The Room is Spinning!: A Comprehensive Guide to Vestibular Disorders
- Denby Williams
- 15 hours ago
- 6 min read
The vestibular system, located in the inner ear, is primarily responsible for maintaining balance and spatial awareness. Without the vestibular system to sense your position in relation to gravity, activities like walking or running would not be possible. It is composed of three structures: the peripheral apparatus, the central processing centers, and the motor output mechanism.
PERIPHERAL VESTIBULAR SYSTEM:
We begin with the outermost part of the inner ear, specifically the winding semicircular canals, which are filled with endolymph fluid, a critical component in maintaining balance. The semicircular canals sense head movement by the motion of fluid when interacting with tiny hair cells. These hair cells send signals to the brain, which is translated into the direction your head is moving and how to maintain a sense of balance. Three different semicircular canals correlate with axes of rotation. Moving further along is the vestibule, inside are the utricle and saccule. The utricle detects horizontal motion (sideways) and the saccule detects vertical motion (up and down). Within the utricle and saccule is the macula, which, when activated by hair cells, sends signals to the vestibular nerve of movement. The vestibular nerve is where we move to the central vestibular system.
CENTRAL VESTIBULAR SYSTEM:
The central vestibular system begins with the vestibular nuclei. Located in the brainstem and medulla, the nuclei are separated into 4 parts: lateral, medial, superior, and descending.
These structures are responsible for:
LATERAL:
tilt
gravity
MEDIAL:
balance
clear vision
posture
SUPERIOR:
coordinating eye movements
stabilizing vision
DESCENDING:
maintaining all previous functions
Along with sending vestibular nerves to the nuclei, they are also sent to the cerebellum. It acts as a double-checker of sorts as it fine-tunes any mishaps made by the nuclei.
MOTOR OUTPUT MECHANISM:
The motor output mechanisms include the vestibulo-ocular reflex (VOR), vestibulospinal reflex (VSR), and vestibulocollic reflex (VCR).
vestibulo-ocular reflex: a reflex that involuntarily stabilizes eye movements. It achieves this by moving the eyes in the opposite direction to the head. This is for rotational and linear movements.
vestibular-spinal reflex: a reflex that operates via the vestibulospinal tract. This is a neurological pathway that connects the inner ear to the spinal cord. From this, posture and limb movements are controlled.
vestibulocollic reflex: a reflex that maintains head posture through the neck muscles. Without these reflexes, the head would not be stabilized.
In simple terms,
your head moves --> inner ear detects movement through peripheral apparatus --> vestibular nerve sends signals to nuclei and cerebellum --> these signals are correlated to VOR, VSR, and VCR reflexes
VESTIBULAR DISORDERS
COMMON:
Benign paroxysmal positional vertigo (BPPV) - like its name suggests, this inner ear disorder is not particularly serious. However, it can cause balance issues in individuals over the age of 65, which may lead to harmful falls. Dizziness, blurred vision, lightheadedness, and rapid eye movements are all temporary symptoms that typically subside within a few hours. The Cleveland Clinic describes BPPV as "when calcium carbonate particles (otoconia) move into your semicircular canals (inner ear structures that control balance) and become trapped." (2022) Treatment for BPPV is typically physical therapy exercises to reposition the calcium carbonate particles.
Ménière’s disease - also known as idopathic endolymphatic hydrops- is a disorder caused by a buildup of endolymph fluid. Typically, the causes are a combination of poor fluid drainage, environmental factors (allergies, migraines, or head injuries), and genetics. Interestingly, there is an autoimmune link as 1/3 of all Ménière’s cases are associated with rheumatoid arthritis, lupus, and ankylosing spondylitis. The Mayo Clinic describes symptoms as "regular dizzy spells, hearing spells, ringing in the ear, and a feeling of fullness in the ear." Treatment for Ménière’s can be a prescription to reduce fluids, but it is commonly recommended for lifestyle changes, such as reducing salt intake, stress, and caffeine/alcohol.
Vestibular neuritis - a condition that is a result of inflammation of the vestibular nerve. This inflammation is typically derived from some kind of infection or autoimmune disorder. Anything from the common cold, measles, Lyme disease, to Guillain-Barré syndrome can cause severe vertigo and nausea. Depending on the severity, individuals can recover within a few weeks to lasting permanent damage. Treatment is a variety of medications: "antiemetics (promethazine, metoclopramide), antihistamines (diphenhydramine, meclizine), and benzodiazepines (diazepam, lorazepam)." (Smith et al, 2023). It is important to note that if not treated, vestibular neuritis can develop into BPPV.
Labyrinthitis - as the name suggests, labyrinthitis refers to inflammation in the inner ear, more specifically in the labyrinth. This can be differentiated between bony and membranous. When combined, the labyrinth encompasses a majority of structures within the vestibular system. While vestibular neuritis occurs due to inflammation of one branch, labyrinthitis is the inflammation of both branches. Women aged 30-60 are at the highest risk, and symptoms include: balance issues, blurred vision, dizziness, hearing loss, involuntary eye movements, and vertigo. As stated by the Cleveland Clinic, "Viral infections cause labyrinthitis in most cases. But bacterial infections can cause it, too. Some of the most common labyrinthitis causes include: Epstein-Barr virus, herpes simplex, stomach flu, and upper respiratory infections."
RARE:
Acoustic neuroma - located on the cranial nerve that connects the inner ear to the brain, an acoustic neuroma is a benign, non-cancerous tumor. Although its symptoms correlate relatively with other vestibular systems, it can become a problem when the tumor presses on the trigeminal nerve. Unlike other disorders, acoustic neuroma is largely genetically related - more specifically, a condition known as NF2-related schwannomatosis. It is an autosomal dominant trait, making the likelihood fairly likely to be passed down. There are no other known risk factors.
Mal de Debarquement Syndrome - Most common in women aged 30-60, Mal de Debarquement Syndrome is a rare disorder in which an individual feels like they are moving, which in fact they are not. It typically happens on boat travel, and can be cured without intervention. Most likely, when the individual is separated from the method of travel, their sense of gravity will return.
Superior Semicircular Canal Dehiscence (SSCD) - SSCD is a rare condition where a hole, or missing bone (dehiscence), is present on the covering of the semicircular canal. Without this protection, the semicircular canal is vulnerable to imbalances of pressure between the inner ear and cranial cavity. Symptoms are more apparent as one will experience vertigo, hypersensitivity to all sounds and one's voice, and the amplification of heartbeat and eye movements. All of this can be very debilitating. The primary treatment for SSCD is craniotomy surgery, where the missing cartilage is replaced with tissue.
Otosclerosis - Caused by an abnormal bone growth, otosclerosis occurs when the smallest bone in our body - the stapes - becomes stuck in place and blocks the inner ear organs. Due to this blockage, sound is unable to travel, which in turn causes gradual hearing loss. Dizziness and loss of balance are also reported frequently. Treatment is typically surgery known as stapedectomy, which involves "...a surgeon inserts a prosthetic device into the middle ear to bypass the abnormal bone and permit sound waves to travel to the inner ear and restore hearing..." (2022)
Although the number of common and rare vestibular diseases extends far beyond these eight conditions, it is important to consistently visit your local otolaryngologist (ENT) for a yearly checkup. In many of these cases, a comprehensive approach between an ENT, audiologist, neurologist, and rehabilitation therapist is required for diagnosis and prospective healing. REFERENCES:
Benign Paroxysmal Positional Vertigo (BPPV). (2022, June 16). Cleveland Clinic.
Hernandez, E., & M Das, J. (2022, October 17). Neuroanatomy, Nucleus Vestibular. PubMed; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK562261/
Labyrinthitis: Causes, symptoms, treatment & what it is. (2024, August 22). Cleveland Clinic. https://my.clevelandclinic.org/health/diseases/22032-labyrinthitis
Meniere’s disease - Symptoms and causes. (2024, January 3). Mayo Clinic. https://www.mayoclinic.org/diseases-conditions/menieres-disease/symptoms-causes/syc-20374910
Paparella, M., Schachern, P., Cüreoǧlu, S., & Penido, N. (n.d.). Peripheral Vestibular System - an overview | ScienceDirect Topics. Www.sciencedirect.com. Retrieved October 15, 2025, from https://www.sciencedirect.com/topics/neuroscience/peripheral-vestibular-system
Smith, T., Rider, J., Cen, S., & Borger, J. (2023, July 21). Vestibular neuritis. Nih.gov; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK549866/
Vestibular Disorders: Symptoms, Causes & Treatment. (2025, October 15). Cleveland Clinic. https://my.clevelandclinic.org/health/diseases/vestibular-disorders
Wilson, K. (2025, August 30). Vestibular System. Physiopedia. https://www.physio-pedia.com/Vestibular_System
Acoustic Neuroma - Symptoms and Causes. (2023, June 20). Mayo Clinic; Disease and Conditions. https://www.mayoclinic.org/diseases-conditions/acoustic-neuroma/symptoms-causes/syc-20356127
Mal de Débarquement Syndrome (MdDS): How To Cope. (2024, February 20). Cleveland Clinic. https://my.clevelandclinic.org/health/diseases/24796-mal-de-debarquement-syndrome-mdds
Gopen, Q., & Yang, I. (n.d.). Superior Semicircular Canal Dehiscence. UCLA Health; Head and Neck Surgery. Retrieved October 16, 2025, from https://www.uclahealth.org/medical-services/head-neck-surgery/conditions-treated/superior-semicircular-canal-dehiscence
Otosclerosis. (2022, March 16). National Institute on Deafness and Other Communication Disorders. https://www.nidcd.nih.gov/health/otosclerosis
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