Vestibular Neuronitis

Aka: Vestibular Neuronitis, Vestibular Neuritis, Acute Vestibular Neuronitis, Epidemic Vertigo

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II. Epidemiology

  1. Second most common peripheral cause of Vertigo
    1. The most common peripheral Vertigo cause is Benign Paroxysmal Positional Vertigo
  2. May occur in several family members (Epidemic Vertigo)
  3. More common in ages 30 to 50 years old

III. Pathophysiology

  1. Vestibular Neuritis is a distinct entity and not synonymous with labyrinthitis
  2. Inflammation and degeneration of Vestibular Nerve
  3. Associated with Viral Infections
    1. Herpesviruses
    2. Borrelia

IV. Symptoms

  1. Vertigo lasting days to weeks (or even months in 50% of patients)
    1. Objects may appear to move in Visual Field (oscillopsia)
    2. Vertigo improves over time with central compensation
    3. Often follows recent viral Upper Respiratory Infection in the prior month
  2. Spontaneous onset and worsened (but not triggered) by rapid head movements
    1. Vertigo may be constant regardless of position changes
    2. Not consistently provoked by head position changes
    3. May persist for months after acute disease resolves
  3. Sense of imbalance and often associated with Ataxia
  4. Nystagmus is variably present
  5. Loss of respose to Cold Calorics (consistent finding)
  6. No Tinnitus
  7. No Hearing Loss

V. Signs

  1. See Vertigo for additional exam components
  2. Vestibular Neuritis is continuous at rest
    1. See Acute Vestibular Syndrome
    2. Contrast with triggered Vertigo seen in BPPV
  3. Negative HiNTs Exam
    1. Contrast with Central Vertigo (e.g. Posterior CVA)
  4. Negative or equivocal Dix-Hallpike Maneuver (or not improved with Epley Maneuver)
    1. Contrast with positive test in Benign Paroxysmal Positional Vertigo (BPPV)

VI. Differential Diagnosis

  1. See Vertigo Causes
  2. Provoked by head position (triggered Vertigo)
    1. Benign Paroxysmal Positional Vertigo (BPPV)
    2. Acute Labyrinthitis (associated with Tinnitus and complete Hearing Loss)
      1. Complete Sensorineural Hearing Loss distinguishes Labyrinthitis from Vestibular Neuronitis
  3. Not provoked by head position
    1. Acute Vestibular Syndrome
      1. Cerebrovascular Accident (posterior CVA)
        1. Most important alternative cause in the Vestibular Neuritis differential diagnosis
    2. Chronic Vertigo
      1. Meniere's Disease (associated with Hearing Loss)

VII. Management

  1. See Vertigo Management
  2. Supportive (limit to 3 days only, to allow central compensation to proceed)
    1. Demenhydrinate 50-100 mg every 4-6 hours as needed or
    2. Meclizine (Antivert) 12.5 to 25 mg orally every 6 hours as needed
  3. Severe Symptoms
    1. Phenergan as needed for 3 to 5 days
    2. Diazepam (Valium) 5 mg orally q6 hours for 3 days

VIII. Management: Disproved strategies

  1. Valacyclovir is not effective
  2. Corticosteroids (for severe symptoms)
    1. Avoid Corticosteroids (no compelling evidence, and Corticosteroid associated risks)
    2. Limited benefit in patient outcomes and not routinely recommended
      1. Goudakos (2010) Otol Neurotol 31(2): 183-9 [PubMed]
    3. Dosing used historically
      1. Prednisone tapered using 5 mg tablets from 7 tabs daily to 1 tab daily
      2. Initial studies demonstrated efficacy in improving Vestibular Function
        1. Started Methylprednisolone (22 day) within 3 days
        2. Strupp (2004) N Engl J Med 351:354-61 [PubMed]

IX. Course

  1. Self limited, acute illness resolves improves within days to weeks (with central compensation)
  2. Postural Vertigo may be residual for weeks to months
    1. May persist for 2 months in up to 50% of patients
    2. Bergenius (1983) Acta Otolaryngol 96(5-6): 389-95 [PubMed]
  3. Other measures
    1. Consider Serial Audiogram
    2. Consider alternative diagnosis if Vertigo attacks do not decrease in duration and intensity over time

X. Complications

  1. Benign Paroxysmal Positional Vertigo (BPPV) may follow Vestibular Neuritis in 15% of cases
    1. Baloh (1987) Neurology 37(3): 371-8 [PubMed]

XI. References

  1. Schessel in Cummings (2005) Otolaryngology p. 3231-2
  2. Labuguen (2006) Am Fam Physician 73:244-54 [PubMed]
  3. Muncie (2017) Am Fam Physician 95(3): 154-62 [PubMed]
  4. Rogers (2023) Am Fam Physician 107(5): 514-23 [PubMed]

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