Vertigo and dizziness are often unsettling. For international patients, we find an effective way forward in the vast majority of cases – based on decades of experience and modern, gentle treatment methods.
From my time as Chairman of a university ENT hospital, I know how important a thorough conversation is. That is why I take the time you need – your treatment success and your well-being are our goal.
Yours, Prof. Dr. med. H.P. ZennerBalance and Vertigo Centre, private ENT clinic in Tübingen/Stuttgart
Vertigo
Vertigo is among the most common complaints of all: year after year it ranks among the ten most frequent reasons for visiting a family doctor. The number of possible causes is just as large – and very often the trigger lies in the ear.
Possible causes of vertigo at a glance:
- Acute vestibular syndrome
- Age-related dizziness, presbyvertigo
- Benign paroxysmal positional vertigo (BPPV), positional vertigo
- Bilateral vestibulopathy (bilateral vestibular hypofunction, bilateral vestibular loss)
- Semicircular canal dehiscence
- Unilateral vestibulopathy (unilateral vestibular hypofunction, unilateral vestibular loss)
- Functional dizziness, persistent postural-perceptual dizziness (PPPD), phobic postural vertigo, chronic vestibular syndrome
- Sudden hearing loss with vertigo (acute idiopathic sensorineural hearing loss with vestibular involvement)
- Idiopathic vertigo, vertigo not otherwise specified
- Labyrinthitis (toxic, bacterial, viral)
- Menière's disease, Lermoyez syndrome
- Vestibular neuritis
- Toxic vestibulopathy (adverse drug reaction, toxic chemicals)
- Trauma (e.g. labyrinthine concussion/contusion, skull base injuries)
- Tumours of the skull base and cerebellopontine angle, vestibular schwannoma (acoustic neuroma)
- Vestibular paroxysmia (neurovascular compression syndrome of the 8th cranial nerve)
- Vestibular migraine
How does vertigo arise? The interplay of the senses
The most important organ of balance is located in the inner ear. But it does not work alone: the eyes also provide crucial information – which is why vertigo often gets worse as soon as you close your eyes. Less well known is that all of the body's voluntary muscles are also part of the balance system. On closer inspection this makes sense: for us to walk upright, the brain has to fine-tune the muscles of the legs and trunk continuously, and the muscles in turn constantly report back whether a movement is proceeding as planned.
All these signals from the inner ear, eyes and muscles converge in specialised regions of the brain, where they are compared with one another.
Vertigo occurs when these centres receive unexpected or contradictory signals – or when familiar signals suddenly stop.
A typical cause of such a conflict is a disorder of the inner ear.
The inner ear
Because of its intricate structure, the balance organ in the inner ear is called the labyrinth. It includes three ring-shaped semicircular canals that register rotations of the head – each one is responsible for one of the three spatial planes and reports rotations in that plane to the brain. In addition, there are two further sensory organs for straight-line movement, cupula and macula. They detect whether the body is moving forwards or backwards, up or down, or sideways; this is why we speak of linear acceleration.
During rotational movements, a mass shifts within the semicircular canals and stimulates the sensory cells. The organs for straight-line movement, by contrast, contain tiny stones, the otoliths, embedded in a fine mesh to which sensory cells are attached. When you move – for example upwards in a lift or forwards as a car pulls away – the otoliths shift. The sensory cells are stimulated and send a signal that reaches the brain via the vestibular nerve.
The visual system
The eyes are another important component. Many people with vertigo know that it gets worse with their eyes closed or in the dark. Via the optic nerve, the brain learns whether we are standing, walking or lying down; this information is processed in the same area as the signals from the inner ear. Incidentally, research has still not identified a single, clearly defined balance centre in the brain.
The muscles
Muscles and tendons also contribute a great deal to stability. That you can touch the tip of your nose or bring a spoon safely to your mouth with your eyes closed is thanks to thousands of sensors in the skeletal muscles and tendons. They continuously inform the brain about the position and tension of the muscles – and these signals, too, arrive in the same processing region as the signals from the ear and eye. Like a high-performance computer, the brain must constantly coordinate a wealth of information so that we can stand and walk safely.
An example: if you tilt your head and upper body to the left, all systems report the same thing. Both inner ears register a tilt of about 35° to the left, the eyes confirm the new head position, and the sensors in the neck and trunk muscles deliver matching signals. As long as everything agrees, balance remains stable – no vertigo. If, however, part of the information deviates from the familiar pattern, you feel dizzy.
When signals contradict each other
Suppose a disease has caused all the balance sensors in the right inner ear to fail – this does actually happen. If you now tilt your head to the left, the left ear, the neck muscles and the eyes correctly report the new position, whereas the right ear sends a false signal. The brain receives contradictory information, and it is precisely this contradiction that you perceive as vertigo.
As long as your eyes are open, vision acts as a kind of referee: the brain usually trusts visual information most and can thus partly compensate for the contradictory signals from the ears. That is why vertigo is often milder with the eyes open. With the eyes closed, this compensation is missing – the faulty signals from the right inner ear then clash unfiltered with those from the left. The result is severe vertigo, often accompanied by nausea and vomiting.
The basic principle, then, is this: vertigo results from confusion in the brain, triggered by faulty or contradictory signals from individual sensors of the balance system.