Hearing and Balance Disorders

Audiologists don’t simply treat hearing loss, they also provide solutions for a number of hearing and balance disorders, from symptoms of dizziness to conditions like Meniere’s disease. The following is an overview of several ways an issue with your auditory system can impact your inner balance.

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Discussion of dizziness

Dizziness is a symptom not a disease. It may be defined as a sensation of unsteadiness, imbalance or disorientation in relation to an individual’s surroundings. The symptom of dizziness may vary widely from person to person and be caused by many difference diseases or conditions. It varies from a mild unsteadiness to a severe whirling sensation known as vertigo. As there is little representation of the balance system in the conscious mind, it is not unusual for it to be difficult for the patient to describe their symptom of dizziness to the physician. In addition, because the symptom of dizziness varies so widely from patient to patient and may be caused by many different diseases, the physician commonly requires testing to be able to provide the patient with some knowledge about the cause of their dizziness. Dizziness may or may not be accompanied by a hearing impairment

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Ear dizziness

Ear dizziness, one of the most common types of dizziness, results from disturbances in the blood circulation or fluid pressure in the inner ear chambers, from direct pressure on the balance nerve or physiologic changes involving the balance nerve or balance mechanisms. Inflammation or infection of the inner ear or balance nerve is also a major cause of ear dizziness.

Any disturbance in pressure, consistency or circulation of the inner ear fluids may result in acute, chronic or recurrent dizziness, with or without hearing loss and head noise. Likewise, any disturbance in the blood circulation to this area or infection of the region may result in similar symptoms. Dizziness may also be produced by an over stimulation of the inner ear fluids, which may be encountered if you spin very fast and then stops suddenly.

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Central dizziness

Central dizziness is usually an unsteadiness brought about by failure of the brain to correctly coordinate or interpret the nerve impulses which it receives. An example of this is the “swimming feeling” or unsteadiness that may accompany emotional stress, tension states, and excessive alcohol intake. Circulatory inefficiency, tumors or injuries may produce this type of unsteadiness, with or without hearing impairment. A feeling of pressure or fullness in the head is common. Occasionally true vertigo (spinning) may be caused by central problems.

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Causes and symptoms of dizziness

Dizziness may be caused by any disturbance in the inner ear, the balance nerve or its central connections. This can be due to a disturbance in circulation, fluid pressure or metabolism, infections, neuritis, drugs, injury or growths.
At times an extensive evaluation is required to determine the cause of dizziness. The tests necessary are determined at the time of examination and may include detailed hearing and balance tests, x-rays, and blood tests. A general physical examination and neurological tests may be advised.

The object of this evaluation is to be certain that there is no serious or life-threatening disease, and to pinpoint the location of the problem. This lays the groundwork for effective medical or surgical treatment.

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Atypical migraine or basilar migraine

Inner ear dizziness due to blood vessel spasm is usually sudden in onset and intermittent in character. It may occur as an isolated event in the patient’s life or repeatedly in association with other symptoms. If it is recurrent it usually is associated with migraine headache-type symptoms. Predisposing causes include fatigue and emotional stress. Certain drugs such as caffeine (coffee) and nicotine (cigarettes) tend to produce blood vessel spasm or constriction and should be avoided. Blood vessel spasm has been noted to occasionally begin after head injury. Although there may have been no direct injury to the inner ear by the trauma, the spasm may begin to damage the ear.

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Benign Positional Paroxysmal Vertigo (BPPV)

BPPB is a common form of balance disturbance due to circulatory changes or to loose calcium deposits (cupuliths) in the inner ear. It is characterized by sudden, brief episodes of vertigo/light-headedness when moving or changing head position. Commonly it is noticed when lying down or arising or when turning over in bed. This type of dizziness as its names suggests is benign, related to positional changes and is short-lived. The vertigo brought on by the movement rarely lasts more than a few minutes, is usually self-limited and responds well to treatment. However, it may reoccur in some patients. Treatment involves attempts to reposition the loose particles and keep the dizziness from occurring (Canalith Repositioning Procedure). If this isn’t successful, additional exercises may be recommended.

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Imbalance related to aging

Some individuals develop imbalance as a result of the aging process. In many cases this is due to circulatory changes in the very small blood vessels supplying the inner ear and balance nerve mechanism. Fortunately, these disturbances, although they may persist, rarely become worse.

Positional vertigo (see above) is the most common balance disturbance of aging. This may develop in younger individuals as a result of head injuries or circulatory disturbances. Dizziness on change of head position is a distressing symptom, which is often helped by vestibular exercises.

Unsteadiness when walking, particularly on stepping up or down or walking on uneven surfaces, develops in some individuals as they progress in age. Using a cane and learning to use the eyes to help the balance is often helpful.

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Infection

Imbalance due to ear infection is usually insidious and mild in onset. Such imbalance may occur with or without hearing impairment. As the infection gets closer to the vital balance mechanism in the inner ear, the dizziness becomes more constant and severe in nature, and is often associated with nausea and vomiting.

Control of an ear infection is imperative in this type of dizziness in order to prevent spread of the infection directly into the balance center of the inner ear. Should this develop, serious complications including total loss of hearing in the involved ear may result. If the infection cannot be eliminated by medical treatment, surgery is indicated to remove the infection.

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Neuritis

Neuritis is a physiological change that occurs in the nerve after injury by trauma, a virus, autoimmune disease or vascular compression. When this occurs, the balance function is impaired, resulting in a severe, and at times prolonged, episode of dizziness, often followed by some unsteadiness or motion for weeks to years. Fortunately, this balance disturbance usually subsides in time and usually does not recur in the majority of cases. It may be, however, very chronic at a moderate to mild level. Medical treatment is helpful in eliminating symptoms until the central nervous system can compensate for the injured nerve. This usually consists of dizziness- suppressing drugs. On occasion, the central nervous system cannot compensate and surgery may be necessary.

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Meniere’s disease (Endolymphatic Hydrops)

Meniere’s disease is a common cause of repeated attacks of dizziness and is thought to be due to (in most cases) increased pressure of the inner ear fluids due to impaired metabolism of the inner ear. Fluids in the inner ear chamber are constantly being produced and absorbed by the circulatory system. Any disturbance of this delicate relationship results in overproduction or underabsorption of the fluid. This leads to an increase in the fluid pressure (hydrops) that may, in turn, produce dizziness that may be associated with fluctuating hearing loss and tinnitus.

A thorough evaluation is necessary to determine the cause of Meniere’s disease, if possible. Circulatory, metabolic, toxic and allergic factors may play a part in any individual. Emotional stress, while making the disease worse, does not cause Meniere’s disease
Meniere’s disease is usually characterized by attacks consisting of vertigo (spinning) that varies in duration from several minutes to hours. Hearing loss and tinnitus, usually accompanying the attacks, may occur suddenly. Violent spinning, whirling, and falling associated with nausea and vomiting are common symptoms. Sensations of pressure and fullness in the ear or head are usually present during the attacks. The individual may be very tired for several hours after the overt spinning stops.

Attacks of dizziness may recur at irregular intervals and the individual may be free of symptoms for years at a time, only to have them recur again. In between major attacks, the individual may have minor episodes occurring more frequently and consisting of unsteadiness lasting for a few seconds to minutes.

There may be many causes of endolymphatic hydrops. It may be caused or aggravated by excessive salt intake or certain medications. The symptoms are highly variable. You may have one symptom or a combination of signs. Often there is a combination of hearing changes, disequilibrium, motion intolerance or short dizzy episodes. There may be tinnitus and/or a pressure feeling in the head or ears. The patient does not have the well-defined attacks of Meniere’s disease (fluctuating hearing loss, tinnitus, and episodes of spinning lasting minutes to hours). 

Medications are first used. Diuretics (water pills) are almost always used. Their purpose is to decrease the fluid pressure in the inner ear. In addition to diuretics, other medications may be indicated, depending on the cause of symptoms in each patient’s case. If these fail, surgery is sometimes indicated. (See Surgery for vertigo elsewhere in this document).

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Treatment of Meniere’s disease (Endolymphatic Hydrops)

The treatment of Meniere’s disease may be medical or surgical, depending upon the patient’s stage of the disease, life circumstances and the condition of the ears. The purpose of the treatment is to prevent the hearing loss and stop the vertigo (spinning).

Treatment is aimed at improving the inner ear circulation and controlling the fluid pressure changes of the inner ear chambers..
Medical treatment of Meniere’s disease varies with the individual patient according to suspected cause and magnitude and frequency of symptoms. It is effective in decreasing the frequency and severity of attacks in 80% of patients. Treatment may consist of medication to decrease the inner ear fluid pressure or prevent inner ear allergic reactions. Various drugs are used as anti-dizziness medication.

Vasoconstricting substances have an opposite effect and, therefore, should be avoided. Such substances are caffeine (coffee) and nicotine (cigarettes).

Diuretics (water pills) may be prescribed to decrease the inner ear fluid pressure.
Meniere’s disease may be caused or aggravated by metabolic or allergic disorders. Special diets or drug therapy are indicated at times to control these problems.

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Metabolic disturbances

Occasionally metabolic disturbances produce dizziness with or without associated hearing loss by interfering with the function of the inner ear or the central nervous system. Occasionally hearing loss may occur without the presence of dizziness.

A change of thyroid function or abnormalities in the blood sugar are the most common metabolic disturbances resulting in dizziness. Rarely, fat metabolism abnormalities may also cause problems resulting in hearing loss and/or dizziness. Thyroid dysfunction is diagnosed by blood tests and treatment consists of taking a thyroid hormone. Abnormalities in the blood sugar are diagnosed, again by blood studies and treatment usually consists of diet control and/or drug therapy. Fat metabolism problems are diagnosed by studies of the fatty acids and cholesterol in the blood. Treatment of these may consist of diet control with or without drug therapy.

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Allergies

Rarely, allergies may cause dizziness and/or vertigo. Allergies are usually diagnosed by obtaining a careful history and occasionally performing a series of skin tests with inhalants and food or blood tests. Treatment usually consists of elimination of the offending agents when possible, or, if this is not possible, by allergy shots to stimulate immunity.

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Injury

Injury to the head occasionally results in dizziness of long-standing origin. If the trauma is severe, it is usually due to the combined damage to the inner ear, balance nerve and central nervous system. Lesser injury may damage any one, or a combination of these components. The unsteadiness is at times prolonged, and may or may not be associated with hearing loss and head noise as well as other symptoms.

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Tumors

A noncancerous tumor occasionally develops on the balance nerve between the ear and the brain. When this occurs, unsteadiness, hearing loss and head noise may develop. Extensive hearing tests, balance tests and x-rays are necessary to diagnose such tumors.
If the diagnosis of a tumor is established, surgical removal is often recommended. Continued growth of the tumor would lead to complications by producing pressure on vital adjacent nerves and the brain. An operation has been developed which allows the removal of these tumors at an early stage. Best results can be obtained if the tumor is diagnosed early and removed while the only symptoms are hearing loss, dizziness and tinnitus (head noise).

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Surgical treatment options for dizziness

Surgery is indicated when medical treatment fails to control the vertigo. The type of operation selected depends on the degree of hearing impairment in the affected ear, the life circumstances of the individual, and the status of the individual’s disease. In some operations the hearing may be occasionally improved following surgery, and in others it may become worse. In most cases it remains the same. Tinnitus may or may not be relieved, and in some cases may become even more marked.

Surgery is most successful in relieving acute attacks of dizziness. Some unsteadiness may persist over a period of several months until the opposite ear and the central nervous system are able to compensate and stabilize the balance system.

Surgical procedures include the use of an endolymphatic shunt, selective vestibular neurectomy and labyrinthectomy. The endolymphatic shunt surgery is intended to drain excess endolymph from the inner ear. It is usually performed under general anesthesia and requires hospitalization for one to two days.

Selective vestibular neurectomy is a surgical option where the balance nerve is cut at the point it leaves the inner ear. This procedure has a high success rate of eliminating the bouts of vertigo and usually preserves hearing. However, imbalance may remain.

Labryinthectomy is a surgical procedure where the balance and hearing portions of the inner ear are destroyed. This procedure is only considered for those who have very little hearing remaining in the affected ear. This procedure has a high rate of success but does destroy any remaining hearing and imbalance may continue to be a problem for the patient.

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Nonsurgical dizziness treatments

Typically, a physical therapist evaluation of patients with vestibular or balance disorders takes approximately 60-90 minutes. The evaluation begins with a history of the patient’s symptoms. This includes how long the patient has been symptomatic, how long the symptoms last, general activity level and medications that the patient is currently taking. Range of motion, strength, coordination, balance and various sensory systems are also assessed. Patients are asked to perform transitional movements such as rolling, supine to sit and sit to stand. This is to determine whether these motions produce or increase symptoms. One of the most difficult things for patients with vestibular disorders to do is walk and move the head. Different combinations of head and neck movements are performed during gait to provoke symptoms. Balance is also tested on a firm surface and again on a compressible surface with eyes open and closed. Time tests of balance are performed with eyes open and closed, while standing on one foot and with feet aligned as if on a tightrope.

Following the evaluation, a treatment plan is developed. The treatment plan may consist of habitual exercises, balance retraining exercise and usually a general conditioning program. The goal of habituation exercises is to decrease the patient’s symptoms of motion provoked dizziness or lightheadedness. The exercises are chosen to address the patient’s particular problems that were discovered during the evaluation. The length and intensity of the program depends upon the patient’s previous activity level and how easily their symptoms are provoked. The patient must consistently perform all the exercises as described in their treatment program to achieve the goals of improving their balance and decreasing their dizziness. Typically, the exercises are performed twice a day. Patients are advised not to avoid positions that provoke symptoms unless they are unsafe.

There are many causes of dizziness. This dizziness may or may not be associated with hearing loss. In most instances the distressing symptoms of dizziness can be greatly benefited or eliminated by medical or surgical management.

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