• Clinical science

Vestibular neuritis

Summary

Vestibular neuritis is idiopathic inflammation of the vestibular nerve that most frequently occurs following viral infections of the upper airways. The disorder manifests with acute-onset vertigo, nausea, vomiting, and gait instability in otherwise healthy patients. Management involves bed rest, corticosteroids, and antivertigo agents (e.g., dimenhydrinate); vestibular rehabilitation therapy may accelerate recovery. Symptoms typically resolve in 2–3 weeks with treatment.

Etiology

  • Vestibular neuritis is an idiopathic disease.
  • It tends to occur more often after upper airway infections [1]

References:[2]

Clinical features

  • Acute onset of symptoms in otherwise healthy patients. Severe symptoms last for 1–2 days, mild symptoms may persist for weeks or even months:
  • Increased risk of falling towards the affected side
  • Patient history may include recent infection of the upper airways.

No cochlear symptoms (e.g., hearing loss, tinnitus)!

References:[2][3]

Diagnostics

Vestibular neuritis is a clinical diagnosis.

  • Positive head thrust test: The examiner turns the patient's head rapidly towards the affected side; the test is considered positive if the patient is unable to maintain visual fixation.
  • Imaging studies (to rule out stroke or brain tumors, but not for routine diagnostics)
  • Audiogram: unremarkable

Imaging studies are indicated in patients older than 60 years, as well as those with persistent vestibular symptoms, headache, vascular risk factors, or focal neurologic symptoms to rule out a lateral medullary/cerebellar stroke!

References:[2]

Differential diagnoses for vertigo

Definitions

  • Dizziness: an umbrella term commonly used by patients to describe a variety of sensations, including vertigo, presyncope, imbalance, and confusion.
  • Vertigo: the sensation of self-motion (internal vertigo) or one's surroundings spinning while stationary (external vertigo)
  • Presyncope (lightheadedness): near loss of consciousness; most commonly due to a drop in systemic blood pressure or hypoxia

Differential diagnosis of vertigo-associated disorders

DDx

Ménière disease Benign paroxysmal positional vertigo Persistent postural-perceptual dizziness Vestibular neuritis
Vertigo
  • Vertigo lasts for minutes to hours
  • Vertigo for only a few seconds
  • Vertigo is always triggered by movement (e.g., lying down, reclining)
  • Not actually vertigo, but a sensation of dizziness that lasts for at least 3 months
  • Severe vertigo for 1–2 days
  • Mild symptoms (e.g., nausea) may persist for weeks or months
Other symptoms
  • No cochlear symptoms
  • No cochlear symptoms
  • Patients often suffer from anxiety and/or depressive disorders

Central vs peripheral vertigo

Central vertigo Peripheral vertigo
Site of underlying disorder
Associated cerebellar symptoms (e.g., ataxia, dysmetria)
  • Marked
  • Absent or mild
Sense of motion
  • Mild
  • Severe
Associated skew deviation
  • Present
  • Absent
Associated nystagmus
  • Can be torsional, horizontal, or vertical
  • Direction of nystagmus changes with gaze change.
  • Gaze fixation worsens nystagmus.
  • Torsional and horizontal (never vertical)
  • Direction of nystagmus does not change with gaze change.
  • Gaze fixation improves nystagmus.
Associated hearing loss and/or tinnitus
  • Rare
  • Common
Associated focal neurological findings (e.g., diplopia)
  • Common
  • Rare
Causes

References:[4][5][3]

Treatment

References:[2][4]

  • 1. Matsuo T. Vestibular Neuronitis —Serum and CSF Virus Antibody Titer—. Auris Nasus Larynx. 1986; 13(1): pp. 11–34. doi: 10.1016/s0385-8146(86)80020-7.
  • 2. Furman JM. Vestibular neuritis and labyrinthitis. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. http://www.uptodate.com/contents/vestibular-neuritis-and-labyrinthitis. Last updated August 9, 2013. Accessed April 3, 2017.
  • 3. Daroff RB, et al. Bradley's Neurology in Clinical Practice. Elsevier.
  • 4. Swartz R, Longwell P. Treatment of vertigo. Am Fam Physician. 2005; 71(6): pp. 1115–1122. pmid: 15791890.
  • 5. Ropper A, Klein J, Samuels M. Adams and Victor's Principles of Neurology 10th Edition. McGraw-Hill Education / Medical; 2014.
  • 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): pp. 1431–1441. doi: 10.1212/wnl.55.10.1431.
  • 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): pp. E571–92. doi: 10.1503/cmaj.100174.
  • 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): pp. 219–225. doi: 10.1111/j.1445-5994.1989.tb00249.x.
  • 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): pp. 559–65. doi: 10.1016/j.jemermed.2011.05.101.
  • 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): pp. 1182–1189. doi: 10.1016/s0196-0644(05)80986-2.
  • Hoffman RM, Einstadter D, Kroenke K. Evaluating dizziness. Am J Med. 1999; 107(5): pp. 468–478. doi: 10.1016/s0002-9343(99)00260-0.
  • Gacek RR, Gacek MR. Comparison of Labyrinthectomy and Vestibular Neurectomy in the Control of Vertigo. Laryngoscope. 1996; 106(2): pp. 225–230. doi: 10.1097/00005537-199602000-00023.
  • Brandt T. Management of vestibular disorders. J Neurol. 2000; 247(7): pp. 491–499. doi: 10.1007/s004150070146.
  • Hillier SL, McDonnell M. Vestibular rehabilitation for unilateral peripheral vestibular dysfunction. Cochrane Database of Systematic Reviews. 2007. doi: 10.1002/14651858.cd005397.pub2.
  • 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): pp. 301–7. doi: 10.3988/jcn.2016.12.3.301.
  • Brian W. Blakley. Update on Intratympanic Gentamicin for Meniere's Disease. Laryngoscope. 2000; 110(2): pp. 236–236. doi: 10.1097/00005537-200002010-00009.
  • 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): pp. 372–374. doi: 10.1097/mao.0000000000002106.
  • Baloh RW. Clinical practice. Vestibular neuritis. N Engl J Med. 2003; 348(11): pp. 1027–32. doi: 10.1056/NEJMcp021154.
  • 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.
  • 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): pp. 48–52. doi: 10.1161/STROKEAHA.110.597070.
  • 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): pp. 434–40. doi: 10.1001/jamaoto.2014.48.
  • LALWANI A. Vertigo, Dysequilibrium, and Imbalance with Aging. Elsevier; 2005: pp. 533–539.
  • Tusa RJ, Gore R. Dizziness and Vertigo: Emergencies and Management. Neurol Clin. 2012; 30(1): pp. 61–74. doi: 10.1016/j.ncl.2011.09.006.
  • Goldman L, Schafer AI. Goldman's Cecil Medicine. Elsevier; 2012: pp. 2461–2469.
  • Walls R, Hockberger R, Gausche-Hill M. Rosen's Emergency Medicine. Philadelphia, PA: Elsevier Health Sciences; 2018.
  • Muncie HL, Sirmans SM, James E. Dizziness: Approach to Evaluation and Management. Am Fam Physician. 2017; 95(3): pp. 154–162. pmid: 28145669.
  • Hotson JR, Baloh RW. Acute vestibular syndrome. N Engl J Med. 1998; 339(10): pp. 680–5. doi: 10.1056/NEJM199809033391007.
  • 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): pp. 1729–42. doi: 10.1097/00003246-199610000-00022.
  • 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): pp. 3504–3510. doi: 10.1161/strokeaha.109.551234.
  • Goddard JC, Fayad JN. Vestibular Neuritis. Otolaryngol Clin North Am. 2011; 44(2): pp. 361–365. doi: 10.1016/j.otc.2011.01.007.
  • 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.
  • Daroff, RB; Aminoff, MJ. Encyclopedia of the Neurological Sciences. Academic Press; 2014.
  • Walter Royal, Diana Vargas. Bell's palsy and vestibular neuronitis. Elsevier; 2014: pp. 763–770.
  • Strupp M, Zingler VC, Arbusow V, et al. Methylprednisolone, valacyclovir, or the combination for vestibular neuritis. N Engl J Med. 2004; 351(4): pp. 354–61. doi: 10.1056/NEJMoa033280.
  • Zee DS. Perspectives on the Pharmacotherapy of Vertigo. Archives of Otolaryngology - Head and Neck Surgery. 1985; 111(9): pp. 609–612. doi: 10.1001/archotol.1985.00800110087009.
  • Shupak A, Issa A, Golz A, Margalit Kaminer, Braverman I. Prednisone treatment for vestibular neuritis. Otol Neurotol. 2008; 29(3): pp. 368–74. doi: 10.1097/MAO.0b013e3181692804.
  • Farrell L. Vestibular Rehabilitation Therapy (VRT). http://vestibular.org/understanding-vestibular-disorder/treatment/treatment-detail-page. Updated January 1, 2015. Accessed May 16, 2017.
  • 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.
last updated 09/17/2020
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