What causes balance disorders?

Balance Disorders: Causes and Management

Balance disorders are primarily caused by dysfunction in the vestibular system, with benign paroxysmal positional vertigo (BPPV) being the most common specific diagnosis, followed by other conditions affecting the inner ear, central nervous system, or proprioceptive pathways.

Common Causes of Balance Disorders

Peripheral Vestibular Disorders

• Benign Paroxysmal Positional Vertigo (BPPV)

  • Most common cause of vertigo 1
  • Characterized by brief episodes of vertigo triggered by head position changes
  • Diagnosed using the Dix-Hallpike maneuver for posterior canal BPPV or supine roll test for lateral canal BPPV 1
  • Treatment: Canalith repositioning procedures (strong recommendation) 1

• Ménière's Disease

  • Characterized by episodic vertigo lasting hours, with fluctuating hearing loss, tinnitus, and aural fullness 1
  • Lifetime prevalence: 0.12-0.5% 2
  • Management includes trigger avoidance, vestibular rehabilitation for chronic imbalance 1

• Vestibular Neuritis

  • Causes acute vestibular syndrome with severe vertigo, nausea, and imbalance lasting days 3
  • Distinguished from stroke through bedside head impulse and oculomotor examination

Central Vestibular Disorders

• Cerebellar Ataxia

  • Characterized by unsteady, irregular stepping pattern, wide-based stance, and lateral veering 4
  • Causes include spinocerebellar ataxias, Friedreich's ataxia, cerebellar stroke or tumor
  • MRI of the head without IV contrast is the preferred initial imaging modality 1, 4

• Vestibular Migraine

  • Produces spinning, rocking, or tilting sensations lasting minutes to days 3
  • Point prevalence: 0.98% 2
  • May be associated with migraine headaches or photophobia

Other Causes

• Superior Canal Dehiscence

  • Defect in the bony roof over the superior semicircular canal
  • Vertigo and oscillopsia provoked by loud sounds and pressure changes 3
  • Diagnosed with temporal bone CT and vestibular evoked myogenic potential testing

• Age-related Degeneration

  • Common in elderly populations
  • Often multifactorial with contributions from proprioceptive loss, visual impairment, and central processing deficits 5

• Medical Conditions

  • Hypertension (32.4%), diabetes mellitus (13.8%), arthritis (8.1%), and heart disease (4.4%) are common underlying causes in elderly patients 5

Diagnostic Approach

1. Clinical History

   • Determine if symptoms are:
     • Acute (sudden onset, severe)
     • Episodic (recurring, triggered by specific positions or situations)
     • Chronic (persistent imbalance or disequilibrium)

2. Physical Examination

   • Dix-Hallpike maneuver: For diagnosing posterior canal BPPV 1
   • Supine roll test: For diagnosing lateral canal BPPV 1
   • Head impulse test: To distinguish vestibular neuritis from stroke 3
   • Neurological examination: To assess for central causes

3. Imaging

   • MRI of the head: Preferred for suspected central causes like cerebellar ataxia 1
   • CT temporal bone: For suspected structural abnormalities like superior canal dehiscence 1
   • Do not routinely order imaging for patients meeting diagnostic criteria for BPPV without additional concerning symptoms 1

Management Strategies

For BPPV

• Canalith repositioning procedures (strong recommendation) 1
• Do not prescribe postprocedural restrictions after repositioning (strong recommendation against) 1
• Do not routinely use vestibular suppressant medications like antihistamines or benzodiazepines (recommendation against) 1

For Chronic Balance Disorders

• Vestibular rehabilitation therapy (VRT)
  • Recommended for chronic imbalance, bilateral Ménière's disease, or following ablative therapy 1
  • Improves symptom control, safety, reduces fall risk, and improves quality of life 1

For Psychological Impact

• Patient education
  • Explain the mechanism of symptoms and adaptation process
  • Reduces anxiety and avoidance behaviors that can perpetuate dizziness 6
  • Educate about safety, disease recurrence, and follow-up importance 1

Special Considerations

Elderly Patients

• Balance disorders are common and often multifactorial
• Head and neck exercises have shown benefit in 56.4% of elderly patients 5
• Assessment for fall risk and home safety is essential 1

Psychological Impact

• Chronic dizziness frequently leads to anxiety, panic, and activity avoidance 6
• This can create a vicious cycle of persistent disorientation and distress
• Addressing psychological aspects is crucial for effective management

Follow-up and Monitoring

• Reassess patients within 1 month after initial treatment to document resolution or persistence of symptoms 1
• Evaluate persistent symptoms for unresolved BPPV or underlying disorders 1
• Document changes in quality of life after treatment 4

Common Pitfalls to Avoid

• Overreliance on vestibular suppressant medications for BPPV
• Failure to perform appropriate diagnostic maneuvers like Dix-Hallpike
• Unnecessary imaging in straightforward BPPV cases
• Neglecting psychological aspects of chronic balance disorders
• Inadequate follow-up to ensure symptom resolution