Vestibular disease
Bilateral vestibulopathy
This information is intended as a general introduction to this topic. As everyone is affected differently by balance and dizziness problems, you should speak to your doctor for individual advice.
For reasons of better readability, the generic masculine is used and the simultaneous use of the language forms male, female and diverse (m/f/d) is dispensed with. Unless otherwise indicated, the personal designations used in this patient information refer to all genders.

What is bilateral vestibulopathy?
Bilateral vestibulopathy (BVP) is damage to the vestibular system in the inner ear, which is part of the vestibular system. "Bilateral" means that the damage occurs on both sides.
BVP is a common cause of balance problems and falls, especially in older people. In one study, people with BVP were 31 times more likely to fall, and one in four said they had recently been injured in a fall. BVP can also cause blurred vision when the person is moving. The problems worsen in the dark or when the person is walking on uneven ground.
The Bárány Society, an international organization for vestibular research, published the classification of BVP in 2017. Some aspects of the syndrome were first described in 1882.
BVP is also known as bilateral vestibular weakness, bilateral vestibular hypofunction, bilateral vestibular paresis or bilateral vestibular failure.
BVP can have a major impact on people's work and daily lives. Many people with BVP adapt certain daily activities to compensate for their balance and vision problems. Those affected may also find it difficult to exercise or move around at night.
It is not clear how many people have BVP, but one estimate is that 28 adults in every 100,000 are affected at any given time. The problem becomes more common with increasing age: Up to 85% of people over the age of 80 have problems with their sense of balance. BVP is less common in children, but many children with bilateral sensorineural hearing loss may also have BVP.
Some people recover from BVP, for others the condition remains for life. In some people the damage is more severe than in others, and in some it is more pronounced on one side than the other. People with BVP may or may not have hearing loss.
Summary
- Damage to the vestibular organs in both inner ears.
- Typical symptoms are balance problems, unsteady gait and "shaky" vision when moving the head.
- Hearing loss may or may not occur.
- Balance problems worsen when walking on uneven ground or in the dark.
- Avoid certain medications that can worsen the damage.
- Avoid unsafe situations to prevent falls.
- Vestibular rehabilitation can help.
- Some people recover, while others suffer from the disease for the rest of their lives.
What causes bilateral vestibulopathy?
BVP can have various causes, e.g:
- Damage to the inner ear caused by drugs such as aminoglycoside antibiotics (e.g. gentamicin, see vestibular toxicity)
- Ménière's disease in both ears
- Acoustic neuroma in both ears or surgery to treat an acoustic neuroma
- Neurofibromatosis type 2, which is a common cause of acoustic neuromas
- Meningitis
- Autoimmune diseases, including autoimmune inner ear disease
- Sarcoidosis, a disease that causes inflammation and growths in various parts of the body
- Some congenital diseases
- Neurodegenerative diseases that lead to a gradual loss of function or death of nerve cells in the brain
- A condition called CANVAS syndrome (cerebellar ataxia, neuropathy and vestibular areflexia syndrome)
In some people, however, it is not clear what has caused the damage. This is known as idiopathic BVP.
How bilateral vestibulopathy affects balance and vision
If the vestibular system is not functioning properly, this means that the balance centers in the brain receive less or no information from the vestibular system.
This can lead to dizziness (as oscillopsia) and balance problems, especially if the other parts of the vestibular system (the visual and proprioceptive systems) cannot compensate for the missing information. This is why people with BVP have more problems when it is dark or when walking on uneven ground:
- When it is dark, the brain cannot receive balance information from the visual system, so it is more difficult to maintain balance.
- If the ground is uneven, the proprioceptive system cannot send reliable information to the brain, making it difficult to balance and walk.
Problems with the vestibular system can also lead to a condition called oscillopsia, where objects in the field of vision appear to jump. This is because the inner ear is not sending information needed for the vestibulo-ocular reflex (VOR). The VOR is responsible for stabilizing the eyes during head movements.
The main symptoms of BVP are:
- Loss of balance (also known as postural instability or loss of postural control)
- Unsteady gait
- Feeling of instability or vertigo
- In some people, blurred or shaky vision when the head moves, especially when walking (fast). The medical term for this is oscillopsia.
The balance and gait problems worsen when it is dark or when the person is standing on uneven, springy ground or moving surfaces.
Those affected usually have no symptoms when sitting or lying still. People with BVP do not usually have vertigo.
Some studies suggest that people with BVP may have problems with spatial memory and navigation. This is still being investigated. People with BVP may also have difficulty concentrating.
Diagnosis of bilateral vestibulopathy
BVP can be diagnosed by a specialist in vertigo, such as a neurologist or ENT specialist.
These specialized doctors will take a thorough medical history, perform a neurological examination and various tests to assess the function of your vestibular system.
To confirm a diagnosis of BVP, you may have some of the following diagnostic tests:
- Vestibular functional examination
- Hearing tests
- Balance tests
Other tests may also be ordered. These can help to determine the cause of BVP.
Treatment of bilateral vestibulopathy
There are four elements in the treatment of BVP:
- Avoid situations that are unsafe or could make your symptoms worse, such as driving a car or walking on uneven ground at night
- Vestibular rehabilitation that improves symptoms and helps you (A) better manage symptoms and (B) learn to better use your vision and proprioception for balance
- Treatment of the underlying cause of BVP, if possible
- Avoidance of medication that could exacerbate the damage
If symptoms are severe, people with BVP may need to use aids such as walking aids, crutches, canes or wheelchairs, especially for the first 3 to 6 months.
Therapy option

Vestibular rehabilitation
Vestibular rehabilitation is an exercise therapy. It is designed to help your brain relearn balance control and respond to signals from the visual, vestibular and proprioceptive systems or compensate for the absence of some signals. A certified IVRT® Dizziness and Vestibular Therapist can help you set treatment goals and create an appropriate program.
If steroid treatment helps, the medication should be taken for a longer period of time before slowly reducing the dose over days or weeks. People with a systemic autoimmune disease will probably need to take steroids for at least a year. However, steroids can have side effects if taken in high doses over a long period of time. Therefore, your doctor will need to find a balance between treating the autoimmune inner ear disease and managing the side effects.
Steroids can initially help about 7 in 10 people with autoimmune inner ear disease. However, over time, steroids help fewer and fewer people. Some studies have shown that only about 14% of those affected benefit from steroid treatment in the long term.
Therapy option

Prevention
If you suffer from BVP, you should avoid ototoxic medications that could exacerbate vestibular problems, e.g:
- Aminoglycoside antibiotics such as gentamicin, streptomycin and tobramycin
- Erythromycin
- Cisplatin, a chemotherapeutic agent
- Loop diuretics such as furosemide and ethacrynic acid
- Medicines with quinine as the active ingredient
In some cases, it may be important to take one of these medications. But you should inform your doctor and pharmacist that you have BVP. In some cases, your doctor may prescribe a different medication that does not damage the vestibular system.
Other medications suppress vestibular input to the brain and can temporarily worsen dizziness. It's a good idea to avoid taking these medications if you can:
- Anti-nausea medication such as dimenhydrinate
- Certain antidepressants
- Benzodiazepines
- Calcium channel blockers
You should discuss with your therapist what else you can do to prevent your symptoms from worsening and to avoid falls.
If you work in a profession where balance is important, such as on the roof or in construction, you should think about changing professions.
What happens next?
What you can expect in the future.
In some cases, depending on the cause of your BVP, some of the damage may heal and your vestibular function may improve. In other cases, with vestibular rehabilitation, people can learn to compensate for the lack of vestibular function and their symptoms improve. People who are diagnosed and treated early seem to recover better. But recovery is slow and can take up to 2 years.
Scientists are researching several new treatments for BVP, including:
- Aids that provide feedback (e.g. through sounds or vibrations) when a person leans or sways
- Devices that function like an artificial vestibular system (vestibular prostheses) and send electrical signals to the vestibular nerve
- Options for regenerating the damaged cells in the inner ear
Research is also looking for ways to protect against drug damage and to predict who is most likely to be affected by drug damage.
In order to keep this patient information as short as possible, we have not included a detailed list of references. However, this can be requested at any time at info@ivrt.de.