Lyme Disease Hearing Loss and Balance Problems

Hearing and balance problems may occur with neurologic Lyme disease.
Objective testing can reveal vestibular abnormalities without dizziness.
Persistent symptoms may warrant specialized evaluation.

Lyme disease hearing loss and balance problems are among the more challenging neurologic symptoms reported by patients. Dizziness, vertigo, imbalance, tinnitus, and hearing changes may occur for several reasons, including possible involvement of the inner ear or vestibular system.

A prospective study published in the Journal of International Advanced Otology evaluated hearing and vestibular function in patients diagnosed with Lyme neuroborreliosis. Researchers found that objective abnormalities did not always correspond with the symptoms patients reported.¹

Perhaps the study’s most interesting finding was that specialized testing identified vestibular dysfunction in several patients who did not report dizziness-related impairment.

What Is Lyme Neuroborreliosis?

Lyme neuroborreliosis occurs when Borrelia burgdorferi infection involves the nervous system. In Europe, it commonly presents with meningoradiculitis, lymphocytic meningitis, or cranial neuropathies such as facial nerve palsy.^2,3

Neurologic Lyme disease can also involve peripheral nerves and, less commonly, structures responsible for hearing and balance. Patients may experience:

• Dizziness or vertigo
• Difficulty with balance
• Lightheadedness
• Hearing changes
• Tinnitus
• Facial weakness or Bell’s palsy
• Headache
• Fatigue

These symptoms can overlap with vestibular disorders, migraine, autonomic dysfunction, medication side effects, cardiovascular conditions, and other neurologic disorders. A careful evaluation is therefore important.

How Did Researchers Study Hearing and Balance?

Danish investigators prospectively enrolled 19 adults with Lyme neuroborreliosis. Diagnosis required neurologic symptoms, an elevated cerebrospinal fluid white blood cell count, and laboratory evidence supporting Borrelia burgdorferi infection.¹

Unlike earlier publications consisting largely of case reports, this study systematically evaluated hearing and vestibular function using:

• Video head impulse testing to assess the semicircular canals
• Caloric testing to evaluate part of the vestibular system
• Pure-tone audiometry
• Structured symptom interviews
• The Dizziness Handicap Inventory

Hearing was assessed shortly after hospitalization and again during follow-up. Vestibular testing was generally performed several weeks after admission.

What Did the Study Find?

Among the 19 patients evaluated:

• Four patients (21%) had objective vestibular dysfunction.
• Nine patients (47%) had sensorineural hearing loss on initial audiometry.
• Ten of 17 patients (59%) had sensorineural hearing loss during follow-up.
• Most measured hearing loss was mild, involved higher frequencies, and was bilateral.
• Dizziness, fatigue, and headache were each reported by 32% of patients.
• Nine patients (47%) had facial nerve palsy.

When all types of peripheral nerve palsy were included—not only facial palsy—the figure was 58%.

The hearing results require caution. Although hearing loss was identified in several participants, hearing thresholds were not significantly different from those of an age- and sex-matched reference population. Some abnormalities may therefore have reflected age-related or preexisting hearing changes rather than Lyme neuroborreliosis alone.

Can Lyme Disease Affect Balance Without Causing Dizziness?

Yes, it may. The study found objective vestibular dysfunction in four of 19 patients with Lyme neuroborreliosis. Surprisingly, none of those four reported dizziness-related impairment on the Dizziness Handicap Inventory.¹

The researchers suggested that central compensation may help explain this mismatch. The brain can sometimes adapt to reduced vestibular input, making an abnormality less noticeable even when specialized testing remains abnormal.

Conversely, some patients reported dizziness despite having no vestibular deficit detected by the tests used in the study. This reinforces an important clinical point: dizziness and vestibular dysfunction are related, but they are not interchangeable.

Dizziness may also result from autonomic dysfunction, migraine, medication effects, dehydration, anemia, cardiac conditions, deconditioning, or other disorders. Vestibular testing may not detect these alternative causes.

Can Lyme Neuroborreliosis Cause Tinnitus?

Tinnitus was uncommon in this study, with only one patient reporting ringing in the ears. Nevertheless, tinnitus has been described in previous reports involving Lyme neuroborreliosis and other neurologic manifestations of Lyme disease.^5,6

Tinnitus has many possible causes, including age-related hearing loss, noise exposure, Ménière disease, migraine, viral infections, medications, and other neurologic conditions. It should not automatically be attributed to Lyme disease.

Why Might Lyme Disease Affect Hearing and Balance?

The mechanism remains uncertain. The investigators discussed several possibilities.

Vestibular nerve involvement. Lyme neuroborreliosis can affect cranial and peripheral nerves. Inflammation involving the vestibular portion of the eighth cranial nerve might contribute to dizziness or imbalance.

Inner-ear involvement. Inflammatory processes associated with a central nervous system infection could potentially reach structures within the cochlea or vestibular system.

Inflammatory or immune-mediated effects. Inflammatory mediators and immune responses associated with Borrelia burgdorferi infection may contribute to neurologic dysfunction.⁷

The study could not determine which mechanism was responsible for the abnormalities. It also found no single pattern of semicircular canal involvement.

Can Facial Palsy Provide an Additional Clue?

Facial nerve palsy was identified in nine of the 19 participants. Five of the 10 patients with measured hearing loss also had facial nerve palsy.¹

The study was not designed to determine whether facial palsy predicts hearing or vestibular dysfunction. Nevertheless, new dizziness, imbalance, tinnitus, or hearing changes accompanying Lyme-associated facial palsy may justify a broader neurologic and audio-vestibular evaluation.

Dizziness in Lyme Disease Can Have More Than One Cause

In my practice, patients with Lyme disease frequently describe disequilibrium, motion sensitivity, lightheadedness, tinnitus, or the sensation that they are “walking on a boat.” These symptoms can significantly interfere with mobility and daily functioning.

Vestibular dysfunction is one possible explanation, but it is not the only one. Patients may also experience dizziness associated with postural orthostatic tachycardia syndrome and other forms of autonomic dysfunction, vestibular migraine, benign paroxysmal positional vertigo, medication side effects, dehydration, anemia, coinfections, anxiety, deconditioning, or unrelated inner-ear disorders.

Lightheadedness after standing, for example, may point toward an autonomic or cardiovascular mechanism rather than an inner-ear problem. True spinning vertigo triggered by changes in head position may suggest a different evaluation.

Some patients have more than one contributing problem. Identifying the dominant mechanism can help guide a more individualized treatment and rehabilitation plan.

Should Patients With Lyme Disease Undergo Hearing Testing?

This study does not establish that every patient with Lyme disease needs audiologic or vestibular testing. Most people with uncomplicated early Lyme disease do not develop significant hearing or balance disorders.

Referral may be considered when a patient develops:

• New or worsening hearing loss
• Persistent tinnitus
• Persistent dizziness or vertigo
• Imbalance, difficulty walking, or unexplained falls
• Facial nerve palsy accompanied by hearing or vestibular symptoms
• Symptoms suggesting Lyme neuroborreliosis

Formal audiometry can identify hearing changes that may not be obvious during a routine office visit. Vestibular testing may detect abnormalities that a patient does not perceive or that the brain has partially compensated for.

Sudden hearing loss, new difficulty walking, facial weakness, fainting, severe headache, double vision, one-sided weakness, or other acute neurologic changes require prompt medical evaluation.

Could Vestibular Rehabilitation Help?

The study did not evaluate vestibular rehabilitation or other treatment outcomes. However, identifying persistent vestibular dysfunction may have practical implications.

Selected patients may benefit from vestibular rehabilitation, which uses individualized exercises to improve balance, gaze stability, and mobility. Rehabilitation does not replace evaluation or treatment of the underlying condition. It may serve as an additional component of care when imbalance continues.

Study Limitations

This investigation had several important limitations:

• Only 19 patients were included.
• The participants had European Lyme neuroborreliosis, so the findings may not apply to every North American presentation.
• Not every participant completed caloric testing.
• The investigators did not assess the utricle and saccule using vestibular evoked myogenic potential testing.
• Vestibular abnormalities may have existed before Lyme neuroborreliosis.
• Hearing was not significantly different from the age- and sex-matched reference data.

The findings demonstrate an association in a small, selected group. They do not prove that Lyme neuroborreliosis caused every hearing or vestibular abnormality observed.

Frequently Asked Questions

Can Lyme disease cause hearing loss?

Lyme neuroborreliosis has been associated with sensorineural hearing loss. In this small study, however, hearing was not significantly different from an age- and sex-matched reference population. Other causes of hearing loss should also be considered.

Can Lyme disease affect your balance even if you do not feel dizzy?

Possibly. Four of 19 patients with Lyme neuroborreliosis had objective vestibular dysfunction, yet none of those four reported dizziness-related impairment on a standardized questionnaire. Central compensation may make some vestibular abnormalities less noticeable.

Does dizziness always mean the vestibular system is abnormal?

No. Dizziness may also be associated with autonomic dysfunction, migraine, medication effects, dehydration, anemia, cardiovascular conditions, or other disorders. Some patients in the study reported dizziness without an abnormality on the vestibular tests performed.

Should everyone with Lyme disease have hearing and balance testing?

No. Specialized testing is not routinely necessary for everyone with Lyme disease. New hearing loss, persistent tinnitus, vertigo, imbalance, unexplained falls, or suspected Lyme neuroborreliosis may justify audiologic, vestibular, or neurologic evaluation.

Clinical Takeaway

A small prospective study found objective vestibular dysfunction in approximately one in five patients with Lyme neuroborreliosis. The most notable finding was that the patients with vestibular abnormalities did not report dizziness-related impairment, illustrating that symptoms and specialized testing do not always correspond.

The hearing findings were less conclusive. Although mild sensorineural hearing loss was identified in several patients, hearing did not differ significantly from an age- and sex-matched reference population.

Persistent balance, hearing, or vestibular symptoms deserve careful evaluation, but the results should be interpreted alongside other neurologic, autonomic, cardiovascular, medication-related, and inner-ear explanations.

Related Articles

Neurologic Lyme Disease: Symptoms and Diagnosis
Lyme Disease Symptoms Guide
Ocular Lyme Disease
Recovery From Lyme Disease

References

1. Jensen ES, Kjærsgaard JB, Cayé-Thomasen P, et al. Audio-vestibular function in patients diagnosed with Lyme neuroborreliosis. J Int Adv Otol. 2025;21(5):e251982. doi:10.5152/iao.2025.251982.
2. Halperin JJ. Neurologic manifestations of Lyme disease. Curr Infect Dis Rep. 2011;13(4):360-366. doi:10.1007/s11908-011-0184-x.
3. Steere AC, Strle F, Wormser GP, et al. Lyme borreliosis. Nat Rev Dis Primers. 2016;2:16090.
4. Lantos PM, Rumbaugh J, Bockenstedt LK, et al. Clinical practice guidelines by the Infectious Diseases Society of America, American Academy of Neurology, and American College of Rheumatology: 2020 guidelines for the prevention, diagnosis and treatment of Lyme disease. Clin Infect Dis. 2021;72(1):e1-e48.
5. Logigian EL, Kaplan RF, Steere AC. Chronic neurologic manifestations of Lyme disease. N Engl J Med. 1990;323(21):1438-1444.
6. Jozefowicz-Korczynska M, Zamyslowska-Szmytke E, Piekarska A, Rosiak O. Vertigo and severe balance instability as symptoms of Lyme disease: Literature review and case report. Front Neurol. 2019;10:1172.
7. Rupprecht TA, Koedel U, Fingerle V, Pfister HW. The pathogenesis of Lyme neuroborreliosis: From infection to inflammation. Mol Med. 2008;14(3-4):205-212.

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Dr. Daniel Cameron, MD, MPH
Lyme disease clinician with over 30 years of experience and past president of ILADS.

Symptoms • Testing • Coinfections • Recovery • Pediatric • Prevention