What are the neuro-otological emergencies?

From the Guidelines

Neuro-otological emergencies, such as acute vestibular syndrome, sudden sensorineural hearing loss, acute facial paralysis, and temporal bone trauma, require prompt recognition and management to prevent permanent neurological damage or death. These conditions can be life-threatening and have a significant impact on morbidity, mortality, and quality of life if not addressed quickly.

Key Conditions

• Acute vestibular syndrome, which includes vestibular neuritis and stroke, requires distinguishing between peripheral and central causes, with the HINTS exam (Head-Impulse, Nystagmus, Test-of-Skew) being a crucial diagnostic tool 1.
• Sudden sensorineural hearing loss necessitates immediate oral prednisone 60mg daily for 7-14 days, with intratympanic steroid injections considered for those who fail oral therapy or have contraindications 1.
• Acute facial paralysis, or Bell's palsy, is treated with prednisone 60mg daily for 5 days with a 5-day taper, antiviral therapy with valacyclovir 1000mg three times daily for 7 days if seen within 72 hours of onset, and eye protection measures 1.
• Temporal bone fractures require immediate evaluation for CSF leakage, facial nerve injury, and vascular complications 1.

Diagnostic Approach

• A thorough history and physical examination are essential in evaluating patients with suspected neuro-otological emergencies, including a detailed assessment of vertigo, hearing loss, and facial weakness 1.
• The HINTS exam can help identify strokes with greater sensitivity than early MRI, and other diagnostic tools, such as CT scans and MRI, may be necessary to rule out other causes of vertigo and hearing loss 1.

Treatment and Management

• Early specialist consultation with otolaryngology and neurology is crucial in managing neuro-otological emergencies, and patients should be advised to seek immediate medical attention for any sudden onset of vertigo, hearing loss, or facial weakness 1.
• Treatment for vestibular neuritis includes methylprednisolone 100mg daily for 3 days followed by a taper, vestibular suppressants like meclizine 25mg every 6 hours as needed, and early vestibular rehabilitation 1.
• Patients with neuro-otological emergencies should be closely monitored and managed to prevent complications and improve outcomes, with a focus on reducing morbidity, mortality, and improving quality of life 1.

From the Research

Neuro-otological Emergencies

• Neuro-otological emergencies, such as acute vertigo, can be a diagnostic challenge for physicians 2
• The clinical presentation of acute central and peripheral dizzy syndromes can be similar, making it difficult to determine the underlying cause 2
• Recent evidence suggests that early steroid treatment in vestibular neuritis may improve long-term outcome, but further trials are needed before routine use can be recommended 2

Diagnosis and Treatment

• A thorough clinical evaluation of the acutely dizzy patient is essential to identify serious conditions such as stroke, which may masquerade as a peripheral labyrinthine disorder 2
• Directed history taking and physical examination are critical components in the diagnostic assessment of patients with vestibular symptoms 3
• Categorizing vestibular symptoms by timing and triggers can help focus the clinician's attention on key syndromic patterns and narrow the differential diagnosis 3
• A practical algorithm can be used to manage vestibular disorders in the acute care setting, based on the speed of onset, duration, and history of similar episodes 4

Management of Vestibular Symptoms

• Vestibular symptoms, including vertigo, dizziness, and gait unsteadiness, are a frequent reason for urgent medical assistance 4
• The causes of vestibular symptoms are numerous and diverse, including neurological, otorhinolaryngological, and systemic diseases 4
• Ondansetron and promethazine are two treatment options for acute peripheral vertigo, with promethazine being more effective in reducing vertigo and ondansetron being more beneficial for improving nausea and vomiting 5
• Access to otologic and neurotologic care during and after the COVID-19 pandemic is dependent on adequate protection of physicians, audiologists, and ancillary support staff 6

Otologic and Neurotologic Care

• Many otologic and neurotologic conditions are not imminently life-threatening but have a major impact on communication, daily functioning, and quality of life 6
• Delay in treatment can result in cranial nerve deficits, intracranial and life-threatening complications, and/or irreversible consequences, making timely attention essential for optimal outcomes 6
• Physicians should proceed with otologic and neurotologic clinic visits and operative cases based on input from expert opinion, clinic/hospital administration, infection prevention and control specialists, and local and state public health leaders 6