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Vestibular Neuronitis
Aka: Vestibular Neuronitis, Vestibular Neuritis, Acute Vestibular Neuronitis, Epidemic Vertigo
- See Also
- Vertigo
- Vertigo Causes
- Peripheral Causes of Vertigo
- Central Causes of Vertigo
- Vertigo Management
- Meniere's Disease
- Motion Sickness
- Benign Paroxysmal Positional Vertigo
- Perilymphatic Fistula (Hennebert's Sign)
- Acute Labyrinthitis
- Bacterial Labyrinthitis (Acute Suppurative Labyrinthitis)
- HiNTs Exam (Three-Step Bedside Oculomotor Examination)
- Horizontal Head Impulse Test (Head Thrust Test, h-HIT)
- Nystagmus
- Skew Deviation (Vertical Ocular Misalignment, Vertical Heterotropia, Vertical Strabismus)
- Dix-Hallpike Maneuver
- Dizziness
- Dysequilibrium
- Syncope
- Light Headedness
- Epidemiology
- Second most common peripheral cause of Vertigo
- May occur in several family members (Epidemic Vertigo)
- More common in ages 30 to 50 years old
- Pathophysiology
- Distinct entity - not synonymous with labyrinthitis
- Inflammation and degeneration of Vestibular Nerve
- Associated with Viral Infections
- Herpesviruses
- Borrelia
- Symptoms
- Vertigo lasting days to weeks (or even months in 50% of patients)
- Objects may appear to move in Visual Field (oscillopsia)
- Vertigo improves over time with central compensation
- Spontaneous onset and worsened (but not triggered) by rapid head movements
- Vertigo may be constant regardless of position changes
- Not consistently provoked by head position changes
- May persist for months after acute disease resolves
- Sense of imbalance
- Nystagmus is variably present
- Loss of respose to Cold Calorics (consistent finding)
- No Tinnitus
- No Hearing Loss
- Signs
- See Vertigo for additional exam components
- Negative HiNTs Exam
- Contrast with Central Vertigo (e.g. Posterior CVA)
- Negative or equivocal Dix-Hallpike Maneuver
- Contrast with positive test in Benign Paroxysmal Positional Vertigo (BPPV)
- Differential Diagnosis
- See Vertigo Causes
- Provoked by head position
- Benign Paroxysmal Positional Vertigo (BPPV)
- Acute Labyrinthitis (associated with Tinnitus and complete Hearing Loss)
- Complete Sensorineural Hearing Loss distinguishes Labyrinthitis from Vestibular Neuronitis
- Not provoked by head position
- Meniere's Disease (associated with Hearing Loss)
- Management
- See Vertigo Management
- Supportive (limit to 3 days only, to allow central compensation to proceed)
- Demenhydrinate 50-100 mg every 4-6 hours as needed or
- Meclizine (Antivert) 12.5 to 25 mg orally every 6 hours as needed
- Severe Symptoms
- Phenergan as needed for 3 to 5 days
- Diazepam (Valium) 5 mg orally q6 hours for 3 days
- Management: Disproved strategies
- Valacyclovir is not effective
- Corticosteroids (for severe symptoms)
- Limited benefit in patient outcomes and not routinely recommended
- Goudakos (2010) Otol Neurotol 31(2): 183-9 [PubMed]
- Dosing used historically
- Prednisone tapered using 5 mg tablets from 7 tabs daily to 1 tab daily
- Initial studies demonstrated efficacy in improving Vestibular Function
- Started Methylprednisolone (22 day) within 3 days
- Strupp (2004) N Engl J Med 351:354-61 [PubMed]
- Course
- Self limited, acute illness resolves improves within days to weeks (with central compensation)
- Postural Vertigo may be residual for weeks to months
- May persist for 2 months in up to 50% of patients
- Bergenius (1983) Acta Otolaryngol 96(5-6): 389-95 [PubMed]
- Other measures
- Consider Serial Audiogram
- Consider alternative diagnosis if Vertigo attacks do not decrease in duration and intensity over time
- Complications
- Benign Paroxysmal Positional Vertigo (BPPV) may follow Vestibular Neuritis in 15% of cases
- Baloh (1987) Neurology 37(3): 371-8 [PubMed]
- References
- Schessel in Cummings (2005) Otolaryngology p. 3231-2
- Labuguen (2006) Am Fam Physician 73:244-54 [PubMed]
- Muncie (2017) Am Fam Physician 95(3): 154-62 [PubMed]