Balance Disorders

Balance Disorder - What are Balance Disorders?

Balance disorders are disturbances in co-ordination that makes a person feel unsteady, dizzy or have a sensation of movement or spinning.

The problem more often than not lies within the ears. Within the ear is a part called the inner ear. This has organs that are responsible for normal balance mechanisms. 

Normal mechanism of balance

The inner ear contains an organ called the labyrinth. The inner ear co-ordinates with the eyes (what they see), as well as the feeling of the bones and joints, to maintain normal balance.

The inner ear sends signals to the brain that also receives signals from these peripheral organs to given an idea of the position of the body. This helps in maintenance of balance.

The labyrinth has a structure called the semicircular canals. These allow a person to feel and experience rotary (circular) motion.

There are three semicircular canals called the superior, posterior, and horizontal canals. The canals converge at a point and this is close to the cochlea that is responsible for hearing. These are filled with a fluid.

As the body moves, this fluid also moves. The ends of the semicircular canals have a bulb like formation that contains hair-like tiny cells.

Rotation of the head causes a movement of the fluid leading to movement of the top portion of the hair cells that are embedded in the jelly-like cupula.

There are two other organs called the utricle and saccule that are called otoliths. These detect linear acceleration, or movement in a straight line. 

Symptoms of balance disorders

The symptoms of balance disorders include difficulty in maintaining orientation. One of the commonest complaints is feeling dizzy or experiencing vertigo. The room appears to be spinning. There may be light headedness or a feeling of floating.

Sometimes there may be blurring of vision as well. Along with vertigo there is commonly nausea and vomiting, diarrhea, faintness, palpitations, drop in blood pressure, fear, anxiety, or panic.

Causes of balance disorders

There are several causes of balance disorders. Diseases and disorders affecting the brain or the inner ears are commonly responsible for balance disorders.

Some common causes include infections of brain or inner ear, head injury, disorders of blood circulation affecting the inner ear or brain, certain medications, as part of aging etc.

Some of the types of balance disorders include Benign Paroxysmal Positional Vertigo (BPPV), labrynthitis, Ménière's disease, vestibular neuronitis etc.

Diagnosis of balance disorders

Diagnosis of a balance disorder involves several laboratory as well as imaging studies. There are several associated conditions that may lead to balance disorders including ear infections, blood pressure changes, problems in vision etc.

Diagnosis is usually made by an ENT specialist (Ear, nose and throat disease specialist) also known as an otolaryngologist.

Treatment of balance disorders

Treatment of balance disorders depends on the cause underlying the condition. Problems of balance are symptoms of an underlying disease rather than a disease in itself.

One of the options is to treat the underlying disease such as ear infection, stroke, or multiple sclerosis.

The second option is to treat the symptoms of the condition. This can be achieved by balance retraining exercises (vestibular rehabilitation) etc. 

What Causes Balance Disorders?

Several diseases and disorders affecting the inner ear or brain or certain medications may cause balance disorders. The causes may vary from infections (viral or bacterial), head injury, disorders of blood circulation etc.

Those who have injuries or illnesses of the eyes or have problems with the skeletal system (e.g. arthritis) may also experience balance difficulties.  These disorders may lead to a conflict of signals to the brain about the sensation of movement and can lead to balance problems.

If there is a conflict of signals between the eyes and the brain, for example, if a person tries to read while riding in a car, there is motion sickness. Some symptoms of motion sickness include dizziness, sweating, nausea, vomiting, and generalized discomfort. 

Main causes of balance disorders

Broadly classifying balance disorders may occur due to problems in any of the four areas:-

  • Disturbances of the labyrinth in the inner ear – Peripheral vestibular disorder
  • Disturbances in the brain or its connecting nerves - Central vestibular disorder
  • Problems of the body other than the head and brain – Systemic disorder
  • Blood flow problems or Vascular disorder

Types of balance disorder

Some of the different types of balance disorder leading to impaired sense and maintenance of balance include:-

Benign Paroxysmal Positional Vertigo (BPPV)

This condition is characterized by brief but severe episodes of vertigo brought about by specific positional change of the head.  The movement could be trivial for example rolling within the bed or trying rise up to a sitting position from lying position or even looking up at an object.

It is found that movement of chalk crystals (otoconia) within the inner ear from one part of the balance system (utricle and saccule) to another part of the balance system (semi-circular canals) due to movement of the head gives rise to the symptoms.

Although the exact cause of the condition is unknown, it is thought to be caused as a part of normal aging, infection or head injury.

Ménière's disease

This is caused by an imbalance between the pressures of the fluids within the inner ear. The exact cause is unknown. There are episodes of vertigo, hearing loss and sensation of fullness in the ear along with tinnitus (a ringing or roaring in the ears).

Labrynthitis

This is caused by infection and/or inflammation of the inner ear causing dizziness and loss of balance.

Vestibular neuronitis

This is caused by an infection of the vestibular nerve caused by a virus. There is generally rotatory vertigo (horizontal or vertical spinning) that may last for up to 48 hours, exacerbated by movement.

Perilymph fistula

In this condition there is leakage of inner ear fluid to the middle ear. This occurs due to head injury.

Other causes of balance disorders

Certain medications that depress the central nervous system may also increase the rate of falls by increasing the lack of coordination.

Arthritis, joint pain, stroke, visual impairment, back or neck pain, myelopathy due to cervival spondylosis,  normal-pressure hydrocephalus, parkinsonism and fall of blood pressure on standing (orthostatic hypotension) are other causes of balance problems and risk of falls among the elderly.

Problems in the cerebellum of the brain also contribute to balance disorders.

Balance Disorder Symptoms

Balance disorders are diseases that give rise to symptoms of impaired balance and co-ordination.

The balance problems are thus symptoms rather than a disease it itself. Some of the symptoms associated with balance disorders include:-

  • Dizziness or vertigo with the room appearing to be spinning.
  • There may be disorientation.
  • There is marked change and deterioration of independent walking and mobility. The gait is typically staggering as the sufferer struggles to maintain balance.
  • Some persons may have difficulty in rising from a lying or sitting position.
  • There may be an increased risk of falls or actual falls. The sufferer may also complain of a feeling of falling.
  • There is a sensation of light headedness or feeling woozy.
  • Sometimes there may be double vision or blurring of vision.
  • Nausea and vomiting, diarrhea and faintness may be seen as associated symptoms.
  • The heart rate may accelerate leading to palpitations. In addition there may be fall in blood pressure accompanied by increased sweating.
  • There may be exaggerated fear, anxiety or panic in response to disorientation.
  • Sometimes there may be symptoms of depression, fatigue and reduced concentration as well.
  • In specific balance disorders like Benign Paroxysmal Positional Vertigo (BPPV) there are characteristic symptoms. These include severe and intense short episodes of dizziness associated with moving the head or even turning over in bed or sitting up from lying position.
  • In acute vestibular neuronitis, or labyrinthitis there is inflammation of the inner ear. This leads to sudden, intense vertigo persisting along with nausea and vomiting for several days. This condition leads to severe disability and mandates bed rest.
  • Meniere's disease leads to repeated sudden episodes of vertigo lasting 30 minutes or longer. This is accompanied by fluctuating hearing loss and a feeling of fullness in the ear. In addition to these symptoms there are symptoms of buzzing or ringing in the ear (tinnitus). 
  • Vestibular Migraine may present with or without severe headaches. The dizziness may last for several minutes to days. The episodes of dizziness may be brought about by quick head turns, driving or riding in a vehicle or when watching TV. In addition there may be hearing loss, and ringing in the ears (tinnitus).

Balance Disorder Pathophysiology

Balance disorders are caused by several incidents that may be episodes of infection, injury or blood flow problems to the inner ear or to the brain.

Normal functioning of the balance organs within the ear

The ears are divided into three discernible parts – the outer, middle and the inner ear. The outer ear is composed of the pinna that brings in sound waves onto the ear drum.

The middle ear amplifies the sound wave and transmits it into the inner ear. 

The inner ear contains an organ called the labyrinth. There two major organs in the inner ear – the cochlea or the shell shaped hearing organ and the semicircular canals or the balance organs.

The semicircular canals work to co-ordinate with the eyes (what they see) as well as the feeling of the bones and joints to maintain normal balance.

When the inner ear coordinates with the signals from the eyes, it is called the vestibulo-ocular reflex (VOR). The inner ear sends signals to the brain that also receives signals from these peripheral organs to given an idea of the position of the body. This helps in maintenance of balance.

The semicircular canals are three tubes set in three different right angles. They have a bulb at their ends. These are called superior, posterior, and horizontal canals. The canals converge at a point and this is close to the cochlea. These are filled with a fluid. As the body or the head moves, this fluid also moves.

The bulbs at the ends of the canals contain tiny hair like structures. Rotation of the head causes a movement of the fluid leading to movement of the top portion of the hair cells that are embedded in the jelly-like cupula.

There are two other organs called the utricle and saccule that are called otoliths. These detect linear acceleration, or movement in a straight line.  When the hair is displaced, it sends signals to the brain via nerves and the body corrects itself or balances accordingly.

Pathophysiology of balance disorders

An acute loss of balance sensation can be either partial or total. It may be caused by viral infections or due to injury to the vital structures of the brain or inner ear.

In the case of benign paroxysmal positional vertigo (BPPV),  calcium carbonate crystals get dislodged from their usual position and move to one of the semicircular canals of the inner ear when the head is moved. There is an incorrect registration of movements with changes in body position and this may trigger an episode of intense vertigo.

Injuries to the central nervous system may be caused by head injury or by disturbances of the blood circulation. This leads to dizziness, vertigo, and disequilibrium.

With age there is a deterioration of the balance system leading to balance problems. Physical disabilities such as arthritis and joint pain also contribute to the problem.

Balance Disorder Diagnosis

There are several disorders that may lead to balance problems. Diagnosis aims at detecting the cause of balance problems. Balance problems thus are symptoms of an underlying condition rather than a disease in itself.

The cause of balance problems may vary between ear infections, blood pressure changes, vision problems or even medications that may cause balance problems.

Steps in diagnosis of the conditions include:-

  • Complete evaluation of the problem with history of onset, duration of the balance disorders and family history.

A precipitating ear infection, vision problem or head injury or a history of intake of a balance problem causing medication is often found upon enquiring the history from the patient. This may provide valuable clues in diagnosing balance problems.

Evaluation and diagnosis may be made by a primary physician who may then request the opinion or refer to an otolaryngologist to help evaluate a balance problem. An otolaryngologist or ENT surgeon is a physician/surgeon who specializes in diseases and disorders of the ear, nose, throat, head, and neck.

  • Physical examination – the next step is to obtain a detailed physical examination. The general health is examined that includes blood pressure and blood sugar evaluations, fluctuations of which may lead to balance problems or dizziness and falls. The ears are examined for abnormalities, hearing difficulties and infections if any.
  • An electronystagmogram (ENG) is often advised. This test checks for abnormalities of the vestibular system. The caloric test may be performed as part of the ENG.

For this test each ear is flushed with warm and then cold water one at a time. When water is flushed, the eyes move rapidly from side to side. This is called nystagmus. The amount of nystagmus resulting from the test is measured. Weak nystagmus or the absence of nystagmus may indicate an inner ear disorder.

  • Another test for vestibular health is called posturography. The patient is asked to stand on a special platform capable of movement within a controlled visual environment. The sway of the body in response to movement and visual environment is recorded.
  • Blood tests for detection of abnormalities like anemia, high or low blood sugar are advised. Usually a complete blood count, thyroid function test, liver and kidney function tests, electrolytes, blood urea nitrogen, creatinine, glucose, and vitamin B12 levels are tested.
  • Imaging studies of the head including CT scan (Computed Tomography scan) or MRI scan (Magnetic resonance imaging scan) are performed to check for injuries and abnormalities in the brain and cerebellum part of the brain that controls balance and coordination.

Balance Disorder Treatments

Balance problems are symptoms of an underlying condition rather than disease in itself. There are several different causes and varieties of disorders that may lead to balance problems.  Thus treatment of balance disorders is also wide ranging and varied.

For example, balance problems caused by ear infections are treated using antibiotics and anti-inflammatory agents while those due to side effects of medications are treated with stopping the suspected drug or medication. Some of the treatment options include:-

  • Treatment for a disease or disorder that is leading to balance problems. This could be an ear infection, stroke, or multiple sclerosis. Other causes such as head injuries and disorders of the joints, high or low blood pressure and blood sugar are also treated specifically.
  • Diet and lifestyle changes – in patients of Ménière's disease, dietary changes such as reducing intake of sodium or salt may help in reducing the symptoms of dizziness. In most patients avoidance of alcohol, caffeine and nicotine is advised.
  • Treatment of inflammation within the inner ear.  This includes labyrinthitis or vestibular neuroninitis. These are treated using anti-inflammatory agents including corticosteroids.
  • Some aminoglycoside antibiotics, such as gentamicin and streptomycin may be used in treatment of balance problems caused by Ménière's disease. Streptomycin injections and application of gentamicin directly into the inner ear are useful for their ability to affect the hair cells of the balance system. Gentamicin also can affect the hair cells of the cochlea leading to hearing loss.
  • Certain drugs may be used in some balance disorders. For example, in Ménière's disease Beta-histine can ease symptoms. Diuretics like hydrochlorthiazide may also be used.

Other drugs include sedatives for dizziness including lorazepam that does not ease symptoms but helps patients cope with the sensation. Some drugs that work on motion sickness may be used. This includes drugs belonging to the classes antihistaminics and anticholinergics.

Some calcium channel blockers like Verapamil and Nimodipine and GABA modulators like gabapentin and Baclofen may also help. Neurotransmitter reuptake inhibitors such as antidepressants SSRIs (Selective Serotonin Reuptake Inhibitors) including Fluoxetine, Escitalopram and trycyclic antidepressants including imipramine etc. may be useful in some patients.

  • Balance retraining exercises (vestibular rehabilitation) – these exercises involve specific movements of the head and body. This helps in promotion of the compensation for the disorder. These are usually performed under the guidance of professionals with knowledge and understanding of the vestibular system and its association with other organs of the body.

Those with Benign Paroxysmal Positional Vertigo (BPPV) suffer from dizziness due to misplaced crystals within the ear. Treatment involves moving these crystals out of areas that may trigger dizziness. This is achieved by head and neck positional exercises.

  • In addition there may be counselling and cognitive behavioral therapy that is useful in persons with anxiety and depression.
  • Surgery is necessitated in some severe causes of balance disorders. For example, in severe cases of Ménière's disease, surgery is the last resort. Surgical methods for Ménière's disease include Vestibular neuronectomy and Labyrinthectomy.

Balance Disorder Research

Balance disorders are a variety of diseases and disorders that affect the inner ear or the brain. These conditions may also be caused as a side effect of several chemicals and medications. Scientists are researching the various underlying pathologies that may give rise to balance problems.

The areas of research include the complex interactions between the balance-sensing organs, vision, labyrinth and the brain.

Age and balance

Researchers are looking at how advanced age is affecting normal balance. With the increase in the elderly population due to longer life expectancies these areas of research are gaining importance.

More elderly are suffering from an impaired quality of life due to impaired mobility, lack of motor co-ordination and inability to lead an independent life.

Vision and balance disorders

The correlation between vision and balance disorders is also an important area of research. Researchers are looking at disease and injuries of the eyes and the nerves that connect the balance organs, eyes and the brain. Researchers are looking at eye movement and posture changes that may affect balance.

Pathological diseases of the inner ear and balance disorders

Pathological diseases of the inner ear and long term consequences of ear infections and brain infections like meningitis and encephalitis are also an area of research.

Genetic causation of ear problems and subsequent balance problems in some diseases and disorders are being studied widely all over the world.

Treatments of balance disorders

The other part of research focuses on treatments of balance disorders. In addition, there are studies supported by the National Institute on Deafness and Other Communication Disorders (NIDCD) that also show that the vestibular system plays an important role in modulating blood pressure. This could help in management of posture related fall of blood pressure called orthostatic hypotension.

Orthostatic hypotension refers to sudden fall of blood pressure when an individual changes his or her position from sitting to standing or lying to sitting. This leads to severe dizziness and balance problems.

Studies on otolithic organs

There are studies that explore otolithic organs within the inner ears that detect linear movement. It is being studied how these organs differentiate between downward (gravitational) motion from linear (forward-backward or side-to side) motion.

Exercises as a treatment

Several researchers are working on the effectiveness of certain exercises as a treatment option. Strategies for new physical rehabilitation are also under investigation in clinical and research settings.

Further research

NIDCD, along with other Institutes at the National Institutes of Health, joined the National Aeronautics and Space Administration (NASA) for Neurolab are studying exposure to the weightlessness of space and balance changes associated with the condition.