There are many causes of dizziness. The term "dizziness"
should be substituted for more descriptive words to describe
your symptoms. Words such as vertigo, which indicates a sensation
of movement or spinning, as well as lightheadedness or faintness
are more helpful to your doctor when trying to diagnose the
specific cause of your "dizziness".
There are many causes of dizziness and a few of the structures
that may be involved are the eyes, the inner ear, the brain
and/or the neck. Disorders of the neck will generally give
you ”odd“ feelings but rarely true vertigo.
The vestibular apparatus is the name of the structure in
your inner ear responsible for balance and thus physiotherapy
designed to restore balance and a sense of stability is termed
Vestibular Rehabilitation Therapy (VRT). We have included
specific information about many vestibular and non-vestibular
causes of dizzines for you to read. Most of this information was extracted
from the Vestibular Disorders website.
Benign Paroxysmal Positional Vertigo Videos
The majority of people presenting with symptoms of vertigo,
a sensation of movement or spinning, will be diagnosed as
having Benign Paroxysmal Positional Vertigo or BPPV.
This is further classified clinically to indicate the canal
of involvement and whether or not the displaced stones are
free floating or stuck on another structure.
We have included short film clips that show
the doctor performing the diagnostic and repositioning maneuvres
as well as the patient undergoing the maneuvres wearing special
goggles. These goggles record the characteristic, automatic
eye movements that occur when structures in the inner ear
are stimulated. Most importantly, there is an animated illustration
included that depicts what is happening inside the inner ear
canals so that you can see exactly what the repositioning
maneuvres are attempting to accomplish.
The film clips were produced by
Bernard Cohen ENT department, hôpital Saint-Antoine, Paris.
BPPV was first described at the beginning of the twentieth century by Barany. It was not until 1952 that Dix and Hallpike described the diagnostic manoeuvre.
These videos are encoded to run with an embeded Adobe Flash
player. If you are experiencing difficulties watching the
installing the latest version.
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Posterior Canal BPPV
Lateral Canal BPPV
Anterior Canal BPPV
Vestibular Rehabilitation Therapy
Why is therapy needed?
If the brain cannot rely on the information it receives from
the vestibular system, a person's ability to maintain posture
and coordinate balance can become overly dependent on vision
or on the information received from the muscles and joints
This can lead to developing new patterns of movement to compensate
for the change and to avoid head movements that are apt to
create symptoms of dizziness and nausea. For example, a person
might adopt an exaggerated hip sway as a method of balancing,
might swivel the entire body rather than just the head in
turning to look at something, or might always look down at
the floor to avoid what appears as a confusing swirl of activity.
Unfortunately, these types of adaptation can result in headache,
neckache, muscle stiffness, general fatigue, and a decrease
in the ability to retrain the brain to adjust to the vestibular
problem, hence making the symptoms much worse.
The goal of VRT is to retrain the brain to recognize and process
signals from the vestibular system in coordination with information
from vision and proprioception. This often involves desensitizing
the balance system to movements that provoke symptoms.
What happens during vestibular therapy?
A qualified therapist will first perform a thorough evaluation.
This includes observing posture, balance, movement, and compensatory
strategies. Using the result of this evaluation, the therapist
will develop an individualized treatment plan that will include
exercises to be performed both in the therapy department and
at home and that combine specific head and body movements
with eye exercises. Many times, treatment may also include
increasing activities and exercise in order to strengthen
muscles and increase tolerance for certain stimuli.
Some of the exercise and activities may at first cause an
increase in symptoms, as the body and brain attempt to sort
out the new pattern of movements. But with time and consistent
work, the coordination signals from the eyes, proprioception,
and vestibular system will occur.
How does therapy help?
In most cases, balance improves if the exercises are correctly
and faithfully performed. Muscle tension, headaches, and fatigue
will diminish, and symptoms of dizziness, vertigo, and nausea
will decrease or disappear. Many times, vestibular VRT is
so successful that no other treatment is required.
Occassionally surgery will be required to correct an inner
ear problem. Often, therapists provide further therapy after
a person has recovered from the surgery.
Why do I feel dizzy?
To understand why we feel dizzy, we first need to describe how the body senses movement. There are three systems or inputs that feed information to the brain regarding your head position in space:
- The first is visual input. Our eyes observe our surroundings and tell the brain if we are moving or stationary.
- The second is input from the body sensors that exist in joints, ligaments and muscles. These sensors allow us to feel where our feet are in space. Closing your eyes and trying to maintain your balance on one leg clearly demonstrates this.
- The final input to the brain, consisting of acceleration/deceleration data, is from a very small structure in the inner ear known as the vestibular apparatus.
The brain takes all the information from these three inputs and compares them against one another for consistency. If they are all telling the brain the same thing about our movement then we feel “normal” and not “dizzy”.
One condition causing “dizziness” is termed Benign Paroxysmal Positional Vertigo (BPPV) and is described below.
The vestibular apparatus of the inner ear consists of two central organs and three surrounding half circle tubes or canals, which are filled with liquid. There are jelly-like structures in the central organs that have rock-type crystals on top of them, i.e. like pebbles on a jelly mold. Sometimes these crystals/pebbles suddenly fall off the jelly mold and roll into one of the surrounding semi-circular tubes. These crystals will then roll around inside these half circle tubes moving the fluid and sending the brain incorrect information about how we’re moving in space. People may even experience a feeling of their eyes moving involuntarily due to the connection between the inner ear and the eyeball muscles. This connection can be stimulated by the out-of-place crystals in the semi-circular tubes, which, in turn, stimulates the eyeball muscles causing the eyes to move. This movement is termed nystagmus.
The goal of therapy for BPPV is to put the out-of-place crystals back where they belong by a series of careful head maneuvers. The maneuvers that are performed are determined by which semi-circular canal has been affected. We can tell which canal is affected by looking at the automatic eye movements that are seen while you wear special infrared goggles. The success of the movements can be instantaneous. To determine if you are a candidate for this type of therapy call us.
Causes of Dizziness, Vertigo, and Imbalance
A large percentage of the adult population reports episodes
of dizziness or vertigo to a physician during their lifetime.
Many of these cases involve vestibular (inner ear) disorders.
Other cases of dizziness are due to problems unrelated to
the inner ear, such as cardiovascular, neurological, or psychological
- Dizziness caused by vestibular disorders
- Dizziness from non-vestibular causes
Dizziness Caused by Vestibular Disorders
The vestibular organs of the inner ear provide the brain
with information about changes in head movement. If the vestibular
system is not functioning properly, dizziness, vertigo, imbalance,
spatial disorientation, and other symptoms can result.
Vestibular-system distress can be caused by a variety of
influences, including viral infections of the labyrinth (labyrinthitis)
or the vestibular nerve (vestibular neuritis). Bacterial infection
of either the middle ear (otitis media) or the brain coverings
(meningitis) may spread to the inner ear. Allergies can cause
changes in the inner ear fluids or middle ear pressure because
of swelling of the Eustachian tube and production of fluid
in the middle ear.
Head trauma is a common cause of inner ear damage in people
under age 50. A blow to the head or a "whiplash" injury can
result in, for example, perilymph fistula or benign paroxysmal
positional vertigo (BPPV). Vestibular-system dysfunction may
appear immediately following head trauma or after a delay
of days, weeks, or months.
Vestibular disorders can also occur from exposure to ototoxins
(drugs or chemicals that are harmful to the inner ear or the
vestibulo-cochlear nerve). Degeneration of the hair cells
in the inner ear is also thought to occur with aging and can
result in dizziness and vertigo as well as hearing loss. A
benign tumor known as an acoustic neuroma can grow on the
vestibulo-cochlear nerve. In many cases of vestibular disorders,
including Meniere's disease and other forms of endolymphatic
hydrops, the underlying or original cause cannot be determined.
Other conditions that may affect vestibular function include
migraine, mal de debarquement (a sensation of rocking that
persists after a cruise or other travel), autoimmune inner
ear disease, cervical (neck) problems, vascular compression
of the vestibular nerve, superior canal dehiscence, cholesteatoma,
enlarged vestibular aqueduct, and others.
Dizziness from Non-Vestibular Causes
Dizziness is the second most common complaint heard in doctors’
offices (after lower back pain). Dizziness has many causes
other than inner ear dysfunction.
Visual disturbances can result in lightheadedness or dizziness.
Some people feel dizzy while adjusting to bifocals or a new
eyeglass prescription, or from reduced vision due to cataracts.
Hyperventilation can cause temporary dizziness. During rapid
breathing, more carbon dioxide than normal is expelled and
the level of carbon dioxide in the blood falls, which in turn
affects the function of brain cells.
Decreased blood flow to the brain or brain stem can cause
dizziness, because insufficient oxygen is reaching the cells.
Conditions that can reduce blood flow to the brain include
orthostatic hypotension (low blood pressure upon suddenly
rising from a lying or sitting position), dehydration, vasovagal
syndrome (a nervous-system response that causes sudden loss
of muscle tone in peripheral blood vessels), arteriosclerosis
(hardening or narrowing of blood vessels), and osteoarthritis
(a joint disease that can narrow the openings in the neck
vertebrae through which blood vessels flow).
Nervous-system disorders such as peripheral neuropathies
(diminished nerve function in the legs or feet) can cause
unsteadiness. A tumor may affect the brain stem, the cerebellum
(the coordination center of the brain), or the part of the
cerebral cortex that controls voluntary muscle movements.
Even stress, tension, or fatigue may cause dizziness. Under
these conditions, the brain stem functions less efficiently,
resulting in some loss of automatic reflex control of balance.
This leads to elevated levels of activity for the cerebral
cortex, as conscious energy is used to help maintain balance
by controlling voluntary muscle movements.Lightheadedness
and unsteadiness can result.
The vestibulo-ocular reflex is a reflex that allows us to
maintain a stable gaze in which our eye is fixated on an object
when we are moving our head. To illustrate we'll get you to
look at the words on this screen and while reading turn your
head to the right all the while maintaining focus on these
words. What just happened? Did your eyes move? If they moved
with your head then you'd now be gazing to the right in the
direction your head turned. In fact your eyes moved in exactly
the opposite direction at exactly the same speed as your head.
So, if your head moved right at 20 degrees/sec then your eyeballs
moved left at 20 degrees/second. This amazing ability of the
eyes to simultaneously perform the opposite movement to that
of the head is driven by the vestibulo-ocular reflex. This
reflex is calibrated in the brain so that the speed of the
head equals speed of the eyes but in opposite directions.
This calibration ratio must be 1 for if it were less or more
the eyes would move more slowly or quickly than the head and
you wouldn't be able to keep the object you'd be looking at
Unfortunately, if an individual is afflicted with vestibular
abnormalities that feed abnormal information to the brain
over long periods of time, this calibration ratio can indeed
change so it is no longer 1. An example of someone whose vestibulo-ocular
reflex may have changed would be someone with Meniere's disease
whose had repeated, prolonged bouts over a long time period.
Symptoms of this type of reflex abnormality would include
feelings of "dizziness" when driving on the highway looking
at fast moving traffic, walking in a mall or generally being
in crowds. Vestibular rehabilitation therapy can address this
altered ratio by instrucing the person in gaze stabilization
exercises called adaptation exercises.
Specific Vestibular Disorders
Benign Paroxysmal Postitional Vertigo (BPPV)
Benign paroxysmal positional vertigo (BPPV) is a disorder that
causes vertigo, dizziness, and other symptoms due to debris
that has collected within a part of the inner ear. This debris,
called otoconia, is made up of small crystals of calcium carbonate
(sometimes referred to colloquially as “ear rocks”). With
head movement, the displaced otoconia shift, sending false signals
to the brain.
Symptoms of BPPV are almost always precipitated by a change
in head position. Getting out of bed and rolling over in bed
are two common "problem" motions. Some people feel dizzy and
unsteady when they tip their heads back to look up. An intermittent
pattern of these symptoms is usual.
About 20% of all dizziness is due to BPPV. The most common
cause of BPPV in people under age 50 is head injury. About 50%
of dizziness in older people is due to BPPV. In half of all
cases, BPPV is idiopathic, which means that it occurs for no
known reason. BPPV is also associated with migraine.
Diagnostic tests for BPPV include tests that look for the characteristic
nystagmus (jumping of the eyes), such as the Dix-Hallpike test
and electronystagmography (ENG).
Particle-repositioning maneuvers, including the Epley maneuvre
and the Semont-liberatory maneuver, are very effective in treating
BPPV and can be performed in the doctor’s office in about 15
minutes. The goal of these maneuvers is to move the detached
otoconia out of one of the semicircular canals. Treatment may
also include individualized vestibular physical therapy exercises
designed to help “retrain the brain.” The Brandt-Daroff
habituation exercises are sometimes recommended and can be done
at home. Canal-plugging surgery may be another option.
Meniere‘s disease is a vestibular disorder that produces a
recurring set of symptoms as a result of abnormally large amounts
of a fluid called endolymph collecting in the inner ear.
The prevalence of Meniere's disease is difficult to assess.
One population study found that 15.3 per 100,000 individuals
develop Meniere's disease annually. Of these, one-third eventually
develop the disease in the second ear as well.
The exact cause of Meniere's disease is not known. Theories
include circulation problems, viral infection, allergies, an
autoimmune reaction, migraine, and the possibility of a genetic
connection. Experts also aren't sure what generates the symptoms
of an acute attack. Some people with Meniere's disease find
that certain triggers can set off attacks, including stress,
overwork, fatigue, emotional distress, additional illnesses,
pressure changes, certain foods, and too much salt in the diet.
Attacks can last from 20 minutes to 24 hours. They can occur
many times per week; or they can be separated by weeks, months,
and even years. The unpredictable nature of this disease makes
it difficult to tell how it will affect a person's future. Symptoms
can disappear one day and never return, or they might become
so severe that they are disabling.
During an attack of early-stage Meniere's disease,
the main symptoms are spontaneous, violent vertigo, fluctuating
hearing loss, ear fullness, and/or tinnitus. Following the attack,
a period of extreme fatigue or exhaustion often occurs, prompting
the need for hours of sleep. The periods between attacks are
symptom-free for some people and symptomatic for others.
Late-stage Meniere’s disease refers to a set of symptoms rather
than a point in time. Hearing loss is more significant and is
less likely to fluctuate. Tinnitus and/or aural fullness may
be stronger and more constant. Attacks of vertigo may be replaced
by more constant struggles with vision and balance, including
difficulty walking in the dark and occasional sudden loss of
balance. Sometimes, drop attacks of vestibular origin (Tumarkin's
otolithic crisis) occur in this stage of Meniere's disease.
In the United States, the most conservative long-term
treatment for Meniere’s disease (aimed at reducing the severity
and number of attacks) involves adhering to a reduced-sodium
diet and using diuretics, or "water pills." The goal of this
treatment is to reduce inner ear fluid pressure. Some physicians,
more commonly outside of the United States, also weigh the potential
efficacy of using betahistine HCl (Serc) as a vestibular suppressant
for Meniere’s disease.
Medications that are used during an attack to reduce the vertigo,
nausea, and vomiting include diazepam (Valium), promethazine
(Phenergan), dimenhydrinate (Dramamine Original Formula), and
meclizine hydrochloride (Antivert, or Dramamine Less Drowsy
Formula). Vestibular rehabilitation therapy is sometimes used
to help with the imbalance that can plague people between attacks.
Its goal is to help retrain the ability of the body and brain
to process balance information.
Another recently introduced, conservative treatment approach
employs a device to deliver a series of low-pressure air pulses
designed to displace inner ear fluids. The use of this device
is approved for general use by the U.S. Food and Drug Administration
(FDA) and is currently undergoing clinical trials in the United
For the 20-40% of people who do not respond to medication or
diet, a physician may recommend a chemical labyrinthectomy,
which destroys vestibular tissue with injections into the ear
of an aminoglycoside antibiotic (gentamicin). Another less conservative
treatment is surgery to relieve the pressure on the inner ear
(although this is not as widely used now as it was in the past)
or to destroy either the inner ear or the vestibular nerve,
so that balance information is not transmitted to the brain.
Secondary Endolymphatic Hydrops
Endolymphatic hydrops may be either primary or secondary. Primary
idiopathic endolymphatic hydrops known as Meniere's disease
occurs for no known reason. Secondary endolymphatic hydrops
appears to occur in response to an event or underlying condition.
For example, it can follow head trauma or ear surgery, and it
can occur with other inner ear disorders, allergies, or systemic
disorders (such as diabetes or autoimmune disorders).
Although the underlying cause of endolymphatic hydrops is unknown,
it is believed to result from abnormalities in the quantity,
composition, and/or pressure of the endolymph, the fluid within
the inner ear. Symptoms typical of endolymphatic hydrops include
pressure or fullness in the ears, tinnitus (ringing or other
noise in the ears), hearing loss, dizziness, and imbalance.
The diagnosis of endolymphatic hydrops is clinicaly based on
the physician’s observations and on the patient's history, symptoms,
and symptom pattern. The clinical diagnosis may be strengthened
by the results of certain tests, including electrocochleography
(ECoG) or audiometry.
Meniere's disease is characterized by sudden, violent attacks
or episodes of vertigo, tinnitus, hearing loss, and aural fullness.
Since secondary endolymphatic hydrops (SEH) results from an
underlying disorder, the symptoms tend to be present more continuously,
rather than occurring in spontaneous attacks. However, they
are often less violent, and SEH may cause less damage to hearing
and balance than does Meniere's disease.
A hydrops diet regimen which emphasizes eating a balanced diet
in moderate amounts at regular intervals, minimizing the use
of salts and sugars, and taking in plenty of fluids-often
makes many people with SEH feel significantly better. A physician
may prescribe diuretics. Other medications may be used to help
with persistent dizziness, nausea, or vomiting.
Vestibular rehabilitation, a type of specialized physical therapy,
can improve tolerance for activity, overall energy level, and
symptoms of dizziness and imbalance. If dizziness and vertigo
become intractable, the hair-cell structures of the inner ear
may be selectively destroyed with the careful use of ototoxic
(ear-poisoning) medication. In rare cases, surgery may be recommended.
Labyrinthitis and Vestibular Neuritis
Labyrinthitis and vestibular neuritis are disorders resulting
from an infection that inflames the inner ear or the vestibulo-cochlear
nerve (the eighth cranial nerve), which connects the inner ear
to the brain. Vertigo, dizziness, and difficulties with balance,
vision, or hearing may result.
Infections of the inner ear are usually viral; less commonly,
the cause is bacterial. Although the symptoms of bacterial and
viral infections may be similar, the treatments are very different,
so proper diagnosis by a physician is essential. Such inner
ear infections are not the same as middle ear infections, which
are the type of bacterial infections common in childhood affecting
the area around the eardrum.
Neuritis (inflammation of the nerve) affects the vestibular
branch of the vestibulo-cochlear nerve, resulting in dizziness
or vertigo but no change in hearing. The term neuronitis is
also used. Labyrinthitis (inflammation of the labyrinth) occurs
when an infection affects both branches of the nerve, resulting
in hearing changes as well as dizziness or vertigo.
An inner ear viral infection may be the result of a systemic
viral illness (one affecting the rest of the body, such as infectious
mononucleosis or measles); or the infection may be confined
to the labyrinth or the vestibulo-cochlear nerve. Usually, only
one ear is affected.
Symptoms of neuritis can be mild or severe, ranging from subtle
dizziness to a violent spinning sensation (vertigo). They can
also include nausea, vomiting, unsteadiness and imbalance, difficulty
with vision, and impaired concentration. Sometimes the symptoms
can be so severe that they affect the ability to sit up, stand,
or walk. Labyrinthitis may produce the same symptoms, along
with tinnitus (ringing or noises in the ear) and/or hearing
The onset is usually very sudden, with severe dizziness developing
abruptly during routine daily activities. In other cases, the
symptoms are present upon awakening in the morning. After a
period of gradual recovery that may last several weeks, some
people are completely free of symptoms. Others have chronic
dizziness, if the virus has damaged the vestibular nerve.
No specific tests exist to diagnose vestibular neuritis or
labyrinthitis. When other illnesses have been ruled out, medications
are often prescribed to control nausea and to suppress dizziness
during the acute phase. Examples include Benadryl (diphenhydramine),
Antivert (meclizine), Phenergen (promethazine hydrochloride),
Ativan (lorazepam), and Valium (diazepam). Other medications
that may be prescribed are steroids (e.g., prednisone), an antiviral
drug (e.g., Acyclovir), or antibiotics (e.g., amoxicillin) if
a middle ear infection is present.
If treated promptly, many inner ear infections cause no permanent
damage. In some cases, however, permanent loss of hearing or
damage to the vestibular system can occur. If symptoms of dizziness
or imbalance persist for several months, vestibular rehabilitation
exercises (a form of physical therapy) may be suggested in order
to retrain the brain's ability to adjust to the vestibular imbalance,
in a process known as compensation. A key component of successful
adaptation is a dedicated effort to keep moving, despite the
symptoms of dizziness and imbalance.
A perilymph fistula is a tear or defect in the oval window
and/or the round window, the small, thin membranes that separate
the middle ear from the fluid-filled inner ear. When a fistula
is present, changes in middle ear pressure will directly affect
the inner ear, stimulating the balance and/or hearing structures
and causing symptoms.
The symptoms of perilymph fistula may include dizziness, vertigo,
imbalance, nausea, and vomiting. Some people experience ringing
or fullness in the ears, and many notice a hearing loss. Most
people with fistulas find that their symptoms get worse with
changes in altitude (elevators, airplanes, travel over mountain
passes) or air pressure (weather changes), as well as with exertion
Head trauma is the most common cause of fistulas. Fistulas
may also develop after rapid or profound changes in intracranial
or atmospheric pressure, such as may occur with SCUBA diving,
aerobatic maneuvers in airplanes, weightlifting, or childbirth.
Fistulas may be present from birth or may result from chronic,
severe ear infections. Rarely, they appear to occur spontaneously.
History, physical examination, and vestibular and audiometric
test results are used to assist in establishing the diagnosis
of perilymph fistula. However, the only positive way the diagnosis
can be confirmed is by performing a tympanotomy (operation)
and directly viewing the area of the suspected fistula. In many
cases, a fistula will heal itself with strict bed rest, to give
the fistula a chance to close. If symptoms are severe and have
not responded to bed rest, or if progressive hearing loss has
occurred, surgical repair of the fistulas may be required.
An acoustic neuroma is a benign tumor on the vestibular portion
of the eighth cranial nerve, which connects the inner ear to
the brain. Both hearing and balance may be affected.
Acoustic neuromas are rare. Only about 2,000 cases are diagnosed
in the United States each year.
Some acoustic neuromas cause a period of unsteadiness or imbalance.
This imbalance can occur without other typical symptoms, such
as one-sided hearing loss or intense ringing in the ear. Most
acoustic neuromas are removed by microsurgery. Other options,
including various types of radiation therapy (often called radiosurgery)
are also available. Each type of treatment entails some risk
of permanent change in hearing, balance, and facial motion.
Some people may experience imbalance for several months after
Ototoxicity ("ear poisoning") is due to drugs or chemicals
that damage the inner ear or the vestibulo-cochlear nerve, which
sends balance and hearing information from the inner ear to
the brain. Ototoxicity can result in temporary or permanent
disturbances of hearing, balance, or both.
Many chemicals have ototoxic potential, including over-the-counter
drugs, prescription medications, and environmental chemicals.
If you are taking any drugs on the advice of your physician,
do not stop taking them just because you see them listed below.
Speak with your doctor or other health care advisor about your
Substances that may cause ototoxicity include:
Aminoglycoside antibiotics, including gentamicin, streptomycin,
kanamycin, tobramycin, neomycin, amikacin, netilmicin, dihydrostreptomycin,
and ribostamycin. All members of this family are well known
for their potential to cause permanent ototoxicity. They can
enter the inner ear through the blood system, through inhalation,
or via diffusion from the middle ear into the inner ear. They
enter the blood stream in largest amounts when given intravenously
Anti-neoplastics (anti-cancer drugs). Cisplatin is well known
to cause hearing loss that is many times massive and permanent.
Carboplatin has been implicated as well.
Environmental chemicals, including butyl nitrite, mercury,
carbon disulfide, styrene, carbon monoxide, tin, hexane, toluene,
lead, trichloroethylene, manganese, and xylene. Most are associated
with hearing disturbances that may be permanent; mercury has
also been linked to permanent balance problems.
Loop diuretics, including bumetanide (Bumex), ethacrynic acid
(Edecrin), furosemide (Lasix), and torsemide (Demadex). These
drugs cause ringing in the ears or decreased hearing that reverses
when the drug is stopped. Note: Hydrochlorothiazide (HCTZ) and
Maxide, diuretics commonly prescribed to people with Meniere's
disease or other forms of endolymphatic hydrops, are not loop
Aspirin and quinine products. These may cause temporary ototoxicity,
particularly tinnitus, but may also reduce hearing.
Symptoms of ototoxicity vary considerably from drug to drug
and person to person. They range from mild imbalance to total
incapacitation, and from tinnitus to total hearing loss.
A bilateral (two-sided) vestibular loss usually doesn't produce
intense vertigo, vomiting, and nystagmus but instead a headache,
a feeling of ear fullness, imbalance to the point of being unable
to walk, and a bouncing and blurring of vision (oscillopsia).
It also produces inability to tolerate head movement, a wide-based
gait (walking with the legs farther apart than usual), difficulty
walking in the dark, a feeling of unsteadiness and actual unsteadiness
while moving, lightheadedness, and severe fatigue. If the damage
is severe, symptoms such as oscillopsia and problems with walking
in the dark or with the eyes closed are not going to go away.
The diagnosis of ototoxicity is based upon the patient’s history,
symptoms, and test results. There is no specific test; this
makes a positive history for ototoxin exposure crucial to the
At present, there are no treatments that can reverse the damage.
Currently available treatments are aimed at reducing the effect
of the damage and rehabilitating function. Individuals with
hearing loss may be helped with hearing aids, and those with
profound bilateral losses have benefited from cochlear implants.
In the case of lost balance function, physical therapy is of
great value for many individuals. The aim is to help the brain
become accustomed to the changed information from the inner
ear and to assist the individual in developing other ways to
Migraine, a disorder usually associated with headache, can
cause several vestibular syndromes. Migraine is extremely common.
Studies suggest that more than 20 million people in the United
States suffer from migraine and that about 25 percent of these
experience dizziness during attacks.
The International Headache Society classifies migraine disorders
into several types. Migraine without aura consists of periodic
headaches that are usually throbbing and one-sided, made worse
by activity, and associated with nausea and increased sensitivity
to light and noise. Vertigo can occur before, during, or separately
from the episodes of migrainous headache. Migraine with aura,
or classic migraine, is associated with short-lived symptoms
(noises, flashes of light, tingling, numbness, vertigo, and
others) known as the aura. These symptoms usually precede the
headache and usually last 5 to 20 minutes. In a variation called
migraine with prolonged aura, these symptoms may last a week.
Migraine patients may experience migraine with aura on some
occasions and migraine without aura on other occasions. Symptoms
of basilar migraine include vertigo, tinnitus, decreased hearing,
and ataxia (loss of coordination).
Several vestibular syndromes are caused by migraine. Benign
recurrent vertigo of adults (not to be confused with BPPV, or
benign paroxysmal positional vertigo) consists of spells of
vertigo, occasionally with tinnitus but without hearing loss.
Doctors must rule out other possible causes before making a
diagnosis of migraine-induced vertigo. Benign paroxysmal vertigo
of childhood (not to be confused with BPPV) consists of spells
of imbalance and vertigo without hearing loss or tinnitus (ringing
in the ears). The majority of cases occur between the ages of
1 and 4 but may occur up to age 10. Migrainous infarction or
complicated migraine is a migraine with aura associated with
a stroke (blood-flow problem resulting in cell death); one of
the symptoms may be vertigo.
In addition to the syndromes caused by migraine, several vestibular
disorders have been associated with migraine. Studies indicate
that people with migraine are much more likely than other people
to experience severe motion sickness and may be more likely
to suffer from Meniere's disease or BPPV.
Stress, anxiety, hypoglycemia, fluctuating estrogen, certain
foods, smoking, and other factors can trigger migraine. Vertigo
and imbalance secondary to migraine usually respond to the same
treatment used for migraine headaches. Treatment of migraine
includes eliminating from the diet substances known to trigger
migraine attacks, such as chocolate, nuts, cheese, red wine,
and other foods. Medications may also be prescribed.
Mal de Debarquement
Mal de debarquement literally means “sickness of disembarkment”.
This term originally referred to the illusion of movement felt
as an aftereffect of travel by ship or boat. Some experts now
include other types of travel (such as by train and airplane)
and situations with new and different movement patterns (such
as reclining on a waterbed).
For a handful of people, this illusion of movement seems to
last for long periods of time: weeks to months, even years after
a voyage. Some physicians refer to it as mal de debarquement
syndrome, reflecting that it is a collection of symptoms rather
than a specific disease. There is no universal agreement among
physicians about what mal de debarquement is or how to diagnose
it. Not all doctors even agree that persistent mal de debarquement
Leading explanations for the syndrome conclude that the problem
is not in the inner ear and most likely occurs someplace in
the balance areas of the brain. The brain adapts to the motion
of the ship or other vehicle; but once the movement stops, the
brain is unable to readapt once again. Why this ability to adapt
would suddenly stop is not understood. One theory is that mal
de debarquement is a migraine variant; long-lasting mal de debarquement
is experienced by middle-aged woman more than by other groups,
and more women than men experience migraines.
Symptoms of mal de debarquement include the sensation of bobbing,
rocking, swaying, swinging, floating and/or tumbling. These
may be accompanied by unsteadiness, disequilibrium, anxiety,
difficulty concentrating, and a loss of self-confidence. The
symptoms usually increase in enclosed spaces and when trying
to be motionless such as when attempting to fall asleep in bed
or when stopped at a traffic light. The symptoms improve during
constant, steady movement such as experienced while in a moving
car. Mal de debarquement does not include spinning vertigo,
vomiting, cold sweat, ear pressure, ear pain, sound sensitivity,
tinnitus, hearing loss or distortion, double vision, or bouncing
Persistent mal de debarquement usually begins within hours
of stopping the novel movement and resolves within about six
to twelve months. There are also reports of it not resolving
A physician diagnoses mal de debarquement by collecting a
thorough history, conducting a physical examination, and doing
tests to rule out other causes for the symptoms. For a diagnosis
of mal de debarquement to be made, there must be a history of
a ship voyage or other new movement, the return to a normal
environment, and then the start of the symptoms. Symptoms start
immediately, not weeks or months later.
At this time there appears to be no single highly successful
treatment approach to mal de debarquement. Standard drugs given
for motion sickness (including meclizine, diphenhydrinate, and
scopolamine patches) seem to be ineffective. Some treatments
suggested by physicians include walking while watching the horizon,
vestibular rehabilitation therapy, diuretics, anti-seizure drugs,
antidepressants of the tricyclic family, and benzodiazepines.
Pediatric Vestibular Disorders
Vestibular disorders in children are generally considered uncommon.
They are not as easily recognized as vestibular disorders in
adults, in part because children cannot describe their symptoms
Symptoms and signs that may indicate vestibular dysfunction
in children include developmental and reflex delays, visual-spatial
problems, hearing loss, tinnitus, motion sensitivity, abnormal
movement patterns, clumsiness, decreased eye-hand and eye-foot
coordination, ataxia, falls, nystagmus, seizures, dizziness,
nausea, ear pressure, difficulty moving in the dark, behavioral
changes, and/or delays in performance of developmental activities
such as riding a bicycle, hopping, and stair climbing involving
alternating left-right leg movements.
Possible causes include head-neck trauma, chronic ear infections,
maternal drug or alcohol abuse during pregnancy, cytomegalovirus,
immune-deficiency disorders, migraine with or without headache,
meningitis, metabolic disorders (e.g., diabetes), ototoxic medications,
neurological disorders (e.g., cerebral palsy, hydrocephalus),
genetic syndromes (e.g., branchio-otorenal syndrome, Mondini
dysplasia, Wallenberg syndrome), posterior brain tumors (e.g.,
malignant medullo-blastomas or the less frequently seen benign
acoustic neuromas), and a family history of vertigo, motion
sensitivity, hearing loss, or vestibular disorders. Dizziness
can be the first symptom of depression in a teenager. Alcohol
intoxication can produce dizziness, imbalance, staggering, and
abnormal eye movements.
Children may also develop a vestibular disorder for no known
reason. The underlying reasons often cannot be determined even
with the most aggressive testing. This does not preclude successful
treatment or recovery.
Children can experience the same vestibular disorders as adults.
Benign paroxysmal positional vertigo (BPPV) in children is typically
associated with physical trauma and can result from accidents,
falls, or sports injuries. Infrequently, BPPV has also been
observed following cochlear implantation. Vestibular neuritis
or labyrinthitis occurs in children, as well as ototoxicity.
Children that experience ototoxicity can have severe imbalance,
falls, and visual-motor problems, including oscillopsia (bouncing
Less common in children is Meniere's disease, enlarged vestibular
aqueduct, perilymph fistula, autoimmune disease, and vascular
In addition to all the vestibular disorders that adults are
subject to, children have two of their own.
Childhood paroxysmal vertigo, often referred to as migraine
equivalent, is typically seen in children 2-12 years old and
is characterized by true spinning vertigo, nystagmus, nausea,
and vomiting. Children tend to ”grow out of“ this condition,
but it may progress into benign positional vertigo or migraine-associated
vertigo in adulthood. Paroxysmal torticollis of infancy consists
of head-tilt spells that may be associated with nausea, vomiting,
pallor, agitation, and ataxia.
Evaluation and treatment: Age-specific techniques are used
for assessment and treatment of vestibular dysfunction in children.
A diagnostic work-up might include a history and physical exam,
a hearing test, and possibly brain scans to rule out other pathologies.
In addition, a vestibular therapist can help evaluate the child's
ability to use the vestibular system for balance and visual-motor
control, as well as test the child’s developmental reflexes
that have control mechanisms in the vestibular system.
Using these results, the therapist develops vestibular-therapy
exercises, which are tailored to the individual child. Children
with vestibular disorders can respond well to such intervention.
In fact, children typically respond more quickly than adults,
because of their greater plasticity the ability of their neurological
systems to more quickly compensate for and adapt to vestibular
deficits. In addition, children tend to be less fearful of movement
than adults, so they participate well in the balance and movement
aspects of therapy. Vestibular therapy can be effective for
reducing or eliminating vertigo, improving visual-motor control,
improving balance and coordination, and promoting normal development
in children with vestibular disorders.
Aging, Balance and Dizziness
Balance: One of the leading health concerns for people over
60 is falling. Balance in walking and standing is dependent
on many factors. The elderly have a higher risk of contracting
many different kinds of diseases that can interfere with balance,
including cataracts, glaucoma, diabetic retinopathy, and macular
degeneration, which all affect vision; peripheral neuropathy,
which affects position sense in the feet and legs; and vestibular-system
Balance is also dependent on good muscle strength and joint
mobility. A sedentary lifestyle and arthritis or other diseases
of bones and muscles can compromise strength and mobility. Yet
even healthy people over 65 appear to have more trouble than
younger people in maintaining their balance on soft or uneven
surfaces when visual cues are not available (e.g., in the dark).
Dizziness in the elderly can be a result of problems with
the vestibular, central (brain-related), and vision systems,
as well as from neuropathy, psychological causes, and unknown
causes. Vestibular disorders, however, are thought to be the
most common cause of dizziness in older people, responsible
for approximately 50% of the reported dizziness in the elderly.
Until recently, relatively little was known about the consequences
of aging for the vestibular system. Anatomical studies have
shown that the number of nerve cells in the vestibular system
grows smaller with age, beginning at about age 55. The loss
becomes more severe as age progresses.
Of all vestibular disorders, benign paroxysmal positional vertigo
(BPPV) is one of the most common. See the description of BPPV
and treatment for it through vestibular rehabilitation therapy
(balance-retraining exercises and maneuvers).
The ability to move about freely is an important factor in
the quality of life of both younger and older people. A healthy
vestibular system is vitally important to freedom of movement.
Neck pain often accompanies dizziness, but it may be difficult
to tell whether the dizziness and the neck pain are related
or just coincidental. In the 1950s, a clinical syndrome of disequilibrium
and disorientation in patients with many different diagnoses
of neck pathology�including cervical spondylosis, cervical
trauma, and cervical arthritis�was introduced as cervical
vertigo. Because true spinning vertigo is rarely associated
with this syndrome, cervicogenic dizziness is a more accurate
name for this syndrome.
Cervicogenic dizziness tends to be a controversial diagnosis,
because there are no tests to confirm that it is the cause of
the dizziness. The diagnosis is provided to people who have
neck injury or pain as well as dizziness and in whom other causes
of dizziness have been ruled out. Although no formal studies
have been completed, true cervicogenic dizziness is thought
to be rare.
People with cervicogenic dizziness tend to complain of dizziness
that is worse during head movements or after maintaining one
head position for a long time. The dizziness usually occurs
after the neck pain and may be accompanied by a headache. The
symptoms of dizziness usually last minutes to hours. People
with cervicogenic dizziness may also complain of general imbalance
that may increase with head movements and with movement in the
An evaluation for cervicogenic dizziness involves a thorough
medical evaluation. Testing of inner ear function is usually
requested to ensure that the peripheral or central vestibular
system is intact. A health care practitioner may perform a maneuver
in which the body is turned while the head is held fixed to
see if it causes nystagmus (eye movements) or dizziness to confirm
the suspected diagnosis. This test can also be positive in healthy
Cervicogenic dizziness often occurs as a result of whiplash
or head injury and is often seen in conjunction with brain injury
or injury to the inner ear. The majority of patients improve
with only treatment of the neck problem. Several studies have
reported that approximately 75 percent of patients improve with
conservative treatment of the neck such as medication, gentle
mobilization, exercise, and instruction in proper posture and
use of the neck.Others improve with treatment of the neck problem
in addition to vestibular therapy.
What is a cholesteatoma? A cholesteatoma is a skin growth that
occurs in an abnormal location: the middle ear behind the eardrum.
It is usually caused by repeated infection that causes an ingrowth
of the skin of the eardrum. Cholesteatomas often take the form
of a cyst or pouch that sheds layers of old skin that builds
up inside the ear. Over time, the cholesteatoma can increase
in size and destroy the surrounding delicate bones of the middle
ear. Hearing loss, dizziness, and facial muscle paralysis are
rare but can result from continued cholesteatoma growth.
How does it occur?
A cholesteatoma usually occurs because of poor eustachian tube
function as well as infection in the middle ear. A rare congenital
form of cholesteatoma (one present at birth) can occur in the
middle ear and elsewhere, such as in the nearby skull bones.
However, the type of cholesteatoma associated with ear infections
is most common.
What are the symptoms?
Initially, the ear may drain, sometimes with a foul odor. As
the cholesteatoma pouch or sac enlarges, it can cause a full
feeling or pressure in the ear, along with hearing loss. (An
ache behind or in the ear, especially at night, may cause significant
discomfort.) Dizziness, or muscle weakness on one side of the
face (the side of the infected ear) can also occur.
An examination by an otolaryngologist-head and neck surgeon
can confirm the presence of a cholesteatoma. Initial treatment
may consist of a careful cleaning of the ear, antibiotics, and
eardrops. Therapy aims to stop drainage in the ear by controlling
the infection. Large or complicated cholesteatomas usually require
surgical treatment to protect the patient from serious complications.
Enlarged Vestibular Aqueduct
The vestibular aqueduct (one on each side of the head) is
a narrow bony canal extending from the middle compartment-vestibule-of
the inner ear toward the brain. It houses the endolymphatic
duct and sac along with a vein and artery.
If a vestibular aqueduct is greater than 1.5 millimeters in
size (approximately the size of the head of a pin), it is considered
to be an enlarged vestibular aqueduct (EVA). An enlarged endolymphatic
duct and sac usually accompany EVA. The fluid-filled duct and
sac are thought to help regulate the concentration of ions in
the inner ear, which are important for initiating the transmission
of sound and balance signals from the ear to the brain.
EVA seems to run in some families but not in others. It occurs
more often in females than males. Genetic and as yet unknown
environmental factors are thought to result in this disorder.
EVA can be a symptom of Pendred syndrome (a genetic disorder
causing childhood hearing loss), Mondini’s deformity (when
the cochlea has only one or 1½ turns rather than the normal
2½), or branchio-otorenal syndrome (a genetic condition affecting
the ears and the kidneys).
Hearing loss is commonly associated with enlarged vestibular
aqueduct and is progressive with Pendred syndrome, sometimes
resulting in total deafness. The hearing loss is generally sensorineural involving
the cochlea and the nerves serving it.
EVA can also produce problems with balance, although vestibular
symptoms can be difficult for a child to describe and thus may
not always be reported. Symptoms described in the medical literature
include episodic spinning vertigo, mild unsteadiness, trouble
watching revolving objects, and decreased visual acuity, among
others. In a young child, signs and symptoms may also include
grabbing of the head and walking in circles.
An EVA diagnosis is made using standard hearing tests and high-resolution,
thin-section computerized tomography of the temporal bone. Vestibular
tests may also be useful in assessing the impact on balance.
Currently, no treatments can reverse or stop the progression
of hearing and/or vestibular losses from EVA. People with EVAS
are advised to avoid head blows and contact sports. Hearing
aids or cochlear implantation may help. Vestibular rehabilitation
therapy might also be helpful for managing imbalance and dizziness
resulting from an enlarged vestibular aqueduct.
Hyperacusis is the perception of an unusual auditory sensitivity
to some environmental noises or tones. It is an abnormal condition
in which the complex electrical signals generated by sound vibrations
are misinterpreted, confused, or exaggerated.
Symptoms of hyperacusis can range from a mild sense of unease
to a complete loss of balance or upright posture with severe
ear pain. In serious cases, it can cause seizure-like activity
in the brain.
What is the difference between cochlear hyperacusis and vestibular
hyperacusis? With cochlear hyperacusis, subjects feel ear pain,
discomfort, annoyance, or some other emotional reaction when
certain sounds are heard, including those that are very soft
or high-pitched. In vestibular hyperacusis, exposure to sound
can result in falling or a loss of balance or postural control.
Such disturbances have been called by various names, including
Tullio's syndrome and audiogenic seizure disorder. Some of
the same reactions as with cochlear hyperacusis can also occur,
along with sudden severe vertigo or nausea. In some cases, vestibular
hyperacusis can affect the autonomic system and cause problems
such as loss of consciousness, mental confusion, nausea, or
extreme fatigue. In both cochlear and vestibular hyperacusis,
headache is common.
Causes: Hyperacusis can be associated with auto-immune disorders,
traumatic brain injury, metabolic disorders, and other conditions,
although it is often ascribed to psychological conditions rather
than being recognized as a physiologic symptom of cochlear or
vestibular damage. The physiologic conditions underlying these
symptoms cannot be identified with certainty because of difficulties
involved with studying the very small inner ear structures without
A suspected cause of cochlear hyperacusis involves a loss of
the regulatory function provided by the system that conducts
impulses along the auditory neural pathways. Thus, for example,
the sound of a passing car might be interpreted as comparable
to the roar of a jet engine. Other possible causes involve brain-chemistry
dysfunction or head trauma that damages the chain of tiny bones
in the middle ear that amplify sound and help transmit vibrations
to the inner ear fluid.
In vestibular hyperacusis, damage to the nerve cells in the
balance system is suspected, possibly from head injury, metabolic
disruptions due to chemical ingestions (e.g., medications or
anesthesia), or circulatory changes due to heart disease or
artery blockages. In addition, autoimmune disease, which can
be triggered by many different causes, can harm the balance
Testing and treatment: While special audiologic tests can reveal
the presence and severity of cochlear hyperacusis, and help
define treatment, diagnosis and treatment of vestibular hyperacusis
is less defined. When vestibular hyperacusis is recognized,
the treatment protocols vary widely and have included a low-salt
diet combined with anti-nausea drugs, and the introduction of
anti-inflammatory medicines directly into the cochlear/vestibular
system using catheters.
Autoimmune Inner Ear Disease
What is autoimmunity?
When a virus attacks, the immune system defends the body. The
defense capabilities of a malfunctioning immune system can harm
the body by mistaking and attacking the body’s own cells as if
they were invading viruses or germs. This is called autoimmunity.
In general, autoimmune disorders occur more frequently in women
than men and less frequently in children and the elderly.
What is autoimmune inner ear disease?
The immune system can attack the whole body or just certain
systems within the body, including the ear. Even if the ear
is not being directly attacked, debris created by an autoimmune
reaction in one part of the body can be transported to the ear
by circulation, and hence cause problems to the ear. When the
ear is attacked, the progression of damage and functional loss
can be rapid.
Some autoimmune disorders that can affect the ear include Cogan’s
syndrome, relapsing polychondritis, polyarteritis nodosa, Wegener’s
granulomatosis, systemic lupus erythematosus, ulcerative colitis,
Sjogren’s syndrome, and rheumatoid arthritis.
The most prominent symptom of autoimmune inner ear disease
is bilateral asymmetric progressive/fluctuating sensorineural
hearing loss, typically occurring over several months. Sometimes
the progression can be over several years. The presence of vertigo
and other symptoms typically related to vestibular loss depends
on the degree of loss and whether the damage has triggered a
problem with fluctuating function (for example, if endolymphatic
hydrops developed from the autoimmune reaction). The symptoms
of autoimmune problems can be similar, even indistinguishable,
from other vestibular disorders; a Meniere�s syndrome is sometimes
Diagnosing an autoimmune disorder as the cause of inner ear
symptoms can be difficult. Aside from a history of other systemic
autoimmune disorders and supportive blood tests, sometimes the
diagnosis is made only if hearing improvement occurs in response
to drug treatment.
An early diagnosis is important because treatment can be effective
in stopping the progression or reversing the damage.
The standard treatment for autoimmune reactions is immunosuppressive
medication, sometimes delivered as long term therapy. Such medications
have body-wide effects and include steroids, chemotherapy agents,
anti-transplant rejection drugs, and the newer anti-tumor, necrosis-factor
drugs. Because a rheumatologist has extensive training and experience
in these treatments, they are often called on to manage the
drug treatment in collaboration with the otolaryngologist or
Superior Canal Dehiscence Syndrome
Superior canal dehiscence syndrome (SCD) results from an opening
(dehiscence) in the bone overlying the superior (uppermost)
semicircular canal within the inner ear. With this dehiscence,
the fluid in the membranous superior canal (which is located
within the tubular cavity of the bony canal) can be displaced
by sound and pressure stimuli.
There are normally only two points of increased compliance
(yielding to pressure) in the inner ear: the oval window, through
which sound energy is transmitted into the inner ear via the
stapes bone; and the round window, through which sound energy
is dissipated from the inner ear after traveling around the
cochlea. SCD creates a third mobile window into the inner ear.
Signs and symptoms of SCD result from the physiological consequences
of this third window.
Vestibular and/or auditory signs and symptoms can occur in
SCD. Vertigo and oscillopsia (the apparent motion of objects
that are known to be stationary) evoked by loud noises and/or
by maneuvers that change middle-ear or intracranial pressure
(such as coughing, sneezing, or straining). Persons with SCD
may experience a feeling of constant disequilibrium and imbalance,
and may perceive that objects are moving in time with their
pulse (pulsatile oscillopsia). Auditory manifestations of SCD
may include autophony (increased resonance of one’s own voice),
hypersensitivity to bone-conducted sounds, and an apparent conductive
hearing loss revealed on audiometry.
The diagnosis of SCD is made based upon characteristic symptoms,
specific findings on clinical examination, CT imaging, and findings
on vestibular evoked myogenic potentials (VEMP) testing. The
diagnosis should never be made exclusively on the basis of CT
For many patients, avoidance of provocative stimuli such as
loud noises may be sufficient treatment. For those patients
who are debilitated by their symptoms, surgical plugging of
the superior canal can be very beneficial in alleviating or
substantially reducing the symptoms and signs.