Vestibular Neuronitis

BASIC INFORMATION

DEFINITION
Vestibular neuronitis is a syndrome of suddenonset dysfunction of the peripheral vestibular
system, often severe, with prolonged vertigo,
nausea, and vomiting.

ICD-9CM CODES
078.81Vestibular neuronitis
386.12Neuronitis, vestibular
ICD-10 CODES
H81.2Vestibular neuronitis
H81.8Other disorders of vestibular function
H81.9Disorder of vestibular function,
unspecified
H81.23Vestibular neuronitis, bilateral

EPIDEMIOLOGY &
DEMOGRAPHICS
Vestibular neuritis is the second most common
cause of peripheral vestibular vertigo with an
incidence of about 3.5:100,000 population.
Although etiology remains uncertain, thought
to result from selective inflammation of the
vestibular nerve, the etiology is presumed to be
viral. Viral origin is supported by the fact that it
occurs in epidemics, may affect several family
members, and occurs more commonly in spring
and early summer. The male-to-female ratio is
nearly 1:1. There is selective damage to the
superior part of the vestibular labyrinth, supplied by the superior vestibular portion of the
eighth cranial nerve.
PHYSICAL FINDINGS & CLINICAL
PRESENTATION
Course: develops, acutely, over period of hours
and resolves over periods of days or weeks,
although long-term sequelae may occur, such
as residual imbalance and nonspecific dizziness
persisting for months. Symptoms include vertigo, spontaneous peripheral nystagmus, positive
head-thrust test, and imbalance. Patient reports
intense sensation of rotation and difficulty
standing and walking and tends to veer toward
affected side; autonomic symptoms occur with
pallor, sweating, nausea, and vomiting.
ETIOLOGY
Etiology remains uncertain. It is thought to be
viral, or secondary to a post-viral inflammatory
disorder, in origin, possibly due to herpes zoster,
reactivation of herpes simplex, or other viruses,
but evidence is circumstantial.

DIFFERENTIAL DIAGNOSIS


Labyrinthitis: similar symptoms of vertigo,
with the addition of unilateral hearing loss
Labyrinthine infarction
Acoustic neuroma
Perilymph fistula
Brain stem and cerebellar infarction
Migraine-associated vertigo
Meniere disease
Multiple sclerosis
WORKUP
Patient may fall toward affected side when
attempting ambulation or during Romberg
tests.
Hallpike maneuver: checking for nystagmus
and asking about recreation of vertigo symptoms
Head-thrust test: grasp patients head, apply
brief small-amplitude rapid head turn, first to
one side and then the other; patient fixates
on examiners nose: positive test is lack of
corrective eye movements (saccades) on
affected side. A postive test supports the
diagnosis of vestibular neuronitis.
Laboratory testing and imaging are generally
not indicated but may help rule out other
etiologies
LABORATORY TESTS
Electronystagmography (ENG): a battery of
eye movement tests that may provide an
objective assessment of the vestibular and
oculomotor systems and may help localize
the lesions site
Audiogram: normal
IMAGING STUDIES
Brain imaging: CT or MRInormal

Rx TREATMENT
NONPHARMACOLOGIC THERAPY
Vestibular exercises, when tolerated, will accelerate recovery.
ACUTE GENERAL Rx
Most treatments are empirical and related to
symptoms. Further studies are needed.
Corticosteroids: corticosteroids are often prescribed, although a recent Cochrane Review
finds that there is insufficient evidence for
administration. Some studies have shown
that glucocorticoids administered within 3
days after onset of vestibular neuronitis may
improve long-time recovery of vestibular
function and reduce the length of hospital
stay and may improve the caloric extent and
recovery of canal paresis.

Antihistamines: e.g., meclizine, dimenhydrinate, promethazine

Anticholinergics: scopolamine
Antiemetics: droperidol, prochlorperazine


Benzodiazepines: e.g., diazepam, valium,
lorazepam
Valacyclovir, either alone or in combination,
is likely ineffective in treating vestibular neuronitis.

CHRONIC Rx
Vestibular rehabilitation exercises
Anti-GABA agents
Antihistamines
DISPOSITION
Most patients can be treated as outpatients,
but inpatient care may be required in cases
where vomiting is uncontrollable. If dehydrated
because of severe vomiting, sufferers may
require brief parenteral therapy.
REFERRAL


ENT: if diagnosis uncertain, and if these
patients are at risk for benign paroxysmal
positional vertigo (BPPV) subsequently; also
if symptoms linger

Neurology: if question of central origin or
migraine

PEARLS &
CONSIDERATIONS

COMMENTS
Diagnosis unlikely to be vestibular neuronitis
if hearing is impaired or other neurologic
signs and symptoms are present.


Although patients may recover from dramatic acute symptoms, subtle vestibular
deficits may linger for prolonged period, if
not indefinitely (i.e., residual imbalance and
nonspecific dizziness).


Program of vestibular habituation head
movement exercises can reduce imbalance
symptoms.
PATIENT & FAMILY EDUCATION
Vestibular Disorders Association: http://www.
vestibular.org
SUGGESTED READINGS
available at www.expertconsult.com
AUTHOR: ROCCO J. RICHARDS, M.D.

Diseases
and Disorders

SYNONYMS
Vestibular neuritis
Acute neuritis
Neurolabyrinthitis
Vestibular neuropathy

Dx DIAGNOSIS

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Vestibular Neuronitis
SUGGESTED READINGS
Baloh RW: Vestibular neuritis, N Engl J Med 348:1027-1032, 2003.
Cohen HS, Kimball KT: Decreased ataxia and improved balance after vestibular
rehabilitation, Otolaryngol Head Neck Surg 130(4):418-425, 2004.
Fishman JM etal: Corticosteroids for the treatment of idiopathic acute vestibular
dysfunction (vestibular neuritis), Cochrane Database Syst Rev 11(5):CD008607,
2011.
Goudakos JK etal: Corticosteroids in the treatment of vestibular neuritis: a systematic review and meta-analysis, Otol Neurotol 31(2):183-189, 2010.
Karlberg ML, Magnusson M: Treatment of acute vestibular neuronitis with glucocorticoids, Otol Neurotol 32(7):1140-1143, 2011.
Strupp M etal: Methylprednisolone, valacyclovir or the combination for vestibular
neuritis, N Engl J Med 351(4):354-361, 2004.

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