Vestibular Disorders

Vestibular disorders may result from a variety of conditions affecting the inner ear and the balance system. Examples include:

• Vestibular labyrinthitis or neuritis (also known as neuronitis)

• Labyrinthine concussion (unilateral or bilateral vestibular lesions)

• Benign paroxysmal positional vertigo (BPPV)

• Perilymphatic fistula

• Primary endolymphatic hydrops (Ménière’s disease)

• Secondary endolymphatic hydrops (traumatic, infectious, etc.)

• Utricular dysfunction

• Superior canal dehiscence syndrome (congenital or trauma-induced)

• Central vestibulopathy (sensory integration dysfunction)

• Drug-induced vestibular toxicity

• Persistent postural-perceptual dizziness (PPPD)

• Mal de Débarquement syndrome (MdDS)

A detailed subjective and objective assessment is essential to identify the cause of dizziness or balance problems and to develop an effective treatment plan.

Subjective Assessment

During subjective evaluation, the following questions should be addressed to thoroughly investigate the patient’s symptoms and condition¹:

• Duration of episodes: How long do episodes of dizziness or vertigo last (seconds, minutes, or hours)?

• Type of dizziness: Does the patient experience a spinning sensation (vertigo) or more general imbalance/disequilibrium (or both)?

• Previous assessment: Has the patient undergone medical investigations or received a specific diagnosis?

• Onset and triggers: Is there a history of head trauma or other precipitating factors?

• Visual or complex environments: Do symptoms occur during visual tasks or in busy, movement-rich environments?

  

Symptoms and Factors to Explore

In addition to general questions, specific aspects should be considered:

• Quality and intensity of dizziness: Rotation, falling sensation, or general unsteadiness?

• Associated symptoms: Nausea, vomiting, visual disturbances, hearing loss?

• Relation to movement: Worsening with head turns or positional changes?

• Psychosocial impact: How do symptoms affect daily life, work, and social function?

Importance of Subjective Assessment

Subjective evaluation provides unique insight into the patient’s experience. This helps to:

• Differentiate between vestibular disorders based on symptom pattern and duration.

• Identify environmental and emotional triggers.

• Guide objective tests to confirm or rule out diagnostic hypotheses.

Mal de Débarquement Syndrome (MdDS)

MdDS is a form of sensory integration dysfunction. Patients typically describe a rocking or swaying sensation, as if being on a boat².

Normally, the vestibular system adapts to continuous passive motion (e.g., sea travel) and readjusts once on land. In MdDS, this readaptation fails, causing symptoms to persist for months or even years³.

A key feature: patients often feel better when in motion, which distinguishes MdDS from other vestibular disorders¹ ².

Motion Sickness

Asking about a history of motion sickness is relevant since it may indicate¹:

• Non-adaptive CNS strategies: Maladaptive central mechanisms in handling sensory conflict.

• Sensory mismatch: Imbalance between vestibular and visual inputs, reducing the ability to adapt to environmental changes¹ ⁵.

Oscillopsia

Oscillopsia is the subjective illusion of visual motion, caused by dysfunction of the vestibulo-ocular reflex (VOR)⁷.

• It occurs only with the eyes open.

• Often linked to bilateral peripheral vestibular lesions (BVLs)¹.

• Patients describe surroundings as moving, especially during gait or head movements.

• It severely impacts orientation and daily activities.

Floating, Swimming, or Spinning Sensations

These symptoms are commonly associated with psychological conditions such as anxiety, depression, or somatoform disorders¹. The vestibular system is rarely the primary cause, highlighting the importance of a biopsychosocial perspective.

Vertical Diplopia

Vertical diplopia refers to double vision where images appear displaced vertically¹.

• Symptoms resolve when one eye is closed.

• Often due to skew deviation, linked to otolith dysfunction or abnormal otolith signal processing.

Vertigo

Vertigo is defined as the illusion of movement of oneself or the environment. It is a subjective phenomenon. When vestibular in origin, it often results from sudden imbalance in tonic neural output¹.

Lightheadedness / Presyncope

These symptoms are usually related to orthostatic hypotension rather than vestibular dysfunction. Differentiating between the two is essential for accurate treatment¹.

Symptom Provocation

During subjective assessment, it is important to explore situations that trigger symptoms¹:

• Do they occur with head or body movements?

• Do they worsen in busy or noisy environments?

• Are they related to visual tasks or activities?

Summary of Symptoms and Mechanisms

Symptom	Likely Mechanism
Unsteadiness – balance problems	Vestibulospinal, proprioceptive, visual, or motor dysfunction; joint pain; psychological factors
Lightheadedness / presyncope	Reduced cerebral blood flow
Rocking/swaying (MdDS)	Maladapted vestibular adaptation to continuous motion
Motion sickness	Visual–vestibular mismatch
Nausea and vomiting	Medullary stimulation
Oscillopsia	Acquired nystagmus (spontaneous) or severe bilateral VOR loss (head-induced)
Floating/swimming sensations	Anxiety, depression, somatoform disorders
Vertical diplopia	Skew deviation from otolith dysfunction
Vertigo (spinning, tilting, linear movement)	Imbalance of neural activity toward vestibular cortex

Fall Risk

• Patients with unilateral vestibular lesions (UVL) generally do not have higher fall risk compared to peers.

• Patients with bilateral vestibular lesions (BVL) have significantly increased fall risk¹.

Questions to ask:

• Did you sustain an injury during the fall?

• When and how did the fall occur?

• Have you changed your lifestyle due to fear of falling?

Functional Status

Subjective Outcome Measure

The Dizziness Handicap Inventory (DHI/DI) is a validated tool for subjective evaluation and treatment outcome measurement. It captures the patient’s perception of handicap and its impact on quality of life¹ ⁹.

Covers three domains¹⁰:

• Functional: Impact on daily activities.

• Physical: Somatic reactions to dizziness.

• Emotional: Psychological burden.

Scoring interpretation:

• 16–34: Mild handicap

• 36–52: Moderate handicap

• 54: Severe handicap¹¹

Psychosocial Status

Psychosocial factors must be considered, since anxiety can interfere with vestibular rehabilitation¹ ¹².

The Positive and Negative Affective Scale (PANAS) may be used for screening anxiety and depression, though it does not identify the underlying cause¹.

Cognitive–Vestibular Interactions

Patients with vestibular disorders may also present with cognitive challenges, such as¹ ¹³:

• Memory deficits

• Reduced concentration

• Impaired multitasking

Background:

• Vestibular projections to cortical areas may explain these interactions¹⁴.

• Brandt et al. introduced the concept of “higher vestibular disorders”, highlighting combined sensory and cognitive integration deficits¹⁴.

This represents difficulties in integrating vestibular and visual sensory inputs.

Summary

• Dizziness and vertigo may result from various conditions.

• Establishing the nature and severity of symptoms is essential before objective testing.

• Subjective assessment provides the foundation for accurate diagnosis and targeted treatment.

Sources:

1.   Tonks B. Vestibular Assessment Course. Plus, 2021.

2.   Saha KC, Fife TD. Mal de débarquement syndrome: Review and proposed diagnostic criteria. Neurol Clin Pract. 2015;5(3):209-15.

3.   Cha YH, Brodsky J, Ishiyama G, Sabatti C, Baloh RW. Clinical features and associated syndromes of mal de debarquement. J Neurol. 2008;255(7):1038-44.

4.   Whiteboard Medical Journal [WMJ]. Mal de debarquement syndrome (Motion sickness WITHOUT the motion). Available from: https://www.youtube.com/watch?v=ybDBcDJjOek [last accessed 5/7/2021].

5.   Koch A, Cascorbi I, Westhofen M, Dafotakis M, Klapa S, Kuhtz-Buschbeck JP. The Neurophysiology and Treatment of Motion Sickness. Dtsch Arztebl Int. 2018;115(41):687-96.

6.   TED-Ed. The mystery of motion sickness - Rose Eveleth. Available from: https://www.youtube.com/watch?v=gKhE3CMz7Sk [last accessed 5/7/2021].

7.   Hain TC, Cherchi M, Yacovino DA. Bilateral vestibular weakness. Front Neurol. 2018;9:344.

8.   PhysioPathoPharmaco. Orthostatic Hypotension (Described Concisely). Available from: https://www.youtube.com/watch?v=kbO67x08mXM [last accessed 5/7/2021].

9.   Tamber AL, Wilhelmsen KT, Strand LI. Measurement properties of the Dizziness Handicap Inventory by cross-sectional and longitudinal designs. Health Qual Life Outcomes. 2009;7:101.

10.   Mutlu B, Serbetcioglu B. Discussion of the dizziness handicap inventory. J Vestib Res. 2013;23(6):271-7.

11.   Jacobson GP, Newman CW. The development of the Dizziness Handicap Inventory. Arch Otolaryngol Head Neck Surg. 1990;116:424-7.

12.   Saman Y, Bamiou DE, Gleeson M, Dutia MB. Interactions between stress and vestibular compensation - a review. Front Neurol. 2012;3:116.

13.   Rizk HG, Sharon JD, Lee JA, Thomas C, Nguyen SA, Meyer TA. Cross-sectional analysis of cognitive dysfunction in patients with vestibular disorders. Ear Hear. 2020;41(4):1020-7.

14.   Brandt T, Strupp M, Dieterich M. Towards a concept of disorders of "higher vestibular function". Front Integr Neurosci. 2014;8:47.