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Vestibular & Balance Disorders

Diagnosis and vestibular rehabilitation from dizziness, disequilibrium, imbalance and other vestibular disorders is offered. Dizziness is one of the most common reasons for a visit to a primary care doctor, but it is not a very descriptive term. It encompasses light-headedness, heavy- headedness, faintness, disorientation, distortion of position in three-dimensional space, turning sensation, spinning sensation, or rocking sensation.

The most common cause of vestibular disorders is the side effect to a medication. However, whenever dizziness is followed by a complete loss of consciousness, serious concerns regarding health of the heart or cardiovascular system need prompt medical attention.

As the ears share the same blood supply as the brain, conditions that restrict blood flow to the brain can lead to dizziness. When dizziness is accompanied by other symptoms such as weakness of an arm or leg, double vision, slurred speech, clumsiness of just one arm or leg, facial numbness or facial weakness, prompt medical attention is warranted.

Benign Paroxysmal Positional Vertigo

Benign Paroxysmal Positional Vertigo (BPPV) is a disorder in which changing your head position with respect to gravity leads to sudden vertigo—a feeling that the room is spinning around. The vertigo can vary in its intensity from mild to severe, usually lasts for less than one minute, and may be accompanied by other symptoms including dizziness, lightheadedness, a sense of imbalance, nausea, and vomiting.

BPPV is not a sign of a serious problem, and it usually disappears on its own within six weeks after its initial onset. However, the symptoms of BPPV can be very disturbing and may be dangerous, especially in older individuals, because the unsteadiness associated with BPPV can lead to falls. About half of all people over age 65 experience an episode of BPPV at some time, and falls in older individuals are a leading cause of fractures.

What causes BPPV?

Benign paroxysmal positional vertigo develops when calcium carbonate crystals, which are known as otoconia, shift into and become trapped within the semicircular canals (one of the vestibular organs of the inner ear). The otoconia make up part of the structure of the utricle, a vestibular organ adjacent to the semicircular canals. In the utricle, the otoconia may be loosened as a result of injury, infection, or age, and they land in a sac (the utriculus), where they are naturally dissolved. However, otoconia in the semicircular canals will not dissolve. As a person’s head position changes with respect to gravity, the otoconia begin to roll around and push on the tiny hairs which line the semicircular canals. Those hairs act as sensors to give the brain information about balance. Vertigo develops when the hairs are stimulated by the rolling otoconia.

Movements that can trigger an episode of BPPV include rolling over or sitting up in bed, bending the head forward to look down, or tipping the head backward. In most people, only a single ear is affected by BPPV, although both ears may be involved on occasion.

Vertigo Diagnosis and Vertigo Treatment

With advances in medical technology, BPPV can be easily diagnosed and treated. The diagnosis can usually be made in the office based on history and physical examination. Treatment of benign paroxysmal positional vertigo involves a short, simple, in-office procedure known as the particle repositioning maneuver.

The particle repositioning procedure takes about 15 minutes to complete and involves a series of physical maneuvers that change the position of the head and body in order to shift the otoconia out of the semicircular canals and back into their proper location in the utriculus. The maneuvers are done while the patient is on a vertigo treatment table. They are very easy to perform, although patients should wear comfortable clothing that will allow them to move freely. Without treatment, the symptoms of BPPV may increase and then diminish over time until they resolve on their own, usually within six weeks. While the occurrence and severity of BPPV may be lessened during that time by paying careful attention to head position and with use of some medications, such as anti-motion sickness drugs to control nausea, it is usually best to attempt the particle repositioning procedure, which is a very safe and rapid way to relieve symptoms and to minimize the chance for falls. Medications should not be used long term.

What if the vertigo procedure doesn’t work?

The particle repositioning procedure is effective as a vertigo treatment about 80 to 90 percent of BPPV cases. Additional exercise or repositioning maneuvers may be needed if symptoms persist.

Can BPPV recur? What should I do?

A new episode of BPPV can develop after successful treatment—on average there is a 15 percent per year rate of recurrence. However, it may be possible to treat the recurrent BPPV at home by performing a series of movements at the time a episode occurs and by following those movements with the post-procedure instructions used after the original treatment. BPPV patients will receive information on ways to handle recurrences on their own, or they can work with a physical therapist or primary care physician to develop a plan.

In general, if you wake up with positional vertigo, slowly move into the good-ear-down position and wait for a minute. Next, slowly move into a facedown position and slide to the foot of the bed. Keep your head down until you reach the end of the bed and are kneeling or standing on the floor. Slowly bring your head backward into and upright position. Hold on to the bed at all times. Follow the post-particle repositioning maneuver instructions you have been given previously.

An alternate method is to sit toward the foot of the bed, leaving enough room to lie back with your head resting comfortably at the end of the bed and slightly extended. Be careful not to overextend your neck, as this may aggravate existing neck problems. If your symptoms are severe, you may need assistance to complete the following maneuver:

  • Step 1: Turn your head toward your affected ear and lie back quickly. HOLD 1-2 min.
  • Step 2: Keeping your head back against the bed, turn it toward the good ear. HOLD
  • Step 3: Roll onto your side with your good ear down. Your nose should be turned toward the floor. HOLD
  • Step 4: Sit up quickly, swinging your feet from the bed to the floor at the side of the bed so your feet touch the floor, keeping your chin tucked in toward your shoulder. You should be sitting on the side of your bed so your feet touch the floor, with your chin still tucked in. HOLD
  • Step 5: Bring your head slowly upright.

If this maneuver does not help, it may be repeated one time.

Feeling Dizzy?

Dizziness is a symptom, not a disease. It is a warning signal sent by the body to tell us that something is not functioning properly. Dizziness is defined as a disorientation in space, a sense of unsteadiness, a feeling of movement within the head such as giddiness or a swimming sensation, lightheadedness or a whirling sensation known as vertigo.

For the body to feel balanced, the brain requires input from the inner ear, eyes, muscles and joints. Since mechanisms for maintaining balance are so complex, finding the exact cause of dizziness is often difficult and requires input from several medical specialties. Dizziness can result from problems associated with the inner ear, brain or heart.

Dizziness accounts for 10 million visits to U.S. office-based physicians annually and is the third most common reason for seeing a primary care physician. Dizziness is generally not serious, however, it can be the only sign preceding a major stroke. Inner ear disorders account for the majority of balance problems.

Disorders of the Inner Ear

Meniere’s Disease
  • This is a problem associated with the fluid balance regulating system in the ear and usually only occurs in one ear.
  • The symptoms are tinnitus (ringing in the ear), muffled or distorted hearing, hearing loss and severe attacks of vertigo accompanied by nausea and vomiting.
  • Attacks are usually sudden in onset and last from 20 minutes to 24 hours.
  • Medical vertigo treatment includes a low-salt diet, a diuretic (water pill) and possible injections of medications into the ear drum or oral medications to combat the nausea.
  • Surgery is recommended only if medical treatment is not successful.
Benign Positional Vertigo
  • Benign positional vertigo results from damage to the delicate sensory units of the balance portion of the inner ear.
  • Symptoms of BPV include a spinning sensation or lightheadedness brought on by changes in head and body position. Nausea may also occur, but hearing loss or tinnitus is not associated with this condition.
  • Medication usually is prescribed to relieve symptoms of dizziness and nausea.
  • People with BPV achieve total recovery by applying certain balance maneuvers in the office, or by practicing home-based vestibular rehabilitation.
Vestibular Neuritis (Labyrinthitis)
  • This condition is caused by the inflammation of the nerve cells in the balance portion of the inner ear.
  • The primary symptom is sudden onset of sustained vertigo, which lasts from one to seven days. In most cases, this condition is associated with a viral respiratory infection like the flu or pneumonia.
  • Treatment includes medication (orally and sometimes through the ear drum) to relieve symptoms of dizziness and nausea. Surgery is rarely indicated. Significant recovery is achieved after six to eight weeks of home-based balance rehabilitation.
Acoustic Neuroma
  • This is a benign tumor that most commonly grows on the balance nerve.
  • Tinnitus is usually the first symptom, after which gradual hearing loss may be experienced. Vertigo is usually not present.
  • Acoustic neuroma surgery, which involves removal of the tumor, is the recommended treatment.
Autoimmune Inner Ear Disease
  • Similar to Meniere’s Disease, this disorder presents with sudden hearing loss in one or both ears.
  • This disorder is more common in people with other autoimmune diseases like lupus or arthritis.
  • Medical treatment includes tapered steroid therapy over one to two months and is most effective with early diagnosis if the patient is treated within the first few weeks of diagnosis.
Perilymph Fistula
  • This disorder may occur after a sudden change in barometric pressure, such as that experienced in airplane landings, scuba diving or a major head injury. The change in pressure can cause a rupture in one of the membranes that separate the middle and inner ear, thus allowing inner ear fluid to escape into the middle ear.
  • Symptoms include hearing loss, vertigo or lightheadedness, and ear pressure. Tinnitus also may occur.
  • In most cases, the rupture will heal on its own. If it does not heal, surgery may be required.

Dizziness Due to Aging

  • As a person grows older, changes occur that affect hearing as well as the system that maintains balance. Forty percent of patients over 60 years old have experienced dizziness severe enough to affect their daily activities.
  • The most common symptoms associated with dizziness due to aging include lightheadedness, a spinning sensation, giddiness, wooziness or unsteadiness that occurs when quickly turning or changing positions. One may also sway or veer from side to side when walking.
  • Here are a few suggestions that may minimize age-related dizziness:
    1. When getting up in the morning, sit on the edge of the bed for several minutes before standing.
    2. Change positions or turn slowly and have something nearby to hold onto.
    3. Never walk in the dark. Use a night light or turn on the light before entering a dark room.
    4. Use a cane or walker for more severe walking problems. Walking and exercising help to maintain good balance.
    5. Keep other medical conditions under control by taking prescribed medications and/or following any prescribed diet.
    6. If recommended, take advantage of a home-based balance rehabilitation program.

If you are feeling dizzy

If you are feeling dizzy, it is important to see your physician for a thorough evaluation. Included in this evaluation should be:

  • A complete medical history
  • An audiogram (basic hearing test) and other specialized speech and hearing tests.
  • An electronystagmogram or ENG (balance test)
  • Two additional and specialized balance tests, rotating chair and posturography.

Depending on what these tests reveal, your physician may recommend a CAT scan (x-ray) or MRI (magnetic resonance imaging). Blood tests to evaluate thyroid function and the immune system also may be recommended, as well as physical therapy evaluation and rehabilitation.

This information is for educational purposes only and should not be relied upon as medical advice. It has not been designed to replace a physician’s independent judgment about the appropriateness or risks of a procedure for a given patient.

Dizziness FAQ

What is dizziness?

Dizziness is one of the most common reasons for a visit to a Primary Care Physician. Dizziness is not a very descriptive term; it is one of the vestibular disorders that encompasses lightheadedness, heavyheadedness, faintness or about to pass out, disorientation, distortion of position in three-dimensional space, turning sensation, spinning sensation, or rocking sensation. To some it may seem that they are moving, to others it may seem the world is moving. Sometimes it is a sensation related to imbalance or a sense of an impending fall. Although vertigo has long been used by doctors as a more specific term to describe an inner ear condition, frequently such a distinction can be misleading.

What causes dizziness?

The most common cause of dizziness is the side effect to a medication. The chemical nature of many medications interferes with the neurotransmission in the brain or may drop the blood flow to the brain to critically low levels (hypotension). However, whenever dizziness is followed by a complete loss of consciousness, serious concerns regarding health of the heart or cardiovascular system need prompt medical attention. As the ears share the same blood supply as the brain, conditions that restrict blood flow to the brain can lead to dizziness.

Whenever dizziness is accompanied by other neurological symptoms such as weakness of an arm or leg, double vision, slurred speech, clumsiness of just one arm or leg, facial numbness or facial weakness, serious concerns regarding stroke need prompt medical attention.

These are important instances when dizziness heralds a life-threatening medical problem, and such concerns should be addressed without delay at a local Emergency Room. More commonly, dizziness is simply a sign of something wrong somewhere in the vastly complex vestibular system. Another common cause of dizziness is anxiety, usually closely coupled with other symptoms of fright or panic.

What is the vestibular system?

A complex system composed of sensors in the inner ear (vestibular labyrinth), upper neck (cervical proprioception), eyes (visual motion and tree dimensional orientation), and body (somatic proprioception) analyzed in several areas of the brain (brainstem, cerebellum, parietal and temporal cortex) affecting eyes (vestibulo-ocular reflexes), neck (vestibulo-collic reflexes), and balance (vestibulo-spinal reflexes) and at the same time keeping us apprised of where were are and how were moving through the world (visuospatial orientation). A system this complex deserves to be called a sense, like our sense of hearing, sight, etc. Its complexity befuddles doctors and patients alike.

What are vestibular tests?

A set of laboratory tests done in hospital or clinic that measure the function of various parts of the system individually. Called electronystagmography (ENG) in the past, today advanced technology allows for more comprehensive testing of vestibular disorders.

Videonystagmography (VNG) is a technique to measure the way eyes move in darkness (without the use of electrodes) using video cameras that see in the dark. Positional testing, including the Dix-Hallpike positioning test, can determine the presence of a common vestibular problem, benign paroxysmal positional vertigo (BPPV).

Caloric testing is a way to compare the response of each ear to warming or cooling stimulation. The damaged ear will respond less vigorously or not at all. Rotational chair (SVAR) testing measures the vestibulo-ocular reflex (VOR), providing information on how the brain is responding to the condition of the vestibular labyrinth, how the brain can suppress stimulation of the vestibular labyrinth, and how well the brain senses visual motion with or without stimulation of the vestibular labyrinth. Computerized dynamic platform posturography (CDPP) testing can assess postural stability.

What is vestibular rehabilitation?

Physical therapy that promotes neurological adaptation required to restore the vestibular sense. A vestibular rehabilitation therapist assesses specific lost abilities and vestibular disorders, then teaches exercises to be done on a daily basis to recover those lost abilities, without the use of medications.

During 6-8 weekly therapy sessions, new exercises are assigned to reach increasingly complex levels of vestibular function. A similar process is used by dancers, skaters, gymnasts, and fighter pilots to maintain a higher level of vestibular fitness necessary for their daily activities. A vestibular rehabilitation therapist is the coach necessary to complete the process in patients with vestibular disorders.


Selected Publications:

Hreib K, White J, Lucey M. Cranial Nerve VIII — "Vestibular." Netter’s Neurology, Ed. H. Royden Jones, Jr., MD, ICON Publishing, Teterboro New Jersey, 2005

White J. — "Meniere’s and otosclerosis." Otoneurologia 2000 18:36-7, 2004.

White J. —"Horizontal semicircular canal benign positional vertigo." Proceedings of the Barany Society XXIII International Congress, J. Vest. Res. 14(2,3):183-4, 2004.

White J. — "Benign paroxysmal positional vertigo." Cleveland Clinic Journal of Medicine, September 2004.

White J, Coale K, Catalano P, Oas J. — "Lateral semicircular canal benign positional vertigo, diagnosis and management." Otolaryngology-Head and Neck Surgery, in press.

White J, Savvides P, Cherian N, Oas J. — "Canalith repositioning for benign paroxysmal positional vertigo, an evidence based review." Otology and Neurotology, in press.

White J, Oas J. — "Diagnosis and management of lateral semicircular canal conversions during particle repositioning therapy." Laryngoscope, in press.

White J, Oas J. — "Meniere’s and migraine." Proceedings of the Fifth International Symposium on Meniere’s, Los Angeles, CA, 2005, in press.

White J. — "Benign paroxysmal positional vertigo," in Practical Management Approaches to the Dizzy Patient, Ed. P. Weber, Thieme Publishing, NY, NY. In press.

White J, Oas J. — "Apogeotropic nystagmus in lateral semicircular canal benign paroxysmal positional vertigo." Neurology (suppl.1) 64(6):A12,2005.

White J, Coale K, Beaudoin K, Catalano P, Cohen N, Oas J. — "Postural control in elderly patients with benign paroxysmal positional vertigo." Submitted to Journal of Vestibular Research.

Vestibular Disorders Overview

The Section of Vestibular Disorders provides a comprehensive multi-specialty approach to the diagnosis and treatment of vestibular disorders and balance problems.

The balance system is complex and depends on the integration of visual, inner ear, and sensory information from the joints and muscles. The central nervous system integrates this input and directs the body to maintain balance in relation to the demands of the environment.

Many vestibular disorders and problems affecting the vestibular and balance system can be diagnosed with a complete history and physical exam with one of our specialized physicians. When coming for an appointment, patients are asked to bring any records of previous evaluations including physician’s notes, audiograms (hearing tests), vestibular testing, and physical therapy findings. The actual films of prior neuroimaging studies of the brain and/or neck are reviewed, as well as reports from those studies. Patients complete questionnaires about the severity of their dizziness and their overall medical history.

Patients with vestibular disorders should wear comfortable clothing, since the examination will likely involve some reclining and moving from side to side. Special glasses equipped with tiny, infrared cameras to record eye movements may be used to help measure the function of the balance system during these movements.

Additional testing may be suggested by the physician if the nature of the problem cannot be determined at the initial visit. Two computerized facilities at Cleveland Clinic allow complete vestibular testing to be done rapidly and include tests that evaluate the ability of the inner ear to respond to rotational and positional cues (the visual component of the balance system) and the ability of the brain to combine visual, inner ear, and muscle and joint information from the neck. Hearing evaluation and neural imaging studies, such as magnetic resonance imaging, can be done, if needed for dizziness or vertigo treatment. Vestibular disorder treatment plans can be formulated for implementation on-site or at home, if patients come from a distance.

Symptoms that bring patients to the vestibular disorders section include vertigo (the illusion of movement), disequilibrium, staggering, and lightheadedness. Fainting or loss of consciousness is not usually related to the vestibular and balance system. Hearing loss may be an associated symptom. Some of the common disorders diagnosed and treated in the section include:

  • Benign positional vertigo or BPV, which can cause brief, intense vertigo reproducible with position change.
  • Meniere’s disease, which is an association of more prolonged episodes of vertigo with fluctuating hearing loss.
  • Labyrinthitis, which is a viral inflammation of the inner ear causing vertigo lasting for weeks with associated hearing loss.

Additional areas of expertise include migraine-associated dizziness and the cardiovascular system’s interaction with the vestibular system. Active research areas include studies and evidence-based reviews of vertigo treatment and new diagnostic options and for vestibular disorders.

The multidisciplinary team includes audiologists, nurses, vestibular testing technicians, and physical therapists trained in specific vestibular disorders and balance therapy techniques. Since the section is located within Cleveland Clinic, rapid access to consultation from many other specialists, such as cardiologists, rehabilitation specialists, and surgical neurotologists, is available, if needed.

Please feel free to contact our office prior to your evaluation if you have questions about what to bring or about medications, or if you are coming from a distance and would like the assistance of our medical concierge service in coordinating the details of your visit.

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