Vestibular neuritis

Last updated: July 19, 2022

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Vestibular neuritis (VN) is the idiopathic inflammation of the vestibular nerve. Although the etiology is unclear, it is thought to be viral in origin because it commonly occurs after upper airway infections. The disorder manifests as acute vestibular syndrome with persistent, acute-onset vertigo, nausea and vomiting, and gait instability in otherwise healthy patients. When hearing loss is present, it is sometimes referred to as labyrinthitis. Diagnosis is clinical and should include a complete otoneurological examination to exclude a central cause of acute vestibular syndrome, such as cerebellar stroke or lateral medullary syndrome. Vestibular rehabilitation therapy is the most important aspect of treatment and should be initiated as soon as possible. Symptomatic therapy with vestibular suppressants may be considered during the acute phase. Glucocorticoids are no longer routinely recommended as there is insufficient evidence regarding their long-term efficacy. The acute phase of severe vertigo usually lasts a few days and symptoms typically resolve in 2–3 weeks with treatment. In refractory cases, which are rare, vestibular ablation therapy or surgery involving the inner ear may be necessary.

See also “Vertigo.”

See also “Acute vestibular syndrome.”

The term dizziness is nonspecific and is variably used to describe distinct symptoms such as vertigo, presyncope, imbalance, and confusion.

Epidemiological data refers to the US, unless otherwise specified.

  • Acute or subacute onset: [1][4]
  • Progression and duration of symptoms
    • Usually develop over several hours
    • Severe symptoms usually last for 1–2 days
    • Mild symptoms may persist for weeks or even months.
  • Examination

Cochlear symptoms (e.g., hearing loss, tinnitus) are usually absent in vestibular neuritis.

The presence of neurological abnormalities (e.g., truncal ataxia) in a patient with acute vestibular syndrome should raise suspicion for a central cause (e.g., cerebellar stroke, lateral medullary syndrome).

Labyrinthitis

See “Approach to vertigo” for details on clinical evaluation, targeted testing (e.g., HINTS examination), and neuroimaging for patients with undifferentiated acute vestibular syndrome.

Hospital admission may be necessary in patients with severe symptoms or if there is any concern for a central etiology of symptoms.

Pharmacotherapy

Therapy is primarily supportive; see “Management of peripheral vertigo” for more information.

  • Antiemetics and vestibular suppressants: only indicated in the acute setting.
  • Corticosteroids (e.g., prednisone ) [12]
    • Not routinely recommended [13]
    • There is evidence they improve recovery at the one-month mark, but long-term benefits are uncertain. [14]
    • If considered , they should be started within 72 hours of symptom onset. [15]
  • Antiviral therapy: not routinely recommended [4][15]

Other therapies [16]

We list the most important complications. The selection is not exhaustive.

  • Spontaneous recovery or central vestibular compensation and habituation within a few weeks is common (good prognosis). [18][19][20]
  • Recurrence is uncommon (2–11%). [2]
  1. Baloh RW. Clinical practice. Vestibular neuritis.. N Engl J Med. 2003; 348 (11): p.1027-32. doi: 10.1056/NEJMcp021154 . | Open in Read by QxMD
  2. Kim J-S. When the Room Is Spinning: Experience of Vestibular Neuritis by a Neurotologist. Front Neurol. 2020; 11 . doi: 10.3389/fneur.2020.00157 . | Open in Read by QxMD
  3. Kim H-A, Lee H. Isolated Vestibular Nucleus Infarction Mimicking Acute Peripheral Vestibulopathy. Stroke. 2010; 41 (7): p.1558-1560. doi: 10.1161/strokeaha.110.582783 . | Open in Read by QxMD
  4. Muncie HL, Sirmans SM, James E. Dizziness: Approach to Evaluation and Management.. Am Fam Physician. 2017; 95 (3): p.154-162.
  5. Taxak P, Ram C. Labyrinthitis and Labyrinthitis Ossificans - A case report and review of the literature. Journal of Radiology Case Reports. 2020; 14 (5). doi: 10.3941/jrcr.v14i5.3706 . | Open in Read by QxMD
  6. Flint PW, Haughey BH, Lund VJ, et al.. Cummings Otolaryngology. Elsevier ; 2020
  7. Kim C-H, Lee J, Choi B, Shin JE. Nystagmus in adult patients with acute otitis media or otitis media with effusion without dizziness. PLoS ONE. 2021; 16 (5): p.e0250357. doi: 10.1371/journal.pone.0250357 . | Open in Read by QxMD
  8. Choi JW, Han K, Nahm H, Shin JE, Kim C-H. Direction-Changing Positional Nystagmus in Acute Otitis Media Complicated by Serous Labyrinthitis: New Insights into Positional Nystagmus. Otology & Neurotology. 2019; 40 (4): p.e393-e398. doi: 10.1097/mao.0000000000002104 . | Open in Read by QxMD
  9. Matsuo T. Vestibular Neuronitis —Serum and CSF Virus Antibody Titer—. Auris Nasus Larynx. 1986; 13 (1): p.11-34. doi: 10.1016/s0385-8146(86)80020-7 . | Open in Read by QxMD
  10. Hotson JR, Baloh RW. Acute vestibular syndrome.. N Engl J Med. 1998; 339 (10): p.680-5. doi: 10.1056/NEJM199809033391007 . | Open in Read by QxMD
  11. Tarnutzer AA, Berkowitz AL, Robinson KA, Hsieh YH, Newman-Toker DE. Does my dizzy patient have a stroke? A systematic review of bedside diagnosis in acute vestibular syndrome. CMAJ. 2011; 183 (9): p.E571-92. doi: 10.1503/cmaj.100174 . | Open in Read by QxMD
  12. Sjögren J, Magnusson M, Tjernström F, Karlberg M. Steroids for Acute Vestibular Neuronitis—the Earlier the Treatment, the Better the Outcome?. Otology & Neurotology. 2019; 40 (3): p.372-374. doi: 10.1097/mao.0000000000002106 . | Open in Read by QxMD
  13. Walter Royal, Diana Vargas. Bell's palsy and vestibular neuronitis. Elsevier ; 2014 : p. 763-770
  14. Fishman JM, Burgess C, Waddell A. Corticosteroids for the treatment of idiopathic acute vestibular dysfunction (vestibular neuritis). Cochrane Database of Systematic Reviews. 2011 . doi: 10.1002/14651858.cd008607.pub2 . | Open in Read by QxMD
  15. Strupp M, Zingler VC, Arbusow V, et al. Methylprednisolone, valacyclovir, or the combination for vestibular neuritis.. N Engl J Med. 2004; 351 (4): p.354-61. doi: 10.1056/NEJMoa033280 . | Open in Read by QxMD
  16. Gacek RR, Gacek MR. Comparison of Labyrinthectomy and Vestibular Neurectomy in the Control of Vertigo. Laryngoscope. 1996; 106 (2): p.225-230. doi: 10.1097/00005537-199602000-00023 . | Open in Read by QxMD
  17. Brian W. Blakley. Update on Intratympanic Gentamicin for Meniere's Disease. Laryngoscope. 2000; 110 (2): p.236-236. doi: 10.1097/00005537-200002010-00009 . | Open in Read by QxMD
  18. Tusa RJ, Gore R. Dizziness and Vertigo: Emergencies and Management. Neurol Clin. 2012; 30 (1): p.61-74. doi: 10.1016/j.ncl.2011.09.006 . | Open in Read by QxMD
  19. Goddard JC, Fayad JN. Vestibular Neuritis. Otolaryngol Clin North Am. 2011; 44 (2): p.361-365. doi: 10.1016/j.otc.2011.01.007 . | Open in Read by QxMD
  20. Brandt T. Management of vestibular disorders. J Neurol. 2000; 247 (7): p.491-499. doi: 10.1007/s004150070146 . | Open in Read by QxMD
  21. Vestibular Rehabilitation Therapy (VRT). http://vestibular.org/understanding-vestibular-disorder/treatment/treatment-detail-page. Updated: January 1, 2015. Accessed: May 16, 2017.
  22. Goldman L, Schafer AI. Goldman's Cecil Medicine. Elsevier ; 2012 : p. 2461-2469
  23. Walls R, Hockberger R, Gausche-Hill M. Rosen's Emergency Medicine. Elsevier Health Sciences ; 2018
  24. Becker KJ, Purcell LL, Hacke W, Hanley DF. Vertebrobasilar thrombosis: diagnosis, management, and the use of intra-arterial thrombolytics.. Crit Care Med. 1996; 24 (10): p.1729-42. doi: 10.1097/00003246-199610000-00022 . | Open in Read by QxMD
  25. Kattah JC, Talkad AV, Wang DZ, Hsieh Y-H, Newman-Toker DE. HINTS to Diagnose Stroke in the Acute Vestibular Syndrome. Stroke. 2009; 40 (11): p.3504-3510. doi: 10.1161/strokeaha.109.551234 . | Open in Read by QxMD
  26. Daroff, RB; Aminoff, MJ. Encyclopedia of the Neurological Sciences. Academic Press ; 2014
  27. Zee DS. Perspectives on the Pharmacotherapy of Vertigo. Archives of Otolaryngology - Head and Neck Surgery. 1985; 111 (9): p.609-612. doi: 10.1001/archotol.1985.00800110087009 . | Open in Read by QxMD
  28. Shupak A, Issa A, Golz A, Margalit Kaminer, Braverman I. Prednisone treatment for vestibular neuritis.. Otol Neurotol. 2008; 29 (3): p.368-74. doi: 10.1097/MAO.0b013e3181692804 . | Open in Read by QxMD
  29. Goudakos JK, Markou KD, Psillas G, Vital V, Tsaligopoulos M. Corticosteroids and vestibular exercises in vestibular neuritis. Single-blind randomized clinical trial.. JAMA otolaryngology-- head & neck surgery. 2014; 140 (5): p.434-40. doi: 10.1001/jamaoto.2014.48 . | Open in Read by QxMD
  30. LALWANI A. Vertigo, Dysequilibrium, and Imbalance with Aging. Elsevier ; 2005 : p. 533-539
  31. Lee SU, Park SH, Kim HJ, Koo JW, Kim JS. Normal Caloric Responses during Acute Phase of Vestibular Neuritis.. Journal of clinical neurology (Seoul, Korea). 2016; 12 (3): p.301-7. doi: 10.3988/jcn.2016.12.3.301 . | Open in Read by QxMD
  32. Lee CC, Su YC, Ho HC, et al. Risk of stroke in patients hospitalized for isolated vertigo: a four-year follow-up study.. Stroke. 2011; 42 (1): p.48-52. doi: 10.1161/STROKEAHA.110.597070 . | Open in Read by QxMD
  33. DAVIS SM, DONNAN GA, TRESS BM, KIERS L, DOWLING R, ROSSITER SC. MAGNETIC RESONANCE IMAGING IN POSTERIOR CIRCULATION INFARCTION: IMPACT ON DIAGNOSIS AND MANAGEMENT. Aust N Z J Med. 1989; 19 (3): p.219-225. doi: 10.1111/j.1445-5994.1989.tb00249.x . | Open in Read by QxMD
  34. Hwang DY, Silva GS, Furie KL, Greer DM. Comparative sensitivity of computed tomography vs. magnetic resonance imaging for detecting acute posterior fossa infarct.. J Emerg Med. 2012; 42 (5): p.559-65. doi: 10.1016/j.jemermed.2011.05.101 . | Open in Read by QxMD
  35. Herr RD, Alvord L, Johnson L, Valenti D, Mabey B. Immediate electronystagmography in the diagnosis of the dizzy patient. Ann Emerg Med. 1993; 22 (7): p.1182-1189. doi: 10.1016/s0196-0644(05)80986-2 . | Open in Read by QxMD
  36. Hoffman RM, Einstadter D, Kroenke K. Evaluating dizziness. Am J Med. 1999; 107 (5): p.468-478. doi: 10.1016/s0002-9343(99)00260-0 . | Open in Read by QxMD
  37. Fife TD, Tusa RJ, Furman JM, et al. Assessment: Vestibular testing techniques in adults and children: Report of the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology. Neurology. 2000; 55 (10): p.1431-1441. doi: 10.1212/wnl.55.10.1431 . | Open in Read by QxMD
  38. Hillier SL, McDonnell M. Vestibular rehabilitation for unilateral peripheral vestibular dysfunction. Cochrane Database of Systematic Reviews. 2007 . doi: 10.1002/14651858.cd005397.pub2 . | Open in Read by QxMD
  39. Huh Y-E, Kim J-S. Bedside Evaluation of Dizzy Patients. J Clin Neurol. 2013; 9 (4): p.203. doi: 10.3988/jcn.2013.9.4.203 . | Open in Read by QxMD

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