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
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
If any of these systems isn't working right, it can affect balance.
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
fear, anxiety, or panic
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.
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)
chronic middle ear infections (otitis media)
other infections (like the cold, flu, meningitis, measles, mumps, or rubella)
motion sickness or sensitivity
Children who have a family history of hearing or vestibular problems, dizziness,
or motion sickness might be more prone to balance disorders, too.
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
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
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.
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
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
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.