Do you feel dizzy sometimes? Your symptoms might be the consequence of a vestibular disorder.
Dizziness is a very broad term, and doctors can struggle to find its true meaning because it is not always easy for patients to explain what they feel. Feeling lightheaded, having a balance disorder, or feeling you are about to faint are all sensations patients usually describe as dizziness.
However, all these symptoms have different causes, so it’s the doctor’s job to find out exactly what you mean when you say you are dizzy. Vertigo is a particular form of dizziness in which you feel the world moving around you.
Most of the time, vertigo is a consequence of a problem in your vestibular system. Approximately 35 % of adults over 40 years in the United States had some form of vestibular dysfunction at some point.
The vestibular system is located in your inner ear and is responsible for maintaining your balance. Loss of balance, vertigo, nystagmus, hearing loss, nausea, and vomiting are common symptoms of vestibular dysfunction.
Vestibular disorders can be central or peripheral. Peripheral vestibular disorders are often benign and easily solvable, like benign positional vertigo, for example. A central vestibular disorder, on the other hand, can represent a serious underlying pathology.
I am a medical doctor. In this article, I will tell you everything you need to know about vestibular disorders.
What is the inner ear?
To understand vestibular disorders is necessary to understand the inner ear and the vestibular apparatus. The inner ear is simply the deepest part of your ears.
The inner ear has two functions: translating sound waves into electrical signals for the brain to interpret and maintaining balance. It is composed of two functional structures: the vestibular system (in charge of balance and equilibrium) and the cochlea (in charge of audition).
The vestibular system consists of 5 different end organs: three semicircular channels, the utricle, and the saccule. The semicircular canals sense rotational movements while the utricle and saccule sense straight-line accelerations.
These structures are filled with liquid. When your head moves, the liquid inside the channels also moves, which in turn drives the tiny hair cells inside of them. These hair cells serve as sensors that detect movement and send electrical signals to the brain stem through the vestibular nerve.
The brain interprets those signals and sends commands to the body to tell it how to stay balanced. If you experience very strong or fast movements (like in a roller coaster), the liquid in your inner ear continues moving after the action has stopped. That is why you feel dizzy after getting down from a roller coaster.
Peripheral vestibular disorders affect one or multiple structures inside the inner ear. The vast majority of vestibular disorders are peripheral in nature. Take benign paroxysmal positional vertigo, for example.
Benign paroxysmal positional vertigo is the most common cause of vertigo worldwide. It happens when calcium crystals that normally are in another part of the inner ear break free and enter the semicircular channels. This alters vestibular function, causing the brain to receive inaccurate information about your body’s position, which in turn leads to dizziness, nausea, imbalance, and an abnormal eye movement called nystagmus.
How does your body manage to balance itself?
Balance is the ability to maintain the body center of mass over a base of support. It allows humans to determine direction and speed of movement, identify position with respect to gravity, and maintain posture and stability in everyday activities. With impaired balance, actions we take for granted, like walking, driving, and standing up, can become challenging or dangerous.
The vestibular system plays a crucial part in maintaining balance but is not the only system involved. Balance maintenance requires the integration of information coming from the eyes, muscles, joints, and vestibular organs. These four sensory systems send information to the vestibular nuclei in the brain stem from electric impulses. In the brain stem, the information is sorted out and integrated with information coming from the cerebellum and the cerebral cortex.
Moreover, after sensory integration occurs, the brain sends feedback to the eyes, muscles, and joints, allowing them to maintain balance and a clear vision. These processes happen all the time and are 100% unconscious and automatic.
In a central vestibular disorder, the problems are not in the inner ear or the vestibular apparatus, but in the brain or the brain stem. More often than not, central vertigo is the consequence of cerebrovascular disease, particularly on the vertebrobasilar system, which provides blood to the areas of the brain and the brainstem involved in posture and equilibrium.
Other causes of central vertigo include central nervous system tumors, trauma, multiple sclerosis, and infection.
How can central vertigo be distinguished from peripheral vertigo:
As you might have guessed by now, distinguishing peripheral vestibular dysfunction from central vestibular dysfunction is very important. Mainly because the causes and management of both conditions are totally different, thankfully, certain characteristics help your doctor distinguish between the two. Here is a list of the key differences between them:
- Onset: Peripheral vestibular dysfunction tends to have a more sudden and memorable onset, while central vertigo symptoms are slow in development. The patient is usually unable to provide a time of onset.
- Duration: Episodes of peripheral vertigo are typically short, lasting a few minutes most of the time and rarely for 24 hours.
- Intensity: Symptoms of peripheral vestibular dysfunction are intense, with a strong feeling of vertigo accompanied by nausea, vomiting, and imbalance. Central dysfunction, on the other hand, tends to have vague symptoms of imbalance and dizziness.
- Triggers: Peripheral vertigo is usually triggered by sudden movements, and central vertigo is not.
- Hearing loss: Because the vestibular apparatus is so close to the cochlea, peripheral dysfunction is more likely to involve hearing loss than the central disease.
- Nystagmus: Nystagmus is an abnormal back and forth moving of the eyes. Peripheral vertigo causes nystagmus, and central vertigo doesn’t. Nystagmus is the most important diagnostic clue in the physical exam for vertigo.
What happens when the vestibular system is damaged?
The vestibular system works together with the brain and other somatosensory systems to control your eyes, head, and body to maintain balance. Thus, any damage to this system will result in balance issues or vestibular imbalance.
Because the eyes are an essential part of the balance system, they also experience alterations when the vestibular system is damaged. Nystagmus is the primary visual symptom of vestibular damage.
It is important to note that there is a vestibular apparatus in each ear. The brain receives signals from both inner ears and compares them. When the head is still, the brain gets equal signals from both sides and interprets the head is still.
When the head moves, the brain detects uneven signals and interprets the head is in motion. Any form of vestibular impairment or vestibular hypofunction from one side will create uneven signals that the brain will interpret as motion.
This illusory sensation of movement is called vertigo and is the key symptom of vestibular disease. Vertigo usually causes nausea, and nausea prompts vomit.
Remember that the vestibular system is just millimeters away from the auditory system. As you may imagine, an inner ear disorder can have both a vestibular deficit and an auditory deficit.
So, although typical vestibular symptoms do not include hearing loss, it can be present in inner ear diseases that affect the vestibular apparatus and de cochlea. Meniere’s disease is an excellent example of a disease that affects both audition and balance.
What causes a vestibular disorder?
Many diseases and conditions can cause vestibular dysfunction. Some of them are transitory, some of them permanent, some easy to treat, some hard to treat. Here is a list of the most common causes of inner ear dysfunction:
- Benign paroxysmal positional vertigo: This one is the most common cause of vertigo. Thankfully, it is also the one with the more straightforward treatment. Patients describe it as a sudden onset of vertigo and nystagmus with sudden movement episodes rarely last longer than a few minutes.
- Benign positional vertigo: It develops when a small calcium crystal lodges itself into the semicircular canals, movement causes the crystal to move, producing an abnormal signal that the brain interprets as a circular movement.
- Meniere’s disease is also known as endolymphatic hydrops: It is a condition in which there is increased hydraulic pressure inside the inner ear. Excess pressure inside the inner ear causes fluctuating hearing loss, episodic vertigo, ringing inside the ears (tinnitus), and a fullness sensation in the ears.
- Labyrinthitis: It is inflammation of the inner ear, usually due to a viral infection. Patients with this condition can present vertigo, hearing loss, ear pain, fever, facial weakness, or asymmetry. Upper respiratory infection symptoms usually precede the vestibular symptoms. Vertigo, nausea, and vomiting typically resolve in a few days, but hearing loss is more variable. Some cases of Laberynthitis result in a profound hearing loss.
Can I have vertigo with an intact vestibular apparatus?
Yes, many times, the problem isn’t located in the vestibular apparatus, but in the nerve that carries movement information to the brain, or even the brain itself. Some examples include:
- Acoustic Neuroma: Acoustic neuromas are benign tumors that appear on the nerve that connects the inner ear to the brain. Acoustic neuromas do not spread to other body parts. They can, however, do severe damage to the vestibulocochlear nerve. These tumors appear in one of every 50000 people. Symptoms only occur when the tumor gets big enough, and the most common symptom is gradual hearing loss. Hearing loss may happen suddenly or slowly over time. Other symptoms include headaches, imbalance, and facial weakness, numbness in the face or ear.
- Vestibular neuritis: It results from the inflammation of the vestibular nerve. When inflamed, the nerve is unable to communicate the information coming from the inner ear properly. Vestibular neuritis can be confused with Laberynthitis because the symptoms are very similar. The main clinical difference is that vestibular neuritis does not cause hearing loss, only vertigo.
- Vestibular Migraine: Migraine headaches are a widespread medical condition, and the leading cause of headaches worldwide. Most migraines involve a headache, vestibular migraines include vertigo, imbalance, and vomit combined (or not) with a headache. The mechanism that causes vestibular migraine isn’t fully understood. Migraine triggers such as chocolate and wine can also trigger vestibular migraines.
- Post-traumatic vertigo: Vertigo is very common in individuals that had a traumatic brain injury. Trauma can affect the centers that integrate the information in the brain or the vestibular structures outside the central nervous system. Diseases like benign positional paroxysmal vertigo, Meniere’s syndrome, and perilymph fistula can exist because of trauma.
- Anxiety disorder: An anxiety attack may cause vertigo and nausea.
Does the vestibular disorder go away?
It depends on the cause and the patient. Some patients recover spontaneously after some rest and symptomatic treatment. Others may require other, more aggressive approaches like middle ear surgery. And, in some cases, vertigo can become a permanent part of everyday life. As you might imagine living with a lifelong vestibular disorder can affect a person’s life in many ways.
The cause of vertigo plays an essential role in how long vertigo will last. Benign paroxysmal vertigo is easily curable and rarely becomes a permanent condition. Meniere’s disease usually subsides with treatment. Inflammatory diseases like vestibular neuritis and labyrinthitis often resolve spontaneously. Still, in a small minority of cases, vestibular symptoms remain after the inflammation subsides. Vertigo caused by stroke or brain injury frequently becomes a permanent or semi-permanent issue.
How common are vestibular disorders?
Vestibular disorders are quite common. They are more frequent in the elderly, but they can occur at any age. Approximately 35% of all adults over forty and 80% of adults over sixty-five years have experienced or continue to experience a vestibular dysfunction. In the United States, 4% of the population report having a chronic vestibular deficit.
Vertigo, due to an alteration in the vestibular apparatus, represents one-third of all cases. Also, benign paroxysmal positional vertigo is the leading cause of dizziness during old age, accounting for 50% of all cases.
How is a vestibular disorder diagnosed?
The diagnosis of balance disorders is mostly clinical. Your doctor will make an exhaustive history and inquire about your principal complaint and any other associated symptoms such as headaches, hearing loss, and fever that might help guide the diagnosis. Your doctor will also inquire about a previous history of an upper respiratory infection or head trauma.
The physical exam includes a full neurological exam and a series of maneuvers that distinguish peripheral from central vertigo. Some of these maneuvers include the Dix-Hallpike test, the Romberg test, and the head thrust test.
Based on what he learns from interrogating you and from the physical exam, he may order some tests. Some useful tests include:
- Audiometry: This test can provide information about hearing loss in Meniere’s disease or labyrinthitis.
- MRI and CT scan: Can help detect tumors like an acoustic schwannoma or brainstem lesion.
- Rotating chair test: This test helps to determine if vertigo comes from the peripheral vestibular system or if it is of central origin, and determining if both ears are affected or just the one, by measuring nystagmus after rotating.
How is a vestibular disorder treated?
The treatment of a vestibular disorder depends on the cause. In broad terms, treatment consists of using vestibulosuppresant agents, antiemetics, antiviral medication (in vestibular neuritis and labyrinthitis), and steroids (in select patients).
Vestibulosupressant agents should only be for very short periods. Many cases of benign positional vertigo don’t require pharmacological treatment by calcium crystal repositioning through an Epley maneuver. The Epley maneuver can be performed at the doctor’s office, or home takes less than 5 minutes and has an immediate effect.
Commonly used anti dizziness medication includes:
- First-generation antihistamines
- Anticholinergic agents
Who can benefit from vestibular rehabilitation?
Patient with chronic dizziness and imbalance that doesn’t respond to treatment can benefit from vestibular rehabilitation therapy. Vestibular therapy can be life-changing to some chronic vestibular patients that are unable to lead normal lives.
Vestibular rehabilitation is an exercise program designed by a vestibular therapist to improve imbalance and dizziness. Some vestibular disorders permanently impair the vestibular sense of movement and posture. The basis of vestibular rehabilitation is to teach the body how to use other senses to compensate.
The goal of vestibular therapy is to use a problem-oriented approach for compensation. The program is tailored for each patient to address that person’s specific problems.
Before beginning an exercise program, your therapist will conduct an extensive clinical examination to identify the magnitude of the problems in relation to your vestibular disorder. Depending on his findings, the therapist will recommend one or a combination of three principal methods of exercise:
- Habituation exercises: To control dizziness produced by motion or visual stimuli
- Gaze stabilization: To improve control of the eyes to have a clear vision during movement
- Balance training: To improve stability and balance.
Are you having symptoms of the vestibular disorder?
This tool is a vestibular disorder symptoms checker. It has the most important signs, symptoms, and risk factors. Therefore, it determines the likelihood of someone having this illness. The most important benefit of this tool is that it is free and would only take a few minutes.