible leaving no motor or sensory symptoms. Symptoms include significant speech disturbance, vertigo, ringing in the ears (tinnitus), sound sensitivity, double vision, loss of balance and decreased loss of consciousness. Read more.
The most common visual issue that causes dizziness is not the clarity of your vision but how your eyes work together and how visual and vestibular information is processed and integrated by the brain. Problems include:
- Eye tracking issues (saccadic eye movements)
- Post Trauma Vision Syndrome (PTVS)
- Eye teaming issues
- Eye focussing issues
- Visual Midline Shift Syndrome (VMSS)
- Light sensitivity
- Visual neglect
- Visually induced dizziness
This type of dizziness is uncommon. The limb sensors in the muscles or joints (usually in the feet or neck) do not work properly or they give information that differs from that given by other balance sensors. Muscle-joint dizziness can cause imbalance, unsteadiness or a sense of disorientation. Treatment often includes hands-on physiotherapy and rehabilitation exercises. Causes of muscle-joint dizziness include:
- Cervicogenic Dizziness (CGD)
Dizziness, imbalance, unsteadiness, or a sense of imbalance resulting from a neck-related injury or disorder including whiplash.
- Muscular dystrophy
Muscular dystrophy is a group of inherited diseases that usually strike children, damaging and weakening their muscles over time leading to imbalance and a greater risk of falls.
- Joint replacements
If your joints are not working well, it becomes difficult for your body to react to motion. It may be difficult to remain upright. Symptoms are usually imbalance and unsteadiness.
- Muscular dystrophy