Vestibular neuritis
Description
- Acute unilateral vestibular nerve dysfunction causing sudden, severe, continuous vertigo lasting days
- Vestibular neuritis = vestibular nerve only (no hearing loss); labyrinthitis = vestibular + cochlear involvement (hearing loss/tinnitus present) - the key distinguishing term
Epidemiology
- Third commonest cause of peripheral vertigo (after BPPV and Meniere)
- Peak incidence 30-60 years; often follows a viral prodrome
Aetiopathogenesis
- Presumed viral (HSV reactivation implicated) or post-viral inflammatory neuropathy of the vestibular nerve
- Labyrinthitis - infection/inflammation extends to the cochlea (viral, or bacterial via otitis media/meningitis extension)
Diagnosis
Clinical
- Acute, severe, continuous vertigo lasting days (peak first 24-48h, gradually improving over 1-2 weeks), worse with head movement, nausea/vomiting
- Spontaneous unidirectional horizontal nystagmus, fast phase away from the affected ear, suppressed by visual fixation
- Unsteady gait (falls toward affected side) but able to walk
- No hearing loss/tinnitus in pure vestibular neuritis; present in labyrinthitis
- No other neurological signs, no headache - any of these should prompt work-up for stroke
HINTS exam - distinguishes peripheral vestibular neuritis from posterior circulation stroke in acute vestibular syndrome
- Head Impulse - abnormal (catch-up saccade) = peripheral (reassuring); normal head impulse with ongoing severe vertigo raises stroke concern
- Nystagmus - direction-fixed, horizontal = peripheral; direction-changing or vertical = central
- Test of Skew - present (vertical ocular misalignment) = central
- *HINTS is more sensitive than early MRI for posterior circulation stroke in this setting* when performed correctly by a trained examiner
- Any red flag (severe headache, diplopia, dysarthria, limb ataxia, cardiovascular risk factors, abnormal HINTS pattern) -> MRI with DWI, posterior circulation stroke work-up
Management
A. Symptomatic (acute phase only)
- Vestibular suppressants (prochlorperazine, or short-course benzodiazepine) for the first 24-72 hours only
- *Prolonged use delays central vestibular compensation* - stop as soon as acute symptoms allow
B. Corticosteroids
- Consider early oral corticosteroids (e.g. prednisolone) - some evidence for faster vestibular recovery in vestibular neuritis; benefit modest and not universally adopted
C. Vestibular rehabilitation - the definitive treatment
- Early mobilisation and vestibular rehabilitation exercises promote central compensation and are the most important driver of recovery
- Avoid prolonged bed rest
D. Labyrinthitis
- If bacterial (associated with otitis media/mastoiditis) - antibiotics and ENT involvement, urgent if suspected suppurative labyrinthitis or meningitis
- Hearing loss - audiology follow-up, ENT referral
Associations
- Preceding viral illness/URTI
- Otitis media, mastoiditis (labyrinthitis)
- HSV reactivation (proposed mechanism)
Natural history & complications
- Acute vertigo peaks in 24-48h, substantially improves over 1-2 weeks as central compensation occurs
- Chronic dizziness/imbalance in a minority if compensation is incomplete - vestibular rehabilitation reduces this risk
- Hearing loss in labyrinthitis may be permanent, especially if bacterial
- Overall good prognosis for functional recovery with rehabilitation
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