Q & A
1.    What is a balance disorder?

Balance disorders span a breadth of conditions, including feeling unsteady, giddy, woozy, or having a sensation of movement, spinning, or floating. We have developed a mechanism for maintaining balance, which consists of visual, vestibular and proprioceptive inputs. These sensory inputs propagate into the central nervous system, where they are integrated and modulated. Any disturbance in these balance systems, e.g. the eyes, inner ears, bones and joints, brain, vascular and nervous system problems, is the main origin of balance disorders. Balance disorders can cause nausea and vomiting.

2.How do we feel a balance disorder?

The vestibular labyrinth, located in the inner ear, serves as a sensory organ for angular and linear movements. The semicircular canals respond to angular accelerations, whereas otolith organs respond to linear accelerations. The vestibular, visual, and somatosensory systems underlie visual fixation, spatial orientation, locomotion, and control of posture. We always adjust our gaze and posture processing information from visual, vestibular, somatosensory inputs. When information from these three input systems is mismatched, we feel dizzy or have vertigo. Dizziness is a sensation of altered orientation in space. Vertigo is an unpleasant illusion of movement, usually that of rotation, although some patients describe a sensation of linear displacement or tilt. Vertigo or dizziness is caused by dysfunction of the ear, eye, neck, brain and so on. To diagnose the cause of dizziness, many clinical examinations are needed.


3. Why do ear diseases cause a balance disorder?

An organ in our inner ear, the labyrinth, is an important part of our vestibular (balance) system. The labyrinth interacts with other systems in the body, such as the visual (eyes) and skeletal (the muscles and joints and their sensors) systems, to maintain the body's position. These systems, along with the brain and nervous system, can be the source of balance problems.

Three semicircular canals in the labyrinth enable motion during a rotary (circular) motion. The semicircular canals, visual and skeletal systems set an individual's orientation. The vestibular system in the labyrinth and visual system keeps objects in focus during head motion. Joint and muscle receptors are also important for maintaining balance. The brain organizes information from these systems that control balance.


4. What should you do when experiencing vertigo (dizziness)? Vertigo is classified into rotatory vertiginous attack with a feeling of rotation of the ceiling or surroundings, and unsteadiness, such as unsteadiness of the body and not walking straight. Rotatory vertigo is mainly caused by an inner ear disorder and is accompanied with cochlear symptoms, such as hearing loss, aural fullness and tinnitus. By contrast, unsteadiness is accompanied with faintness, headache, and numbness and it is sometimes reinforced by moving the body or head. Elderly people who are unsteady often have accompanying diseases, such as hypertension, hyperlipidemia, diabetes, and cardiac disorder. Rotatory vertigo is common and is accompanied with nausea and vomiting when its onset is acute. Bed rest and lying down in a darkened room are recommended under the above circumstances. Anti-motion sickness or antiemetic medication is effective; however, brain diseases, such as cerebellar hemorrhage, should be differentiated if the symptoms persist or symptoms such as numbness of the extremities, palsy, or headache occur. In addition, prompt treatment is required when cochlear symptoms are present; therefore, early consultation at an emergency, otorhinolaryngology, neurology, or neurosurgery department is recommended for patients with the above symptoms. Even if the onset is gradual, detailed examination is required for patients with persistent symptoms because general diseases, such as of the brain or cervical vertebra, might be present.

5. Diagnostic tests for vertigo and dizziness (see drawing below):Patients often experience the illusion of rotatory self-motion sensation, postural instability, and nausea/vomiting. Vertigo/dizziness is generally caused by damage to the labyrinth (semicircular canals and/or otolithic organs), eighth cranial nerve, or central nervous system (e.g., brainstem and cerebellum, see section 2). Thus, it is necessary to distinguish peripheral disorders from central disorders and to evaluate the extent of damage.

Diagnostic tests can include oculomotor, balance, hearing, and vestibular function tests, which are performed as necessary. Electronystagmography (ENG) is the gold standard for laboratory evaluations of oculomotorvestibular functions. A brain CT or MRI aids with the diagnosis of central nervous system involvement.


6. What department should you visit?

Vertigo/dizziness may occur in various diseases; therefore, it may be difficult to decide the department to consult. An important point is accompanying symptoms. If you feel hearing loss, ringing in the ear, or pressure in the ear, you should see an otolaryngologist because your symptoms may be caused by a disorder of the balance organs in the ear. If you feel faint, experience double vision, difficulty speaking, or paralyses of the legs or arms, you should see a neurologist or neurosurgeon because your symptoms may be caused by a brain disorder. If you experience vertigo/dizziness but no other symptoms, you could see an otolaryngologist, neurologist or neurosurgeon because you could have any one of a number of diseases. If your vertigo/dizziness is the first episode and you have difficulty moving, you should visit the emergency room. If you need information concerning specialists in balance problems, please check the other pages of this website, where you will find lists of specialists in balance problems in Japan.


7. Prevention of vertigo

Vertigo can be due to a variety of causes.  Hyperlipemia, hypertension and arrhythmia are implicated in vertigo due to ischemic diseases of the inner ear and brain; therefore, a routine physical examination and attention to your diet and habits (e.g. tobacco and alcohol) are very important, in addition to preventing or relieving myocardial infarction and stroke.  In addition, ischemic changes can also be caused by diabetes.  Disorders of the autonomic nerve system are possibly related to the pathogenesis of inner ear-related diseases, such as Meniere’s disease.  Our advice is to lead a well-regulated life and to avoid staying up late at night, and dietary imprudence.  Since mental stress also destabilizes the autonomic nerve function, a stress-free life may prevent vertigo.  Lack of balance and falling are not only caused by disorders of the brain and inner ear functions but also by weakness of the lower limbs; therefore, avoiding a sedentary lifestyle and taking moderate exercise may activate your brain and inner ear, also protecting against aging.

8.Life style

Patients who experience dizziness frequently complain of stressful conditions in their working place or at home, sleeplessness and overwork. These psychological backgrounds are among the factors causing dizziness so it is beneficial for dizzy patients to avoid stress and relax.

Most diseases causing vertigo or dizziness are common at ages between 40s and 60s, the age at which the menopause occurs in women. Attacks of dizziness or vertigo often occur at the beginning of spring and autumn. The cause of vertigo or dizziness therefore may be related with dysfunction of the autonomic nervous system.

Many patients with dizziness also have hypotension, anemia, and allergy. They also have lifestyle-related diseases, such as diabetes, hyperlipidemia, heart diseases, and hypertension, so those patients must improve their lifestyle.

Regarding blood pressure, hypotensive patients tend to develop dizziness or vertigo, which may also occur when they take too many antihypertensive drugs. It is therefore important to measure blood pressure routinely.


9. What is Meniere’s disease?

Prosper Ménière (17991862, French) first described episodic vertigo as being associated with a peripheral end organ of inner ear rather than with the brain; therefore, this disease was named “Meniere’s disease”, which is characterized by repeated intermittent episodic vertigo with fluctuating sensory hearing loss, tinnitus and feeling of ear fullness.  Patients often suffer from severe vertigo with nausea and emesis during vertigo attacks; however, they do not complain of fainting and motor ataxia.  Most patients have up-sloping low frequency sensorineural hearing loss with repeated episodic vertigo attacks, and in some cases could lead to flat sensorineural hearing loss over time and after many fluctuations.  The frequency of vertigo attacks varies from once a week to once a year.  In most, the vertigo attacks resolve a few years after the first attack; however, some patients suffer from repeated vertigo attacks for several years.  Vertigo and hearing loss (e.g. betahistine, antihistamines, steroids and diuretics) are treated conservatively in the acute phase, while this disease can be managed by combination therapy of medical treatment, psychological counseling, lifestyle change, sodium dietary changes and intermittent pressure therapy in order to prevent recurrent attacks and prolong the time between attacks in the remission phase.  Endolymphatic sac surgery and intratympanic gentamicine therapy have been also performed in patients with intractable vertigo.


10. BPPV

Benign paroxysmal positional vertigo (BPPV) is a condition of the inner ear, and is a common cause of vertigo, especially in older people.
     * "Benign" means that it is due to neither a cancerous nor a serious cause. (The symptoms of BPPV may be unpleasant but the underlying cause is not serious.)
     * "Paroxysmal" means 'recurring sudden episodes of symptoms'.
   * "Positional" means that the symptoms are triggered by certain  positions. In the case of BPPV, certain positions of the head trigger symptoms.
     * "Vertigo" is dizziness with a spinning sensation. If you experience vertigo, you feel as if the world is spinning around you, and you feel very unsteady. Often you will also feel sick, and may vomit.
BPPV is one of the most common causes of vertigo. This disease  accounts for at least 20% of patients who present with vertigo. However, since BPPV can occur concomitantly with other  inner ear diseases (for example, a patient may have both Meniere's disease and BPPV), this statistic may be skewed toward lower numbers. Most cases of BPPV occur in people over the age of 40. Women are affected about twice as often as men.
The main symptom of this disease is vertigo, which lasts for a short time, typically less than 30 seconds. Vertigo is usually triggered by a change in head position. Getting out of bed, lying down, and rolling over in bed are three of the most common movements that trigger a short episode of vertigo. Sometimes just looking up triggers an episode of vertigo. Between episodes of BPPV you feel well.

It is thought that BPPV is caused by tiny solid fragments ('debris')  that float about in the fluid of the labyrinth. These fragments are made up of calcium carbonate crystals, which are thought to have broken off  the inside lining of the vestibule part of the labyrinth. These tiny fragments are called otoconia and cause no problems if they remain in the vestibule; however, problems occur if a fragment enters one of the semicircular canals.
The posterior canal is most commonly affected. In this situation, when your head is still, the fragment 'sits' at the bottom of the posterior  canal, but when the head moves in certain directions, the fragment gets carried along with the flow of fluid. The fragment brushes the delicate hairs that line the semicircular canal and this sends messages down the vestibular nerve.
These extra messages from the affected ear conflict with the normal messages from the other ear and visual and somatosensory inputs. The brain becomes very confused and 'reacts' to cause vertigo. In most cases, the symptoms clear within several weeks or months.  The fragments of debris may 'dissolve' or float out of the posterior semicircular canal and lodge in the vestibule where they cause no  symptoms; however, after the symptoms have gone, some people have symptom recurrence months or years later. In some cases, symptoms persist for years.


11. Vestibular Neuritis

Vestibular neuritis, also called vestibular neuronitis,  is a  paroxysmal, sudden attack of vertigo that lasts for several hours to a few days. In the acute phase, it may be associated with nausea and vomiting. No auditory symptoms are generally found during the course of this disease. Most patients experience complete recovery within a few weeks. A minority have vertiginous episodes following rapid head movement for years after onset.
Its etiology remains largely unknown, yet the underlying  pathophysiology of vestibular neuritis appears to be a sudden disruption of afferent neuronal input from a unilateral vestibular apparatus. This induces an imbalance in vestibular neurologic input to  the central nervous system and causes symptoms of vertigo.  Reactivation of latent herpes simplex virus type 1 in the vestibular ganglia can explain at least some vestibular neuritis cases.
Spontaneous, unidirectional, mixed horizontal and torsional nystagmus is the most marked physical findings. Its fast phase beats toward the healthy ear, and it is suppressed by visual fixation. Patients, especially in the acute phase, tend to fall toward their affected side when attempting ambulation or during Romberg tests. The affected side  shows no response to caloric stimulation.
Acutely, vestibular neuritis is usually treated symptomatically,  meaning that medications are given for nausea (anti-emetics) and to reduce dizziness (vestibular suppressants). Steroids are also used for some cases. Vestibular rehabilitation may help speed full recovery via compensation.


12. What kind of condition is sudden deafness?

Although there is no single cause, sudden deafness is a condition in which function of the inner ear declines suddenly.  Not only does hearing become impaired, but people also suffer from vertigo or dizziness.  The reason is that the inner ear, besides being responsible for hearing, helps the body maintain balance and equilibrium; therefore, when you experience vertigo or dizziness, you should have your hearing checked.  However, there is also a type of sudden deafness in which hearing impairment occurs without vertigo or dizziness. In either case, early treatment is necessary.  There are some other conditions besides sudden deafness in which people experience both hearing impairment plus vertigo or dizziness, such as tinnitus and aural fullness. It is strongly suggested that you consult with a doctor specializing in otorhinolaryngology.


13.What kind of disease is "dangerous dizziness (or vertigo)"?  Dizziness is an unpleasant symptom. When a patient experiences dizziness or vertigo for the first time, they may have impressions such as, "I thought it was a cerebrovascular accident" or "I felt that I was dying". Actually, life-threatening dizziness or with serious sequelae (aftereffects) is not common; however, "dangerous dizziness" is sometimes caused by a serious brain disease, such as a cerebrovascular accident (acute cerebrovascular disorder), such as a brain tumor.


1.) Dizziness (vertigo) caused by cerebrovascular stroke (acute cerebrovascular disorder).

              In your brain, the area causing dizziness is not large.  In the brain, the cerebellum regulates motion, and the brainstem is next to the cerebellum. If a cerebrovascular accident occurs in such a part of the brain, severe dizziness may occur, which resembles dizziness originating from an inner ear disorder.  Cerebral vascular accidents include ischemic attack or cerebral hemorrhage. In some instances, these accidents are related to heart disorder (arrhythmia, a valve disorder), high blood pressure, diabetes, and hyperlipemia.

              "Dangerous dizziness", caused by cerebrovascular stroke, frequently accompanies other symptoms, as follows; loss of consciousness, difficulty speaking (slurring words, disarthria), difficulty moving or walking, difficulty swallowing, abnormal senses, double vision, and severe and sudden headache are seen in addition to dizziness. However, these symptoms do not occur simultaneously with dizziness, so precise consultation and careful follow-up by a specialist in dizziness is necessary.

2.) Dizziness (vertigo) caused by brain tumors.

              Dizziness caused by a brain tumor is a rare condition, but like a cerebrovascular accident, a brain tumor may cause various neural symptoms other than dizziness and is sometimes fatal, and attention should therefore be paid in patients with a brain tumor.

Characteristics of dizziness caused by a brain tumor are summarized as follows:

@Severe dizziness, such as in Meniere's disease, is rarely seen.

ASlight dizziness, with a floating sensation, may continue for a long time.

B Patients usually complain of disturbed balance, such like difficulty standing and staggering when walking, rather than dizziness.

CVarious accompanying neural symptoms.

DDepending on the location and the size of the tumor, patients may not complain of dizziness or floating sensation.

              The most common brain tumor which causes dizziness is an acoustic tumor (vestibular schwannoma). This tumor is benign and arises in the auditory nerve which connects the brain and the inner ear. Symptoms caused by this tumor are mainly hearing loss, and dizziness is relatively unusual. Some patients may complain of slight dizziness and a floating sensation. Generally, dizziness caused by brain diseases continues for a long time, takes a long time to resolve, and is accompanied by other neural symptoms. We recommend early consultation with specialists if the above symptoms occur.

14. Why do I get lightheaded when I stand up?

In childhood, when you were standing up for a long time, did you ever have to sit down because you suddenly felt sick and blacked out? This symptom is lightheadedness and is classified as an equilibrium disorder.  Lightheadedness can occur in both children and adults.  When you stand up suddenly, or remain standing for a long time, the blood vessels in the legs constrict so that an adequate amount of blood can flow to the brain, which needs to consume blood-borne oxygen in large quantities.  But when people suffer from an autonomic nervous system impairment, the body fails to constrict the blood vessels in the legs, causing blood circulation to the brain to decrease, which results in lightheadedness.

Autonomic nervous system impairment is diagnosed by measuring the blood pressure difference between upright and supine (lying down) positions.  Treatment for such a condition usually involves changing the lifestyle and taking medication to regulate the autonomic nervous system.  If a specific cause for the condition has been identified, the treatment should focus on the cause as well as the symptoms.


15. Vertigo and dizziness of unknown origin

Vertigo/dizziness has a variety of causes (see section 9-14). Patients with recurrent vertigo may feel anxious when the cause of vertigo is not identifiable after a thorough examination. Please pay attention to the following:

1) Residual symptoms other than vertigo: If any, they will sometimes help to identify the cause of the disease.

2) Contributing factors to vertigo: Physical or mental stress could be a trigger for initiating vertigo. Leading a regular lifestyle can prevent vertigo (see section 8).

3) During an attack of vertigo: As for vertigo of peripheral origin, stay in bed and take anti-vertiginous and -emetic drugs to obtain relief from vertigo.