Dizziness

Some people describe their balance problem by saying they feel dizzy, unsteady or giddy. This feeling of imbalance without a sensation of turning or spinning is called disequilibrium (“dis-ee-quill-lib-bree-um”) and is sometimes due to an inner ear problem. On the other hand some people describe their balance problem by using the word vertigo, which comes from the Latin verb “to turn”. They often say that they or their surroundings are turning or spinning. Vertigo is often due to an inner ear problem. It’s often hard to describe just how you feel when you are dizzy. Normal balance is a sensation that most people take for granted unless they have a problem. Each year more than 2 million people visit a doctor for dizziness or vertigo, so it’s a very common problem and one that almost everyone will experience at some point in their lives. Dizziness and vertigo all relate to a change in the sense of balance. Your sense of balance is maintained by a complicated interaction between several parts of your nervous system:

  1. The inner ear monitors the direction of movement, such as turning or forward-backward, side-to-side and up-and-down motions. The three balance centers in the inner ear that provide this information are the horizontal, posterior and superior semicircular canals.
  2. The eyes monitor where the body is in space and also the direction of motion.
  3. The skin pressure receptors, such as those in your feet and your seat tell what part of the body is touching the ground or furniture.
  4. The muscle and joint sensory receptors tell what parts of the body are really moving and which parts are still.
  5. The central nervous system (the brain and spinal cord) processes all the information sent by the other systems and puts it all together so we can achieve balance.

Dizziness and vertigo are not diseases, they are symptoms that let you know that there has been a change in the way your body behaves. Vertigo appears when the central nervous system receives conflicting messages from one or more of the other four systems. The reaction to these messages can be so strong that it causes you to sweat, feel sick to your stomach or even vomit. For instance, suppose that you are riding in an airplane during a storm and your plane is being tossed about by air turbulence. Your eyes don’t detect all of this motion because all you see is the inside of the airplane (and it doesn’t seem to be moving). Your brain, however, receives messages from the other systems that don’t match up with your eyes. The mismatch in information may cause you to become “air sick”, or at the very least, uncomfortable. Let’s use a medical problem as an example, suppose your inner ear on one side is hurt from an injury or infection. The damaged ear doesn’t send the same signals about motion to the brain as the healthy ear. This causes a conflict in the information the brain receives about the sense of rotation, and you could suffer spinning or vertigo, along with nausea, vomiting and sweating.

Common Causes of Dizziness

Visual Problems

An imbalance in the eye muscles or trouble seeing can make you unsteady. A good example of this type of imbalance is the unsteadiness that might happen when you try to walk while wearing someone else’s glasses. Treatment of eye problems will require the help of an eye specialist.

Circulatory Problems

Disorders of blood circulation are among the most common causes of dizziness. If your brain doesn’t get enough blood flow you might feel lightheaded. Problems with the heart and/or blood vessels can cause this type of dizziness. Almost everyone has felt the sensation when they stand up too quickly after sitting or lying down for an extended period of time.

Vertebrobasilar insufficiency

Some people have frequent or even constant lightheadedness due to poor circulation. Vertebrobasilar (“ver-tee-bro-baz-i-lar”) insufficiency can be caused by atherosclerosis or hardening of the arteries. It is commonly seen in people who have high blood pressure, diabetes or high cholesterol levels in their blood. It is sometimes seen in people who are anemic or have heart problems. Another cause of this disease is kinking or narrowing of the vertebral arteries as they pass through the spinal column in the neck. This might happen in people who suffer from arthritis of the spine.

Spasm and migraine associated dizziness

Certain drugs, like caffeine and nicotine, decrease blood flow to the brain by causing arterial spasm. Spasm can also be caused by anxiety, tension or migraine headaches. When a person is felt to have dizziness without the bad headache due to migraine, they are said to have migraine associated dizziness. If the inner ear does not get enough blood flow for any reason, a person usually feels the sensation of true whirling vertigo that might be accompanied by nausea, sweating or even a hearing loss and tinnitus. The inner ear is very sensitive to changes in blood flow. Treatment of dizziness or vertigo from circulatory problems can include medicines that thin the blood or reduce the chances of spasm and prevent migraine. Sometimes people are referred to doctors who specialize in migraine or disorders of circulation.

Injury

A blow to the head may cause an injury that immediately or sometime later will result in damage to the inner ear. A skull fracture that damages the inner ear can cause severe vertigo along with nausea, vomiting and a hearing loss. The dizziness may last for several weeks, then slowly get better as the other, normal side takes over all of the inner ear functions. In rare cases, surgery is needed to get rid of the constant vertigo from a head injury. Some people develop a tear in the fine membranes that separate the middle and the inner ears. These membranes, called the round window and the oval window, separate the air-filled middle ear space and the liquid- filled inner ear. A tear in one or both of these membranes is called a perilymphatic (“pear-ee-limp-fat-ick”) fistula. A fistula can happen from a blow to the head or with rapid changes in pressure, such as may be felt during SCUBA diving, air travel, or intense straining during weightlifting. Symptoms of a perilymphatic fistula can include vertigo, imbalance, nausea, vomiting, ringing or fullness in the ear, and a hearing loss. Most people who have a fistula find that their symptoms get worse with changes in air pressure or altitude, including those seen with weather changes. In many people, a fistula will heal with bed rest. If this doesn’t help, or if there is progressive hearing loss, surgery may be required. The operation involves placing a piece of tissue, called a graft, into the oval and round window to seal the leak of inner ear fluid.

Benign paroxysmal positional vertigo (BPPV)

BPPV is a disorder of one of the balance centers in the inner ear, usually the posterior semicircular canal. It is one of several types of positional vertigo and by far the most common. BPPV is benign because it is not life-threatening; paroxysmal because the dizziness comes on suddenly and without warning; it is positional because the dizziness either starts or is made worse with head or body movement; and it is vertigo because the dizziness is a whirling type of sensation. BPPV is thought to be caused by a previous head injury that could have happened years before the dizziness started. The main symptoms of BPPV are vertigo, imbalance and nausea that last for a short time, only to return with a change in body or head position. Some people report a feeling of imbalance that lasts throughout the day. BPPV is a very common problem and accounts for almost half of the balance problems seen by our group. BPPV is usually relieved by performing special balance exercises or using a canalith repositioning maneuver. The canalith repositioning maneuver, or Epley maneuver, is a physical therapy we perform in our office that effectively eliminates the dizziness associated with BPPV in 90% of people. Rarely, an operation will be needed to control the vertigo associated with BPPV.

Infection

Vestibular neuritis and viral labyrinthitis

Viruses or bacteria can attack the inner ear or its nerve connection to the brain resulting in dizziness or even a hearing loss. A virus that causes the common cold or the flu can attack the nerve of balance as it travels from the balance center to the brain, resulting in a condition called vestibular (“vest-tib-you-lar”) neuritis (“new-right-is”). A virus can also affect the inner ear involving the balance nerve and the hearing nerve resulting in a disorder called viral labyrinthitis (“lab-rin-thigh-tis”). Both of these problems can cause a severe whirling dizziness and hearing loss will be absent in people suffering from neuritis and present in those with labyrinthitis. In many instances, the illness is associated with nausea and vomiting. The severe part of the illness might last several days, followed by a gradual recovery over a period of months. Treatment of vestibular neuritis and viral labyrinthitis is aimed at relieving the symptoms of vertigo and nausea by using medicine. On occasion, a person may have to be hospitalized for treatment of dehydration. If a hearing loss accompanies the other symptoms we will recommend specific medications to try and control or reverse your hearing loss.

Bacterial labyrinthitis

A bacterial infection of the mastoid or middle ear can invade the inner ear, resulting in a severe hearing loss and vertigo along with nausea and vomiting. This serious condition is fortunately very rare but will require hospitalization with antibiotics. If the infection spreads to the brain or cannot be controlled with antibiotics surgery will be required.

What will an ear specialist do for my dizziness?

Because the inner ear controls both balance and hearing, diseases that might cause your dizziness could affect your hearing, even though you may not think you have a hearing loss. For this reason, you will be asked to have a hearing test, called an audiogram, before your ear specialist sees you. You will then be asked a number of questions about your dizziness on a questionnaire. Some of them might be whether you have lightheadedness or a sensation of moving, how long you have had the problem, and how often your dizziness occurs. You will be asked about your general health, any medicines that you take and about your family medical history. It is very important to include information from other doctors visits and any tests or imaging studies that you may have had done. Your doctor will look at your ears and do some nerve and balance tests. Depending on what he feels is the cause of your dizziness, he may order a special hearing test called an auditory brainstem response or ABR test, a radiologic test of your brain and inner ears called a magnetic resonance image or MRI scan, or special balance tests. He may also order blood tests or recommend that you see a heart specialist or a neurologist. Not everyone will need every test or see another specialist. After your testing, your doctor will recommend a specific treatment plan to help you with your dizziness.

Regardless of the reason for your dizziness, you should be as active as you wish but don’t place yourself or others at risk for an injury. Hold on to objects if you need more support. Use a cane or walking stick if you need to. You might be dizzy at night so be sure to have a night light on. You’ll be relying more on your vision to help maintain your balance. You will also want to make sure that the path to your bathroom is free from throw rugs or other loose objects. Any form of exercise is good; it may help your balance function and will certainly increase your confidence level.

Although some people who have dizziness can safely drive a car while their symptoms are mild, you should do so at your own risk. Nothing our group says or writes in your medical chart, or no medicine that we prescribe for you, will relieve you of your legal responsibility if you are involved in an accident because of your dizziness. As you learn more about your problem, you will understand the symptoms and be more successful in coping with them.

For more information visit the Vestibular Disorders Association web site: vestibular.org

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