Vestibular Neuronitis

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

1. See Also
   1. Vertigo
   2. Vertigo Causes
   3. Peripheral Causes of Vertigo
   4. Central Causes of Vertigo
   5. Vertigo Management
   6. Meniere's Disease
   7. Motion Sickness
   8. Benign Paroxysmal Positional Vertigo
   9. Perilymphatic Fistula (Hennebert's Sign)
   10. Acute Labyrinthitis
   11. Bacterial Labyrinthitis (Acute Suppurative Labyrinthitis)
   12. HiNTs Exam (Three-Step Bedside Oculomotor Examination)
   13. Horizontal Head Impulse Test (Head Thrust Test, h-HIT)
   14. Nystagmus
   15. Skew Deviation (Vertical Ocular Misalignment, Vertical Heterotropia, Vertical Strabismus)
   16. Dix-Hallpike Maneuver
   17. Dizziness
   18. Dysequilibrium
   19. Syncope
   20. Light Headedness
2. Epidemiology
   1. Second most common peripheral cause of Vertigo
   2. May occur in several family members (Epidemic Vertigo)
   3. More common in ages 30 to 50 years old
3. Pathophysiology
   1. Distinct entity - not synonymous with labyrinthitis
   2. Inflammation and degeneration of Vestibular Nerve
   3. Associated with viral infections
      1. Herpesviruses
      2. Borrelia
4. 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
   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
   4. Nystagmus is variably present
   5. Loss of respose to Cold Calorics (consistent finding)
   6. No Tinnitus
   7. No Hearing Loss
5. Signs
   1. See Vertigo for additional exam components
   2. Negative HiNTs Exam
      1. Contrast with Central Vertigo (e.g. Posterior CVA)
   3. Negative or equivocal Dix-Hallpike Maneuver
      1. Contrast with positive test in Benign Paroxysmal Positional Vertigo (BPPV)
6. Differential Diagnosis
   1. See Vertigo Causes
   2. Provoked by head position
      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. Meniere's Disease (associated with Hearing Loss)
7. 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
8. Management: Disproved strategies
   1. Valacyclovir is not effective
   2. Corticosteroids (for severe symptoms)
      1. Limited benefit in patient outcomes and not routinely recommended
         1. Goudakos (2010) Otol Neurotol 31(2): 183-9 [PubMed]
      2. 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]
9. 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
10. Complications
    1. Benign Paroxysmal Positional Vertigo (BPPV) may follow Vestibular Neuritis in 15% of cases
       1. Baloh (1987) Neurology 37(3): 371-8 [PubMed]
11. 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]