Dizziness, Vertigo and Balance Disorders

by Michael Gordon, M.D., F.A.C.S.

What is "dizziness"? Dizziness is a term often used by patients to relate a disturbance in their equilibrium. The term is very general and can include a wide array of symptoms such as fatigue, visual disturbance, lightheadedness, confusion, vertigo, and many others. It is often difficult for the patient to adequately describe the symptoms. One of the goals of the physician specializing in dizziness is to gain an understanding as to what type of “dizziness” the patient has been experiencing.

What is "vertigo"? Vertigo is a symptom, not a diagnosis. Vertigo is defined as the hallucination of motion. These motions can be "objective" — the patient perceives movement of the environment, or "subjective" — the patient perceives an internal sense of motion. Objective vertigo is nearly always related to problems of the inner ear or the ear's complex connections to the central nervous system. Subjective vertigo can be ear-related as well but can also have numerous other causes.

What are some of the common diagnoses that can cause vertigo?

Meniere's disease: This disease is an inner ear disorder related to abnormal inner ear fluid pressure. The symptoms can include: episodes of vertigo, fluctuating hearing loss, and tinnitus (ear noises).

Benign Paroxysmal Positional Vertigo ("BPPV"): Occasionally, particles form or settle in one of the semicircular canals of the inner ear. The particles tend to sink to the lowest point of the canal. Certain positional changes, such as rolling to one’s side in bed, can result in reorientation of the canal in space, causing the particles to sink to the new "bottom." This typically results in a sensation of "room spinning" that lasts for less than one minute.

Labyrinthitis: Inflammation in the inner ear can result from bacterial middle ear infections or, more commonly, from viral infections. Labyrinthitis can cause rapid progression of vertigo and possibly hearing loss. The term “labyrinthitis” is also occasionally used in a generic way — to indicate that a patient’s symptoms appear to be on the basis of an unspecified inner ear disorder.

Vestibular Neuronitis: Viral infection of the vestibular (balance) nerve can result in vertigo lasting for several days, followed by more prolonged imbalance.

Other: There are many less common causes of vertigo, some ear-related and some neurologic.

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What can be done about my vertigo?

  1. Diagnosis The first step to solving the problem of vertigo is obtaining the correct diagnosis. This is often a complicated process. The history and physical examination remain the most important elements of the evaluation. Additionally, nearly all patients should undergo hearing testing to help evaluate inner ear function. Some patients may also require other audiological testing such as brainstem auditory evoked response testing (BAER), optoacoustic emissions (OAEs), electrocochleography (ECoG) and electro- or videonystagmography (ENG or VNG). Occasionally, radiological studies such as CT or MRI may be requested as well. Not every patient requires every test. The specialist analyzes the information gathered from the history and physical examination as well as the various diagnostic studies in order to determine the diagnosis.
  2. Treatment The treatment options vary greatly with the specific diagnosis. Some available treatments include: dietary changes, oral medications, instillation of medication into the middle ear, positional maneuvers, vestibular rehabilitation (specialized physical therapy), and surgery.

Balance Disorders

Balance problems are extremely common, particularly in senior citizens. Falls are among the leading causes of fatal and non-fatal injuries in the elderly. Our balance depends mostly on the function of 3 systems:

  1. Vision: Our eyes give us important information in reference to our orientation, position, and movement relative to our environment.
  2. Proprioception (position sense): Provides information regarding our orientation relative to gravity. When a person leans, he should be able to feel the shift in pressure of his feet against the floor. Similarly, there should be some detection of leaning in the muscles of the trunk.
  3. Vestibular: The inner ear balance system is responsible for maintaining balance and equilibrium, particularly during motion. In general, if there is weakness in one of these systems, the remaining 2 systems should allow the individual to compensate and to maintain balance under most conditions. If the weakness in one system is overwhelming, or if there is weakness in more than one system, imbalance may result. There are numerous other health, fitness and environmental factors that can that can contribute to balance disorders. The primary goals of the balance evaluation are to determine which of these systems is contributing to the imbalance and to determine if there is an underlying disorder that requires treatment. In nearly all cases, measures can be taken to help improve balance and to reduce the risks of falls and injury.
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