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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Related Studies

Ontology: Viral labyrinthitis (C0155508)

Concepts Disease or Syndrome (T047)
ICD9 386.35
SnomedCT 34243007, 409711008
Italian Labirintite virale
Japanese ウイルス性迷路炎, ｳｲﾙｽｾｲﾒｲﾛｴﾝ
English viral labyrinthitis (diagnosis), viral labyrinthitis, labyrinthitis viral, Viral labyrinthitis, Viral labyrinthitis, NOS, Viral otitis interna, NOS, Viral labyrinthitis (disorder), Viral otitis interna
Czech Virová labyrintitida
Hungarian vírusos labyrinthitis
Spanish laberintitis vírica, laberintitis virósica, otitis interna viral, Laberintitis vírica, laberintitis viral (trastorno), laberintitis viral
Portuguese Labirintite viral
Dutch virale labyrinthitis
French Labyrinthite virale
German virale Labyrinthitis
Derived from the NIH UMLS (Unified Medical Language System)

Ontology: Vestibular Neuronitis (C0751908)

Definition (MSH) Idiopathic inflammation of the VESTIBULAR NERVE, characterized clinically by the acute or subacute onset of VERTIGO; NAUSEA; and imbalance. The COCHLEAR NERVE is typically spared and HEARING LOSS and TINNITUS do not usually occur. Symptoms usually resolve over a period of days to weeks. (Adams et al., Principles of Neurology, 6th ed, p304)
Concepts Disease or Syndrome (T047)
MSH D020338
ICD9 078.81, 386.12
ICD10 H81.2 , A88.1, H81.20
SnomedCT 123053001, 232293008, 186738001, 34243007, 155236001, 194356004, 43680000
English Vestibular Neuronitis, VESTIBULAR NERVE INFLAMM, vestibular neuronitis (diagnosis), vestibular neuronitis, epidemic vertigo (diagnosis), epidemic vertigo, Epidemic Neurolabyrinthitides, Epidemic Neurolabyrinthitis, Neurolabyrinthitides, Epidemic, Neurolabyrinthitis, Epidemic, Inflammation, Vestibular Nerve, Inflammations, Vestibular Nerve, Nerve Inflammation, Vestibular, Nerve Inflammations, Vestibular, Vestibular Nerve Inflammation, Vestibular Nerve Inflammations, Nerve Neuritides, Vestibular, Nerve Neuritis, Vestibular, Neuritides, Vestibular Nerve, Neuritis, Vestibular Nerve, Vestibular Nerve Neuritides, Vestibular Nerve Neuritis, Neuritides, Vestibular, Neuritis, Vestibular, Vestibular Neuritides, Vestibular Neuritis, Neuronitides, Vestibular, Neuronitis, Vestibular, Vestibular Neuronitides, Vestibular neuronitis, unspecified ear, Vestibular Neuronitis [Disease/Finding], Vestibular neuropathy, Vestibular neuronitis (disorder), Acute vestibular neuronitis (disorder), Acute vestibular neuronitis, Epidemic vertigo (finding), Epidemic vertigo, Acute epidemic vertigo, Epidemic vertigo (disorder), neuronitis; vestibular, vestibular; neuronitis, Vestibular neuronitis -RETIRED-, Vestibular neuronitis, Epidemic neurolabyrinthitis, Vestibular neuritis, vestibular neuritis
Swedish Vestibulär neuronit
Japanese ｾﾞﾝﾃｲｼﾝｹｲｴﾝ, 流行性回転性めまい, ﾘｭｳｺｳｾｲｶｲﾃﾝｾｲﾒﾏｲ, 前庭ニューロン炎, 神経炎-前庭, 前庭神経元炎, 前庭神経炎, ニューロン炎-前庭, 前庭迷路炎-流行性, 流行性前庭迷路炎, 神経元炎-前庭
Czech neuritida vestibulární, vestibulární neuronitida, epidemická neurolabyrintitida, Vestibulární neuronitis, Vertigo epidemica
Finnish Vestibulaarineuroniitti
Russian VESTIBULIARNYI NEVRIT, NEIRONIT VESTIBULIARNYI, NEVRIT VESTIBULIARNYI, NEIROLABIRINTIT EPIDEMICHESKII, ВЕСТИБУЛЯРНЫЙ НЕВРИТ, НЕВРИТ ВЕСТИБУЛЯРНЫЙ, НЕЙРОЛАБИРИНТИТ ЭПИДЕМИЧЕСКИЙ, НЕЙРОНИТ ВЕСТИБУЛЯРНЫЙ
German Epidemischer Schwindel, Neuropathia vestibularis, epidemischer Schwindel, Epidemische Neurolabyrinthitis, Neuronitis vestibularis, Neuritis, vestibuläre, Vestibuläre Neuritis
Korean 유행성 현기증, 전정신경염
Spanish Vértigo epidémico, vértigo epidémico (hallazgo), neuronitis vestibular aguda, neuronitis vestibular - RETIRADO - (concepto no activo), neuronitis vestibular aguda (trastorno), neuronitis vestibular, neuronitis vestibular - RETIRADO -, neurolaberintitis epidémica, vértigo epidémico (trastorno), vértigo epidémico agudo, vértigo epidémico, Neuronitis vestibular, Neuritis Vestibular, Neurolaberintitis Epidémica, Neuronitis Vestibular
Portuguese Vertigem epidémica, Neuronite Vestibular, Neuronite vestibular, Neurite Vestibular, Neurolabirintite Epidêmica
Dutch epidemische vertigo, neuronitis; vestibularis, vestibularis; neuronitis, Epidemische duizeligheid, Neuronitis vestibularis, vestibulaire neuronitis, Epidemische neurolabyrinthitis, Neuronitis, vestibulaire, Vestibulaire neuritis, Vestibulaire neuronitis
Italian Vertigine epidemica, Neurite del verbo vestibolare, Infiammazione del nervo vestibolare, Neurite vestibolare, Neuronite vestibolare
French Vertige épidémique, Névrite vestibulaire, Vestibulopathie périphérique
Polish Zapalenie nerwu przedsionkowego
Hungarian vestibularis neuronitis, Epidemiás vertigo
Norwegian Vestibularisnevritt, Vestibulær nevronitt
Derived from the NIH UMLS (Unified Medical Language System)

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