Balance problems and the Otolaryngologist

At hudsonENT, we see people daily for balance problems. There are many providers of medicine who might be involved in helping these symptoms. For the sake of simplification, the umbrella term “balance problem” encompasses vertigo, dizziness, wooziness, off-kilter, off-balance, giddiness and probably several other terms.

I point this out, because it is so important to get the right history when evaluating someone with a balance problem. We want to know exactly, on a unique personal level, things like:

-when did it start?

-how does it feel (without using those balance words listed above)?

-any ear symptoms (e.g. hearing problem, tinnitus, etc.)

-any head trauma?

-any headache?

And much more.

Now, the “textbook answer” is that these “crystals” that people read about on are the cause of the majority of cases. This might be true in primary care, but not so for the otolaryngologist. At least not at hudsonENT. By the time people get to us, this has resolved, been treated with home maneuvers, or with physical therapy. So we have to dig deeper.

Most of the time, when the ear or ears are truly the cause of the balance problem, the result is “true-vertigo”: this is correctly defined as a spinning sensation and most often in the lateral / horizontal plane. This means left to right or vice versa and not “butt-over-tea-kettle”, although that rarely is possible.

Sometimes, there is a new hearing problem that started with the event which brings in the idea of labyrinthitis. Sometimes, there is a fullness or pressure in the ear which brings up the possibility of Meniere’s.

The start of the evaluation of such a problem will include an audiogram with our audiologist before seeing the otolaryngologist. This is because, looking with any tool in the ear does not reveal what the inner ear is like, and the audiogram can give much greater detail about that.

Some patients are not interested in this, since nowadays those over fifty years of age typically get bombarded with mail from those looking to give you free hearing tests. The intention here is not like that at all, because very often there are subtle cues that can be teased with the hearing test.

The other main test we have at hudsonENT, among several, is the videonystagmography (VNG). There are not many who have this technology in our area and the value is that it can give us some idea of where the problem is coming from. This test is not necessary in many, but there are challenging cases and/or “overlap” cases where the diagnosis can not be made with history (i.e. the symptoms) alone.

The VNG is also preceded by an audiogram unless one has been done already, and the test can last up to two hours. Goggles and electrodes applied to the head measure how the eyes move in relation to certain maneuvers, and how the eyes respond gives the providers a sense of the source of the problem.

Many times, and maybe even the majority of times, the problem is not coming from the ears at all. Many are surprised or dismayed to learn that their balance problem is coming from the “CNS”, or central nervous system. This creates some anxiety, to be sure. Such an entity could be “white matter changes” consistent with age; small blood vessel diseases; sometime Lyme disease; and commonly it can be due to “a pinched nerve” in the neck, which is part of the “CNS”.

In summary, we have equipment and ways to help you get back on your feet and steady. We hope you never have a balance problem, because they can be difficult but we also want you to know there is help!