Dizziness, Balance, and Vertigo
Dizziness is one of the most common reasons patients are referred to an ENT surgeon. It is also one of the most misunderstood, partly because the word "dizziness" covers a wide range of different sensations, and partly because the causes range from the entirely benign to a small number of conditions that genuinely need careful assessment.
I see patients with dizziness regularly in my NHS and private practice in Oxford, and I run the multidisciplinary balance clinic at the John Radcliffe Hospital, where complex cases are reviewed jointly with audiovestibular and physiotherapy colleagues.
Vertigo is a symptom, not a diagnosis
A common source of confusion. Patients are often told they "have vertigo" and reasonably assume this is a diagnosis. It is not. Vertigo simply describes a particular kind of dizziness: the sensation that you or your surroundings are moving when in fact neither is. Spinning is the most familiar form, but it can also feel like tilting, swaying, or being pulled to one side. The clinical question is always what is causing the vertigo, rather than vertigo itself being the answer.
It is also important to recognise that not all dizziness is vertigo. Other common patterns include:
Lightheadedness or presyncope, often related to blood pressure or hydration
Unsteadiness on walking
A more diffuse sense of being "off", floaty, or detached, sometimes with brain fog or difficulty concentrating
The character of the dizziness gives important diagnostic clues. Brief episodes of true rotational vertigo triggered by head movement point one way; constant unsteadiness on walking points another; lightheadedness on standing points somewhere different again. Describing the symptoms as accurately as you can, even where the language feels imprecise, is the single most useful thing you can do in the consultation.
How balance works
Balance depends on several systems in the body working together and agreeing with each other. The brain receives information from each of them, compares the inputs, and uses the result to determine your position in space and whether you are moving.
The three principal inputs are:
The inner ears. Each inner ear contains the vestibular system, a small set of fluid-filled structures that detect rotation and gravity. There is one in each ear.
The eyes. Vision tells the brain about your position relative to your surroundings.
Sensation from muscles and joints (proprioception). Sensors throughout the body, particularly in the feet, ankles, neck, and spine, report on how the body is positioned and where the ground is.
When all three systems agree, balance feels effortless. When they conflict, the result is dizziness. This is why dizziness can arise from any one of these sources, not only the ear, and why a proper assessment goes beyond examining the ear in isolation.
Two ordinary situations illustrate the point well. Reading in a moving car, or looking at a screen while walking on a treadmill, produces a mismatch between what the eyes and the inner ears are reporting, and the brain has difficulty reconciling the two. Stepping off a boat or a stopped escalator produces a similar effect: the brain has been compensating for one pattern of motion and takes a moment to readjust. Both are normal responses and not signs of disease. They are a useful reminder that balance is a whole-body process.
The brain adapts to loss of one balance organ
This is reassuring to know, particularly for patients facing conditions or treatments that may affect one inner ear. If one vestibular system stops working completely, which can occur after some infections, after certain operations, or because of conditions such as vestibular neuritis, the initial result is significant dizziness. Over time, however, the brain learns to rely on the remaining inner ear, the eyes, and proprioception to fill the gap. This process is called vestibular compensation. It usually takes some weeks to a few months, and for most people balance returns close to normal in everyday situations. Many people run, play sport, drive, and live entirely unrestricted lives with only one functioning vestibular system.
The brain's capacity to adapt is also the basis for vestibular rehabilitation exercises: structured exercises that deliberately challenge the balance system to drive compensation. These are typically prescribed and supervised by a specialist vestibular physiotherapist, and are one of the most effective treatments available for many types of ongoing dizziness. The best-known published set is the Cawthorne-Cooksey exercises, originally developed in the 1940s and still widely used; the ENT UK patient page sets them out clearly. For anyone who has been dizzy for several weeks or longer, vestibular rehabilitation should be part of the conversation.
Other factors that affect balance
A number of factors can produce dizziness or unsteadiness that have nothing to do with the ear. These often go unrecognised, and many can be addressed without medication or specialist intervention.
Common contributors include:
Dehydration. A frequent cause of low-grade unsteadiness and lightheadedness, particularly in older adults or in hot weather.
Low blood pressure or postural hypotension. Usually felt as lightheadedness rather than spinning, and worse on standing from sitting or lying.
Poor sleep. Sleep deprivation has a measurable impact on balance.
Hypoglycaemia (low blood sugar). Particularly if you have skipped meals.
Medications. Many commonly prescribed medications can cause dizziness as a side effect, including antihypertensives, certain antidepressants, some analgesics, and many others. A new dizziness following the introduction of a new medication is always worth considering in this context.
Anaemia.
Visual problems or recent changes in glasses prescription.
Neck problems. Particularly common in patients with cervical spine arthritis or recent neck strain.
Hyperventilation
Often overlooked, and well worth recognising. Breathing too rapidly or too deeply over a period (often without the person being aware of the change) reduces the level of carbon dioxide in the blood. This in turn reduces cerebral blood flow and produces lightheadedness, dizziness, tingling in the fingers and around the mouth, and sometimes a sense of detachment or unreality. Patients often describe it as a "swimmy" or floaty sensation that is difficult to characterise precisely.
Hyperventilation is frequently driven by anxiety or stress, without the breathing pattern itself being noticed. It can also become habitual, particularly in patients who are already dizzy from another cause and begin to over-breathe in response. The dizziness then increases the anxiety, the anxiety drives further over-breathing, and a self-perpetuating cycle develops.
The intervention is straightforward. Slowing the breath, breathing gently through the nose, or using a structured technique such as box breathing (in for four, hold for four, out for four, hold for four) will often settle the symptoms within a few minutes. For patients in whom this is a recurring problem, anything that supports a calmer breathing pattern over time, including mindfulness, yoga, or formal breathing exercises, is worth pursuing.
Stress and anxiety
Stress and anxiety produce real physiological effects on balance. They increase muscle tension, alter breathing patterns, disturb sleep, affect hydration and appetite, and influence how the brain processes the various balance inputs it receives. None of this is to suggest that the dizziness is imagined: the effects on balance are genuine and physiological. Many patients with ongoing dizziness find that stress is a significant amplifier of their symptoms, even when it is not the original cause.
A specific condition worth knowing about in this context is Persistent Postural-Perceptual Dizziness (PPPD). PPPD typically develops after another episode of dizziness, such as vestibular neuritis or BPPV, has resolved. The brain remains on heightened alert for balance signals and continues to interpret normal sensations as threatening, producing persistent unsteadiness particularly in busy visual environments: supermarkets, crowds, screens, scrolling on a phone. PPPD responds to a combination of vestibular rehabilitation, attention to underlying anxiety, and in some cases medication. Recognising it is the essential first step.
The broader practical point: attention to sleep, hydration, regular meals, stress management, and regular gentle exercise makes a meaningful difference to almost every type of dizziness. These are not peripheral measures; they are often the most effective part of treatment.
The main causes of dizziness arising from the ear or balance system
Once general contributors have been considered, several specific conditions need to be thought about. The three most common in adult ENT practice are BPPV, Ménière's disease, and vestibular migraine.
Benign Paroxysmal Positional Vertigo (BPPV)
BPPV is among the most common causes of true rotational vertigo, and one of the most readily treatable. Small calcium carbonate crystals (otoconia) that normally sit in one part of the inner ear become displaced into one of the balance canals. Each time the head moves into certain positions, the crystals shift within the canal and trigger a brief burst of spinning.
The characteristic pattern is:
Short, intense episodes of rotational vertigo, typically lasting 10 to 60 seconds, triggered by specific head movements
Common provoking movements include rolling over in bed, looking upwards, bending forward, or lying back (often noticed at the hairdresser or dentist)
Symptoms settle quickly when the head is held still, but recur with the next provoking movement
No associated change in hearing or fullness in the ear
The diagnosis is made by a positional test in clinic (the Dix-Hallpike manoeuvre). The treatment is a specific sequence of head and body movements (the Epley manoeuvre), which repositions the crystals back into the part of the inner ear where they belong. The condition often resolves in one or two sessions, though BPPV can recur and need re-treatment. A set of home exercises called the Brandt-Daroff exercises can also be useful, either as an alternative for patients in whom the Epley manoeuvre is not practical, or to be done at home between sessions to reduce the chance of recurrence.
If your BPPV keeps coming back, it is worth having your vitamin D level checked. Low vitamin D is linked to recurrent BPPV, and correcting a deficiency where one is found can reduce the chance of further attacks.
BPPV is frequently missed or misattributed for some time before being correctly identified. If your dizziness has the pattern described above, it is worth being assessed specifically for BPPV.
Ménière's disease
Ménière's disease is a condition where pressure builds up in the fluid-filled chambers of the inner ear, leading to episodes of severe vertigo (often with nausea and vomiting), fluctuating hearing loss, tinnitus, and a sense of fullness in the affected ear. Attacks typically last from 20 minutes up to several hours, and patients can be left feeling drained for some time afterwards.
It usually affects one ear at first, and the hearing typically fluctuates during the early stages before becoming more permanently affected over time. Between attacks, many patients feel relatively normal, although some have ongoing background unsteadiness or tinnitus.
Treatment is usually approached in steps:
Lifestyle measures. Reducing salt, caffeine, and alcohol, maintaining good hydration, adequate sleep, and stress management are well-established as the first measures to address, and for many patients they have a substantial effect on attack frequency.
Medication. Betahistine (Serc) is commonly prescribed as a preventive agent, though the evidence base for its effect is mixed; some patients find it helpful, others less so. Diuretics are sometimes used with the aim of reducing inner ear fluid pressure.
More involved treatments. For patients with frequent attacks not controlled by the above, options include intratympanic injections (delivered into the middle ear) and, less commonly, surgical interventions. These are decisions taken jointly in clinic.
Monitoring hearing between appointments. Patients with Ménière's are well placed to track their own hearing over time, and there is a useful tool for this. The Mimi Hearing Test app, available free on iOS and Android, allows you to test your hearing through your own headphones. It is not a substitute for formal audiometry in clinic, but it provides useful longitudinal data and can be particularly helpful in identifying fluctuations between visits.
A more detailed page on Ménière's disease is in preparation.
Vestibular migraine
Vestibular migraine is among the most common causes of recurrent dizziness in adults, and it is frequently missed because patients do not necessarily have a headache at the time of the dizziness. Many people who would not have described themselves as migraine sufferers in fact have vestibular migraine as the cause of their balance symptoms.
Typical features include:
Episodes of vertigo or unsteadiness, lasting from minutes to days
Sensitivity to light, sound, or motion during episodes
A headache may or may not be present, before, during, or after the episode
A personal or family history of migraine elsewhere in life
Common triggers including poor sleep, missed meals, stress, dehydration, certain foods, alcohol, and hormonal changes
The diagnosis is clinical, based on the history and the pattern of attacks. Treatment follows the principles of migraine management more generally:
Identifying and avoiding triggers where possible. A brief diary kept over a few weeks often reveals patterns that are not otherwise obvious.
Attention to sleep, regular meals, hydration, regular gentle exercise, and stress management. These measures are the foundation of treatment, not an adjunct to it.
Standard migraine preventive medications can be very effective, particularly amitriptyline, propranolol, and topiramate. These are usually prescribed by your GP or a headache specialist.
Pain relief and anti-emetics for acute attacks.
The Migraine Trust is the leading UK migraine charity and provides excellent evidence-based patient information specifically on vestibular migraine. I recommend their resources to most patients with this diagnosis.
Vestibular neuritis and labyrinthitis
Sudden onset of severe spinning vertigo, usually following a viral illness, often lasting days to weeks. The vertigo is usually constant rather than triggered by movement (although movement makes it worse). Vestibular neuritis affects balance only; labyrinthitis is similar but also affects hearing on the same side. Both usually settle on their own, with the brain compensating over the following weeks, and vestibular rehabilitation exercises can accelerate recovery.
Other less common ENT causes
A vestibular schwannoma (a benign growth on the hearing and balance nerve) can occasionally present with imbalance and one-sided hearing loss or tinnitus. There is more on this on my Hearing Loss page.
A perilymph fistula (a tiny leak from the inner ear) is uncommon but can follow trauma or straining.
Superior semicircular canal dehiscence is a rare condition where a thin part of the bone overlying the balance organ is missing, causing dizziness with loud noise or pressure changes.
These are uncommon but worth knowing about, particularly when symptoms don't fit any of the more common patterns.
Exercise and balance
Regular physical activity, particularly any that gently challenges balance (walking on uneven ground, Tai Chi, yoga, dancing, swimming) is one of the most effective long-term interventions for ongoing balance problems. The brain's capacity to maintain and adapt the balance system depends on regular use of it. Patients who reduce or stop physical activity in response to feeling unsteady often find that their unsteadiness becomes more entrenched, not less.
The usual approach is sequential: identify and address any specific underlying cause, undertake appropriate vestibular rehabilitation, and gradually build regular gentle physical activity into daily life. The progression is incremental, beginning at a level the patient can comfortably sustain. The aim is not athletic; it is a steady, regular, low-intensity challenge to the balance system, ideally on most days.
When should I see someone about dizziness?
Most dizziness is not dangerous, but a few presentations need urgent assessment. Call 999 or go to A&E if your dizziness comes with any of:
Sudden severe headache, particularly the worst you have ever had
Weakness or numbness in your face, arm, or leg
Difficulty speaking, slurred speech, or trouble understanding speech
Sudden loss of vision or double vision
Loss of consciousness or near-fainting
Chest pain or breathlessness
Sudden hearing loss (this is a separate emergency in its own right, see my Hearing Loss page)
Recent head injury
Otherwise, it is worth booking an appointment if:
Your dizziness has been going on for more than a week or two
Your dizziness is interfering with daily life
You are having recurrent episodes that you can't explain
You have any associated hearing loss, tinnitus, fullness in the ear, or facial symptoms
You are unsure what is causing it and would like a clear assessment
When should you come and see me?
Come and see me if you have ongoing or recurrent dizziness, particularly where there are associated ear symptoms, or if you would like a thorough ENT opinion on what is happening. I will take a detailed history, examine your ears under the microscope, perform basic balance and positional testing where appropriate, and arrange formal audiometry, further balance investigation with an audiovestibular specialist, or imaging where indicated.
For many patients, the most useful part of the appointment is being heard properly and given a clear, structured explanation. Dizziness is a distressing symptom and uncertainty about its cause often compounds the difficulty. A clear assessment and plan, even where the problem is not resolved at a single visit, is often the most valuable outcome.
If you would like to be seen urgently, please contact my secretary and I will do my best to accommodate.
Helpful resources
Disclaimer
This page is intended as general information only. It does not replace a consultation, examination, hearing assessment, or individual medical advice. If you have ongoing dizziness or balance problems, please get in touch to book an appointment so I can assess things properly and give you advice specific to your situation.
I have no financial interest in the Mimi hearing test app.