Balance Disorders

Your sense of balance is made up of the way that your senses, such as sight and hearing, define and experience the interaction of gravity and motion. Your ear is an intricate system of bone, cartilage and otolithic organs—a complex network of canals, semicircular canals, and fluid-filled pouches—all which make up your vestibular system (the balance portions of the inner ear, nerves and brain).

As you move, the fluid in your otolithic organs moves with you and contributes to your brain's assessment of balance. Likewise, the semicircular canals assess the sensation of movement, as fluid in the canals moves over highly sensitive hairs within those canals. Dizziness, vertigo, and motion sickness all relate to the sense of balance and equilibrium.

The otolaryngologists at Brigham and Women’s Hospital (BWH) treat diseases, conditions and dysfunctions that affect balance including dizziness and vertigo, acoustic neuromas, Meniere’s disease, eardrum perforations and tinnitus.

Balance Disorder Topics

Sense of Balance

Your sense of balance is maintained by the complex interaction of the following parts of the nervous system.

  • The inner ear (also called the labyrinth) which monitors the directions of motion, such as turning, rolling, forward-backward, side-to-side, and up-and-down motions.
  • The eyes which monitor where the body is in space—upside down, right side up—and also the direction of motion.
  • The pressure receptors in the joints of the lower extremities and the spine which tell what part of the body is down and touching the ground.
  • The muscle and joint sensory receptors (also called proprioception) which tell what parts of the body are moving.
  • The central nervous system (the brain and spinal cord) which processes all the information from the four other systems to maintain balance and equilibrium.

The symptoms of motion sickness and dizziness occur when the central nervous system receives conflicting messages from the other four systems.

Learn more about vertigo, dizziness, and your sense of balance.

Vertigo and Dizziness

Feeling unsteady or dizzy can be caused by many factors such as poor circulation, inner ear disease, medication usage, injury, infection, allergies, and/or neurological disease. Dizziness is treatable, but it is important for your doctor to help you determine the cause so that the correct treatment is implemented. While each person will be affected differently, symptoms that warrant a visit to the doctor include a high fever, severe headache, convulsions, ongoing vomiting, chest pain, heart palpitations, shortness of breath, inability to move an arm or leg, a change in vision or speech, or hearing loss.

Causes of Dizziness

  • Circulation: If your brain does not get enough blood flow, you feel lightheaded. Almost everyone has experienced this on occasion when standing up quickly from a lying-down position. But some people have light-headedness from poor circulation on a frequent or chronic basis. This could be caused by arteriosclerosis or hardening of the arteries, and it is commonly seen in patients who have high blood pressure, diabetes, or high levels of blood fats (cholesterol). It is sometimes seen in patients with inadequate cardiac (heart) function, hypoglycemia (low blood sugar), or anemia (low iron).
  • Certain drugs also decrease the blood flow to the brain, especially stimulants such as nicotine and caffeine. Excess salt in the diet also leads to poor circulation. Sometimes circulation is impaired by spasms in the arteries caused by emotional stress, anxiety, and tension.
  • If the inner ear fails to receive enough blood flow, the more specific type of dizziness—vertigo—occurs. The inner ear is very sensitive to minor alterations of blood flow and all of the causes mentioned for poor circulation to the brain also apply specifically to the inner ear.
  • Neurological diseases: A number of diseases of the nerves can affect balance, such as multiple sclerosis, syphilis or tumors. These are uncommon causes.
  • Anxiety: Anxiety can also be a cause of dizziness and lightheadedness.

Causes of Vertigo

Vertigo is a specific type of dizziness in which a patient inappropriately experiences the perception of motion, usually a spinning motion. Vertigo is most often due to an issue with the inner ear.

The common causes of vertigo are (in order):

  • Benign Positional Vertigo (BPV): Can be experienced after a change in head position such as lying down, turning in bed, looking up, or stooping. It lasts about 30 seconds and ceases when the head is still. It is due to a dislodged otolith crystal entering one of the semicircular balance canals. It can last for days, weeks or months. The Epley "repositioning" treatment by an otolaryngologist is usually curative. This vertigo is the most common cause of dizziness.
  • Meniere's Disease: An inner ear disorder with attacks of vertigo (lasting hours), nausea, or vomiting, and tinnitus (loud noise) in the ear (which often feels blocked or full). There is usually a decrease in hearing as well.
  • Migraine: Some individuals with a prior classical migraine headache history can experience vertigo attacks similar to Meniere's disease. Usually there is an accompanying headache, but can also occur without the headache.
  • Infection: Viruses can attack the inner ear, usually a nerve connection to the brain, causing acute vertigo (lasting days) without hearing loss—termed vestibular neuronitis. However, a bacterial infection such as mastoiditis that extends into the inner ear can completely destroy both the hearing and equilibrium function of that ear, called labyrinthitis.
  • Injury: A skull fracture that damages the inner ear can produce a profound and incapacitating vertigo with nausea and hearing loss. The dizziness will last for several weeks and slowly improve as the other (normal) side takes over. Benign positional vertigo (see above) commonly occurs after head injury.
  • Allergy: Some people experience dizziness and/or vertigo attacks when they are exposed to foods or airborne particles (such as dust, molds, pollens, dander, etc.) to which they are allergic.
Balance Assessment Testing

Videonystagmography or Electronystagmography (VNG/ENG) are diagnostic tests used to evaluate the vestibular system (balance portions of the inner ear, nerve, and brain). When the head is in motion, the inner-ear balance organs send signals to the eye muscles to keep vision in focus. Therefore, eye movements can be used to evaluate the balance system. Specialized video goggles with infrared cameras, are used to measure eye movements.

Each ear canal is irrigated with small amounts of warm and cool air (caloric test) as the patient lies on an examination table. The air causes a temperature change that creates eye movements (nystagmus) that can be measured and compared for each ear. Information obtained from the ENG, along with information from other clinical tests, can help make a diagnosis and recommendations for treatment.

Learn more about balance assessment testing at Brigham and Women’s Hospital.

What You Should Expect

You will receive a thorough diagnostic examination to evaluate if you have a balance disorder and determine what course of treatment is needed. Careful monitoring and the involvement of an experienced otolaryngologist are important to the successful outcome for patients with ear, nose and throat disorders and conditions.

If you are having surgery or a procedure, you will likely be scheduled for a visit to the Weiner Center for Preoperative Evaluation for pre-operative information and tests.

The day of surgery, you will be taken care of in the operating room by otolaryngologist, anesthesiologists and nurses who specialize in surgery for patients with balance disorders. After surgery, you will go to the post-surgical care unit where you will receive comprehensive care by experienced surgical and nursing staff.

Learn more about your hospital stay, patient-centered care and returning home.

Multidisciplinary Care

Brigham and Women’s Hospital provides a multidisciplinary approach to patient care by collaborating with colleagues who have extensive experience in diagnosing and treating ear, nose and throat disorders and conditions. In addition, patients have full access to BWH’s world-renowned academic medical community, with its diverse specialists, and state-of-the-art facilities.


Learn more about balance disorders in our health library.

Read about Superior Semicircular Canal Dehiscence which can cause balance disorders.

Visit the Kessler Health Education Library in the Bretholtz Center to access computers and knowledgeable staff.

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