Balance and balance disorders
Introduction
This factsheet has been written for parents to provide information about the balance
system and balance disorders. You may have been given this factsheet when balance
tests are recommended. If you have any questions or concerns about your child’s
balance discuss them with your child’s doctor.
Balance problems can occur when the organ of balance does not work properly
(vestibular hypofunction). Children can be born with this or acquire it with illness or
trauma. With hypofunction development of balance function may be delayed and this
might mean that babies and young children take longer to reach developmental
milestones such as sitting unsupported and walking. Older children may have difficulties
with certain activities such as learning to ride a bike. This is called imbalance.
Other types of balance problem can give rise to dizziness or vertigo or episodes of
unsteadiness. These can occur at any time in childhood.
Throughout the factsheet we use the term ‘your doctor’ which could be a paediatrician
who specialises in audiology, an ear, nose and throat (ENT) consultant or an
audiological physician.
Contents
How the balance system works
Why is the balance system tested?
How is the balance system tested?
Helping balance problems
Some conditions that may include balance problems
Useful organisations
More information
NDCS uses the word ‘deaf’ to refer to all levels of hearing loss.
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Balance and balance disorders
How the balance system works
The inner ear consists of the cochlea, the vestibule and the semicircular canals. The
cochlea is the organ of hearing and looks like a snail’s shell. The organ of balance
includes the vestibule and the semicircular canals. These structures are filled with fluid
and have sense organs made up of small hair cells which detect movement and gravity.
As we move in space these sense organs send information about our balance to the
brain.
As well as the vestibular system in the inner ear, the brain also uses information from
two other systems to maintain balance:
Visual information from the eyes tells the brain where we are in relation to the
environment around us. For example, when we are walking our brain is receiving
different visual information from our surroundings.
Special pressure receptors in the legs and body, known as proprioceptors, send
signals to the brain that tell it about posture and movement and also about the
surrounding physical environment such as uneven or sloping ground.
Information from these three systems is received and interpreted by the brain, which
then sends back instructions to the muscles controlling our movement so that we are
able to keep our balance. A temporary change or problem with one part of the system
can result in temporary dizziness or unsteadiness, for example inner ear infection or
glue ear. Sometimes the vestibular system is affected by injury, illness or a long-term
condition, for example migraine. Sometimes the vestibular system and the cochlea have
been affected by the same problem and so deafness and balance problems can occur
together, for example meningitis, EVA, CHARGE and other syndromic causes of
deafness. However, this is not always the case and many deaf children have excellent
balance while dizzy children can have normal hearing.
For more information telephone the Freephone Helpline on 0808 800 8880 (voice and text).
NDCS is a registered charity in England and Wales no. 1016532 and in Scotland no. SC040779
Balance and balance disorders
Why is the balance system tested?
Tests of the balance system can be done when:
there is a history of dizziness
there is some difficulty with balance
A deaf child may also have balance tests when:
there has been delay in learning to sit or walk
the deafness is one-sided (unilateral) or a different level in each ear (asymmetrical)
the level of deafness is changing
a cochlear implant is being considered
the cause of the deafness is being examined in detail
The tests can:
help to determine the cause of balance problems and/or dizziness
give more information about the function of the inner ear
may help find the cause of the child’s deafness
Even if a deaf child appears to have good balance it can still be useful to look more
closely at their balance system. Children are clever at compensating for weaknesses in
the balance system and it may not be obvious until full testing is done. Identification of
balance problems can help your doctor understand more about your child and can
sometimes help to understand the cause of the deafness.
How is the balance system tested?
Your child’s doctor will carry out a clinical examination to assess your child’s balance.
These will include observation of some simple activities such as walking, marching on
the spot and hopping on one foot, often with the eyes open and then closed. In very
young babies an assessment of head control and muscle tone will give the doctor
information about the child’s balance system.
Your child’s doctor may recommend that a more detailed assessment of the balance is
done. Some of the tests used in this assessment are described below. Your child’s
doctor will discuss which tests are planned and why they are recommended. A full
balance assessment may last between 1½ to 3 hours.
Preparation for the tests
Balance tests are painless, but some of them may make your child feel unsteady, dizzy,
or occasionally, sick. Most children do not have any trouble with testing and many even
enjoy them. If your child does experience problems during testing, the tester will stop
and give them a chance to recover.
Some tests are carried out in the dark. If your child lip-reads or uses sign language it is
important that they understand what will happen before the lights are turned off. One
test may involve putting water into the ear canal and therefore the removal of any
hearing aids.
For more information telephone the Freephone Helpline on 0808 800 8880 (voice and text).
NDCS is a registered charity in England and Wales no. 1016532 and in Scotland no. SC040779
Balance and balance disorders
Some medication/drugs can affect balance tests and you may be advised to stop using
them before coming to the clinic. Alcohol can also affect results and young adults
should not drink for 48 hours before testing.
Balance Tests
Balance tests rely on looking for and recording eye movements. Eye movements are
recorded because there is an interaction between the eyes, eye muscles, and the
vestibular system in the inner ear. These movements are called ‘nystagmus’.
Nystagmus is an involuntary jerking of the eyes that occur when the balance system is
stimulated. During everyday life nystagmus is not usually seen but it can be induced by
certain movements or stimulating the vestibular system. Measuring nystagmus helps to
determine the origin of the dizziness.
Video-Nystagmography (VNG)
The VNG measures movement of the eyes using special goggles. Your child will wear
these goggles in a darkened room while their eye movements are recorded.
Electronystagmogram (ENG)
The ENG records eye movements using small stickers called electrodes, which are
placed on the skin around the eyes. These electrodes pick up changes in the electricity
within the eye as it moves.
With both VNG and ENG your child will have eye movements recorded while they watch
a bright light or a striped curtain (saccades, gaze testing, smooth pursuit tracking and
optokinetic testing). In addition your child may be tested when sitting in a computercontrolled chair that rotates gently back and forth or round and round (sinusoidal and
impulsive rotation). Very young children may be tested sitting on their parent’s lap. Most
of these tests are performed in a very dark room.
Calorics
Caloric testing is performed using either VNG or ENG recordings. A small earpiece is
placed at the entrance of the ear canal and through this warm and/or cool water is
washed into the outer ear for about 30 seconds. The water is a few degrees above or
below body temperature. The temperature change caused by the water stimulates a
response from the balance system. Eye movements are measured to record this
response. Caloric testing is not painful, but may make your child feel lightheaded or
dizzy for a short time.
Posturography
Your child will stand barefoot on a platform that measures how much they sway. The
platform moves back and forth during the test and records how well they keep their
balance. Your child will be wearing a safety harness so that they cannot fall.
For more information telephone the Freephone Helpline on 0808 800 8880 (voice and text).
NDCS is a registered charity in England and Wales no. 1016532 and in Scotland no. SC040779
Balance and balance disorders
Vestibular evoked myogenic potentials (VEMP)
VEMP are used to measure the function of the sense organs of the vestibule. Small
sticky electrodes are placed on the muscles of the neck and a sound is played into the
ear. The sound waves stimulate the balance sense organ and the resultant change in
tension of the muscle in the neck is measured. This is painless. This test is uncommon.
Helping balance problems
Dizziness or vertigo
Some causes of dizziness are self-limiting and the child recovers quickly without the
need for specific help. However children who develop recurrent or persistent dizziness
often need quite specific help. Depending on the cause this may involve medication,
physiotherapy exercises, occupational therapy or psychology. Your child’s doctor will
advise if these are necessary.
Imbalance
If a child is born with or acquires a balance problem early in life it is likely that they will
develop ways of compensating quite naturally without the need for any special help or
therapy. However it will be helpful to know that there are weaknesses in their system so
that simple steps can be taken to help if necessary. For example, a child may manage
extremely well during the day but have difficulty walking in a straight line in the dark. It
might be helpful for this child to have a night light in hallways in case they need to get
up at night to prevent them bumping into doorways etc. It is unlikely that a balance
problem will prevent a child from doing normal childhood activities but it is also
important to know if there are any safety precautions to be aware of. For example,
ensuring that children are closely supervised when swimming in case they become
disorientated underwater, and giving children extra time and support when learning to
ride a bike.
Some conditions that may include balance problems
Benign paroxysmal vertigo of childhood (BPVC) is characterised by brief episodes of
vertigo and nausea with no change in hearing or loss of consciousness. Children may
also be sick. This sometimes, but not often, happens when children get migraine. For
more information about migraine in children go the www.patient.co.uk/ and type
‘migraine in children’ into the search box. The Migraine Action Association also hosts a
website for children and teenagers at www.migraine4kids.org.uk. For further information
about migraine contact The Migraine Association (details can be found in the Useful
Organisations section at the end of this factsheet).
CHARGE syndrome is a congenital (born with) condition affecting about one in 10,000
births. The condition affects several areas of the body and development. The acronym
CHARGE reflects the involvement of Coloboma (a hole in one of the structures of the
eye), Heart defects, Atresia choanae (blockage of the nasal passages), Restricted
growth and development, Genital hypoplasia and Ear anomalies. For further information
about CHARGE contact Contact a Family (details can be found in the Useful
Organisations section at the end of this factsheet).
For more information telephone the Freephone Helpline on 0808 800 8880 (voice and text).
NDCS is a registered charity in England and Wales no. 1016532 and in Scotland no. SC040779
Balance and balance disorders
Diabetes. There are a number of very rare forms of diabetes that may be associated
with deafness. Some of these are genetic (inherited) disorders of the mitochondria
(small organelles within the body’s cells that play a critical role in energy production).
Mitochondrial DNA is inherited only from the mother and cells that are especially
vulnerable to any defect of this sort may be damaged. DIDMOAD (Diabetes Insipidus,
Diabetes Mellitus, Optic Atrophy and Deafness) or Wolfram's Syndrome is one of these.
For further information go to Children with Diabetes website at
www.childrenwithdiabetes.com.
Enlarged Vestibular Aqueduct (EVA) is a congenital (born-with) condition that can cause
progressive or fluctuating deafness. Some children also experience a feeling of
dizziness and imbalance, and a general lack of co-ordination. EVA is sometimes known
as wide vestibular aqueduct or large vestibular aqueduct. Children with Pendred
syndrome have an EVA but not all children with EVA have Pendred syndrome. See
below for more information on Pendred syndrome. For more information on EVA read
the NDCS Enlarged Vestibular Aqueducts publication.
Glue ear is a very common childhood condition. It is caused by is a temporary build-up
of fluid blocking the middle ear that makes it harder for sound to pass through to the
inner ear. This can make quieter sounds difficult to hear. Sometimes glue ear can also
affect a child’s behaviour, for example becoming tired and frustrated, poor concentration
and preferring to play alone. Some parents also notice that their child has more
problems with their balance or become clumsy whilst they have glue ear. For more
information on glue ear read the NDCS Glue Ear leaflet.
Jervell and Länge-Nielsen or Long QT syndrome is a congenital (born with) condition
that may be genetic (inherited). Jervell and Länge-Nielsen syndrome is characterized by
deafness and abnormality of the heart rhythm that may cause fainting or be life
threatening. Profoundly deaf children should be offered an ECG to help rule out the
condition as a cause for their deafness. If the condition is diagnosed most people with
the condition respond well to medication or other treatment. For further information
about Jervell and Länge-Nielsen or Long QT syndrome contact Contact a Family
(details can be found in the Useful Organisations section at the end of this factsheet).
Meningitis is inflammation of the ‘meninges’, the lining that surrounds the brain. This is
usually caused by bacterial and viral infections. Meningitis can cause hearing loss in a
number of ways. The most common cause is the infection spreading into the inner ear.
This can damage the cochlea in the inner ear. Another possible cause is inflammation
of the auditory nerve, the nerve that carries sound signals to the brain. For more
information on meningitis, phone the Meningitis Trust helpline on 0800 028 1828 or visit
their website at www.meningitis-trust.org. For more information on meningitis and
deafness read the NDCS ‘Meningitis and childhood deafness’ leaflet.
Pendred syndrome is a genetic (inherited) condition. Pendred syndrome causes
progressive deafness (becoming worse over time) as well as affecting the thyroid gland
and sometimes a child’s balance. The deafness in Pendred syndrome is caused by
enlarged vestibular aqueducts (see EVA for more information). For more information on
Pendred syndrome go to the National Institute on Deafness and Other Communication
Disorders website at http://www.nidcd.nih.gov/health/hearing/pendred.asp.
For more information telephone the Freephone Helpline on 0808 800 8880 (voice and text).
NDCS is a registered charity in England and Wales no. 1016532 and in Scotland no. SC040779
Balance and balance disorders
Usher syndrome is a genetic (inherited) condition which affects around 3% to 6% of
those children in the UK who are born with a hearing loss. During mid- to latechildhood, children with Usher syndrome start to have sight problems caused by a form
of retinitis pigmentosa. The retina slowly loses its ability to send pictures to the brain.
The early symptoms include difficulty seeing in the dark and in different lighting
conditions. Over time, the field of vision gradually deteriorates until tunnel vision
develops. For further information about Usher Syndrome contact Sense (details can be
found in the Useful Organisations section at the end of this factsheet).
Waardenburg syndrome is a genetic (inherited) condition. The common features of the
syndrome can be deafness associated with wide spacing between the eyes, broadening
of the bridge of the nose, different coloured eyes or a different coloured segment in one
or both eyes and sometimes a distinctive white forelock of hair present above their
forehead. Some people with Waardenburg syndrome are reported to have problems
with balance as a result of the vestibular system being affected.
Useful organisations
Contact a Family is the only UK-wide charity providing advice, information and support
to the parents of all disabled children - no matter what their disability or health condition.
They enable parents to get in contact with other families, both on a local and national
basis. They offer a range of services to support families including a freephone helpline
and a number of offices, staff and volunteers around the UK. They provide information
to professionals and developmental advice to support groups. They also work to
influence services and have campaigns that aim to improve the quality of life for families
with disabled children.
209-211 City Road
London
EC1V 1JN
Phone: 020 7608 8700
Fax: 020 7608 8701
Helpline 0808 808 3555 or Textphone 0808 808 3556
Freephone for parents and families (Mon-Fri, 10am-4pm)
e-mail: [email protected]
www.cafamily.org.uk
Sense is a national charity that supports and campaigns on behalf of children and adults
who are deafblind. They provide specialist information, advice and services to deafblind
people, their families, carers and the professionals who work with them. They also
support people who have sensory impairments (deafness or blindness) and other
disabilities.
101 Pentonville Road
London
N1 9LG
Telephone: 0845 127 0060
Textphone: 0845 127 0062
Fax: 0845 127 0061
Email: [email protected]
Website: www.sense.org.uk
For more information telephone the Freephone Helpline on 0808 800 8880 (voice and text).
NDCS is a registered charity in England and Wales no. 1016532 and in Scotland no. SC040779
Balance and balance disorders
SENSE also has offices in Scotland, Wales and Northern Ireland, and regional offices in
England.
The Migraine Action Association is a charity, which helps people to understand what
migraine is, how it can affect your life and the lives of those around you such as your
family and friends. They also try to help people find ways to get better. They raise
money for more research into what causes migraine and finding new treatments for
special clinics where people with migraine can be treated by expert doctors and nurses.
27 East Street
Leicester
LE1 6NB
e-mail: [email protected]
www.migraine4kids.org.uk
More information
If you are interested in finding out about or your child is already undergoing tests to try
and establish the cause of their deafness you may like to read the NDCS publication
Understanding your child’s hearing tests which explains the different tests available.
If you have been referred for genetic counselling or testing or you already know that
your child has a genetic condition you may like to read the NDCS publication Genetic
Counselling.
All the publications mentioned in this factsheet are available to download from the
NDCS website at www.ndcs.org.uk
For hard copies of any of the NDCS publications or information and practical support on
issues related to your child’s deafness, contact the NDCS Freephone Helpline on 0808
800 8880, email us at [email protected] or contact us via Live Chat at
www.ndcs.org.uk/livechat.
If you prefer to speak a language other than English, tell us the language of your choice
and your phone number (in English). We will call you back with an interpreter within a
few minutes.
Thanks
We would like to thank Dr Katherine Harrup-Griffiths who provided some of the text from
an existing leaflet, as well as all the professionals who commented on the contents of
this factsheet.
This information can be requested in large print, audio CD and in Braille.
March 2008
For more information telephone the Freephone Helpline on 0808 800 8880 (voice and text).
NDCS is a registered charity in England and Wales no. 1016532 and in Scotland no. SC040779