Diagnosis and Treatment of Dizziness and Balance Disorders

Dizziness and balance disorders are common complaints that may be symptoms of different diseases. A detailed clinical history, examination, and objective tests are performed for an accurate diagnosis. During this process, inner ear, nervous system, and cardiovascular causes are distinguished, and the appropriate treatment is determined.

Audiometric tests, vestibular assessments, and imaging methods are used during the diagnostic stage. In particular, methods such as computerized dynamic posturography and caloric testing allow the balance systems to be examined in detail. This enables an accurate diagnosis.

The treatment process is planned according to the disease causing the dizziness. Vestibular rehabilitation, medication, or surgical methods may be used. Lifestyle modifications also play a supportive role in controlling balance disorders.

Regular follow-up is critically important in preventing the recurrence of dizziness and balance loss. Early diagnosis and personalized treatment improve patients’ quality of life. This makes daily activities safer and minimizes the risk of falling.

What Is Benign Paroxysmal Positional Vertigo?

Benign Paroxysmal Positional Vertigo (BPPV) is the most common type of peripheral vertigo. This condition is characterized by sudden dizziness attacks triggered by changes in head position. Vertigo is generally experienced as a brief spinning sensation lasting several seconds, and certain movements may trigger it. BPPV occurs as a result of displacement of the otoliths in the inner ear. Otoliths are small crystals that detect head movement, and abnormal positioning of these crystals causes incorrect signals to be sent to the brain.

BPPV is generally diagnosed with the Dix-Hallpike test. During this test, the physician rapidly moves the patient into a lying position while holding the head at a specific angle. Vertigo and nystagmus may be observed during this procedure. BPPV is most commonly managed with specific positional maneuvers such as the Epley maneuver. These maneuvers are designed to return the otoliths to their correct positions within the ear.

Management Methods:

• Epley maneuver
• Semont maneuver
• Brandt-Daroff exercises

These treatment methods are effective for most patients and generally do not require surgical intervention. However, some patients may experience temporary discomfort after these maneuvers. If symptoms continue despite treatment, patients are advised to consult a specialist for a more detailed evaluation of their condition.

Which Treatment Approaches Are Available for Benign Paroxysmal Positional Vertigo?

Benign Paroxysmal Positional Vertigo (BPPV) occurs as a result of displacement of small calcium carbonate crystals in the inner ear. Patients generally consult a physician with complaints of sudden dizziness and imbalance. The first step in managing this condition is patient education and appropriate counseling. Healthcare professionals should inform patients about the causes of the symptoms and the treatment process. A comprehensive treatment plan is also implemented to improve patients’ quality of life.

Repositioning maneuvers are highly effective in the treatment of BPPV. These maneuvers aim to move the otolith particles to the correct position within the inner ear. Repositioning maneuvers are generally simple and safe to perform. They can be learned easily by emergency department physicians and primary healthcare providers. During the treatment process, the affected side is determined using the Dix-Hallpike maneuver, followed by the Epley maneuver.

Points to consider during maneuver applications include:

• PRM and the Epley maneuver are used in the treatment of posterior canal BPPV.
• The Semont maneuver is an effective alternative that is particularly well tolerated by patients.
• The Epley maneuver involves moving the head through various positions and is performed in the following sequence:
  • Starting in a seated position, the patient turns the head toward the affected side.
  • While lying on the back, the patient turns the head 45 degrees toward the affected side.
  • The patient then lies on the side while the head is turned toward the opposite side.
  • Finally, the patient returns to a seated position and the head is brought back to the midline.

Some patients may require medication during treatment. Antihistamines may reduce vertigo symptoms by suppressing the vestibular system. However, because vertigo attacks associated with BPPV are generally very brief, medication is not always recommended.

Antiemetics may be used for additional symptoms such as nausea and vomiting. These medications should be administered at appropriate doses to reduce patients’ symptoms and side effects.

In some cases, more specific maneuvers may be required for certain types of BPPV. Different repositioning maneuvers may be performed particularly for lateral and horizontal canal BPPV. In these cases, patients are referred to ear, nose, and throat specialists for further evaluation and treatment.

How Is Meniere’s Disease Defined?

Meniere’s disease is a chronic condition caused by fluid imbalances in the inner ear. It is characterized by hearing loss, tinnitus, and episodic attacks of dizziness. The disease generally affects one ear and impairs the individual’s hearing and balance functions. This condition progresses slowly and has significant effects on social life.

The diagnosis of Meniere’s disease is classified into two main categories:

Symptoms of definite Meniere’s disease:

• Two or more spontaneous vertigo attacks, each lasting from 20 minutes to 12 hours.
• Hearing loss in the affected ear has been documented audiometrically before, during, or after one of the vertigo attacks.
• Fluctuating auditory symptoms, including fullness, hearing loss, and tinnitus.
• The symptoms cannot be explained by another vestibular diagnosis.

Symptoms of probable Meniere’s disease:

• Two or more episodes of dizziness or vertigo, each lasting from 20 minutes to 24 hours.
• Fluctuating auditory symptoms in the affected ear, including fullness, changes in hearing, or tinnitus.
• This condition may be better explained by another vestibular diagnosis.

Which Treatment Options Are Available for Meniere’s Disease?

Meniere’s disease is a condition associated with fluid accumulation in the inner ear and causes various symptoms. The aim of treatment is to reduce the frequency and severity of the symptoms. Treatment methods for Meniere’s disease progress gradually from non-invasive approaches to more invasive methods. Preserving patients’ quality of life is the primary objective throughout this process.

• Sodium-Restricted Diet: Reducing sodium intake in Meniere’s disease may help control the frequency of attacks. This method can be implemented easily through dietary changes and carries no risk of side effects.
• Thiazide Diuretics: These medications are widely used in the management of Meniere’s disease. They help relieve symptoms by reducing the amount of fluid in the body. However, this treatment does not prevent hearing loss.
• Intratympanic Steroid Injections: This treatment has the potential to preserve hearing function while reducing vertigo attacks. Steroids exert their effects by reducing inflammation in the inner ear.
• Vestibular Nerve Section and Labyrinthectomy: These surgical procedures are performed in severe cases of Meniere’s disease that do not respond to other treatment methods. The procedures provide vertigo control but may cause permanent consequences such as hearing loss.

In the treatment of Meniere’s disease, it is important to begin with the least invasive method possible and advance the treatment according to the patient’s condition.

What Is Vestibular Neuritis and How Is It Treated?

Vestibular neuritis develops as a result of inflammation of the eighth cranial nerve, and its main symptoms include dizziness, nausea, and balance disorders. This condition generally develops after a viral infection and is known as a benign, self-limiting disease. Although symptoms may decrease within several days, complete recovery may take weeks or months. Diagnosing the disease requires a careful clinical evaluation to avoid confusing it with other conditions that cause similar symptoms.

The treatment process is shaped according to the severity of the symptoms and the patient’s general health condition. Medications used during the initial stage of treatment include:

• Antiemetics
• Antihistamines
• Benzodiazepines

These medications aim to control dizziness and nausea. After the initial stage, vestibular rehabilitation becomes important as the patient’s condition begins to improve. This treatment aims to reduce balance problems and accelerate the patient’s return to daily activities. The rehabilitation process begins as the symptoms subside and includes personalized exercises.

Vestibular neuritis is a condition that tends to improve over time. However, the combined use of medical treatment and rehabilitation is recommended for a rapid and effective recovery. Treatment is planned with the goals of improving the patient’s quality of life and restoring functionality.

What Are the Treatment Methods for Vestibular Neuritis?

Vestibular neuritis occurs as a result of inflammation of the nerves in the inner ear and is characterized by symptoms such as imbalance and dizziness. The treatment process is shaped according to the severity of the symptoms and the patient’s general health condition. Various medications are initially used to control acute symptoms.

• Antihistamines
• Antiemetics
• Benzodiazepines

The use of these medications is generally limited to three days. This is because prolonged use may delay central nervous system compensation and potentially lead to chronic problems. Following the initial treatment phase, vestibular rehabilitation is recommended according to the patient’s condition. This rehabilitation helps reduce the feeling of imbalance and accelerate the return to normal daily activities.

Although corticosteroids were preferred in some cases in the past, there are various debates regarding the effectiveness of this method. Studies have shown that these medications do not provide a definite benefit in the treatment of vestibular neuritis. Antiviral treatment approaches based on a viral etiology have also generally been found to be ineffective.

What Is a Perilymphatic Fistula and Why Is It Important?

A perilymphatic fistula is an abnormal connection between the inner ear and the surrounding structures. This condition specifically causes leakage of perilymphatic fluid from the inner ear. First described in four patients in 1970, it is known particularly as a problem that develops after stapedectomy or stapes mobilization.

Symptoms caused by a perilymphatic fistula include:

• Fluctuations in hearing
• A feeling of fullness in the ear
• Vertigo
• Tinnitus
• Imbalance

Which Treatment Approaches Are Used for Perilymphatic Fistulas?

Surgical and conservative methods are considered together in the treatment of perilymphatic fistulas. During the initial stage, keeping the head elevated and resting in bed are recommended. This balances the pressure in the inner ear and may reduce the severity of the symptoms. If these methods do not improve the symptoms, surgical intervention is considered. Surgical procedures are generally effective in relieving symptoms but may increase the risk of hearing loss.

Surgical treatment options include:

• Exploratory tympanotomy: It generally reduces dizziness and vertigo symptoms.
• Corticosteroid administration: It may support hearing recovery.
• Mastoid obliteration: It may improve postoperative dizziness.

In fistulas caused by cholesteatoma, the fistula is completely cleaned and then closed. This process generally carries a risk of canal function loss. However, resurfacing the horizontal semicircular canal may reduce this risk. Surgical approaches generally provide better outcomes for vestibular symptoms but are less effective for auditory symptoms. During treatment, the patient and physician should remain attentive to the recurrence of symptoms and potential risks.

What Is Orthostatic Hypotension and What Are Its Effects?

Orthostatic hypotension is a condition in which blood pressure decreases with postural changes. This disorder involves a sudden reduction in blood pressure when moving from a seated or lying position to standing. It generally occurs due to an inadequate response of the autonomic nervous system. This condition is particularly common in older adults and may lead to serious health problems.

This health condition presents with the following symptoms:

• Dizziness
• Visual disturbances
• A feeling of fatigue
• Fainting and a feeling of faintness

Risk factors include advanced age, certain medications, or volume depletion. Autonomic failure or serious diseases may also cause orthostatic hypotension. The condition is generally diagnosed through clinical examination and specialized tests. The tilt table test is one of the important methods used in diagnosis.

The management of orthostatic hypotension varies according to the severity of the symptoms and the patient’s general health condition. Points to consider during the management process include:

• Adequate fluid intake
• Increasing salt consumption
• Adjusting medication doses

In addition, certain lifestyle changes are also highly important. Regular exercise and changing positions slowly may help overcome these problems. Patients are advised to be careful while managing this condition and take precautions against risks such as falls.

How Is Orthostatic Hypotension Managed?

Orthostatic hypotension may occur for various reasons, and its treatment varies accordingly. Persistent conditions such as Parkinson’s disease should be considered when determining treatment strategies. On the other hand, correctable causes such as anemia require prompt intervention. Effective management by healthcare providers is essential for reversible conditions such as dehydration, medication side effects, and infections.

Non-Pharmacological Measures:

• Change your movements slowly and gradually; move from lying to sitting and from sitting to standing.
• Ensure adequate fluid intake and avoid dehydration.
• Avoid alcohol, hot environments, and large meals.
• Sleep with the head of the bed elevated.
• Follow regular exercise programs.
• While standing, support blood circulation by crossing your legs and tightening your hip muscles.
• Use compression stockings for the lower extremities.
• Wrap the abdominal region with supportive binders.

During treatment, patients are informed about the symptoms and triggering factors of orthostatic hypotension. Worsening of symptoms is generally associated with situations such as standing for long periods or taking hot baths. Avoiding these factors is critically important in managing the symptoms.

Frequently Asked Questions

Dr. Ody. Emel Uğur

Dr. Audiologist Emel Uğur was born in 1982 in Çanakkale. She specialized in Pediatric Audiology, Otologic Disorders, and Vestibular System Disorders, and served for 15 years at the Istanbul Training and Research Hospital. In 2015, she joined the Acıbadem Healthcare Group. She currently works as an Audiologist at the Acıbadem Altunizade Hospital and also serves as a faculty member and program director in the Acıbadem University Vocational School of Health Services Audiometry Program.