Dizziness is not a disease itself but a symptom that can arise from various causes. Patients may describe it differently as imbalance, lightheadedness, blurred vision, or mild to severe spinning sensations. Complaints can range in severity from mild imbalance to intense spinning feelings, depending on the underlying factors. Dizziness can occur as a standalone symptom or alongside hearing loss and/or tinnitus.
The ear is divided into three sections: the external ear, middle ear, and inner ear. The structures of the external and middle ear collect sound waves, amplify them, and transmit them to the fluids of the inner ear. The hearing and balance centers are located within the ear bones in the inner ear and are filled with inner ear fluids (endolymph and perilymph). The sensitive nerve endings and nerve cells of the hearing and balance nerves are in constant contact with these fluids. Sound waves reaching the inner ear are transmitted through these fluids, stimulating nerve endings and generating electrical impulses. Hearing occurs as these impulses are transmitted via the auditory nerve to the brain.
Table of Contents
MAINTAINING BALANCE
The balance system consists of a central hub and three different sensory systems. The brain acts as a central processor, continuously gathering and processing information about body position relative to the environment from the eyes, balance centers in the inner ear, and muscles, joints, and tendons. These three systems operate independently but work together to maintain body balance.
The eyes provide information about the body’s position relative to the environment by transmitting visual images to the brain, while signals from muscles, tendons, and joints inform the brain about the body’s position relative to the head. The inner ear’s balance system comprises semicircular canals that detect rotational movements and vestibules that detect linear movements. Together, these two fluid-filled structures are known as the “labyrinth.” When the head moves, the fluids in the inner ear move as well, and the pattern and direction of this movement stimulate different nerve endings, sending signals to the brain about the head’s movement.
The balance organs in the labyrinths on both sides produce symmetrical signals. Signals resulting from head rotation are generated in the semicircular canals, while signals from forward-backward or up-down linear movements are produced in the vestibules. Calcium carbonate crystals attached to cells in the vestibular balance centers shift position due to gravity, allowing the brain to perceive the direction and intensity of head movements.
When a balance center in one inner ear malfunctions, the symmetry of signals sent to the brain is disrupted, creating a sensation of imbalance. This disruption causes the brain to send signals to the eye muscles, resulting in involuntary eye movements (nystagmus). These eye movements can create the perception that the surroundings or oneself are spinning.
Information from all balance-detecting centers is combined with corrective reflexes formed in the cerebellum and intentional responses in the brain to send signals to body muscles to perform movements that maintain balance. The balance centers in the cerebellum and brainstem can adapt to asymmetric signals from the inner ear over time, which allows the body to ignore these imbalances. This feature enables the correction or prevention of imbalance through appropriate exercises, even in cases of diseases causing dizziness or in normal conditions that could disrupt balance.
TYPES OF DIZZINESS
Problems in any of the centers involved in maintaining balance can lead to symptoms such as dizziness, imbalance, and lightheadedness.
Inner Ear Diseases:
Dizziness caused by inner ear disorders results from changes in the pressure of inner ear fluids or directly affecting the balance centers and/or balance nerves.
The sensitive endings of the hearing and balance nerves terminate in different parts of the inner ear that contain the same fluid (endolymph). Changes in the circulation, pressure, or composition of this fluid can stimulate nerve endings, leading to acute, chronic, or recurrent dizziness, with or without accompanying hearing loss.
Other problems that disrupt blood circulation in the inner ear or affect the balance nerves can produce similar symptoms.
Brain-Related Diseases:
Dizziness occurs when the brain’s ability to interpret signals from the balance organs is impaired, disrupting appropriate responses. This can be accompanied by hearing loss and/or tinnitus. These issues can result from aging, vascular blockages or spasms, allergic or metabolic diseases, and benign or malignant tumors.
Excessive stress, panic attacks, depression, and tension can also cause similar symptoms, often accompanied by a sensation of fullness and pressure in the head and ears.
Neck Diseases:
Dizziness can result from disruptions in the position information signals sent from neck muscles to the balance centers in the brainstem. Traumas, degenerative joint diseases in the neck, or pressure on neck nerves can cause spasms in the neck muscles, leading to abnormalities in position signals sent to the brain and resulting in balance disorders.
Visual Disorders:
Visual impairments or diseases of the eye muscles can cause involuntary eye movements, leading to discrepancies between visual signals and those from other balance-detecting structures. This mismatch can result in dizziness. Additionally, other inappropriate signals in the nervous system can cause symptoms like sweating, nausea, and vomiting.
SYMPTOMS IN INNER EAR-RELATED DIZZINESS
Diseases affecting inner ear functions or the connection between the inner ear and the central nervous system can cause symptoms such as dizziness, hearing loss, and tinnitus. These symptoms can appear alone or in combination, depending on the affected functions.
Dizziness can manifest as intense spinning sensations, imbalance, or lightheadedness. Symptoms may be continuous or intermittent and are often exacerbated by head movements. Nausea and vomiting are common, but loss of consciousness does not occur in inner ear-related dizziness.
The primary causes of inner ear function disorders include viral infections (most commonly), impaired blood circulation, changes in inner ear fluid pressure, nerve inflammations, traumas, medications, and tumors. A detailed medical history and examination are crucial for diagnosis. Most patients require hearing and balance tests. In cases where a diagnosis cannot be established through these steps, further evaluations such as radiological assessments, hormonal and metabolic tests, allergy tests, and neurological evaluations may be necessary.
These evaluations help determine whether there is an underlying serious or life-threatening pathology. The results of these tests assist in selecting appropriate medical or surgical treatments following diagnosis.
BLOOD CIRCULATION-RELATED DISEASES
Circulatory disorders such as blood vessel spasms, blockages, ruptures, and bleeding affecting the balance organs in the inner ear can cause dizziness, hearing loss, and tinnitus. Dizziness caused by blood vessel spasms typically begins suddenly and is recurrent. Nerve fatigue, emotional stresses, certain medications, nicotine, and caffeine can contribute to blood vessel spasms.
When blood vessel blockages occur gradually with age and arterial stiffness, inner ear structures can adapt to the decreasing blood flow over time. This can result in a persistent sensation of imbalance, which may worsen with sudden movements or rapid changes in posture.
In cases of sudden complete blockages, severe dizziness is often accompanied by nausea and vomiting.
Severe symptoms typically decrease within a few days and resolve as the healthy ear compensates for the affected ear’s functions. In cases of blood vessel ruptures caused by high blood pressure or trauma, symptoms resembling sudden blockages are observed.
Treatment for blood circulation-related dizziness includes early administration of medications to alleviate the spinning sensation along with vasodilators. Additionally, sedatives that suppress the balance centers to reduce symptoms may be used early on. Avoiding vasoconstrictive substances like nicotine and caffeine is essential. Sedatives that suppress inner ear functions should not be used long-term to prevent delaying the healthy ear’s compensation.
POSITIVE DIZZINESS
The most common cause of dizziness in young and middle-aged individuals is benign positional vertigo (Benign Paroxysmal Positional Vertigo – BPPV). Information about this condition is provided under the heading “Positional Dizziness.”
AGE-RELATED BALANCE LOSS
Age-related balance problems are primarily due to impaired circulation in the capillaries supplying the balance centers and balance nerves in the inner ear. This issue rarely causes severe symptoms. Reduced blood circulation in the vestibule can lead to dysfunction of balance organs, causing calcium carbonate crystals in the inner ear to dislodge and result in positional dizziness.
Balance exercises are generally beneficial for this patient group. Aging-related slowing of vascular reflexes, especially in patients using medications for high blood pressure, can lead to balance loss when standing up suddenly.
INFECTIONS
Early stages of inner ear infections may present with mild symptoms, but when the sensitive balance regions are affected, severe dizziness and symptoms like nausea and vomiting can occur.
Treatment involves promptly addressing the source of the infection. Due to risks like hearing loss and the spread of the infection into the brain, surgical treatment options may be considered if medical treatment does not quickly control the symptoms.
VESTIBULAR NEURITIS
Severe dizziness lasting weeks can result from viral infections affecting the balance nerves or balance centers in the brainstem. In these patients, balance tests may take months to show improvement after clinical symptoms have subsided.
This condition usually resolves without lasting damage and rarely recurs. Treatment involves early medical intervention to alleviate severe symptoms, followed by supportive therapy and adaptation exercises.
METABOLIC DISEASES AND ALLERGIES
This group can present with dizziness alongside hearing loss and tinnitus. Common causes include thyroid gland disorders, diabetes-related balance issues, food and respiratory allergies. Treatment involves addressing the underlying condition.
TRAUMA
Dizziness can occur as a result of impacts to the head, affecting the inner ear balance centers or its blood circulation. This may be accompanied by tinnitus and/or hearing loss.
Treatment involves using sedatives to alleviate symptoms and medications that increase blood circulation to the inner ear. Typically, this condition gradually improves over time.
AUTOIMMUNE INNER EAR DISEASES
These are conditions where the body’s immune system damages the inner ear. Symptoms can include dizziness, hearing loss, and tinnitus. Diagnosis is made through blood tests. Treatment involves steroids and immunosuppressive medications. In recent years, Low-Level Laser Therapy (LLLT) has been used effectively to repair inner ear damage.
TUMORS
The most common tumor pathology causing balance disorders is vestibular schwannoma, a benign tumor originating from the balance nerve. Patients typically experience dizziness, tinnitus, and hearing loss. Treatment decisions are based on the tumor’s location, size, growth rate, the patient’s age, overall health, and hearing status. Early diagnosis and surgical removal are preferred to prevent the tumor from pressing on critical structures like the brainstem.
MENIÈRE’S DISEASE
Menière’s Disease is one of the most common causes of recurrent dizziness attacks. It results from increased pressure of inner ear fluids (endolymph).
The fluids in the inner ear are continuously produced on one side and reabsorbed on the other, maintaining a fluid circulation system. Problems in this system, such as increased production or decreased reabsorption, lead to elevated fluid pressure, causing typical symptoms. The exact cause is unknown, but genetic predisposition is suspected. Attacks are triggered by metabolic, circulatory, allergic, autoimmune, toxic, or emotional factors. Typically affecting one ear, Menière’s Disease is characterized by irregular, recurring dizziness attacks lasting from minutes to hours, along with low-frequency (bass) hearing loss, tinnitus, and a sensation of fullness and pressure in the affected ear. Dizziness attacks begin suddenly and are often accompanied by nausea and vomiting, resulting in severe spinning sensations.
The severity of recurring attacks generally decreases over time, with patients experiencing no noticeable symptoms between episodes.
In addition to the classic form, there is a rarer form called cochlear hydrops, which presents with hearing loss, tinnitus, and a sensation of fullness without dizziness. Vestibular hydrops, another rare form, involves only dizziness attacks without hearing symptoms. Treatment is the same for all types.
WHY IS DIAGNOSING AND TREATING BALANCE AND MOVEMENT DISORDERS DIFFICULT DESPITE ADVANCED TECHNOLOGY?
The complexity arises from the interaction and coordination of sensory (visual, inner ear-related, perceptual) and motor systems involved in maintaining balance, as well as the involvement of multiple organs. The human balance system is highly intricate, requiring the harmonious interaction of various organs. Most specialists and clinics still use traditional methods for diagnosing and treating balance disorders. These diagnostic tests often provide findings related to a single organ, offering limited contribution to the diagnosis or treatment of balance diseases. Moreover, these disorders can affect not only the balance systems but also other systems like the brain. Traditional clinical approaches fail to systematically relate the integration of sensory and motor control systems for balance and movement. Consequently, diagnosing these types of diseases can be challenging. Physicians may begin to question whether the patient is misguiding them or if sedatives or tranquilizers should have been administered to help the patient manage or suppress symptoms. Similarly, patients may feel that the physician does not understand their problem or is overlooking their condition.
The majority of chronic balance disorders can be corrected through rehabilitation, allowing patients to compensate for their deficits. However, treating balance disorders is highly complex and requires consultations with specialists from various branches, leading to the concept of a balance center. A balance center involves collaborating with specialists trained in dizziness and balance disorders across different fields. This team typically includes ENT (neurology), neurology, neurosurgery, audiology, psychiatry, physical therapy, and family medicine experts. All team members must be experienced in diagnosing and treating balance disorders. The balance center approach involves having all specialists work together, enabling the team to see more dizzy patients, gain more experience, and utilize feedback effectively. Family physicians refer patients with dizziness to the balance center, ensuring that patients receive faster, more affordable, and more effective care from a multidisciplinary team. Balance centers should be promoted and developed within the community, with talks and support groups established to prevent imbalance and falls. Ultimately, a true balance center is essential for the treatment of patients with dizziness and balance disorders, and a multidisciplinary balance center is ideal for meeting these patients’ needs.
Dizziness and balance disorders have led approximately 70% of people to seek medical attention at least once in their lifetime. However, these patients are often dissatisfied with their diagnosis and treatment because these disorders can originate from many organs and systems. Initially, patients may not see the correct specialist, leading to evaluations by various specialists, and patients may not understand which category they fall into. This causes patients to feel neglected, and lack of communication among doctors from different branches exacerbates the issue. Tests like Electronystagmography (ENG) and vestibular tests have limited roles in monitoring patients with balance disorders. Individuals with vestibular or central diseases causing environmental disorientation and balance disorders require additional support for evaluating their functional capacities. In 1971, a technological device was developed in the United States to monitor the balance systems of astronauts and help them adapt to gravity upon returning to Earth. This device was later used in balance rehabilitation centers to diagnose balance problems and rehabilitate patients. Today, multi-purpose usage continues in balance rehabilitation centers established in certain parts of the world.
HOW ARE THE CAUSES OF DIZZINESS DIAGNOSED?
TARGET PATIENT GROUP:
- Inner ear-related dizziness and imbalance
- Head traumas (e.g., post-vehicle accidents)
- Cerebellar (cerebellum diseases)
- Stroke (infarctions commonly seen in elderly patients)
- Multiple Sclerosis
- Parkinson’s Disease
- Cerebral Palsy (congenital brain disorders)
- Peripheral Neuropathies
- Diabetes-related balance disorders
- Neck diseases causing dizziness (cervical spondylosis, herniated discs, etc.)
- Elderly patients and those frequently experiencing falls
COMPUTERIZED DYNAMIC POSTUROGRAPHY:
Most inner ear-related dizziness and balance disorders can be controlled during crisis or acute periods with medical or surgical treatments. However, balance issues between crisis periods persist. At this point, patients undergo rehabilitation with Computerized Dynamic Posturography (CDP) over 6 or 7 weeks, with at least two sessions per week. This method is particularly effective for patients with Motion Sickness (Motion Entoloren). Another group benefiting from CDP treatment includes patients with Multiple Sclerosis and Parkinson’s Disease, who experience balance problems due to ongoing pathologies affecting balance centers in the brain. CDP is highly effective in evaluating the success of surgeries performed on Parkinson’s patients and in their post-operative rehabilitation.
In the United States, approximately 1,000,000 individuals visit emergency departments each year due to head traumas, with those experiencing severe head traumas potentially facing balance issues for up to five years. Some may develop permanent balance defects. Among traffic accident victims, dizziness or imbalance is the most common symptom. If these patients are rehabilitated with Posturography without delay, it prevents the development of permanent defects and allows patients to reintegrate into social life quickly.
Stroke patients (known as “infarctions”) number about 700,000 annually and experience some of the most impactful balance disorders in daily life. Medical support for these conditions costs approximately $40 billion annually. Particularly in elderly individuals, degenerative wear of balance centers due to aging can cause imbalances, leading to orthopaedic and sometimes life-threatening traumas. In these cases, Posturography has been developed over the last 10 years as a “gold standard” for diagnosing balance disorders and rehabilitating patients, revolutionizing the treatment of dizziness and balance disorders.
TREATMENT OF MENIÈRE’S DISEASE:
Treatment can involve medical and surgical methods. The primary principles are to maintain fluid circulation in the inner ear and prevent increased pressure. If these goals are not achieved, destructive methods such as eliminating the inner ear balance centers or cutting the balance nerves may be applied.
The majority of patients can alleviate their symptoms through medical treatment.
Treatment content includes:
- The probable cause of the disease
- Frequency of symptoms
- Severity of symptoms
- Determined based on the degree to which the patient is affected by the disease
Basic Principles:
- Regulating circulation in the inner ear
- Reducing fluid pressure in the inner ear
- Suppressing immunological and/or allergic reactions in the inner ear
- Medications used in treatment include:
- Vasodilators
- Diuretics
- Steroids
- Sedatives
In special cases, immunosuppressive medications or drugs that impair balance center functions may be used. When medical (drug-based) treatments do not achieve the desired results, surgical treatment options are considered. There are two types of surgical approaches: those that preserve and those that do not preserve hearing and balance functions. Surgical methods that preserve hearing are preferred as long as hearing remains functional.
In recent years, increasingly used are intracochlear steroid injections, which yield good results while avoiding serious side effects that affect the entire body. Despite using hearing-preserving methods, if symptoms cannot be controlled, methods aimed at completely eliminating the balance centers in the affected inner ear are used. As a result, the balance center functions in the healthy ear can quickly compensate and normalize.
LOW-LEVEL LASER THERAPY (LLLT)
Low-Level Laser Therapy (LLLT) is successfully applied in all pathologies affecting the sensitive hearing and balance organs of the inner ear, including Menière’s Disease. The fundamental principle of this treatment method is to enhance the healing and functional potential of damaged cells and tissues by applying laser light of specific wavelengths. Detailed information about this treatment method is provided under the heading “Low-Level Laser Applications.”