Dizziness is a nonspecific term used to describe a variety of sensations a person may feel including lightheadedness, off-balance, floating, fuzzy thinking, and faintness. Dizziness that gives the person a sensation of spinning is known as vertigo. Dizziness can be caused by a number of different causes including inner ear disorders, central brain disorders, vascular problems, metabolic problems, and infections. Patients experiencing symptoms of ongoing, or recurrent, dizziness should be evaluated by their physician. Vestibular testing may be useful in determining the cause of dizziness.
Vertigo is a term used to describe a whirling or spinning sensation either of the individual or the surrounding environment. Vertigo is a description of a symptom and not a diagnosis. Vertigo can be caused by dysfunction of the inner ear's balance organ or may be caused by a problem in the brain's processing of the balance signals. Vestibular testing can be used to help determine the cause of vertigo.
A balance disorder is any disturbance that causes an individual feel dizzy, unsteady, light headed, sensation of spinning, vertiginous, or, in general, leads to difficulty maintaining his or her balance. The labyrinth (inner ear balance organ) is an important part of the balance system. The labyrinth must interact with other body systems including visual (eyes) and proprioceptive (muscles, tendons and joints) to maintain balance. In addition, the brain has to appropriately integrate and interpret all of the signals and subsequently send appropriate instructions back to the body regarding proper balance alignment. Functional problems of the labyrinth, visual or proprioceptive inputs, or the brain's interpretation of the inputs, can negatively affect one's balance.
Vestibular test modalities and radiologic studies help us to evaluate the potential cause of a specific balance disorder. The Balance Center at Westchester Medical Center uses the most technologically advanced test modalities to evaluate causes of balance disorders. Test equipment including Videonystagmography (VNG/ENG), Rotary Chair Testing, and Computerized Dynamic Posturography may be used to evaluate causes of balance disorders and effect appropriate intervention.
Ménière's disease is a disorder of the inner ear resulting from increased and fluctuating pressure of endolymph fluid. Ménière's disease is characterized by symptoms of fluctuating low frequency hearing loss, recurrent vertigo events lasting 15 minutes-2 hours in duration, fullness or pressure in the ear, and tinnitus. The vertigo events, known as Ménière's attacks, may occur as infrequently as once every few years, to as often as several times a week. With repeat occurrences, many patients will experience a gradual decline in hearing in the affected ear. Patients with frequent vertigo events may have chronic dizziness or balance problems, even when not experience an acute Ménière's attack. The potential factors contributing to Ménière's disease include trauma, infection, allergies, autoimmune disorders, stress, diet and metabolic imbalance, but for many patients there is no identifiable contributing cause. Ménière's disease usually presents in one ear, but over 20 years, approximately 20% of patients will exhibit symptoms in both ears.
Ménière's disease is a clinical diagnosis, based on the presentation of the classic symptoms listed above. However, vestibular test modalities including VNG, Rotary Chair and Posturography are useful in confirming the diagnosis and in establishing a care plan for an individual patient. Vestibular testing may also be employed to assess the inner ear function and balance compensation after certain treatments are administered.
While there is no cure for Ménière's disease, there are many treatment options available that can effectively control symptoms of the disease. First level interventions include medical therapy with diuretics, allergy management, and dietary control. Second level treatment options including endolymphatic sac/shunt surgery, inner ear gentamicin perfusion, inner ear steroid perfusion, and the Meniett Device. Third level interventions, reserved for patients who have failed first and second level treatments, include surgical interventions of labyrinthectomy and vestibular nerve section. Because Ménière's disease presents differently in each individual, the best treatment plan will also vary from patient to patient. Patients with Ménière's disease should be managed by a neurotologist, specializing in disorders of the inner ear, and capable of providing them with a range of treatment options to control the disease.
Benign Paroxysmal Positional Vertigo (BPPV)
Benign paroxysmal positional vertigo, also known as positional vertigo, benign positional vertigo, canalithiasis, cupulolithiasis, and BPPV, is the most common cause of peripheral (inner ear) vertigo. It is characterized by brief spinning vertigo lasting several seconds to a few minutes, usually occurring with turning the head, tilting the head back or leaning forward. Individuals with BPPV often complain of symptoms with rolling over in bed, getting in or out of bed, as well as symptoms throughout the day with head movement. Usually, symptoms are worse with turning to the affected side. In addition to the intermittent spinning sensation with head movement, some patients will have persistent dizziness, or a lightheaded sensation throughout the day. Often, symptoms will spontaneously resolve with in a few days. However, many patients have symptoms that, if left untreated, will last for weeks to months.
BPPV is caused by free-floating crystals (otoliths) in the balance canals. Otoliths are tiny calcium carbonate crystals that normally are positioned in another part of the inner ear, known as the utricle. When otoliths get displaced into a balance canal, symptoms of BPPV occur. The problem can occur in older children and adults of any age, but there is an increased incidence with advanced age. BPPV is also more common after head trauma, and in diagnoses of Ménière's disease, vestibular neuritis, and migrainous dizziness.
BPPV can often be diagnosed on direct physical examination. Sometimes, specialized testing using VNG/ENG equipment is needed to confirm the diagnosis.
Relief from persistent symptoms for most patients can be achieved by treatment in the office using an Epley Maneuver, also known as canalith repositioning maneuver, to move the otoliths out of the balance canal. This treatment can be performed by a balance therapist or by a physician. Some patients with persistent dizziness and balance problems may require longer term Vestibular and Balance Therapy to resolve all of their symptoms. Rarely surgery may be required to treat BPPV.
Aging of Balance System
Proper balance function is dependent on a variety of factors that may be affected as an individual ages. For many people, the inner ear balance organ weakens with age. Also, the brain's processing of signals from the inner ear can be slower and less effective. Orthopedic issues that affect muscles and joints can adversely affect balance function, as can other medical problems that affect a person's ability to stay physically active. Necessary medications may also impact balance function. As there is no one problem that causes balance dysfunction in older people, it is important to have an appropriate assessment to determine the potential causes as well as ways to improve the balance function. Vestbular testing including VNG, rotary chair and posturography help identify causes of balance dysfunction in older patients. Vestibular rehabilitation therapy can significantly improve balance function and restore safety for a significant percentage of individuals suffering from balance disorders related to aging.
Vertigo of Central (brain) Origin
Central vertigo is a term used to describe vertigo arising from the central nervous system (CNS) and includes diseases affecting the brain and cranial nerves. Any of a number of diagnoses that affect the CNS, including stroke and ischemia (vertebrobasilar disease), multiple sclerosis, migrainous vertigo, infections of the brain, benign and malignant tumors of the brain, and acoustic neuromas may cause central vertigo. Patients with central causes of vertigo tend to have more lengthy periods of dizziness and vertigo that do not follow a specific pattern for a peripheral (inner ear) vertigo. They may also exhibit other neurological symptoms including headaches, and sensory or motor symptoms. A careful review of symptoms, physical examination, vestibular tests and radiology studies are used to identify central vertigo diagnoses. Results of vestibular testing including ENG/VNG, Rotary Chair Testing and Computerized Dynamic Posturography can often be used to help distinguish between central and peripheral vertigo causes.
Migrainous dizziness and vertigo refers to symptoms of dizziness, lightheadedness, or spinning sensation that occur due to migraine. Patients with a history of migraines or a strong family history of migraines are more likely to experience migrainous dizziness. These symptoms can occur with associated headache symptoms, but can also present independent of the classic migraine picture. Migrainous dizziness and vertigo tends to persist for longer duration than is typically seen in inner ear disorders. Some patients may also experience other ear related symptoms including hearing loss and tinnitus. Interestingly, migrainous dizziness has been shown to have an increased frequency in patients with other inner ear disorders including BPPV and Ménière's disease. The understanding of migrainous dizziness and vertigo is relatively new and evolving. Currently, there is not a definitive test to diagnose the problem, although there is evidence that certain findings on VNG and Rotary Chair testing are specific to migrainous dizziness. Patients with migrainous dizziness should be evaluated and managed by a neurologist or neurotologist. Effective management can usually be achieved by treatment with suppressive migraine therapies and by following a migraine diet.
Labyrinthitis is defined as an acute inflammation of the labyrinth (inner ear hearing and balance organs). When suffering from labyrinthitis, an individual will experience a combination of severe vertigo, dizziness and associated hearing loss. This diagnosis differs from Vestibluar Neuritis where only the balance function is impaired. Labyrinthitis is usually due to a viral etiology and often will follow a flu-like illness. Rarely, it is caused by an acute bacterial infection, or by a more chronic disease process, such as cholesteatoma. Labyrinthitis is usually treated acutely with supportive care for the vertigo, and steroids for the inner ear inflammation. Vestibular testing may be useful to determine the amount of acute damage caused by the labyrinthitis to the inner ear, and the resulting level of balance dysfunction. Many patients may benefit from Vestibular Rehabilitation (balance) Therapy for persistent balance problems. Some patients may also need amplification for hearing loss. Patients with labyrinthitis symptoms should be seen by an ear specialist to maximize their recovery from the event.
Vestibular neuritis is defined as an acute inflammation of the vestibular (balance) nerve. In an attack of vestibular neuritis, the patient will experience severe vertigo, nausea, and vomiting that may last for several days, followed by persistent balance dysfunction that lasts for weeks to months. This diagnosis differs from labyrinthitis, where both the hearing and balance function are affected. The cause of vestibular neuritis is thought to be viral and occurrence is often preceded by cold or flu-like symptoms. Vestibular neuritis is usually treated acutely with supportive care for the vertigo, and steroids for the inner ear inflammation. Vestibular testing may be useful to determine the amount of acute damage caused by the vestibular neuritis to the vestibular nerve, and the resulting level of balance dysfunction. Many patients may benefit from Vestibular Rehabilitation (balance) Therapy for persistent balance problems. Patients with vestibular neuritis symptoms should be seen by an ear specialist to maximize their recovery from the event.
A stroke involving the brainstem or cerebellum may cause acute vertigo or dizziness symptoms. Usually there are other presenting stroke symptoms such as difficulty speaking and paralysis that occur in addition to vertigo. However, occasionally the patient presents with severe vertigo as the only symptom. Chronic balance dysfunction commonly persists after the initial recovery period. Vestibular testing can determine the degree of persistent balance dysfunction following a stroke. Most individuals who have suffered a stroke will benefit from Vestibular Rehabilitation (balance) Therapy to improve their overall balance function and safety in movement.
An Vestibular Schwannoma (also known as an Acoustic Neuroma) is a non-cancerous tumor that grows on the cochleovestibular (hearing and balance) nerve that connects the inner ear to the brain. The tumor actually arises from support cells, known as schwann cells, that surround the nerve and typically starts on the vestibular (balance) nerve, but will often invade the cochlear (hearing) nerve as it grows. Symptoms of vestibular schwannomas include hearing loss and tinnitus on the affected side, and dizziness or balance problems. As these symptoms are also associated with a variety of other diagnoses affecting the ear and brain, just having the above symptoms does not mean one has an acoustic neuroma. An MRI scan with contrast can confirm or disprove the presence of an acoustic neuroma. Vestibular testing is often useful in determining the amount of damage to the balance nerve by the tumor. Recommended treatment is dependent on several factors including the size of the tumor, the patient's age, hearing, and general health. Treatment options include surgery, stereotactic radiotherapy (cyberknife, gammaknife) and observation. Patients with acoustic neuromas should be evaluated and managed by a skull base surgery team including a neurotologist, neurosurgeon, neuroradiologist and radiation oncologist. (link to skull base surgery center when available).
Patients who have undergone treatment for vestibular schwannomas often have long-term balance problems and can benefit from Vestibular Rehabilitation (balance) Therapy to help them recover function and improve safety in movement.
Motor or Visual Disturbances
The body's visual and motor systems are essential to maintain proper balance. An ongoing problem with either system can independently cause dizziness or balance problems, or can intensify an underlying balance problem. Visual disturbances include such problems as presbyopia, glaucoma, cataracts, macular degeneration, as well as motor problems of the eye such as strabismus. Motor problems include any disease process that affects motion and stability of the limbs and include such disorders such as Parkinson's disease and Multiple Sclerosis. Specialized balance tests, particularly Computerized Dynamic Posturography, can help determine how much motor and vestibular disturbances may be contributing to an individual's balance problems. Patients with motor or visual disturbances that affect their balance function can benefit from Vestibular Rehabilitation Therapy to improve their overall balance function and safety in movement.