Vestibular neuritis, also known by the name vestibular neuronitis, is thought to be caused by inflammation of the vestibular portion of the eighth cranial nerve and classically presents with vertigo, nausea, and gait imbalance. It is believed to be associated with preceding or accompanying viral infection. It is considered a benign, self-limited condition that typically lasts several days, but can take weeks to months for all vestibular symptoms to completely resolve. Vestibular neuritis is a clinical diagnosis, and it’s the clinician's task to differentiate this benign self-limiting disease from other central causes such as cerebrovascular syndromes, which may share a similar history and physical exam findings. The mainstay in medical treatment for vestibular neuritis is generally supportive, often consisting of antiemetics, antihistamines, and benzodiazepines. Vestibular rehabilitation should start once the initial bouts of nausea and vomiting are under control.
Vestibular neuritis is believed to be an inflammatory disorder selectively affecting the vestibular portion of the eighth cranial nerve. The cause is presumed to be of viral origin.
The data is lacking regarding the incidence of acute vestibular neuritis, but it is known to be the third most common cause of peripheral vertigo following BPPV and Meniere disease. Estimates are that acute vestibular neuritis or labyrinthitis gets diagnosed in 6% of patients who present to emergency departments in the USA the complaint of dizziness. This stat is likely an under-representation of its true incidence as another 22% of the patients complaining of dizziness are discharged without anything more specific than “dizziness” or “vertigo.” A portion of these non-specific diagnoses likely includes actual cases of acute vestibular neuritis. It has no gender preference and usually affects those in their middle ages.
Vestibular neuritis is believed to be an inflammatory disorder selectively affecting the vestibular portion of the 8th cranial nerve. The cause is presumed to be of viral origin (e.g., the reactivation of latent HSV infection), but other causes of vascular etiology and immunologic in origin are proposals. Vestibular damage appears to have a predilection for the superior portion of the vestibular labyrinth (supplied by the superior division of the vestibular nerve) over the inferior aspect of the vestibular labyrinth (supplied by the inferior portion of the vestibular nerve). The underlying mechanism is unclear, but this phenomenon may be explainable by anatomical differences between the two vestibular divisions.
The typical presentation of vestibular neuritis is usually with the acute onset of the following:
The symptoms in vestibular neuritis are typically constant, in contrast to the episodic symptoms of other peripheral causes such as BPPV or Meniere's disease. Symptoms are worsened with head movement but not triggered. Symptoms generally develop over several hours, peak within the first 24 to 48 hours, and typically last several days before resolving without intervention. Patients will likely note a preceding or concurrent viral illness, but it is important to note that the lack of this history does not rule out the disease as it is reported to be absent in up to 50% of patients .
Other symptoms, such as headaches, are usually absent. It is vital to ask the patient about accompanying symptoms that may suggest central disorders of vertigo, such as visual changes, somatosensory changes, weakness, dysarthria, incoordination, or an inability to walk. If any of these are present, one must broaden the differential with to central causes of vertigo. When the additional symptom of unilateral hearing loss is present, this shifts the diagnosis towards labyrinthitis . When attempting to differentiate this associated hearing change from Meniere disease, it is important to know that Meniere disease also presents with vestibular and auditory dysfunction. Still, patients with Meniere have more episodic and not continuous symptoms lasting 20 minutes to usually no more than 12 hours.
Patients presenting with vestibular neuritis will have a normal physical exam and neurological exam. The clinician needs to look for clues that might point to a central cause of vertigo, warranting a more thorough evaluation. Central causes of vertigo are usually continuous symptoms along with truncal instability, an unsteady gait, dysarthria, and other focal neurological symptoms. Symptoms that are episodic in nature point to the more common other peripheral causes like BPPV and Meniere’s disease. Other findings that are consistent with peripheral causes of vertigo, like vestibular neuritis, include a negative HINTs exam. The HINTS examination (see figure 1) consists of three components: Head Impulse, Nystagmus, and Test of Skew. It has been found to have high sensitivity and specificity (100% and 96%) for distinguishing peripheral from central vertigo in patients presenting with acute vestibular syndrome when performed correctly by the experienced clinician. Videos of this exam are available online. The following components make up this exam are described as follows:
Other neurologic signs and symptoms: dysarthria, dysphagia, facial droop, dysmetria, motor weakness, sensory loss, and abnormal reflexes are typically absent. The auditory function in patients with vestibular neuritis is usually preserved, but when there is combined unilateral hearing loss, it is called labyrinthitis. It is crucial to assess the patient's gait and posture as it can help localize the affected ear or be a signal of a more grave diagnosis. Their seated posture should be normal, and while their gait is usually unaffected, they will tend to veer or fall toward the affected side (opposite to nystagmus fast phase).
The diagnostic basis is mostly on key signs and symptoms of acute vestibular dysfunction, as mentioned above. However, because vestibular neuritis is a diagnosis of exclusion, the main focus in patients presenting with acute spontaneous vertigo is to rule out a stroke or other central causes.
Neuroimaging of the brain with MRI or CT imaging is not indicated in most cases but can be helpful when exam findings of a peripheral lesion are inconsistent if risk factors for stroke exist and symptoms do not show improvement within 48 hours. If a rule test is needed, an MRI of the brain is more sensitive than a CT scan to rule out a CVA.
Other tests like cervical and ocular vestibular evoked myogenic potentials along with video head impulse testing have made it possible to determine which vestibular division is involved in vestibular neuritis.
The treatment of vestibular neuritis usually consists of acute symptomatic treatment with medications such as antiemetics (promethazine, metoclopramide), antihistamines (diphenhydramine, meclizine), and benzodiazepines (diazepam, lorazepam). Following the acute phase, other therapies, such as vestibular rehabilitation, are often recommendations. The utilization of the above antiemetics, antihistamines, and benzodiazepines should be used for no more than three days or so as these medications can delay central compensation and lead to chronic problems and recurrent vertigo.
In the past, the use of corticosteroids has been a therapeutic option, but their efficacy remains controversial. This therapy was studied in a 2011 Cochrane review, which found insufficient evidence to recommend their use in those with acute vestibular dysfunction.
The viral etiology hypothesis has led to the theoretical benefit from antiviral medications; however, the use of valacyclovir either alone or combined with a glucocorticoid has not been shown to be effective.
The differential diagnosis in patients presenting with vertigo can be broken down to that of peripheral or central etiologies as well as those with or without hearing loss:
Hearing Loss Present:
Hearing Loss Absent:
The natural history of this disease is uncomplicated with complete resolution in most cases. Some can have incomplete resolution and with a study showing 15% with persistent symptoms at one year. Recurrence of vestibular neuritis is infrequent, with studies that have shown its recurrence in only 2 to 11% of patients.
Two important complications associated with vestibular neuritis are benign paroxysmal positional vertigo (BPPV) and persistent postural-perceptual dizziness (PPPD), a relatively new term. Research has found that 10 to 15% of patients with vestibular neuritis will develop BPPV in the affected ear within a few weeks. PPPD is a new diagnostic syndrome of non-spinning vertigo and unsteadiness, which combines significant features of chronic subjective dizziness, phobic postural vertigo, and other related disorders. One study found PPPD in 25% of patients who were followed 3 to 12 months after acute or episodic vestibular disorders.
One should suspect vestibular neuritis if the patient experiences an acute onset of persistent vertigo that lasts hours to several days.
Patients who experience the above seek consultation with their primary care, emergency, or ENT physician.
Physicians will primarily exclude vertigo secondary to another more severe disease of the brain or its blood vessels, and refer the patient to an ENT (otolaryngologist) for further testing and treatment.
The word “dizziness” is very vague and may be described differently among patients. Patients may characterize it as light-headedness, faintness, nausea, or an unsteady feeling. On the other hand, true vertigo is a spinning sensation of movement and more suggestive of vestibular disease. Complicating the diagnosis of vertigo is the fact that the above sensations often accompany vestibular disease. These demonstrate is why the management of vestibular vertigo requires the effort of a collaborative interprofessional healthcare team.
The main concern in a patient presenting with acute vertigo is a vascular accident of the cerebellum or brainstem. However, vestibular neuritis is distinguishable from a central cause such as a cerebrovascular event with the use of the HINTS exam either by a specialist or someone specifically trained in the examination. In these patients, a referral to an ENT colleague is a strong recommendation.
A pharmacist can perform medication reconciliation to see if any drugs are known to cause vertigo, and if the clinician initiates pharmaceutical therapy for the vertigo, the pharmacist can verify dosing and counsel the patient on administration, adverse effects, etc. Nursing can monitor treatment progress, answer patient questions, check and reinforce administration, and report any concerns to the treating clinician.
Vestibular neuritis is a self-limiting disease with vestibular symptoms lasting for one to two days, followed by a gradual reduction in symptoms. Rarely does the illness lasts more than several days to a few weeks. Early improvement in symptoms is believed mainly due to central compensation. For this reason, symptomatic treatment with medications is stopped within the first 48 to 72 hours of the patient’s symptoms as it may interfere with central compensation and long-term recovery.
Most patients will experience vestibular neuritis only once, with some experiencing a residual imbalance and nonspecific dizziness persisting for months. If this occurs, the vestibular function can substantially be improved if patients follow through an individually designed vestibular rehabilitation program. The interprofessional team can guide these cases to their optimal result through open communication and collaborative teamwork. [Level 5]
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