Balance disorders are common and may significantly impact upon quality of life and independence. Impaired balance may result in falls with resulting morbidity and mortality, particularly in older people. The prevalence of balance problems at age 70 years is reported to be 36% in women and 29% in men. 
Most patients with dizziness or balance difficulty will have a peripheral vestibular disorder such as viral vestibular neuritis/labyrinthitis, Meniere disease, or benign paroxysmal positional vertigo (vertigo caused by the presence of a canalith in the vestibular apparatus).  In cases of Meniere syndrome there is fluctuating sensorineural hearing loss, tinnitus, and a sense of aural fullness in the affected ear during episodes of vertigo. Acute-onset dizziness accompanied by bilateral hearing loss may be due to inner ear ototoxicity or, less commonly, autoimmune inner ear disease, both of which require urgent intervention. Chronic progressive imbalance with bilateral sensorineural hearing loss in an older person may be due to degenerative inner ear disease. Chronic imbalance in patients with congenital hearing loss may be due to congenital bilateral peripheral vestibular loss. Chronic imbalance from bilateral peripheral vestibular loss with preserved hearing may be due to sequential vestibular neuritis or may be idiopathic.
Neurologic causes of balance difficulty are less common but may be life-threatening (e.g., cerebellar or brainstem infarction). Reversible causes include tabes dorsalis and subacute combined degeneration of the spinal cord.
Medications may impair balance and a careful review of medication history is needed in order to identify potential culprits (e.g., aminoglycosides, cisplatin, anticonvulsants, tranquilizers, antihypertensives, diuretics, amiodarone, alcohol, and methotrexate). Dizziness and balance difficulty may also result from psychiatric disease, especially panic or anxiety disorders. However, patients with vestibular disorders also have a higher prevalence of panic and anxiety disorders.
It is also important to consider that the cause of the balance disorder may be multifactorial. For example, a chronic alcoholic may have problems with balance due to alcohol-related neuropathy, alcohol-related cerebellar degeneration, and bilateral vestibulopathies from thiamine deficiency. In older patients there may be no identifiable cause.
A detailed history must focus on the time course of the balance disorder and any associated auditory, visual, or neurologic symptoms. For example, a history of brief recurring vertigo that is related to change in head position and is not associated with any auditory symptoms is most likely due to canalithiasis. The presence of associated auditory symptoms (hearing loss and tinnitus) and ear pain or blockage indicate likely inner ear disease. However, the absence of these symptoms does not exclude inner ear disease.
Balance disorders should be distinguished from syncope or presyncope, in which degrees of loss of consciousness occur and which are likely to be due to cardiovascular or neurovascular causes and require urgent evaluation.
The physical examination must look for signs of peripheral vestibular dysfunction and neurologic deficits.
Instructor in Otology and Laryngology
Harvard Medical School
AP declares that he has no competing interests.
Assistant Professor in Ophthalmology
Director of Neuro-ophthalmology
Beth Israel Deaconess Medical Center
Harvard Medical School
NT declares that she has no competing interests.
Professor and Vice-Chairman
Department of Otolaryngology-Head and Neck Surgery
Dizziness and Balance Center
Washington University School of Medicine
JAG has been reimbursed for conference speaking and clinical research support by NeuroCom Intl, Inc. and for conference speaking by MicroMedical Technologies, Inc.
Department of Otolaryngology
University of Colorado
SPC is an author of a number of references cited in this monograph.
Instructor in Neurology
Department of Neurology
Massachusetts General Hospital
DJC declares that he has no competing interests.
Clinical Senior Lecturer & Consultant in Audiovestibular Medicine
UCL Ear Institute
DB declares that she has no competing interests.
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