How does our balance system work?

The ear has three main parts: the external or outer ear (the visible part on the outside), the middle ear (the main function of which is to transmit sound from the outer to the inner ear), and the inner ear (the labyrinth). The balance system is a complex system of nerves, small tubes called semicircular canals, and fluid inside the labyrinth. It includes parts of the brain and other components.

The Labyrinth

The labyrinth is located deep inside some of the hardest bones in the skull. It is divided into the cochlea (the organ responsible for hearing) and the vestibular organs (responsible for balance). Because of the close link between the hearing and balance systems, your neurotologist will ask you about your hearing when investigating your dizziness and balance problems.
The vestibular (balance) systems inform your brain about the movements and position of your head. There are three sets of tubes (semicircular canals) in each vestibular system and these detect when you move your head. There are also two structures Called the “otoliths” which inform your brain when your head is moving in a straight line and indicate the position of your head in respect of the pull of gravity. Dizziness or vertigo occurs when the right and left balance systems do not work together in symmetry and your brain thinks your head is moving when it is not. This is why many forms of dizziness are triggered or made worse by moving your head. Vision and other parts of the balance system
Maintaining balance is a complex function and, although the ear is a very important component in the balance system, other factors play a role. To have a good sense of balance we need to be able to see where we are and be aware of the position of certain key parts of our body in relation to other parts of the body and in relation to the world around us. For example, your brain needs to know how your feet and legs are positioned in relation to your chest and shoulders. This information is conveyed to your brain by movement and position detectors located in your muscles, tendons, and joints, particularly in the neck, ankles, legs, and hips.

The Balance System

A crucial aspect of a good balance system is that your brain can control your balance by using the most reliable information it receives for any given moment or situation. For instance, in the dark, when the information conveyed by your eyes is reduced or unreliable, your brain will use more information from your legs and feet and your inner ear. Alternatively, if you are walking in daylight on a sandy beach, the information coming from your legs and feet will be less reliable and your brain will rely more on your vision and vestibular systems. We almost never have to rely solely on the information provided by the balance organs of the ear. Many people retain a good sense of balance despite inner ear problems due to the complementary support provided by the eyes, and movement and position detectors in our joints and muscles. This is why even people who have lost the function of both inner ears do not entirely lose their sense of balance.

What other symptoms might I have?

If your dizziness is caused by inner ear problems you might also experience problems with your hearing. This is because the balance and hearing systems are close together in the inner ear. If you do have hearing problems, they are likely to be either tinnitus (a ringing or buzzing noise in one or both ears) or varying degrees of hearing loss. Some people experience clumsiness or unsteadiness because of physical problems like numbness or weakness in their legs. Other possible symptoms are double vision, numbness in your face, and problems with your speech. These might be signs that there are problems with the nerves in your face or head. These symptoms should be investigated by your doctor. If you have had repetitive ear infections with discharge from your ear, your dizziness could be due to the balance systems in your inner ear being affected by a previous or current infection.

Tests and Investigations

What questions might my doctor ask?

As well as asking you about your symptoms, your doctor will ask you about the circumstances of your dizziness to find out how long it lasts, whether it started spontaneously, whether it appears to be related to the movement or position of your head, whether it came out of the blue, or whether it first started after you had a bad cold or influenza (the ‘flu). You should try to answer your doctor’s questions as accurately as possible. Your GP might treat you with medication before referring you to a specialist.

What tests might I have?

GPs refer people with dizziness and balance problems to many different hospital specialists. You might be referred to see a neurologist (a doctor who specializes in the diagnosis and treatment of people with brain and spine conditions) or an otologist (a doctor who specializes in the diagnosis and treatment of people with problems relating to the ear). The otologist might be an audiovestibular specialist or an ear, nose, and throat specialist (an ENT surgeon).

CT or MRI scan

You might have a scan of your ear or ears or a scan of your brain. It is most likely to be a CT (Computerised Tomography) scan or an MRI(Magnetic Resonance Imaging) scan. The scan is to check for any cysts, abnormal growths, inflammation, or problems with the blood supply to your brain that might be causing your dizziness.

Hearing tests

You might have your hearing tested. This could involve you having a series of different hearing tests. Some of them might involve you saying when you can hear certain tones

Special Balance Tests

The Hallpike test (positional test)

The Hallpike or positional test is the key test that most people with dizziness and balance problems will have. It is a clinical test carried out by the specialist during your examination. The Hallpike test will establish whether your dizziness is triggered or made worse by particular movements of your head. Sitting on a couch or bed, you will be asked to lie down very quickly with your head turned to one side, then the other The maneuver can bring on certain forms of dizziness but they will be temporary and should not last more than a minute. The procedure will not make your dizziness problem worse. It is crucial that you keep your eyes open during the test because the doctor will establish from your eye movements during and immediately after the test what form of dizziness you have. Certain conditions like benign paroxysmal positional vertigo can only be diagnosed by performing the Hallpike test and effective treatment can only be prescribed after an accurate diagnosis.

Videonystagmography (VNG)

Videonystagmography (VNG) is one of the more common balance tests and records your eye movements. It can be carried out using video goggles. A VNG test is performed because the balance systems in the inner ear control the movement of our eyes very precisely and a problem with the balance centers in the ear or brain can cause abnormalities in our eye movement.

Caloric test

The caloric test involves you having a small amount of cool or warm water trickled into your ears to modify the temperature of the balance organs in your inner ear. A small amount of pressurized air might be used instead of water. This test temporarily creates a small difference between the balance systems in the left and right sides of your head respectively. It can make you feel dizzy for a few minutes but will help diagnose problems with the balance mechanism in the ear.

What conditions and diseases can cause dizziness?

Many different conditions can cause dizziness or sensations of being off-balance, for example, certain heart conditions, or blood disorders like anemia. However, if you have been referred to a neurologist or an otologist, general conditions like these will usually have already been ruled out. Dizziness is also the unwanted side effect of many different medications. You should discuss any concerns you have about medication with your GP or pharmacist. Being stressed, anxious, tense or irritable can also provoke dizziness or a sense of imbalance. This can lead to a vicious circle effect as feeling dizzy in itself can lead to feeling stressed, anxious or depressed. Traveling by road, rail, air or sea can cause motion or travel sickness. The common symptoms are dizziness, nausea (feeling sick) and vomiting (being sick).

Vestibular Neuritis (labyrinthitis)

Vestibular neuritis is a viral infection of the inner ear (it is sometimes called labyrinthitis or viral labyrinthitis). People with vestibular neuritis usually experience a sudden onset of dizziness with a spinning sensation (vertigo), accompanied by nausea (feeling sick) and general unsteadiness. These symptoms often develop a few days or weeks after a bad cold or influenza (the ‘flu). People with vestibular neuritis often prefer to stay in bed because any movement makes their dizziness worse. The symptoms might last for just a few days but, in some cases, can persist for two or three weeks. Some people remain a little unsteady afterward but most make a full recovery. Only a minority of people with vestibular neuritis will experience persistent, troublesome dizziness or suffer recurrences of the condition. Recurrences might be spontaneous or associated with further colds or bouts of influenza. Vestibular neuritis does not cause hearing problems. The initial dizziness caused by vestibular neuritis can be intense and very distressing.

Benign paroxysmal positional vertigo (BPPV)

People with benign paroxysmal positional vertigo (BPPV) experience intense bouts of dizziness with a revolving or spinning sensation. The dizziness is very short-lived, usually only lasting a minute or less, and is brought on by particular head movements. For example, movements like turning over in bed, or looking up to place a book on a shelf. Most people with this form of dizziness know exactly what sort of movements trigger their symptoms and can try to avoid them. Specialists have established that the cause of BPPV is the build-up of certain particles, or crystals, within one of the tubes in the balance system called the posterior semicircular canal BPPV can only be diagnosed by the Hallpike or positional test Due to the intricate connections between the balance system of the inner ear and the eye muscles, at its worst, BPPV causes a specific nystagmus (jerking movements of the eye)unique to the condition. Recent developments in treatments have focussed on clearing out the particles trapped in the posterior semicircular canal. These treatments include the Canalith repositioning procedures or particle repositioning procedures. These effective, non-invasive treatments can be performed in your doctor’s room and do not require the use of any specialized instruments. They are usually performed by a specialist rather than your GP who might not be familiar with them.

Migrainous vertigo

People diagnosed with migrainous vertigo (or migraine-associated vertigo) experience vertigo as a symptom of a migraine. Vertigo might be the main or only symptom of their migraine. The most common symptoms of a migraine are an intense headache, nausea (feeling sick) and vomiting (being sick). People might also have visual problems, speech problems, stiffness in their neck, and an increased sensitivity to light. Avoiding trigger factors can be an effective way of preventing migraines. These include stress, tiredness, and loss of sleep, certain food and drink (for example, chocolate, cheese or alcohol), and smoking or smoky environments.

Ménière’s Disease

People with Ménière’s disease experience repeated attacks of intense dizziness with a spinning sensation. Each attack can last from two to 24 hours and often involves the affected person vomiting (being sick). People with Ménière’s disease usually experience noticeable changes in their hearing either before or during their vertigo attacks, including tinnitus and a loss of hearing. Commonly, they also feel a tenderness or pressure in one of their ears immediately before or during the attacks. In the initial stages of the condition, people might maintain good balance and not experience any dizziness between attacks, but they are likely to experience varying degrees of hearing loss. This hearing loss usually fluctuates at first and improves after each dizziness attack. However, there is a tendency for hearing loss to get worse over time and it can become permanent. Usually, there is no warning sign that a dizziness attack is going to happen. People are often anxious about having an attack in public places because they are concerned that on-lookers will think they are drunk. The symptoms of an attack (being sick and losing balance) can be mistaken for drunkenness. Specialists have not established the specific cause of Ménière’s disease but each attack results from a build-up of pressure in the inner ear (a condition called endolymphatic hydrops). The main treatment for Ménière’s disease is a strict low-salt diet and diuretic medication (“water tablets”) the combination of which helps to get rid of excess salt and fluid in the body and reduces the risk of a build-up of salt, fluid, and pressure in the ear. This treatment can help reduce the frequency and intensity of each vertigo attack but, unfortunately, will not necessarily slow down the progression of the deafness.

Vascular Vertigo

The term vascular is used to describe conditions related to the blood vessels and caused by a reduced supply of blood reaching a particular part of the body. In the case of dizziness, the areas receiving a reduced blood supply are the labyrinth (inner ear) and the lowermost part of the brain containing the balance centers. The labyrinth’s and the brain’s balance centers are supplied by the same blood vessels, so vascular dizziness can be caused by a combination of peripheral (inner ear) or central (brain) dysfunction. The symptoms can include hearing loss, visual problems (double vision, blurred vision or problems with peripheral vision), and numbness in the face or limbs. People with vascular vertigo usually have other symptoms besides dizziness. Dizziness on its own rarely has a vascular cause. Vascular causes are more likely in older people. Their symptoms are usually an indication of general vascular disease and relate to risk factors like high blood pressure, smoking, high cholesterol, diabetes, or a family history of vascular disease (high blood pressure, heart attacks, and strokes). For these people, treatment is aimed at reducing the vascular risks and most doctors will prescribe a small dose of aspirin a day to thin the blood as long as there are no reasons for someone to avoid taking it (for example, other medication, indigestion or other stomach problems).

Post-traumatic vertigo

People diagnosed with post-traumatic vertigo have dizziness after trauma (injury) to the head. Dizziness can occur after only minor head injuries. The actual cause of the dizziness can be a combination of the inner ear or brain disorders. Of course, after an accident involving a head injury, people might also have injuries to other parts of their body (for example, broken limbs). And, as a result of their head injury, they might have health concerns more seriously than dizziness problems. Dizziness and balance problems might not become apparent until the person is well enough to be up and about again. This might be some time after their accident.

Visual vertigo

Some people find that certain visual surroundings can trigger dizziness, or make existing dizziness and balance problems worse. For example, some people feel disorientated and dizzy in supermarkets when they are surrounded by tall stacked shelves, or in crowded train stations when they are surrounded by people. Others find that the sight of fast-moving or spinning objects can cause dizziness or make their dizziness worse. People might experience dizziness in a car when they see fast-moving scenery out of the window, or when they see fast-paced action on a TV or cinema screen. People might also experience dizziness when they are adjusting to new prescription glasses Visual vertigo can also occur if people are experiencing problems like reduced or blurred vision. You should speak with your GP, optician or specialist if you experience problems with your vision.

Peripheral Vestibular Disorders

In many cases, doctors are not able to diagnose an underlying condition or disease, they are only able to diagnose that the cause someone’s dizziness is related to the inner ear rather than the brain (a peripheral vestibular disorder). Strictly speaking, vestibular neuritis, BPPV and Ménière’s disease are all peripheral vestibular diseases, but some people experience dizziness caused by a condition that cannot be categorized into any of these well-defined groups. For some people, abnormalities might show up in the specialized balance tests but, for others, even these special tests might not show anything. People might experience ever-present minor symptoms, or recurrent episodes of vertigo triggered by certain factors like head movements, tiredness, stress, menstrual periods, or viral infections. You should not worry if your doctor is unable to diagnose a specific cause of your dizziness and balance problems. The majority of people in this situation experience improvements and recoveries over the long-term. Recovery can be helped by rehabilitation procedures

Central Neurological Disorders

A minority of people with dizziness and balance problems have a neurological condition. The part of the brain that organizes balance is the lowermost part and includes the brain stem and the cerebellum. This part of the brain is also responsible for movement, posture, and speech, so these might also be affected. It is unlikely that dizziness will be the only symptom you experience if you have a neurological condition. Strokes, demyelinating diseases of the nervous system (for example, multiple sclerosis), inflammation, or tumors can cause dizziness and balance problems. Other less common causes are bony deformities at the back of the head and the top of the spine. These neurological causes can be identified by brain scans and a neurological examination. Your specialist will advise you.

Many causes of dizziness, like vestibular neuritis, BPPV, post-traumatic and non-specific peripheral vestibular disorders, tend to recover on their own. However, if you have been referred to a specialist it is likely that your dizziness is not clearing up of its own accord and you will need some form of treatment. There are various possible treatments for dizziness and balance problems. Your specialist will assess which treatment might be suitable for you.

Vestibular rehabilitation

The key treatment for almost all of the conditions that can cause dizziness is vestibular rehabilitation. The aim of vestibular rehabilitation is to help the development of vestibular compensation. The key way to assist the development of vestibular compensation is by doing vestibular rehabilitation exercises. These exercises involve movements of the eyes, the head, the upper body, and then the whole body under different visual situations (for example, with the eyes open or closed, or looking at steady objects or a moving ball), on different surfaces and in a different environment A key factor is that the brain must sense the presence of dizziness or imbalance to begin the process of vestibular compensation. If, for example, you are regularly taking anti-vertigo drugs or lying still in bed, you might not experience dizziness. When the brain does not sense any dizziness or imbalance it does not realize something is wrong and consequently will not begin the process of vestibular compensation. For this reason, it might be the specialist overseeing your rehabilitation asks you to reduce and eventually stop taking your anti-vertigo medication. As you progress in your rehabilitation programme to the more difficult vestibular exercises, you might experience dizziness when you perform them. This should not be seen as a setback or a reason to stop. It just means that an imbalance between your left and right vestibular systems still exists and the exercises you are doing will help your brain detect the imbalance so it can gradually begin to put it right. However, you should not go to the extreme of trying to induce dizziness by moving or exercising to the extent that you are sick or become exhausted.

Please note that you should not attempt any of these exercises without first seeing a specialist for a comprehensive assessment, advice, and guidance…

Cawthorne-Cooksey exercises

The aims of the Cawthorne-Cooksey exercises include relaxing the neck and shoulder muscles, training the eyes to move independently of the head, practising good balance in everyday situations, practicing the head movements that cause dizziness), improving general coordination, and encouraging natural spontaneous movement You should be assessed for an individual exercise programme to ensure you are doing the appropriate exercises. You could ask if it is possible for a friend or relative to accompany you at the assessment. It can be helpful if someone else learns the exercises and helps you with them. You will be given guidance on how many repetitions of each exercise to do and when to progress to the next set of exercises. As a general rule, you should build up gradually from one set of exercises to the next. You might find that your dizziness problems get worse for a few days after you start the exercises, but you should persevere with them. Make sure that you are in a safe environment before you start any of the exercises to reduce the risk of injury.

Gaze stabilization exercises

The aim of gaze stabilization exercises is to improve vision and the ability to focus on a stationary object while the head is moving.

Canalith repositioning procedures (CRP)

Canalith repositioning procedures (CRP) are the key treatment for benign paroxysmal positional vertigo (BPPV). Although most people with BPPV will recover within a few weeks or months, CRP can bring about a rapid recovery after just one or two sessions. CRP involves a series of head and upper body movements performed by a trained specialist who watches your eye movements with each change of position. The aim is to clear out particles trapped in the posterior semicircular canal in your inner ear. The two main CRP treatments are the Epley maneuver and the Semont (Semont-Liberatory) maneuver. Your specialist will assess you and advise which treatment is best for you. It is important that Ithese maneuvers are only performed by a specialist who can prevent the risk of neck and back injuries. People with recurrences of BPPV can have repeated CRP treatment or might be shown exercises to perform at home. For some people, it might be that stress and anxiety themselves lead to dizziness and balance problems. Some people feel anxious in stressful situations like crowded public places, or in enclosed or confined spaces. This anxiety can lead to panic attacks. Some people might experience hyperventilation (quickened and excessive breathing) during a panic attack. Hyperventilation can cause light-headedness and dizziness in people who might not otherwise experience it. For some people, feeling tense or stressed is enough to make them feel dizzy even if they do not experience panic attacks and hyperventilation. Surgery

Only a very small minority of people with dizziness and balance problems will need surgery to improve their symptoms. Surgery will only be considered as an option for people who have not had noticeable improvements in their dizziness after long-term drug and rehabilitation treatments. People with dizziness associated with ear discharge, long-standing middle ear infections, or eardrum perforations are the group most likely to be considered for surgery.

Keep active

You should not try to prevent episodes of dizziness by becoming inactive and avoiding doing the things that might cause them. It might be tempting to avoid moving around as normal to prevent feeling dizzy but this can lead to you not engaging in your usual everyday activities. You might even start avoiding being out and about to the extent that you withdraw from your usual social activities. Unfortunately, this inactivity means that your brain is not exposed to the mismatching signals coming from the two balance systems in your inner ears and prevents the process of vestibular compensation. Without the vestibular compensation process, your dizziness will not go away. In turn, this can lead to depression, anxiety, increased inactivity, and more dizziness problems. Try to participate fully and actively in your rehabilitation programme and have faith in the recovery process. You should do your vestibular rehabilitation exercises regularly and take part in physical activities and sports. Ball games requiring eye-head-body co-ordination are ideal. Initially, just going for walks might be enough physical exercise to help the process of vestibular compensation. (Cycling and swimming are probably less effective in helping vestibular compensation but are worth trying if they are your preferred form of exercise.

Don’t suffer in silence

Try not to keep how you are feeling to yourself. Don’t suffer in silence. Talk to your friends and family. Sharing your concerns and talking things through with them can be really helpful. Dizziness and balance problems are more common than people often think. You could well find that your friends and family have experienced dizziness themselves, or know someone who has. Most of them will have experienced a good recovery and talking to them can help you stay positive about your situation.

Keep a diary

Keeping a diary of your dizziness and balance problems can be a useful way to record when and where you experience dizziness and to track any changes in your condition. Take the diary to your medical appointments. The more information you are able to give your specialist, the better able they are to help you.