Vestibular Disorders

Vestibular disorders occur if disease or injury damages the processing areas of the vestibular system. The vestibular system includes parts of the inner ear and brain that processes the sensory information involved with controlling balance and eye movements.

What Causes Vestibular Disorders?

Genetic and environmental conditions, as well as disease, aging or injury can affect the vestibular system causing the disorders, or the disorders can occur for unknown reasons.

What are the Most Diagnosed Vestibular Disorders?

The most commonly diagnosed vestibular disorders include:

  • Benign Paroxysmal Positional Vertigo (BPPV)
  • Labyrinthitis and Vestibular Neuritis
  • Meniere’s Disease
  • Secondary Endolymphatic Hydrops
  • Perilymph Fistula
  • Superior Canal Dehiscence
  • Acoustic Neuroma
  • Ototoxicity
  • Enlarged Vestibular Aqueduct Syndrome
  • Mal De Debarquement

Plus, there are other problems related to vestibular dysfunction, including a vestibular migraine and complications from autoimmune disorders and allergies.

How Common are Vestibular Disorders?

Vestibular disorders can affect people of any age. According to a 2009 epidemiological study, as many as 35% of adults 40 years or older in the United States–approximately 69 million Americans–have experienced some form of vestibular dysfunction.2 According to the National Institute on Deafness and Other Communication Disorders (NIDCD), a further 4% (8 million) of American adults report a chronic problem with balance, while an additional 1.1% (2.4 million) report a chronic problem with dizziness alone.3 Eighty percent of people aged 65 years and older have experienced dizziness,4 and BPPV, the most common vestibular disorder, is the cause of approximately 50% of dizziness in older people.5 Overall, vertigo from a vestibular problem accounts for a third of all dizziness and vertigo symptoms reported to health care professionals.6

Do Vestibular Disorders Affect Children as Well?

Vestibular disorders mostly affect adults, however, they can affect children as well. Unfortunately, children are not typically screened for pediatric vestibular disorders and fail to receive medical treatment. This trend, however, is changing as clinicians recognize that it has been an overlooked problem and is now receiving more attention.7

What can Happen if Children aren’t Diagnosed?

If children don’t receive a proper evaluation and diagnosis, they may have impairments of motor development and balance. The disorder may also cause gaze stability that inhibits children from learning to read.  

What is the Impact on Daily Life?

Chronic symptoms of dizziness or imbalance can have a profound effect on a person’s ability to perform daily activities, such as bathing, dressing or simply getting around inside the home. It is estimated that 11.5% of adults with chronic dizziness and 33.4% of adults with chronic imbalance are significantly affected, having economic as well as social impact.

What are the Symptoms of a Vestibular Disorder?

Disease, aging or injury can cause the system to be damaged and a vestibular disorder can result and is often associated with one or more of these symptoms:

Vertigo and Dizziness

Spinning or Whirling Sensation, Lightheaded, Floating or Rocking Sensation (Dizziness), Sensation of Being Heavily Weighted or Pulled in One Direction.

Balance and Spatial Disorientation  

Imbalance, Stumbling, Difficulty Walking Straight, Clumsiness or Difficulty with Coordination, Difficulty Maintaining Straight Posture, Tendency to Look Downward, Tendency to Touch or Hold Onto Something When Standing.

Vision Disturbance

Trouble Focusing or Tracking Objects with Eyes, Discomfort From Busy Visual Environments Such as Traffic, Crowds, Stores and Patterns, Sensitivity to Lights, Glare or Flickering Lights, Sensitivity to Certain Types of Computer Monitors and Digital Televisions, Tendency to Focus on Nearby Objects, Increased Night Blindness, Difficulty Walking in the Dark, Poor Depth Perception.

Hearing Changes

Hearing Loss, Tinnitus (ringing, roaring, buzzing, whooshing), Sensitivity to Loud Noises or Environments, Sudden Loud Sounds May Increase Symptoms of Vertigo, Dizziness, or Imbalance.

Cognitive and/or Psychological Changes

Difficulty Concentrating and Paying Attention, Easily Distracted, Forgetfulness and Short-Term Memory Lapses, Confusion, Disorientation, Difficulty Comprehending Directions or Instructions, Difficulty Understanding Conversations, Loss of Self-Reliance, Self-Confidence, and Self Esteem, Anxiety, Panic, Social Isolation, and Depression.

Other Symptoms

Nausea, Vomiting, Motion Sickness, Feeling of Hangover or Seasickness, Fullness in the Ears, Ear Pain, Headaches, and Slurred Speech.

The severity of symptoms may vary, but all have an impact on a person’s life performing routine daily functions.

How are Vestibular Disorders Diagnosed?

Because the inner ear’s vestibular organs and the associated nerves and brain centers form a complex system that serves many functions, it can be affected by a number of outside systems. As a result, a thorough evaluation of the inner ear is necessary and may require several different kinds of tests.

Your doctor will review your medical history and perform a physical examination to determine which diagnostic tests are needed to assess your vestibular system function and rule out any alternative causes of symptoms. Testing can sometimes be fatiguing and result in temporary unsteadiness, but most people tolerate it well.

How do you Test for Vestibular Dysfunction?

Many vestibular tests use equipment to monitor the eyes for normal and abnormal movements when the vestibular system is stimulated. Testing is done to evaluate proper function–such as good balance, and good eye muscle movements (vestibulo-ocular reflex or VOR).

The following is a brief summary of tests that your doctor may order for you.

Electro/Video-Nystagmography (ENG or VNG)

Electronystagmography (ENG) testing uses small electrodes placed over the skin around the eyes. Videonystagmography (VNG) testing uses goggles with video cameras to monitor the eyes. Both the video cameras and the electrodes can measure eye movements to evaluate signs of vestibular dysfunction or neurological problems. Generally, these tests are performed in a room that is dark or with low lighting. The examiner asks random questions that are meant to occupy the person being tested and keep them alert. ENG/VNG tests are the most common set of tests administered to people with dizziness, vertigo, and/ or imbalance.

Rotation Tests

Rotation tests evaluate how well the eyes and inner ear work together. These tests use video goggles or electrodes to monitor eye movements. The head is rotated side to side at moderate or slow speeds, and associated eye movements are analyzed. Like the ENG/VNG, rotation tests are performed in a room that is dark with the examiner asking random questions during testing. Rotation tests provide information beyond the ENG/ VNG about how well the balance organs are functioning.

Video Head Impulse Testing (vHIT)

vHIT evaluates how well the eyes and inner ears work together. A small set of glasses with a camera are used to monitor eye movements. The vHIT is similar to rotational testing, where the head is moved to evaluate the vestibulo-ocular reflex. However, the vHIT test uses very small and quick movements of the head to evaluate reflex function, as opposed to the slow or moderate speeds used in rotation testing.

Vestibular Evoked Myogenic Potential (VEMP)

VEMP testing is used to evaluate whether certain vestibular organs and associated nerves are intact and functioning normally. Responses in this test are measured from different muscles in the neck and around the eyes. VEMP testing uses adhesive, skin surface electrodes (like ENG or some rotational tests) and earphones (like those used during a hearing test). Sound is played for a few seconds through the earphones, the vestibular organs are stimulated and activate muscle responses, and electrodes record the results.  

Computerized Dynamic Posturography (CDP)

CDP tests postural stability or the ability to maintain upright posture in different environmental conditions. Maintenance of postural stability depends on sensory information from the body’s muscles/joints, eyes, and inner ears. This testing investigates relationships among these three sensory systems and records the balance and posture adjustments made when different challenges are presented.

Audiometry (Hearing Tests)

Audiometry measures hearing function. Hearing evaluations are an important part of vestibular diagnostics because the inner ear contains both hearing and balance organs. More than one hearing test may be required when a person has a vestibular disorder, especially when there is evidence of hearing loss, a sensation of fullness in the ears, or tinnitus (ringing or noise in the ears).

Another part of a standard hearing test is tympanometry, which can help detect problems between the eardrum and the inner ear. Tympanometry uses a small earpiece that creates pressure and plays sound in the ear canal to gather information. The same equipment can also be used for acoustic-reflex testing, which measures the reflex of muscles in the middle ear in response to pressure and loud sound.

Otoacoustic Emissions (OAE)

OAE testing provides information about how the hair cells of the cochlea are working. It measures the responsiveness of hair cells to a series of clicks produced from a tiny speaker inserted into the ear canal. Most often this test is used to evaluate hearing for people who are unable to respond to a traditional hearing test (such as infants).  

Electrocochleography (ECoG)

ECoG measures a response to sound from the nervous system. It utilizes an earphone and electrodes while the person being tested lays still in a comfortable position. An earphone plays sound in the ear and an electrode measures a response. Different electrodes can be used in this test.

Auditory Brainstem Response Test (ABR)

The ABR measures how the nervous system responds to sound. The test setup and procedure is similar to the ECoG. Most often ABR is used to test hearing for people who are unable to respond for audiometry (such as infants). Occasionally this test is used when someone cannot have imaging performed (such as people with a metal plate in the body/brain).

Under certain circumstances, this test can indicate the presence of an acoustic neuroma (a rare, benign tumor of the vestibulo-cochlear nerve). It may also help identify conditions such as multiple sclerosis if they have affected the auditory pathway to the brain.

Magnetic Resonance Imaging (MRI)

MRI uses a magnetic field and radio waves to produce cross-sectional images of body tissues being scanned. An MRI of the brain can reveal the presence of tumors, stroke damage, and other soft-tissue abnormalities that might cause dizziness or vertigo. MRIs of structures in and around the inner ear can be helpful in the diagnosis of some vestibular disorders.   

Computerized Axial Tomography (CAT or CT)

A CT scan is an x-ray technique that is best for studying bony structures, and it is used to look for abnormalities around the inner ear, such as fractures or areas with thinning bone.  

Other Tests

Depending on your circumstances, other tests may be necessary to discover the cause of a balance disorder. Blood work, allergy tests, vision tests, and other exams may help rule out causes of imbalance that are unrelated to the vestibular system.

What Treatment Options are Available?

There are several treatment options available for vertigo, imbalance, and dizziness due to vestibular dysfunction. Your prescribed treatment will depend on your symptoms, medical history and general health, your diagnostic test results, and your physical exam. Your doctor will prescribe the best treatment option for you the addresses your specific condition and any other underlying disease that may be contributing to your balance disorder.

Some of those treatment options are discussed below.

Vestibular Rehabilitation Therapy (VRT)

VRT uses specific head, body, and eye exercises designed to retrain the brain to recognize and process signals from the vestibular system and coordinate them with information from vision and proprioception. The choice and form of VRT exercises will differ from person to person.

Canalith Repositioning Maneuvers (e.g., The Epley Maneuver)

A specialized form of VRT is available to treat benign paroxysmal positional vertigo (BPPV). This treatment is often referred to as the Epley maneuver and involves a series of specifically patterned head and trunk movements to move tiny displaced otoliths to a place in the inner ear where they can’t cause symptoms.

Home-Based Exercise

A physical or occupational therapist will assign VRT exercises for you to perform at home at a prescribed pace, along with a progressive fitness program to increase energy and reduce stress.

Dietary Adjustments

Many people with Ménière’s disease, secondary endolymphatic hydrops, and migraine-associated dizziness find that certain modifications in diet are helpful in managing their disorder. Avoidance of non-dietary substances such as nicotine and some types of medications may also reduce symptoms.

Counseling

Symptoms of vestibular disorders often contribute to a wide range of psychological distress, and as a result, patients may benefit from counseling to cope with lifestyle changes, depression, guilt, and grief that comes from no longer being able to meet their own or others’ expectations.

Medication

Medication is often prescribed for patients who have a vestibular system dysfunction in an acute phase (lasting up to 5 days) or a chronic phase (ongoing). For acute cases, medications including vestibular suppressants may be prescribed to reduce motion sickness, anti-emetics to reduce nausea, and steroid, antiviral drugs or antibiotics to treat ear infections. For chronic cases, vestibular suppressants are not appropriate for long-term use, as they can slow down or stop the process of vestibular compensation (symptoms must be actively experienced without interference in order for the brain to adjust).

Surgery

Surgery may be considered when medical treatment isn’t effective in controlling symptoms of vestibular system dysfunction. The type of surgery performed depends upon each individual’s diagnosis and physical condition.

Labyrinthectomy

This procedure is done for patients with Ménière’s disease. The balance end organs are removed so that the brain no longer receives signals from the parts of the inner ear that sense gravity and motion changes. The hearing organ (cochlea) is also sacrificed with this procedure.

Vestibular Nerve Section

This procedure is done for patients with Ménière’s disease. The vestibular branch of the vestibulo-cochlear nerve is cut in one ear to stop the flow of balance information from that ear to the brain. The brain can then compensate for the loss, using only the opposite ear to maintain balance.

Chemical Labyrinthectomy

This procedure is also done for patients with Ménière’s disease. A chemical labyrinthectomy is also known as transtympanic or intratympanic treatment or gentamicin infusion. An antibiotic called gentamicin is introduced into the middle ear and absorbed via the round window. The drug destroys the vestibular hair cells so that they cannot send signals to the brain.

Endolymphatic Sac Decompression

Endolymphatic sac decompression is a stabilizing procedure sometimes used for Ménière’s disease or secondary endolymphatic hydrops to relieve endolymphatic pressure in the cochlea and vestibular system. A variety of techniques exist. One method involves allowing the sac to decompress by removing the mastoid bone surrounding it. Other methods involve inserting a shunt (a tube or strip) into the endolymphatic sac so that, theoretically, excess fluid can drain out into the mastoid cavity or other location. The effectiveness of decompression techniques in controlling vertigo remains in doubt.

Oval or Round Window Plugging

Oval or round window plugging is a stabilizing procedure sometimes used for repair of perilymph fistulas. Openings in the oval and/or round windows are patched with tissue taken from the external ear or from behind the ear so that perilymph fluid does not leak through the fistulas.

Pneumatic Equalization (PE) Tubes

Pneumatic equalization (PE) is a stabilizing procedure sometimes used for treating perilymph fistulas. A tube is inserted through the tympanic membrane (eardrum) with one end in the ear canal and the other in the middle ear, to equalize the air pressure on the two sides of the eardrum.

Canal Partitioning (Canal Plugging)

Canal partitioning is a stabilizing procedure sometimes used for treating BPPV or superior semicircular canal dehiscence. The problematic semicircular canal is partitioned or plugged with small bone chips and human fibrinogen glue to stop the movement of endolymph and foreign particles within the canal so that it no longer sends false signals to the brain.

Microvascular Decompression

Microvascular decompression is performed to relieve the abnormal pressure of the vascular loop (blood vessel) on the vestibulo-cochlear nerve.

Stapedectomy

Stapedectomy is a stabilizing procedure sometimes used for otosclerosis where the stapes bone is replaced with a prosthesis.

Acoustic Neuroma (Vestibular Schwannoma) Removal

This procedure involves the removal of a noncancerous tumor that grows from the tissue of the vestibular branch of the vestibulo-cochlear nerve.

Cholesteatoma Removal

This procedure involves the removal of a skin growth that starts in the middle ear and that can secrete enzymes that destroy bone and surrounding structures.

Ultrasound Surgery

Ultrasound is applied to the ear to destroy the balance end organs so that the brain no longer receives signals from the parts of the ear that sense gravity and motion changes.

Cochlear Dialysis

Cochlear dialysis is a stabilizing procedure sometimes used to promote movement of excess fluid out of the inner ear, filling the scala tympani with a chemical solution.

Contact Us

Please contact SCENT  at (661) 259-2500 to schedule an appointment for vestibular testing. You can also schedule an appointment online. To learn more about us, please browse our website.

Sources

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