Balance Disorders

When you think about balance, the role that ears play might not come to mind. But ears are crucial to maintaining balance thanks to their vestibulocochlear nerve. This nerve sends signals to the brain that control hearing (auditory function) and help with balance (vestibular function).

But the ears aren’t the only organs that help us balance. Ears, eyes, joints, and muscles work together to keep us steady and upright. When one or more of these systems is out of whack, it can be hard to get around and just function, day to day. The simplest things — like walking, riding a bike, doing school work, even playing — can become difficult and frustrating.

Balance disorders are considered uncommon in kids and teens, but might be underestimated — symptoms could be misdiagnosed as something else or missed altogether. But resolving kids’ balance problems can make a big improvement in their overall quality of life — their ability to play, learn, and feel as happy and healthy as possible.

How Balance Works

To understand balance problems, it’s important to understand how balance works normally. Basically, the body relies on three separate systems, each sending nerve impulses to the brain:

• In the neck, torso, leg joints, and feet are pressure sensors that send information to the brain about where the body is in relation to the world (known as proprioception). Messages are sent when we do things like turn our heads, move, and walk on different surfaces.
• In the front of the inner ear, or labyrinth, are the cochlea, involved in hearing; in the rear are semicircular canals, which affect balance. Connecting them is the vestibule (with sensory organs known as the utricle and saccule), which affects balance and equilibrium. When we turn our heads rapidly, the liquid in the semicircular canals moves the tiny hairs lining the cochlea, sending a message (through the vestibulocochlear nerve) to the brain about the movement. In less than a second, the brain sends messages to the muscles needed to maintain balance and help the eyes stay focused.
• In the eyes, the nerve endings in the retina (at the back of the eye) have light-sensitive cells called rods and cones. When we look at something, light hits the retina, and the rods and cones send electrical signals to the brain through the optic nerve. The brain uses these signals to interpret what we’re seeing and create visual images. Each eye gets slightly different images of (and information about) the same object, which aids depth perception (how far away an object is) and is vital to maintaining balance.

If any of these systems isn’t working right, it can affect balance.

Symptoms

Depending on the type of balance disorder and what’s causing it, symptoms can vary from child to child. Some kids and teens may experience severe symptoms, making it hard for them to function. Others might only have mild symptoms that are barely noticed.

In general, though, children with balance disorders have symptoms of disequilibrium — an unsteady, “woozy” feeling that makes it hard to stand up, walk, turn corners, or climb the stairs without falling, bumping into things, stumbling, or tripping.

They also might walk with their legs too far apart or be unable to walk without staggering. Walking in the dark or over uneven surfaces can be tricky, too. All of this can make them seem uncoordinated and clumsy.

Another common symptom of a balance problem is vertigo. Most people think of this as a sudden sensation that the room is spinning or whirling or that you’re moving when sitting or standing still. But kids may describe it as feeling like they’re rocking, floating, or “on a merry-go-round.” Kids also might feel dizzy, lightheaded, or disoriented.

Balance disorders can cause vision problems, too. Kids may see images that bounce or look blurry whenever they move their heads. This is called oscillopsia, which can make reading and writing really tough.

Symptoms also can include:

• involuntary eye movements (called nystagmus)
• discomfort or difficulty looking at sun glare or lights (especially fluorescent, flashing, or moving lights)
• discomfort in situations with “busy” visuals (patterns, crowds, heavy traffic, and jam-packed areas like shopping malls)
• depth perception disruptions that can affect hand-eye or eye-foot coordination (making things like catching or kicking a ball difficult)

Balance issues also can impact hearing. Sounds might seem muffled, especially amid background noise. Kids might also have bothersome, distracting ear problems like ear pain, pressure or “fullness”in the ears, and tinnitus (ringing or other sounds like whirring, humming, or buzzing).

These kinds of balance-related symptoms can take a real toll on kids — physically and emotionally — and cause other symptoms like:

• frequent headaches or migraines
• nausea, vomiting, and diarrhea
• motion (car) sickness
• changes in heart rate and blood pressure
• fatigue
• seizures
• fear, anxiety, or panic
• depression

Of course, symptoms involving kids’ movement, sight, hearing — and just how they feel, day to day — can affect their ability to keep up in class, whether in preschool or high school. Balance problems can make it hard to remember things, concentrate, pay attention, and follow directions. Kids might not be able to hear the teacher or focus their eyes on the chalkboard or their books. And they might become frustrated in gym class and with sports.

Some kids and teens with balance disorders might seem like they’re being lazy or not paying attention or trying in school. Probably the most aggravating part for them is feeling like they’re trying their very best, but being unable to do some things they want or need to do — and not knowing why.

Types of Balance Disorders

Although balance disorders aren’t common in kids and teens (again, probably because they’re so hard to catch), the most frequently diagnosed vestibular conditions are:

• Benign paroxysmal torticollis of infancy, which usually starts during a child’s first 6 months. Torticollis literally means “twisted neck” and kids with this condition tend to keep their heads tilted from feeling so dizzy. They might also have headaches, sweat a lot, vomit, look pale, seem fussy, and walk or toddle strangely. Some may have BPV, too.
• Benign paroxysmal vertigo of childhood (or BPV, sometimes also called childhood paroxysmal vertigo), in which fluid or tiny particles can detach and build up in the inner ear. This may cause vertigo that comes on suddenly (often when rapidly moving the head) and disappears in a matter of minutes. Kids may seem momentarily scared and unsteady and also may have nausea, vomiting, involuntary eye movements, or headaches. BPV, which usually affects kids ages 2 to 12, can go away on its own as kids grow or continue into adulthood to become benign positional vertigo or migraine-associated vertigo.
• Vestibular neuronitis (or neuritis), an infection that causes inflammation of the vestibular nerve, might cause a sudden case of vertigo, nausea, vomiting, and involuntary eye movements.
• Labyrinthitis can be caused by a viral (or, rarely, a bacterial) infection of the inner ear’s labyrinth, which also can bring on sudden vertigo, tinnitus, and temporary mild hearing loss in some kids.

Other conditions are far less common; for example, perilymph fistula (PLF) is an abnormality (often a tear or defect) in the connections between the inner ear and middle ear that may cause vertigo, unsteadiness, hearing loss, and ear pressure. And an inner ear disorder called Meniere’s disease can bring on tinnitus, hearing loss, ear fullness, and lengthy episodes of vertigo that may last anywhere from 30 minutes to an hour or longer.

Causes

Doctors can’t always pinpoint the cause of a balance problem. But balance-related symptoms may be brought on by any number of things, such as:

• ear, head, or neck injuries
• ototoxicity (when certain medications, including specific antibiotics and chemotherapy drugs, damage the inner ear)
• migraines
• hearing loss
• chronic middle ear infections (otitis media)
• other infections (like the cold, flu, meningitis, measles, mumps, or rubella)
• depression
• alcohol abuse
• motion sickness or sensitivity
• seizure disorders

Children who have a family history of hearing or vestibular problems, dizziness, or motion sickness might be more prone to balance disorders, too.

Diagnosis

Detecting and diagnosing balance disorders in kids and teens can be tricky. Unfortunately, kids with many common balance problems may be so young that they can’t describe how they’re feeling or respond to certain tests. And to parents, they might just seem clumsy and fussy.

If you think your child might be having balance problems, call your doctor, who will do a physical exam and look at your child’s symptoms and medical history. If the doctor thinks that your child’s balance is affected, you might be referred to an audiologist (a hearing specialist), an otolaryngologist (an ear, nose, and throat specialist, or ENT), and/or a neurolotologist (a specialist in ear disorders).

Tests can include:

• imaging tests, like an MRI or a CT scan
• motor function tests to look at fine and gross motor skills
• behavioral hearing tests. These involve careful observation of a child’s behavioral response to sounds like pure tones. Pure tones are the distinct pitches (frequencies) of sounds. Sometimes other signals are used to obtain frequency information.
• otoacoustic emissions (OAE) test. A tiny probe is placed in the ear canal, then many pulse-type sounds are introduced and an “echo” response from cells in the inner ear is recorded. A normal recording is associated with normal inner ear function and reflects normal hearing. This test, along with the ABR, is usually used on infants and young children.
• electronystagmogram (ENG). To assess balance, electrodes are placed around the eyes and a computer monitors involuntary eye movements while a child is asked to focus on a visual target or while hot or cold water is injected into the ear canal. The head may also be manipulated into different positions while doctors observe eye movements.
• videonystagmography (VNG). This test is similar to an ENG, only the child has to focus on the visual target while wearing special video recording goggles. Then the eye movements are evaluated as cool and warm air is gently blown into the ear canals.
• auditory brainstem response (ABR) test. Tiny earphones are placed in the ear canals. Usually, click-type sounds are amplified through the earphones, and electrodes measure the auditory (hearing) nerve’s response to those sounds.
• vestibular evoked myogenic potential (VEMP). This fairly new test assesses parts of the inner ear that the ENG, VNG, and ABR tests don’t. Like the ABR, earphones are placed in each ear to listen to loud clicks. And electrodes put on the head and neck record the child’s response to the clicks as he or she contracts neck muscles.
• posturography. This test measures a child’s ability to balance while standing on a stable or unstable platform.
• balance questionnaires. Kids who are old enough to describe a medical problem may be asked questions about the level of dizziness experienced throughout the day while performing different activities.

Treatment

Kids can just outgrow some balance disorders. For example, both BPV of childhood and benign paroxysmal torticollis of infancy usually go away, without treatment, by the time a child is 5 years old. And vestibular neuronitis and labyrinthitis often disappear on their own, too.

Still, doctors can help manage kids’ symptoms and make their lives a little easier with rehabilitation and sometimes medicine or surgery.

Balance therapy (also called vestibular rehabilitation) with a physical or vestibular therapist may include training exercises that help strengthen balance skills and coordination. Exercises might involve things like bending down, standing or walking with eyes open and then with eyes closed, swimming, or walking barefoot on various uneven surfaces. Kids often do very well with vestibular therapy because they’re better able to adapt to balance problems than adults.

For kids with BPV of childhood, a therapist can sometimes relieve vertigo and dizziness by gently repositioning the head at different angles to move fluid or the tiny particles floating around in the inner ear (this is known as the canalinth repositioning or Epley maneuver).

And kids with significant hearing loss that’s affecting their balance may need one or more of the following:

• a hearing aid (that fits inside or behind the ear and make sounds louder)
• an FM system or “auditory trainer” (specialized devices that block out background noise)
• a cochlear implant (a surgically implanted device that helps overcome problems in the inner ear, or cochlea)
• listening therapy with an audiologist (which uses music and sounds to help kids adapt their hearing and balance)

When to See a Doctor

It’s important to remember that although things like dizziness and clumsiness are common signs of a balance disorder, on their own these symptoms aren’t necessarily a sign of a balance problem — or any other chronic problem, for that matter. For example, it’s perfectly normal for kids to feel woozy if they’re dehydrated or they stand up too fast. And lots of kids stumble and fall sometimes, especially toddlers just learning to walk and preschoolers getting used to how their bodies move.

However, if you’re seeing a pattern — if you notice one or more possibly balance-related symptoms happening regularly — it’s a good idea to call your doctor to find out what’s going on. Diagnosing and treating balance disorders can help kids develop more normally, become more steady and coordinated, and just function and feel better physically and emotionally.