Dizziness (Vertigo) and Balance Disorders

Are dizziness and vertigo the same thing?

In everyday language, “dizziness” covers several different sensations. Vertigo is the perception that the surroundings or one’s own body are spinning or moving when they are not; it is the typical form of complaints arising from the inner ear and balance system. Beyond this, a fading sensation on standing up, persistent light-headedness and unsteadiness while walking may also be described as dizziness, but the likely causes of these presentations differ.

The type of complaint, how long it lasts, what triggers it and what accompanies it are the most important clues in assessment. Observing the complaint before the consultation therefore gives the physician valuable information: for example, noting whether the spinning lasts seconds or hours, and whether it is triggered by turning over in bed.

Common ear-related causes

A large part of the sense of balance comes from the semicircular canals of the inner ear and the balance nerve. Disorders of this system are among the most frequent causes of vertigo:

• BPPV (benign paroxysmal positional vertigo): Brief spinning attacks lasting seconds, triggered by head movement. Described in detail below.
• Vestibular neuritis: Sudden loss of function of the balance nerve. Its cause is not known with certainty, but it is thought to be related to a viral or recent infection; it produces severe, continuous vertigo and unsteadiness lasting hours to days, and hearing is usually preserved.
• Ménière’s disease: An inner-ear disorder with recurrent vertigo attacks lasting minutes to hours, accompanied by fluctuating hearing loss, a feeling of pressure in the ear and tinnitus.
• Labyrinthitis: Inflammation affecting both the balance and the hearing parts of the inner ear; vertigo is accompanied by hearing loss.

Not all dizziness comes from the ear. Cardiovascular causes such as blood-pressure changes and rhythm disturbances, some neurological diseases, vestibular migraine, anaemia, low blood sugar and the side effects of some medicines can also cause dizziness. One purpose of assessment is to determine whether the complaint originates in the ear and, where necessary, to refer to the relevant specialty.

BPPV: the most common positional vertigo

BPPV (benign paroxysmal positional vertigo) arises when microscopic calcium crystals from the gravity-sensing part of the inner ear become displaced and enter the semicircular canals. As the head moves, the crystals stimulate the fluid in the canal and produce a brief spinning sensation.

The typical picture consists of spinning attacks, usually lasting less than a minute, triggered by turning over in bed, getting up, tilting the head back or bending forward. A mild sense of unsteadiness may persist between attacks; hearing loss is not an expected feature of BPPV.

The diagnosis is made with positional tests performed during the examination (for example the Dix-Hallpike test): eye movements are observed while the head is brought into specific positions. The basis of treatment is repositioning manoeuvres that guide the crystals back to where they belong (the best known being the Epley manoeuvre). Current clinical guidelines recommend these manoeuvres as the standard treatment for BPPV, and their effectiveness has been shown in research; the manoeuvre used is chosen according to the canal identified at examination.

Because the ear and canal to be treated are determined by the examination findings, the initial assessment and treatment should be carried out by a healthcare professional trained in this area. BPPV can recur over time; the approach to recurrence is planned together with the physician. This page deliberately does not contain step-by-step manoeuvre instructions.

What is assessed in an ENT examination?

The first and most important part of the assessment is a detailed history: the nature, duration and triggers of the complaint, any accompanying change in hearing, tinnitus, nausea and headache, and the medicines being taken.

During the examination the eardrum and ear canal are inspected with an otoscope; eye movements and nystagmus (involuntary flicking of the eyes) are assessed; positional tests such as the Dix-Hallpike test are performed where needed, and balance and gait are examined.

Depending on the findings, a hearing test (audiometry), further tests of balance function or imaging may be requested; if the picture suggests a cause outside the inner ear, referral to the relevant department is made. Which investigations are needed is decided individually, together with the examination findings.

Treatment and management approaches

Treatment is planned according to the identified cause; there is no single “dizziness treatment”.

In BPPV the basic approach is repositioning manoeuvres matched to the canal identified at examination. After vestibular neuritis and in persistent unsteadiness, vestibular rehabilitation exercises that help the balance system readapt play an important role. In Ménière’s disease, lifestyle measures and stepwise treatment options aimed at reducing the frequency of attacks are considered together with the physician.

Medicines that suppress nausea and the spinning sensation may have a short-term, symptomatic place in some acute inner-ear conditions; when and for how long they are used is decided with the physician according to the condition. It is recognised that using these medicines for longer than necessary, particularly after the acute phase, may delay the readaptation of the balance system. In BPPV, medication is not a routine approach; the main treatment is repositioning manoeuvres. This page deliberately contains no drug names or doses.

Follow-up according to the course of the symptoms is a natural part of treatment: some conditions settle on their own, others run a recurring course. Follow-up intervals and the approach to recurrence are planned together, based on the result of the assessment.