Most of us take our sense of balance for granted. My brother-in-law John Heinrich no longer has that luxury.

Nearly 10 years ago, John went to the emergency room with terrible vertigo. His eyes were rapidly moving back and forth and he was violently ill with nausea. “Violent is the correct term for it,” he says.

A dose of Valium provided temporary relief, but the episodes continued as he sought help from one doctor to the next.

John’s story is disturbing, but many people experience trouble with their vestibular system, which helps the body sense spatial orientation and movement. “Seventy percent of people in the U.S. experience a problem with their vestibular system at some time in their lives,” says P. Ashley Wackym, a neuro-otologist at Legacy Health in Portland, Ore.

Vertigo: Source of the spinning
The inner ear is often the source of vertigo. There, tiny crystals of calcium, or otoconia, can detach and move freely through the semicircular canals. Movement causes otoconia to stimulate the motion-sensitive cupula, which sends false signals to the brain, creating vertigo.

(Patterson Clark/Sources: Timothy C. Hain, Tinnitus Journal)

Vertigo — dizziness or difficulty maintaining your balance — is a common reason for people to seek medical help. Often the symptom is caused by a short-term problem, such as an ear infection. Other times the problem endures. That’s when the condition causing the vertigo can be most difficult to diagnose.

Indeed, researchers described a new disorder of the vestibular system as recently as 1998. In that condition, called superior semicircular canal dehiscence, an opening in one of the canals of the inner ear causes vertigo and/or auditory disturbances.

To the afflicted, vertigo — along with related symptoms such as ringing in the ears or hearing one’s own eyes blinking — is vexing, and the sensations are difficult to describe. “Patients can feel isolated and alone,” says Cynthia Ryan, the executive director of the Vestibular Disorders Association, based in Portland.

Misdiagnosis or delayed diagnosis is a common story for people with chronic vertigo. Wackym says his patients typically report seeing four to 10 doctors before coming to him.

My brother-in-law finally found an ear, nose, and throat doctor who ruled out many of the causes of chronic vertigo before coming to a diagnosis — that a viral infection had caused permanent damage to a nerve in his inner ear. “It was a process of elimination,” John says.

Our sense of balance depends on visual information from our eyes, mechanical input from our joints, and movement and positional information from our inner ears. All this gets integrated in the brain to tell us where we are in space.

In my brother-in-law’s case, he lost the input from his left inner ear, a loss that tricked his brain into making him feel off balance and woozy. John spent months in physical therapy that focused on retraining his brain to compensate for the missing data. “It took me six months to be okay walking,” he says. “It’s like a home movie, when someone is walking with the video camera: The image is bouncing. When I walk, that’s what I see. That’s what I had to get used to.”

More-common causes of vertigo are fluid buildup in the inner ear — called Meniere’s disease — and benign paroxysmal positional vertigo, or BPPV, in which calcium carbonate crystals become dislodged from their place in the inner ear and migrate into the canals. Vertigo also can be triggered by certain medications and illnesses.

In Meniere’s, treatment is focused on reducing inner ear fluid. In BPPV, patients undergo the Epley maneuver, in which their heads are moved slowly through several different positions to clear the crystals.

“It’s like tilting a pinball machine to get the silver ball to go where you want,” says David Zee, a professor of neurology and otolaryngology at Johns Hopkins University in Baltimore.

Vertigo is associated with migraines in some people. Sudden episodes of extreme dizziness can occur with or without a headache. Like visual auras associated with migraine, Zee calls this a vestibular aura. Sometimes these episodes are triggered by looking at things in motion, “such as disco lights or an action movie,” Zee says.

Vertigo can be a symptom of stroke. While 2.6 million Americans go to the emergency room with vertigo every year, only about 4 percent of them have had a stroke.

Zee says an eye-movement exam can sometimes be better than an MRI scan for figuring out inner-ear problems. And a new device, which looks like a pair of goggles, is being tested by Johns Hopkins doctors to gauge inner-ear problems quickly at the bedside. “It’s like an EKG of the eyes,” Zee says.

Meanwhile, it’s duck hunting season in Wisconsin. My brother-in-law will go, as he has done most years of his life, but he doesn’t expect to bring home a bird. The three-dimensional coordination needed to swing a gun and shoot at a moving object exposes his balance deficit to the max.

Even in everyday life, he says, his condition is unpleasant. “But if this is the worst thing that happens to me? I can deal with it.”