Vestibular Neuronitis and Labyrinthitis
Vestibular neuronitis and labyrinthitis are both causes of acute peripheral vertigo. Vestibular neuronitis, also known as vestibular neuritis, refers to the inflammation of the vestibular nerve of cranial nerve VIII, causing acute spontaneous vertigo without hearing loss. Labyrinthitis is inflammation of the inner ear labyrinth, causing a similar acute vertigo syndrome but with additional cochlear symptoms, such as hearing loss and tinnitus.
This updated UKMLA guide to vestibular neuronitis and labyrinthitis is based on NICE CKS, which covers causes, symptoms, diagnosis and management.
Peripheral Vertigo: Key Differentials
| Feature | BPPV | Meniere’s disease | Vestibular neuronitis | Labyrinthitis |
|---|---|---|---|---|
| Core mechanism | Displaced otoconia in semi-circular canals | Inflammation of the vestibular portion of CN VIII | Inflammation of the labyrinth (affecting both vestibular and cochlear structures) | Endolymphatic hydrops |
| Course | Recurrent attacks, may resolve spontaneously | Recurrent attacks + progressively worsen over time | Singe acute episode | Singe acute episode |
| Trigger | Change in head position | Spontaneous | Spontaneous | Spontaneous |
| Vertigo duration | <1 min | 20 min to 24 hours | Days to weeks | Days to weeks |
| Cochlear symptoms (hearing loss, tinnitus) | Absent | Present | Absent | Present |
| Diagnosis | Dix-Hallpike test | Clinical diagnosis + audiometry | Clinical diagnosis | Clinical diagnosis |
| Management | Epley manoeuvre and other repositioning manoeuvres +/- vestibular rehabilitation | Short-term vestibular suppressants +/- betahistine | Short-term vestibular suppressants +/- vestibular rehabilitation | Short-term vestibular suppressants +/- vestibular rehabilitation |
Causes
Both vestibular neuronitis and labyrinthitis most commonly occur after a viral infection (e.g. URTI)
Bacterial vestibular neuronitis is uncommon; bacterial labyrinthitis usually arises from acute otitis media or bacterial meningitis [Ref]
Clinical Features
Both vestibular neuronitis and labyrinthitis present very similarly, with one exception: cochlear symptoms (i.e. hearing loss and tinnitus) are ONLY present in labyrinthitis, but NOT vestibular neuronitis.
Learning aid:
- Vestibular neuronitis affects the vestibular portion of CN VIII only, so it spares the cochlea
- Labyrinthitis involves the inner ear labyrinth, affecting both vestibular and cochlear structures
Shared features in vestibular neuronitis and labyrinthitis:
- A preceding history of viral URTI is classic
- Spontaneous vertigo attacks
- Exacerbated by changes of head position, but constant even when the head is still
- Duration: days (unlike in <1 min episodes in BPPV and <24 hours episodes in Meniere’s disease)
- Course: worsens over the first few hours and reaches a peak during the first day, but then usually eases over the following 2 days, with further resolution over subsequent weeks
- Nausea and vomiting (and other autonomic symptoms like sweating, pallor, malaise)
- Nystagmus
- Balance problems
BPPV can develop following vestibular neuronitis in 10-15% cases.
Investigation and Diagnosis
Clinical diagnosis based on clinical history.
It is important to exclude central causes of vertigo, particularly posterior circulation stroke, as vestibular neuronitis and labyrinthitis can present with acute, continuous vertigo that may mimic a cerebrovascular event.
Red flag features of central vertigo:
- New focal neurological deficit (e.g. facial weakness, limb weakness or sensory loss, diplopia, dysphagia)
- New unilateral hearing loss
- Cerebellar features (e.g. dysdiadochokinesis, ataxia, intentional tremor, slurred speech, hypotonia)
- New-onset headache
- HINTS examination suggesting a central cause:
- Normal head impulse test
- Vertical or direction-changing nystagmus
- Vertical skew deviation
Other factors that support / points towards acute vertigo secondary to cerebrovascular accident include:
- Older age
- Presence of vascular risk factors (e.g. smoker, hypertension, diabetes, hyperlipidaemia, previous cardiovascular diseases)
Management
Vestibular neuronitis and labyrinthitis share the same supportive management principles.
Conservative / General Management
Counsel the patient that:
- Symptoms will usually settle over 2-6 weeks, even without treatment
- Bed rest may be necessary if symptoms are severe, but normal activity should be resumed ASAP
Advise the person not to drive when they are dizzy, or if they are likely to experience an episode of vertigo while driving
Acute Symptomatic Management
Depends on the severity of symptoms:
| Severity | Management |
|---|---|
| Unable to tolerate oral fluids or medications | Admit to hospital |
| Severe nausea or vomiting | Consider:
|
| Less severe nausea, vomiting and vertigo | 1st line: consider a short course (take regularly for up to 3 days) of oral
|
Advise the person to return if symptoms deteriorate or are not fully resolved after 1 week.
Chronic Management
Refer to a balance specialist (audiovestibular physician / neurologist) for further assessment or consideration of vestibular rehabilitation (e.g. Cawthorne-Cooksey exercises) if
- Symptoms persist without improvement for >1 week despite treatment (urgent referral)
- Symptoms persist for >6 weeks
- Symptoms are not typical of vestibular neuronitis (e.g. additional neurological symptoms)