Lyme Disease Hearing Loss and Balance Problems

Hearing loss and balance problems can occur in Lyme disease.
A new study found measurable vestibular dysfunction in Lyme neuroborreliosis.
Objective testing may detect abnormalities that symptoms alone can miss.

Dizziness, vertigo, imbalance, tinnitus, and hearing changes are among the more challenging neurological symptoms reported by patients with Lyme disease. While facial nerve palsy has long been recognized as a manifestation of Lyme neuroborreliosis, less is known about how frequently the inner ear and vestibular system are affected.

A prospective study published in the Journal of International Advanced Otology provides important new insights into this question. Researchers performed detailed hearing and vestibular testing in patients with confirmed Lyme neuroborreliosis and found that objective abnormalities were relatively common, even when patients reported few audio-vestibular symptoms.

Perhaps the most important message from the study is that symptoms alone may underestimate vestibular involvement. Specialized testing identified abnormalities that would likely have been missed using patient-reported symptoms alone.

What is Lyme neuroborreliosis?

Lyme neuroborreliosis occurs when Borrelia burgdorferi affects the nervous system. In Europe, the condition most commonly presents with meningoradiculitis (Bannwarth syndrome), lymphocytic meningitis, or cranial neuropathies such as facial nerve palsy. Neurologic Lyme disease can also involve peripheral nerves and, less commonly, structures responsible for hearing and balance.

Although neurological manifestations differ somewhat between Europe and North America, patients on both continents may develop dizziness, imbalance, hearing changes, or tinnitus when the nervous system is affected. Additional studies in North American patients will help determine how broadly these findings apply.

Patients with Lyme neuroborreliosis may experience:

• dizziness or vertigo
• difficulty with balance
• lightheadedness
• hearing changes
• tinnitus (ringing in the ears)
• facial weakness or Bell’s palsy
• headache
• fatigue

Many of these symptoms overlap with vestibular disorders, migraine, autonomic dysfunction, medication side effects, and other neurological conditions, making a careful evaluation essential.

How did researchers study hearing and balance?

Danish investigators prospectively enrolled adults with confirmed Lyme neuroborreliosis over a two-year period. Diagnosis required neurological symptoms consistent with Lyme neuroborreliosis together with cerebrospinal fluid pleocytosis and laboratory evidence supporting Borrelia burgdorferi infection.

Unlike earlier publications that consisted largely of case reports, this study systematically evaluated both hearing and vestibular function using objective testing.

The investigators performed:

• video head impulse testing (vHIT) to assess all six semicircular canals
• caloric testing to evaluate horizontal semicircular canal function
• pure-tone audiometry
• structured symptom interviews
• the Dizziness Handicap Inventory (DHI)

Patients underwent hearing assessment shortly after hospitalization and repeat audiometry approximately one month later.

What did the study find?

Nineteen patients with confirmed Lyme neuroborreliosis completed the evaluation.

The investigators reported:

• 21% had objective vestibular dysfunction.
• 47% had sensorineural hearing loss on initial audiometry.
• 59% demonstrated sensorineural hearing loss on follow-up testing.
• Most hearing loss was mild, involved higher frequencies, and was usually bilateral.
• The most commonly reported symptoms were peripheral nerve palsy (58%), dizziness (32%), fatigue (32%), and headache (32%).

Interestingly, hearing thresholds were not significantly different from an age- and sex-matched control population. This finding suggests that at least some measured hearing loss may reflect age-related changes rather than Lyme disease alone. The authors appropriately caution against assuming that every abnormal audiogram is directly attributable to Lyme neuroborreliosis.

Can Lyme neuroborreliosis cause tinnitus?

Tinnitus was uncommon in this study, with only one patient reporting ringing in the ears. Nevertheless, previous case reports and clinical experience suggest that tinnitus can occur in Lyme neuroborreliosis, particularly when the auditory system or eighth cranial nerve is affected.

Because tinnitus has many potential causes—including age-related hearing loss, noise exposure, Ménière disease, medications, migraine, and other neurological disorders—it should always be evaluated in the broader clinical context rather than automatically attributed to Lyme disease.

Symptoms and objective testing did not always agree

Perhaps the most intriguing finding was the poor correlation between patient-reported symptoms and objective vestibular testing.

Several patients with measurable vestibular abnormalities reported little or no dizziness on the Dizziness Handicap Inventory. Conversely, some patients describing dizziness had no objective vestibular deficits detected by testing.

The authors suggest that central compensation may explain part of this discrepancy. Following vestibular injury, the brain often adapts over time, allowing patients to experience fewer symptoms despite persistent abnormalities on specialized testing.

This observation is clinically important because physicians cannot always rely solely on symptoms when deciding whether additional vestibular evaluation is warranted.

Why might Lyme disease affect hearing and balance?

The exact mechanism remains uncertain.

The investigators discussed several possible explanations.

Inflammation involving the vestibular nerve. Lyme neuroborreliosis commonly affects cranial and peripheral nerves. Inflammation involving the vestibular portion of the eighth cranial nerve could contribute to dizziness and imbalance.

Direct involvement of the inner ear. Similar to bacterial meningitis, inflammatory processes within the central nervous system could spread into the cochlea and vestibular organs through anatomical pathways connecting the meninges and inner ear.

Immune-mediated injury. Previous research suggests that inflammatory mediators and immune responses triggered by Borrelia burgdorferi infection may contribute to neurological dysfunction beyond direct bacterial invasion.

The current study cannot distinguish among these mechanisms, but it supports further investigation into how Lyme neuroborreliosis affects both the auditory and vestibular systems.

Facial palsy may provide an important clue

Peripheral nerve palsy—primarily facial nerve palsy—was the most common neurological manifestation in this study, affecting 58% of participants.

Because the facial nerve travels near structures responsible for hearing and balance, clinicians should consider audiologic or vestibular evaluation when patients with Lyme-associated facial palsy also report dizziness, tinnitus, hearing loss, or persistent imbalance.

Although the study was not designed to determine whether facial palsy predicts vestibular dysfunction, the frequent coexistence of cranial neuropathy and audio-vestibular symptoms underscores the importance of a comprehensive neurological examination.

Clinical perspective

In my practice, patients with Lyme disease frequently describe dizziness, disequilibrium, motion sensitivity, tinnitus, or the sensation that they are “walking on a boat.” These symptoms can significantly impair daily functioning and are often among the most frustrating neurological complaints.

This study reinforces an important clinical principle: dizziness has many possible causes in patients with Lyme disease.

Vestibular dysfunction is one possible explanation, but it is not the only one. Patients may also experience dizziness related to autonomic dysfunction such as postural orthostatic tachycardia syndrome (POTS), vestibular migraine, benign paroxysmal positional vertigo (BPPV), medication side effects, dehydration, anemia, coinfections, anxiety, deconditioning, or unrelated inner ear disorders.

Likewise, hearing loss and tinnitus should not automatically be attributed to Lyme disease without considering age-related hearing loss, occupational noise exposure, Ménière disease, viral infections, medication effects, or other neurological conditions.

In my experience, dizziness is considerably more common than measurable hearing loss. Patients with persistent disequilibrium often have multiple contributing factors, including vestibular dysfunction, autonomic instability, and deconditioning. Identifying the dominant cause helps guide a more individualized treatment plan.

The strength of this study is that it reminds clinicians to maintain a broad differential diagnosis while recognizing that objective vestibular abnormalities can occur in Lyme neuroborreliosis. When persistent dizziness, imbalance, hearing complaints, or tinnitus continue despite appropriate treatment, additional evaluation—including formal audiology or vestibular testing in selected patients—may help clarify the underlying cause.

Should patients with Lyme disease undergo hearing testing?

This study does not suggest that every patient with Lyme disease requires formal audiologic or vestibular testing. Most patients with uncomplicated early Lyme disease recover without developing significant hearing or balance disorders.

However, the findings suggest clinicians should have a lower threshold for referral in patients with:

• persistent dizziness or vertigo
• new hearing loss
• persistent tinnitus
• imbalance or frequent falls
• Lyme-associated facial nerve palsy accompanied by vestibular symptoms
• suspected Lyme neuroborreliosis

Formal audiometry may identify hearing loss that is not apparent during a routine office visit. Likewise, vestibular testing may detect abnormalities that patients no longer perceive because the brain has partially compensated for the injury.

Vestibular rehabilitation may help selected patients

Although this study did not evaluate treatment outcomes, identifying vestibular dysfunction has practical implications. Patients with persistent imbalance after Lyme neuroborreliosis may benefit from vestibular rehabilitation therapy, a structured program designed to improve balance, gaze stability, and mobility through individualized exercises.

Vestibular rehabilitation should not replace treatment directed at the underlying infection when active Lyme disease is present. Instead, it may serve as an adjunctive therapy for patients who continue to experience balance impairment despite appropriate medical management.

Study limitations

Like all clinical studies, this investigation has important limitations.

• Only 19 patients completed the study, limiting statistical power.
• The participants had confirmed European Lyme neuroborreliosis, so the findings may not apply to every patient with Lyme disease, particularly those with North American presentations.
• Not every participant underwent complete caloric testing because of technical limitations or patient cooperation.
• The investigators did not assess otolith function using vestibular evoked myogenic potential (VEMP) testing, so additional vestibular abnormalities may have gone undetected.
• Some hearing loss may have reflected age-related changes rather than Lyme disease itself, although the investigators attempted to address this by comparing patients with age- and sex-matched controls.

The authors appropriately conclude that larger prospective studies are needed before firm conclusions can be drawn regarding the frequency, mechanisms, and long-term consequences of vestibular dysfunction in Lyme neuroborreliosis.

What does this mean for patients?

This study offers reassurance as well as practical guidance.

Most patients did not have severe hearing loss, and only a minority demonstrated objective vestibular dysfunction. Nevertheless, the study confirms that hearing and balance problems can occur in Lyme neuroborreliosis and deserve careful evaluation when symptoms persist.

Patients should also remember that dizziness has many possible causes. Lyme disease may contribute, but autonomic dysfunction, vestibular migraine, benign positional vertigo, dehydration, medication side effects, cardiovascular disease, anemia, and unrelated inner ear disorders should also be considered.

If dizziness, imbalance, hearing loss, or tinnitus continue after treatment, discussing these symptoms with your healthcare provider may help determine whether referral for audiologic or vestibular evaluation is appropriate.

Clinical Takeaway

This prospective study provides objective evidence that Lyme neuroborreliosis can affect both hearing and vestibular function. Approximately one in five patients demonstrated measurable vestibular dysfunction, while nearly half had mild sensorineural hearing loss on audiometric testing. Perhaps the study’s most important observation was that objective abnormalities often did not correlate with patients’ reported symptoms, suggesting that specialized testing may identify deficits that are easily overlooked during routine clinical evaluation.

For clinicians, the findings reinforce the importance of considering vestibular involvement when evaluating patients with Lyme neuroborreliosis who report persistent dizziness, imbalance, tinnitus, hearing loss, or facial nerve palsy. For patients, the study offers reassurance that these symptoms deserve thoughtful evaluation and should not automatically be attributed to anxiety, aging, or deconditioning without an appropriate medical assessment.

Frequently Asked Questions

Can Lyme disease cause hearing loss?

Yes. Lyme neuroborreliosis can be associated with sensorineural hearing loss, although hearing loss appears to be relatively uncommon and is often mild. Other causes of hearing loss should always be considered during the evaluation.

Can Lyme disease affect balance?

Yes. Lyme neuroborreliosis may involve the vestibular system, leading to dizziness, vertigo, or balance problems. However, balance symptoms in Lyme disease may also result from autonomic dysfunction, vestibular migraine, medication side effects, or unrelated inner ear disorders.

Can vestibular testing be abnormal even if I don’t feel dizzy?

Possibly. In this study, several patients had measurable vestibular abnormalities despite reporting little or no dizziness. The brain can compensate for vestibular injury over time, reducing symptoms even when objective deficits remain.

Should everyone with Lyme disease have hearing and balance testing?

No. Most patients recover without requiring specialized testing. However, persistent dizziness, hearing loss, tinnitus, imbalance, facial nerve palsy accompanied by vestibular symptoms, or suspected Lyme neuroborreliosis may justify referral for formal audiologic or vestibular evaluation.

Related Articles

If you are experiencing neurological symptoms associated with Lyme disease, you may also find these articles helpful:

• Neurologic Lyme Disease: Symptoms and Diagnosis
• Brain Fog in Lyme Disease
• POTS and Lyme Disease
• Ocular Lyme Disease
• Recovery From Lyme Disease

References

1. 1. 1. Jensen ES, Kjærsgaard JB, Cayé-Thomasen P, Hougaard DD, Lyneborg N, Brandt CT, Kirchmann M. 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, Hu LT, Branda JA, Hovius JWR, Li X, Mead PS. 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