Balance disorders

Overview: What are balance disorders?

Brief dizziness, a perceived sway – disturbances of balance can last only a fraction of a second, but can also be longer or recurrent. Especially when the disorders appear for the first time, they unsettle and cause anxiety. Around one in four people experience balance disorders at least once in their lives. With increasing age, the risk of balance disorders and dizziness increases.

The sense of balance is a complicated network and reacts sensitively. The organ of balance is located in the right and left inner ear, protected by the respective temporal bone. It consists of five different tiny hollow organs: two atrial sacs (otolith organs) and three archways arranged in different spatial directions, approximately at right angles to each other. All these hollow organs contain a gel on their membrane as well as liquid in the interior and are lined with sensory cells, which in turn contain tiny antenna-like hairs. Tiny calcium carbonate crystals, the otoliths, also called ear stones, sit on the hairs of the otolith organs.

Each movement of the head changes the position of the fluid. This change in position is transmitted by the hairs to the sensory cells as a stimulus. From them, nerve tracts (vestibular nerve) lead to the brain, and this is how the stimulus is transmitted to the vestibular center of the brain. Here, these stimuli are processed together with the information sent by the eyes – as well as by sensors in muscles and joints (position sensation). In this way, the brain receives an impression of our current position, posture and orientation.

Balance disorders: causes and risk factors

The sense of balance is therefore dependent on many different factors. The causes can be just as varied when it comes to disturbances in balance and dizziness.

Among the best-known causes of imbalance are the use of alcohol and other drugs. However, the swaying ground during a boat trip, driving along a winding road, or turbulence during a flight can also flood the inner ear with stimuli. Dizziness, but also vomiting can be the consequences, this phenomenon is summarized under the term motion sickness.

Some drugs used to treat cardiovascular diseases, such as antihypertensives, can also cause balance disorders as a side effect. This risk may also exist with psychotropic drugs, as well as with sedatives and some hormonal drugs such as thyroid hormones.

However, experts distinguish the causes of balance disorders primarily by whether they are caused by disorders in the ear, i.e. in the organ of balance, or by problems in other organs.

Vestibular disorders – causes in the organ of balance

• Benign positional vertigo: This is the most common form of vertigo, in which some of the crystals have detached from the hairs and have been washed into the archways. Here, the loosened ear stones cause false messages to the brain that have nothing to do with the actual body position.
• Inflammation of the inner ear
• Inflammation of the vestibular nerves
• Tumor between the brain and the auditory canal, such as an acoustic neuroma
• Disease of the bone at one of the arcades, which can lead to an anatomical change of the organ of equilibrium, such as arcade dehiscence
• Meniere’s disease: This is a disease of the inner ear, where there is a buildup of fluid inside, which in turn can cause vertigo attacks

Balance disorders – causes that do not affect the ear

• Fluid deficiency
• Metabolic disorders such as hypoglycemia
• Diseases of the cardiovascular system, for example high blood pressure (hypertension), low blood pressure (hypotension), stroke
• Heat stroke, sunstroke
• Nervous diseases such as multiple sclerosis, Parkinson’s disease, epilepsy, polyneuropathy
• Dementia
• Meningitis and encephalitis
• Concussion, cerebral hemorrhage
• Cerebellar tumors

Why the very elderly often suffer from balance disorders

Especially in old age, many complain of dizziness and disturbances of balance with gait disturbances, often referred to as senile vertigo. This is because age-related changes are important risk factors for these problems. Thus, blood circulation no longer works as well as it did in younger years. The inner ear is also affected by this reduced blood flow. In addition, the transmission of stimuli via the nerves is no longer as rapid. Such symptoms should not be accepted in principle as “age-related”, as often appropriate measures can be taken through close examination and assessment, for example to be able to reduce the risk of falls as an important consequence of dizziness.

Other areas of the body that have to do with balance are often also impaired by signs of aging: The eyes no longer function as well, osteoarthritis causes gait instability. A not insignificant role is played by medications that older people often have to take.

Balance disorders with gait disturbances are also often the reason why older people have a high risk of falling. They cannot react as quickly when they stumble and often do not have the muscle strength to break the fall. This increases the risk of injury for them.

Symptoms: Dizziness and coordination problems

Everyone has probably experienced the signs – the world seems to spin around you, as can typically occur with too much alcohol, for example, or when you stand up too quickly after sitting or lying down for a long time. Sometimes those affected also have the feeling that the ground is being pulled out from under their feet for a moment or that they are falling into the void.

In addition, hearing and visual disturbances may occur, and headaches, nausea and vomiting are also possible. Overall, those affected feel very insecure. Because the problems are unsettling and ultimately there is a fear that “something might be wrong in the brain.”

In old age, symptoms can often be subtle or “atypical” or less easily attributed to a specific cause. Here, geriatric assessment can help identify potential age-associated diseases and problems in those affected and provide individualized treatment planning.

Balance disorders: diagnosis with us

Alarm signs are:

• Dizziness plus vomiting
• Dizziness accompanied by visual disturbances or shortness of breath
• Balance disorders that occur in the context of an infection
• Vertigo that always occurs with certain head movements
• Dizziness that led to a fall

Have these symptoms clarified by us in a timely manner. We will first ask you about your symptoms and will also want to know your other health conditions, medications taken, and more. Guides include standardized questionnaires such as Dizziness Handicap Inventory (DHI-G) or Vertigo Symptom Scale (VSS-G).

This is linked to various diagnostic options that can be used to clarify what causes the balance disorders and what form of vertigo it is:

Romberg test and Unterberger test for balance disorders

There are two frequently used methods for testing balance: For the first, the Romberg test, the person concerned must stand upright with their legs closed – first with their eyes open, then with them closed. If it fluctuates, this is considered an indication of a disorder of the vestibular organ. This can also be checked with the second method, the Unterberger test: the person concerned walks on the spot, arms stretched out in front, eyes closed. If the organ of equilibrium does not function adequately, the affected person spins around himself, for example.

Nystagmus test with Frenzel glasses

Nystagmus, involuntary eye tremor, is also considered to indicate a disorder of the vestibular organ. The tremor forms in response to the false messages to the brain. When the gaze is fixed, however, the tremor cannot be detected. This is where the Frenzel glasses help. It enlarges very much. Due to these strong magnifying glasses, it is impossible for the affected person to fix anything accurately and we can see the eye tremor.

Positional testing and thermal irritation

• Positional testing: The person concerned sits down on the examination couch and then has to assume various, rapidly changing positions, partly with our help. This can be used to diagnose benign positional vertigo, for example.
• Thermal irritation: In thermal irritation we put warm and then cool water into the ear. With a well-functioning vestibular organ, this caloric test results in nystagmus.

Further examinations for balance disorders

In order to check the functions of the different organs related to our sense of balance, other examinations can be performed if necessary, such as:

• Hearing and vision tests
• Computed tomography (CT)
• Magnetic resonance imaging (MRI)
• Electroencephalography (EEG)
• Blood tests
• Cerebrospinal fluid examination (CSF puncture)
• Orthostasis test
• Functional balance test (e.g. tandem stance test, Tinneti test, or mountain balance scale)

Balance disorders: prevention, early detection, prognosis

To avoid dizziness and balance problems as much as possible, this advice will help:

• Drink enough, at least two liters per day, if you sweat a lot, accordingly more.
• Don’t physically exhaust yourself, don’t push yourself beyond your limits.
• Get enough and regular sleep.
• Eat sensibly and sufficiently.
• Drink alcohol only occasionally, if at all, and in small amounts.
• If you have high blood pressure and/or diabetes: Check your values regularly and optimize them if necessary.
• Reduce stress.
• Look at the medications you are taking to see if dizziness is listed as a side effect. Then talk to us about it, maybe you can switch to another remedy.
• Keep moving as you age, for example, through regular dancing or other movement exercises such as tai chi or Jaques-Dalcroze rhythmics that promote balance
• Avoid taking sleeping pills or sedatives that can affect balance as you age

Course and prognosis (disturbances of equilibrium)

In the vast majority of cases, balance disorders disappear again – with the appropriate therapy and if the causes are eliminated. Often, however, medication alone is not enough; the affected person must become active on a regular basis.

Balance disorders: treatment depends on cause

In most cases, the trigger for the balance disorders can be found with careful diagnosis. Then we can put together the appropriate therapy. In case of a surgical intervention, the Institute of Anesthesiology will select the anesthesia procedure that is individually adapted to you.