Clinical evidence that the vestibular system participates in autonomic control

The vestibular system, including both the peripheral vestibular system, that is, the labyrinth, and the central vestibular system, is known to influence autonomic function in several ways that have clinical implications. This paper discusses evidence for vestibular influences on autonomic control from normal human subjects, evidence for vestibular influences on autonomic control from patients, clinical implications of vestibulo-autonomic regulation, and speculations regarding possible clinical implications of vestibulo-autonomic control. Situations that provoke vestibular-induced autonomic responses in normal subjects include vestibular laboratory testing, vehicular motion, simulators, and, possibly, exposure to microgravity. Patients with peripheral and central vestibular abnormalities manifest both symptoms and signs of autonomic dysfunction presumably via vestibulo-autonomic connections. Vestibulo-autonomic regulation impacts vestibular diagnostic testing, clinical diagnosis of balance disorders, and treatment of balance disorders. In addition to well-recognized peripheral and central vestibular disorders, anxiety disorders have recently been linked to vestibular dysfunction in a subset of patients. In particular, vestibular dysfunction has been linked to panic disorder and agoraphobia. Vestibular-autonomic connections may form a basis for an association between vestibular dysfunction and panic attacks. The importance of vestibulo-autonomic regulation in the clinical arena is not fully known. Two speculative areas discussed in this paper include vestibular-induced orthostatic intolerance and the role of vestibular-respiratory pathways on sleep apnea.