Chapter 22. Dizziness, Imbalance, and Vestibular Dysfunction

Maura K. Cosetti, M.D.; Anil K. Lalwani, M.D.
DOI: 10.1176/appi.books.9781585624201.681032



Since the 1940s, dizziness, vertigo, and imbalance have been well documented and commonly reported sequelae of traumatic brain injury (TBI) (Maskell et al. 2006). While long recognized, the complex relationship between dizziness and TBI remains incompletely understood. "Dizziness" in itself is a nonspecific term that may encompass a wide variety of symptoms, including vertigo, imbalance, disequilibrium, light-headedness, altered coordination, and disorientation. Entangled and often inseparable, these symptoms represent a complex continuum of sequelae that cross vestibular, cognitive, and psychosocial domains. This broad spectrum of symptomatology gives some insight into the diversity of pathology present in the TBI patient. It is both the diversity and complexity of injuries that pose unique diagnostic and treatment challenges to the clinician.

Your session has timed out. Please sign back in to continue.
Sign In Your Session has timed out. Please sign back in to continue.
Sign In to Access Full Content
Sign in via Athens (What is this?)
Athens is a service for single sign-on which enables access to all of an institution's subscriptions on- or off-site.
Not a subscriber?

Subscribe Now/Learn More

PsychiatryOnline subscription options offer access to the DSM-5 library, books, journals, CME, and patient resources. This all-in-one virtual library provides psychiatrists and mental health professionals with key resources for diagnosis, treatment, research, and professional development.

Need more help? PsychiatryOnline Customer Service may be reached by emailing PsychiatryOnline@psych.org or by calling 800-368-5777 (in the U.S.) or 703-907-7322 (outside the U.S.).

Figure 22–1. Anatomy and physiology of the vestibular system.A. The peripheral auditory and vestibular systems are composed of the external ear, including the auricle and external auditory canal (EAC); the middle ear, including the tympanic membrane (TM) and three ossicles, specifically the malleus (M), incus (I), and stapes (S); and the inner ear, composed of the cochlea and the three semicircular canals (SC) of the vestibular apparatus, specifically the lateral (Lat SC), superior (Sup SC), and posterior (Post SC).B. Focused view of the dilated, or ampullated, end of a semicircular canal showing the cristae ampullaris, neuroepithelium (including the hair cells), and the cupula. Fluid motion, generated by head rotation, generates forces across the cupula that bend the stereocilia of the hair cells, resulting in release of neurotransmitter into the vestibular synapse.C. Focused view of vestibular hair cells within the ampulla. Each hair cell has approximately 70 short stereocilia and one longer kinocilium that project into the gelatinous cupula. It is the laterally located kinocilium that is the primary determinant of the direction of polarization. Each hair cell is innervated by vestibular afferent neurons that allow transmission of positional information to the brain.

Figure 22–2. Vestibular ocular reflex.Connections among the vestibular, abducens, and oculomotor nuclei allow maintenance of vision during head movement. Rotational head movement yields both excitatory and inhibitory peripheral signals depending on the direction of motion. In this example, maintenance of an image on the retina during head rotation to the right requires conjugate leftward gaze. This is accomplished by stimulation of the right lateral semicircular canal and subsequent activation of the vestibular, abducens, and oculomotor nuclei. Ultimately, this neural circuitry culminates in activation of the left lateral and right medial rectus muscles and inhibition of left medial and right lateral recti. Integration of these signals takes place directly in the medial longitudinal fasciculus and indirectly in the pontine reticular formation (not shown).
Table Reference Number
Table 22–1. Vestibular history taking: questions to assist in diagnosis
Table Reference Number
Table 22–2. Diagnostic testing and application to TBI


Alexander MP: Mild traumatic brain injury: physiology, natural history, and clinical management. Neurology 45:1253–1260, 1995
Andersson G, Yardley L, Luxon L: A dual-task study of interference between mental activity and control of balance. Am J Otol 19:632–637, 1998
Basford JR, Chou LS, Kaufman KR, et al: An assessment of gait and balance deficits after traumatic brain injury. Arch Phys Med Rehabil 84:343–349, 2003
Barin K, Duyrrant JD: Applied physiology of the vestibular system, in The Ear: Comprehensive Otology. Edited by Lambert PR, Canalis RF. Philadelphia, PA, Lippincott, 2000, pp 113–140
Chamelian L, Feinstein A: Outcome after mild to moderate traumatic brain injury: the role of dizziness. Arch Phys Med Rehabil 85:1662–1666, 2004
Emmet JR, Shea JJ: Traumatic perilymph fistula. Laryngoscope 90:1513–1530, 1980
Fukuda T: The stepping test: two phases of the labyrinthine reflex. Acta Otolaryngol 50:95–108, 1959
Geurts AC, Ribbers GM, Knoop JA, et al: Identification of static and dynamic postural instability following traumatic brain injury. Arch Phys Med Rehabil 77:639–644, 1996
Greinwald JH, Kelly KE, Tami TA: Temporal bone and skull base trauma, in Neurotology. Edited by Jackler RK, Brackman DE. Philadelphia, PA, Elsevier, 2005, pp 1070–1088
Griffiths MV: The incidence of auditory and vestibular concussion following minor head injury. J Laryngol Otol 93:253–265, 1979
Gurr B, Moffat N: Psychological consequences of vertigo and the effectiveness of vestibular rehabilitation for brain injury patients. Brain Inj 15:387–400, 2001
Hellawell DJ, Taylor R, Pentland B: Cognitive and psychosocial outcome following moderate or severe traumatic brain injury. Brain Inj 13:489–504, 1999
Highstein SE, Holstein GR: The anatomy of the vestibular nuclei. Prog Brain Res 151:157–203, 2006
Hoffer ME, Gottshall KR, Moore R, et al: Characterizing and treating dizziness after mild head trauma. Otol Neurotol 25:135–138, 2004
Johnson F, Semaan MT, Megerian CA: Temporal bone fracture: evaluation and management in the modern era. Otolaryngol Clin N Am 41:597–618, 2008
Katsarkas A: Benign paroxysmal positional vertigo (BPPV): idiopathic versus post-traumatic. Acta Otolaryngol 119:745, 1999
Lambert PR, Canalis RF: Anatomy and embryology of the auditory and vestibular systems, in The Ear: Comprehensive Otology. Edited by Lambert PR, Canalis RF. Philadelphia, PA, Lippincott, 2000, pp 17–65
Longridge NS, Mallinson AI: "Across the board" posturography abnormalities in vestibular injury. Otol Neurotol 26:695–698, 2005
Maskell F, Chiarelli P, Isles R: Dizziness after traumatic brain injury: overview and measurement in the clinical setting. Brain Inj 20:293–305, 2006
Maskell F, Chiarelli P, Isles R: Dizziness after traumatic brain injury: results from an interview study. Brain Inj 21:741–752, 2007
Motin M, Keren O, Groswasser Z, et al: Benign paroxysmal positional vertigo as the cause of dizziness in patients after severe brain injury: diagnosis and treatment. Brain Inj 19:693–697, 2005
Ostrowski VB, Bojrab DI: Otolith dysfunction and semi-circular canal dysfunction, in Neurotology. Edited by Jackler RK, Brackman DE. Philadelphia, PA, Elsevier, 2005, pp 241–253
Ritenour AE, Wickley A, Ritenour JS, et al: Tympanic membrane perforation and hearing loss from blast overpressure in Operation Enduring Freedom and Operation Iraqi Freedom wounded. J Trauma 64:174–178, 2008
Seemungal BM, Bronstein AM: A practical approach to acute vertigo. Pract Neurol 8:211–221, 2008
Shepard NT, Telian SA: Programmatic vestibular rehabilitation. Otolaryngol Head Neck Surg 112:173–182, 1995
Suh M, Basu S, Kolster R, et al: Increased oculomotor deficits during target blanking as an indicator of mild traumatic brain injury. Neurosci Lett 410:203–207, 2006
Xydakis MS, Bebarta VS, Harrison CD, et al: Tympanic-membrane perforation as a marker of concussive brain injury in Iraq. N Engl J Med 357: 830–831, 2007
Yang CC, Tu YK, Hua MS, et al: The association between postconcussion symptoms and clinical outcomes for patients with mild traumatic brain injury. J Trauma 62:657–663, 2007
Citing articles are presented as examples only. In non-demo SCM6 implementation, integration with CrossRef’s "Cited By" API will populate this tab (http://www.crossref.org/citedby.html).
Related Content
Textbook of Traumatic Brain Injury, 2nd Edition > Chapter 2.  >
Textbook of Traumatic Brain Injury, 2nd Edition > Chapter 4.  >
Textbook of Traumatic Brain Injury, 2nd Edition > Chapter 5.  >
Textbook of Traumatic Brain Injury, 2nd Edition > Chapter 7.  >
Textbook of Traumatic Brain Injury, 2nd Edition > Chapter 12.  >
Topic Collections
Psychiatric News
PubMed Articles
Postural control after traumatic brain injury in patients with neuro-ophthalmic deficits. Gait Posture 2011;34(2):248-53.doi:10.1016/j.gaitpost.2011.05.008.
  • Print
  • PDF
  • E-mail
  • Chapter Alerts
  • Get Citation