Balance and tinnitus | British Tinnitus Association
The control of balance in humans is quite complex and involves coordination of several sensory systems. These are the musculoskeletal system (proprioception), vision and the balance organs in the internal ears. These systems are linked to a centre at the base of the brain – the vestibular nucleus. This, in turn, sends information to, and also receives input from a nearby organ – the cerebellum. The coordination of posture and balance is carried out by the cerebellum.
The sensory systems
Let us now look at all the sensory systems which are responsible for balance.
The muscles, bones and joints have sensory nerves which send messages to the brain about muscle activity and movement of the body. The most important joints are those which are involved in weight bearing. These are the ankles, knees, hips and spine. The ankles regulate minor swaying movements, while the knees and hips control larger sway of the body. The muscles of the spine have the function of maintaining the curvature of the spine, preventing people from leaning too far forwards or backwards. They also maintain the head in an upright position.
The sensory nerves travel up the spinal cord and terminate in the vestibular nuclei and cerebellum.
The eyes also play an important part in our balance. We are able to keep our gaze on an object during head movements, and also when we are moving. We can also shift our gaze between objects; if an object (car, animal) starts moving, we can follow this movement quite easily without any disturbance in our balance.
All these activities are possible because of complex connections between the eyes and vestibular system.
The balance organs
These organs are located in the internal ears and they provide vital information about the body’s position in space. One part of the organ detects angular movement such as body tilt, while another section receives signals about linear movement. The organs in the two ears are the mirror images of each other and each sends information to the vestibular nucleus.
Most balance problems are caused by disorders of the balance organs or the pathways of balance in the brain.
Damage to the balance organs could take one of many forms. The organ may show increased activity – an irritative lesion. In these cases, people often have severe nausea and may even vomit. There is also a sensation of spinning to the same side. This may result in falls to the same side. However, the damage may cause reduced activity – a paralytic lesion. Here, the spinning and falling
A common cause for a paralytic lesion is viral labyrinthitis or vestibular neuritis. Sometimes this can occur after a cold or ‘flu-like illness. The symptoms may persist for days or weeks.
The initial attack is caused by increased activity of the balance organ, hence the feeling of spinning is to the same side. During the recovery phase, there is a tendency to spin and fall to the opposite side.
A condition which is closely linked to Ménière’s Disease is a vestibular migraine, also known as migrainous vertigo. The symptoms are quite variable. These may be a feeling of spinning (vertigo
Dizziness may also be caused by disorders of balance pathways within the brain. This frequently occurs in people with poor blood circulation.This occurs due to reduced blood flow in the vertebral arteries and is known as vertebrobasilar insufficiency. Unlike conditions affecting the balance organs, here the feeling of imbalance is more or less constant. There is usually no nausea and the condition does not respond to ‘anti sickness’ medication.
In many people, the sensation of dizziness may cause a feeling of anxiety. Indeed anxiety may be the reason for the dizziness. Those so affected should be made aware of the nature of their condition. They should be offered
In most cases, there will be a gradual recovery of balance function. This process may be prolonged if there is ongoing anxiety or a lack of mobility. Simple provocation exercises are the best treatment for those with disorders of the balance organs and balance pathways. They should also be encouraged to keep active. This could take various forms such as gardening and
Specific treatment measures may be used in the disorders which have been mentioned. Let us look at these in more detail.
Viral labyrinthitis treatment
If the symptoms continue for weeks without improving, exercises which are designed to improve the body’s ability to adapt (Cawthorne Cooksey exercises, gaze stabilization exercises) could prove useful.
Ménière’s Disease treatment
If the symptoms are severe, conservative measures such as a low salt diet, together with drugs such as betahistine and bendroflumethiazide may be adequate. In more severe cases surgical procedures (intratympanic gentamicin therapy, vestibular neurectomy) may be successful.
Vestibular migraine treatment
This is often triggered off by stress. Hence various forms of stress management (yoga, pilates) may be useful. If the symptoms are severe and persistent, there are several drugs which may provide relief. These include beta blockers, amitriptyline, pizotifen, acetazolamide and sodium valproate.
Benign Paroxysmal Positional Vertigo (BPPV) treatment
In some cases, the condition may not clear up by itself. In these patients, particular reposition manoeuvres (Epley, Semont) may be necessary. The condition may also improve following certain specific exercises such as Brandt Daroff.
Vertebrobasilar insufficiency treatment
In these cases, drugs which tend to improve blood flow (aspirin, clopidogrel) could be very helpful. They may also benefit from Cawthorne Cooksey and gaze stabilization exercises.