Vertigo (Dizziness) / Diseases That Cause Imbalance

Inner ear conditions that cause vertigo (dizziness) lead to a disruption in the sense of balance and impair an individual’s spatial orientation and navigation skills.

For example, Benign Paroxysmal Positional Vertigo (BPPV), one of the most common inner ear disorders, is characterized by sudden episodes of vertigo triggered by head movements. On the other hand, Meniere’s Disease is associated with an excessive increase in endolymph fluid in the inner ear.

An increase in fluid in the inner ear—which houses both the balance and hearing organs—can also cause additional symptoms such as hearing loss, a feeling of fullness, and tinnitus. Conditions like motion sickness or Migraine-Associated Vertigo (Vestibular Migraine) can negatively affect daily life. Therefore, not every balance disorder and dizziness is the same, and their treatment and rehabilitation cannot be identical.

Doctor Audiologist Emel Uğur

Dr. Audiologist Emel Uğur was born in 1982 in Çanakkale. During her 15-year tenure at Istanbul Training and Research Hospital, she primarily worked on Pediatric Audiology (Hearing Loss in Infants and Children), Otological Diseases (Ear Diseases and Hearing Health), and Vestibular System Disorders (Vertigo and Imbalance). In 2015, she joined the Acıbadem Healthcare Group.

About Me

What is Benign Paroxysmal Positional Vertigo (BPPV)?

Benign Paroxysmal Positional Vertigo (BPPV) occurs as a result of the displacement of otoconia (calcium carbonate crystals) in the inner ear. This condition causes imbalance and severe vertigo when the head changes position. Diagnostic tests for positional dizziness trigger vertigo to confirm the diagnosis.

• The condition is generally observed in individuals between 50 and 70 years of age, although it can occur at any age.
• It is less common in those under 35 and mostly develops after head trauma.
• Studies in the United States report 64 cases per 100,000 people per year, although its frequency is likely higher. Various studies showing an annual increase of 38% are more reflective of patients’ access to hospitals, the availability of diagnostic methods, and the number of specialists focused on balance disorders.
• A study in Europe determined the lifetime prevalence of BPPV to be 2.4%.
• Women are more affected than men; prevalence rates of 3.2% in women versus 1.6% in men have been observed.
• In Japan, the annual incidence has been reported to range between 10.7 and 17.3 per 100,000.

What is Labyrinthitis?

Labyrinthitis is the inflammation of the membranous labyrinth in the inner ear. It presents with symptoms such as severe vertigo, hearing loss, and nausea. The primary causes include viral and bacterial infections.

Viral labyrinthitis typically develops after an upper respiratory tract infection. Bacterial labyrinthitis is less common and can lead to serious complications. The inflammation in the inner ear directly affects both hearing and balance functions.

To choose an effective treatment method, it is first necessary to accurately determine the etiology. Therefore, collaboration between ENT specialists and audiologists is required. While viral labyrinthitis generally resolves on its own, bacterial labyrinthitis requires antibiotic treatment. In both cases, supportive treatments can be applied to alleviate the symptoms.

During the course of the illness, special measures are recommended to help patients maintain their balance and prevent falls. Additionally, to minimize labyrinthitis damage and, if possible, ensure recovery without harm, vestibular rehabilitation should begin as soon as possible.

Causes:

• Viral infections
• Bacterial infections

Symptoms:

• Vertigo
• Hearing loss
• Nausea

Treatment:

• Supportive treatment for viral labyrinthitis
• Antibiotic treatment for bacterial labyrinthitis

Rehabilitation:

• Control of vertigo
• Restoration of balance
• Improvement of dynamic balance skills

What is Meniere’s Disease?

Meniere’s Disease is a type of inner ear disorder. It presents with distinct symptoms that significantly reduce an individual’s quality of life. The disease is characterized by hearing loss, tinnitus, a feeling of fullness in the ear, and severe vertigo attacks. The duration of these attacks can vary between twenty (20) minutes and one hour.

The associated symptoms are defined as a documented low- to mid-frequency sensorineural hearing loss in the affected ear. Another key feature in Meniere’s patients is the fluctuation of hearing—either an increase during an attack, a return to baseline after an attack, or fluctuating auditory symptoms.

According to international consensus, the diagnostic criteria for Meniere’s Disease have been reclassified into possible (probable) and definite Meniere’s.

Definite Meniere’s:

• Two or more spontaneous vertigo attacks, each lasting between twenty minutes and twelve hours.
• At least one of the vertigo attacks includes significant hearing loss in the affected ear.
• Fluctuating auditory symptoms: ear fullness, hearing loss, tinnitus.
• Conditions that cannot be explained by any other vestibular diagnosis.

In possible Meniere’s disease:

• There are two or more episodes of imbalance or vertigo lasting between twenty minutes and twenty-four hours.
• Auditory symptoms are observed, except in cases better explained by another vestibular diagnosis.

The prevalence of the disease is variable. It is more frequently observed in the white race and among women, and is known to be associated with autoimmune disorders.

Meniere’s Disease interacts with motion sickness, visually induced motion sickness (VIMS), and vestibular migraine. In this context, it is thought that Meniere’s Disease is related to both genetic and environmental factors.

Meeting the definitive diagnostic criteria is very important in combating the disease. For this reason, the patient should undergo a complete audiological (hearing and balance) evaluation. Tests such as the caloric test and VEMP, among others, should be included in the differential diagnosis. A detailed evaluation is critical for both the treatment and rehabilitation approaches for the patient.

What is Vestibular Neuritis?

Vestibular neuritis is caused by the inflammation of the vestibular nerve. Acute vestibular neuritis is the third most common cause of peripheral vertigo. Vestibular neuritis presents with severe vertigo, nausea, and balance problems. This condition, which is usually seen following viral infections, is very distressing. The diagnosis is based on clinical findings and should not be confused with other conditions that exhibit similar symptoms.

The acute phase subsides within a few days, but complete recovery may take time. Recovery is not solely based on the patient’s subjective sense of improvement; clinically, the symptoms must subside and inner ear functions must return to normal. Therefore, along with treatments arranged by ENT specialists, audiologists should begin vestibular rehabilitation as early as possible.

It may be advisable to wait until the acute phase has passed before starting vestibular rehabilitation. However, with minor cues, the patient’s dizziness can be kept under control. Estimates in the United States suggest that about six percent of patients presenting with dizziness in the emergency department receive this diagnosis, although these figures may not fully reflect the true incidence.

This is because twenty percent of patients presenting with dizziness are discharged with non-specific diagnoses, which affects the statistics. Vestibular neuritis generally does not show a gender bias.

The management of the condition varies according to the severity of the symptoms and the overall condition of the patient. A personalized treatment and rehabilitation plan should be developed to meet each patient’s needs.

What is a Perilymphatic Fistula?

First described in 1970, a perilymphatic fistula is a problem originating from the membranous labyrinth of the inner ear. A structural leak in the membranous labyrinth can result in the mixing of inner ear fluids. It is known as an abnormal communication that becomes especially pronounced during increases in intracranial pressure and can cause vertigo. The symptoms of a perilymphatic fistula are quite pronounced and can significantly reduce a patient’s quality of life.

These symptoms include:

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

Perilymphatic fistula usually occurs as a result of damage caused by cholesteatoma and/or chronic infections, or spontaneously. It is rare, and the symptoms experienced can be very distressing. A comprehensive evaluation is essential before planning the treatment of a perilymphatic fistula.

The treatment process varies according to the severity of the patient’s symptoms and the extent of the damage caused by the fistula. In such cases, a multidisciplinary approach is important because proper management of the fistula is essential both for preserving hearing health and controlling symptoms such as vertigo.

What is Persistent Postural-Perceptual Dizziness (PPPD)?

Persistent Postural-Perceptual Dizziness (PPPD) is an internationally recognized vestibular disorder that was classified in 2017. This condition typically manifests when the person is in motion or in visually busy environments. Its features include:

• Symptoms that can last 90 days or more and typically occur daily.
• They are most pronounced when sitting upright, standing, or walking.
• Complex visual stimuli can exacerbate these symptoms.

This condition arises due to disturbances in visual processing and postural control mechanisms. Its association with other disorders explains its complex nature.

It is particularly associated with migraine, anxiety, and depression. It is essential to diagnose the underlying cause. Persistent Postural-Perceptual Dizziness is more commonly seen in women and is most prevalent in adults between 30 and 50 years of age. Additionally, it is observed four times more frequently in women than in men. Treatment methods include:

• Medical treatment targeting the underlying cause
• Vestibular rehabilitation
• Cognitive-behavioral therapy

What is Acoustic Neuroma (Vestibular Schwannoma)?

An acoustic neuroma is a generally benign, unilateral tumor originating from the vestibular nerve. Although the vestibular nerve is involved, the primary symptoms are tinnitus and unilateral hearing loss. Since balance control is based on multimodal integration, most patients are unaware of their balance impairment. Additionally, some patients may develop facial numbness and weakness.

Tumor Types:

• Sporadic acoustic neuroma: This type constitutes the majority and is generally unilateral.
• Bilateral acoustic neuroma: Typically associated with neurofibromatosis type 2 (NF2) and can affect both ears.

In NF2, tumors generally appear at an earlier age and are thought to have a genetic basis. Regular screening is important for early diagnosis and management.

What is Ramsay Hunt Syndrome?

Ramsay Hunt Syndrome is a condition caused by the varicella-zoster virus. It typically presents with severe ear pain, facial weakness, and a characteristic rash. Due to the affected nerves, facial paralysis is often observed in patients. Additionally, ear pain, rash, hyperacusis (increased sensitivity to sound), hearing loss, and balance loss are defining features of the syndrome.

A multidisciplinary evaluation is necessary. In cases where patients experience balance loss, vestibular rehabilitation should definitely be initiated.

What is Motion Sickness?

Motion sickness is a response by the body to real or perceived movement. This condition is typically seen during sea, train, car, or airplane travel. When there is a mismatch between the vestibular system and visual and proprioceptive inputs, the symptoms of motion sickness begin to manifest.

The most prominent symptom is nausea. Generally, symptoms such as imbalance, fatigue, weakness, sweating, and drowsiness are also present. The symptoms of motion sickness become even more pronounced when sensory cues conflict.

Individual susceptibility to motion sickness varies greatly:

• Gender: Women are generally more susceptible than men. For example, during the premenstrual phase or pregnancy, women’s sensitivity to motion increases.
• Age: Children, especially those between 6 and 9 years old, are more prone to motion sickness; this tendency decreases during adolescence.
• Fitness Level: Individuals with high aerobic capacity may experience increased sensitivity.

People with Meniere’s Disease, vestibular migraine, and migraine are more susceptible.

Motion Sickness Treatment

Treatment for motion sickness is symptomatic. However, patients benefit greatly from vestibular rehabilitation applications based on virtual reality.

Understanding and managing motion sickness requires consideration of individual factors.

What is Mal de Débarquement Syndrome (MdDS)?

Mal de Débarquement Syndrome (MdDS) is a form of motion sickness that is more common than previously thought. Although it is rare, it is a distinct form of dizziness with specific characteristics. This condition is typically characterized by a sensation of imbalance that occurs after prolonged motion, for example, after sea or air travel. Patients often feel as if they are swaying or rocking when in a stable position, and they may feel more comfortable when in motion.

Prevalence and Frequency:

• Transient MdDS symptoms after exposure to passive motion are observed at high rates among healthy individuals.
• Chronic MdDS is a rarer condition, and its prevalence has not yet been fully determined.

Demographic Data:

• MdDS shows a higher incidence particularly among middle-aged women.
• Women constitute the majority of MdDS patients.
• The highest incidence is observed in individuals in their fifties.
• There is limited data regarding ethnic distribution.

Associated Conditions:

• There is a notable relationship between migraine and MdDS.
• MdDS is associated with motion sickness and increased visual sensitivity.

Psychosocial and Economic Impact:

• MdDS can lower patients’ quality of life and increase rates of anxiety and depression.
• Patients often experience prolonged periods before receiving an accurate diagnosis from the onset of symptoms, during which adaptation may occur and symptoms may resolve. In chronic cases, virtual reality rehabilitation is very beneficial.
• This condition can lead to changes in patients’ work and social lives, creating a significant socioeconomic burden.

What is Migraine-Associated Vertigo (Vestibular Migraine)?

Dizziness associated with migraine is typically seen in migraine patients. Although headache does not always accompany it, when vertigo occurs as part of a migraine, special criteria are required for diagnosis. It is particularly concurrent with migraine aura.

The criteria for diagnosing vestibular migraine are as follows:

• At least 5 episodes of vestibular symptoms of moderate to severe intensity
• Each episode lasts between 5 minutes and 72 hours
• In at least 50% of the episodes, one or more of the following migraine features are observed:
  • Throbbing headache
  • Photophobia (sensitivity to light) or phonophobia (sensitivity to sound)
  • Visual aura

The vestibular symptoms experienced by patients can be described as a sensation of back-and-forth movement or swaying. These symptoms may also occur without other migraine symptoms.

Thus, making a diagnosis is not easy. However, an accurate diagnosis can significantly improve the patient’s quality of life. A multidisciplinary approach helps the patient better understand and manage their symptoms.

Although the prevalence of vestibular migraine in the general population is low, it can cause significant discomfort and functional impairment in affected individuals. This condition, which is more common among women, typically begins in middle age and may present with vertigo following migraine attacks.

Management of vestibular migraine allows patients to control their symptoms and continue with their daily activities. In particular, vestibular rehabilitation with virtual reality is beneficial for improving these individuals’ quality of life.

What is Vestibular Dysfunction (Hypofunction)?

Vestibular dysfunction is a disorder of the inner ear system that maintains balance. It occurs when the two inner ears do not function equally or when both fail to perform their tasks. The primary manifestation is a chronic sense of imbalance. In sudden movements, fatigue, and stress, the feeling of imbalance increases.

Vestibular dysfunction can be caused by two main factors: issues related to the peripheral system (inner ear) and those related to the central system (the neural pathways between the inner ear and the brain). Peripheral vestibular dysfunction is a natural consequence of inner ear disorders such as Meniere’s disease.

Therefore, the proper diagnosis, treatment, and rehabilitation planning for Meniere’s disease are very important in the long term to reduce the likelihood of experiencing vestibular hypofunction. On the other hand, central vestibular dysfunction is caused by more serious conditions. The most common causes include stroke and demyelinating diseases. In this regard, early diagnosis is of great importance.

Risk Factors for Vestibular Dysfunction

• Gender: Women are more predisposed to vestibular disorders and are therefore at greater risk for vestibular dysfunction.
• Access to healthcare is an important parameter for vestibular dysfunction. The ability of individuals with imbalance or dizziness to access accurate diagnosis, treatment, and rehabilitation services significantly affects their quality of life.
• Being over 40 years old is significant in many disorders, including vestibular disorders. In inner ear conditions such as Meniere’s and migraine—which are more common in women—the cumulative effect of age-related biological changes is also important in vestibular hypofunction. A healthy or improved vestibular system is important to prevent traumatic events like falls.
• Systemic diseases such as cardiovascular diseases and diabetes affect balance control. These diseases, which have micro effects on both the circulatory and nervous systems, actually accelerate vestibular aging. Although emotional states do not trigger vestibular hypofunction, problems in vestibular function can trigger conditions such as depression and anxiety.

In individuals with vestibular hypofunction, chronic imbalance, postural instability, intolerance to head movement, and occasional episodes of dizziness and nausea/vomiting may occur. A complete history, a detailed physical examination, and a vestibular evaluation are required to diagnose vestibular dysfunction.

Differentiating between peripheral and central vestibular dysfunction is critical for determining the appropriate treatment method. Understanding the differences between these two types can guide the treatment process correctly.

Patients with vestibular dysfunction are at risk of falls due to vertigo and walking instability. These falls can have serious consequences, especially in patients over 70 years old. Therefore, early diagnosis, effective treatment, and vestibular rehabilitation are very important.