Balance Disorders

What is a balance disorder?

A balance disorder is a condition that makes you feel unsteady or dizzy, as if you are moving, spinning, or floating, even though you are standing still or lying down. Balance disorders can be caused by certain health conditions, medications, or a problem in the inner ear or the brain.

Our sense of balance is primarily controlled by a maze-like structure in our inner ear called the labyrinth, which is made of bone and soft tissue. At one end of the labyrinth is an intricate system of loops and pouches called the semicircular canals and the otolithic organs, which help us maintain our balance. At the other end is a snail-shaped organ called the cochlea, which enables us to hear. The medical term for all of the parts of the inner ear involved with balance is the vestibular system.

How does the vestibular system work?

Our vestibular system works with other sensorimotor systems in the body, such as our visual system (eyes) and skeletal system (bones and joints), to check and maintain the position of our body at rest or in motion. It also helps us maintain a steady focus on objects even though the position of our body changes. The vestibular system does this by detecting mechanical forces, including gravity, that act upon our vestibular organs when we move. Two sections of the labyrinth help us accomplish these tasks: the semicircular canals and the otolithic organs.

The semicircular canals are three fluid-filled loops arranged roughly at right angles to each other. They tell the brain when our head moves in a rotating or circular way, such as when we nod our head up and down or look from right to left.

Each semicircular canal has a plump base, which contains a raindrop-shaped structure filled with a gel-like substance. This structure, called the cupula, sits on top of a cluster of sensory cells, called hair cells. The hair cells have long threadlike extensions, called stereocilia, that extend into the gel. When the head moves, fluid inside the semicircular canal moves. This motion causes the cupula to bend and the stereocilia within it to tilt to one side. The tilting action creates a signal that travels to the brain to tell it the movement and position of your head.

Between the semicircular canals and the cochlea lie the otolithic organs, which are two fluid-filled pouches called the utricle and the saccule. These organs tell the brain when our body is moving in a straight line, such as when we stand up or ride in a car or on a bike. They also tell the brain the position of our head with respect to gravity, such as whether we are sitting up, leaning back, or lying down.

Like the semicircular canals, the utricle and the saccule have sensory hair cells. These hair cells line the bottom of each pouch, and their stereocilia extend into an overlying gel-like layer. On top of the gel are tiny grains made of calcium carbonate called otoconia. When you tilt your head, gravity pulls on the grains, which then move the stereocilia. As with the semicircular canals, this movement creates a signal that tells the brain the head's position.

Our visual system works with our vestibular system to keep objects from blurring when our head moves and to keep us aware of our position when we walk or when we ride in a vehicle. Sensory receptors in our joints and muscles also help us maintain our balance when we stand still or walk. The brain receives, interprets, and processes the information from these systems to control our balance.

Figure 1. Diagram of outer, middle, and inner ear. The outer ear is labeled in the figure and includes the ear canal. The middle ear includes the eardrum (tympanic membrane) and three tiny bones for hearing. The bones are called the hammer (malleus), anvil (incus), and stirrup (stapes) to reflect their shapes. The middle ear connects to the back of the throat by the Eustachian tube. The inner ear (labyrinth) contains the semicircular canals and vestibule for balance, and the cochlea for hearing.

The vestibular structures of the inner ear are the vestibule (which is made up of the utricle and saccule) and the three semicircular canals. These structures work somewhat like a carpenter's level (a tool used to show how "level" a horizontal or vertical surface is). That is, they work by way of the vestibulocochlear nerve with the vestibular center in the brain to deal with body balance and position. (The rest of the inner ear, that is, the cochlea, is concerned with hearing.) Thus, the vestibular system includes the vestibule, the semicircular canals, the vestibular branch of the vestibulocochlear nerve, and the vestibular center in the brain.

The vestibular system measures linear and rotational movement. A number of disorders can cause this system to stop working or provide inappropriate information. These disorders include Ménière syndrome, labyrinthitis, benign paroxysmal positional vertigo, ear infections, tumors, or trauma. Each of these conditions is discussed below.


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Hearing and Balance Anatomy

Medical Author: Benjamin C. Wedro, MD, FACEP, FAAEM
Medical Editor: William C. Shiel, Jr., MD, FACP, FACR

The anatomy of the ear can be a little confusing, especially since the ear is responsible not only for hearing, but also for balance.

There are three components to the ear: the outer ear, the middle ear and the inner ear. All three are involved in hearing but only the inner ear is responsible for balance.

The outer ear is composed of the pinna, or ear lobe, and the external auditory canal. Both structures funnel sound waves towards the ear drum or tympanic membrane allowing it to vibrate. The pinna is also responsible for protecting the ear drum from damage. Modified sweat glands in the ear canal form ear wax.

The middle ear is an air filled space located in the temporal bone of the skull. Air pressure is equalized in this space via the Eustachian tube which drains into the nasopharynx or the back of the throat and nose. There are three small bones, or ossicles, that are located adjacent to the tympanic membrane. The malleus, incus, and stapes are attached like a chain to the tympanic membrane and convert sound waves that vibrate the membrane into mechanical vibrations of the three bones. The stapes fills the oval window which is the connection to the inner ear.


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