What are the treatment steps for labyrinthitis?

Treatment of Labyrinthitis

The treatment of labyrinthitis should follow a stepwise approach, beginning with supportive care and symptom management, followed by targeted pharmacological therapy based on the underlying cause, with surgical interventions reserved for severe cases that fail to respond to medical management.

Initial Assessment and Supportive Care

• Identify the underlying cause: Distinguish between viral, bacterial, or autoimmune labyrinthitis as this determines treatment approach
• Symptom management:
  • Bed rest during acute vertigo episodes
  • Adequate hydration
  • Avoidance of sudden head movements
  • Gradual mobilization as symptoms permit

Pharmacological Management

Vestibular Suppressants (for acute vertigo)

• First-line: Antihistamines (e.g., meclizine 25mg every 4-6 hours as needed)
• Alternative options:
  • Benzodiazepines (e.g., diazepam 2-5mg every 6-8 hours)
  • Anticholinergics (e.g., scopolamine transdermal patch)

Anti-inflammatory Therapy

• For viral labyrinthitis:
  • Short course of oral corticosteroids (e.g., prednisone 60mg daily with taper over 10-14 days)
  • Consider combined treatment with ampicillin and prednisone for better hearing preservation 1

Antimicrobial Therapy

• For bacterial labyrinthitis:
  • Broad-spectrum IV antibiotics (e.g., third-generation cephalosporins plus vancomycin)
  • Duration: 2-4 weeks depending on clinical response
  • Prompt antibiotic treatment is crucial as suppurative labyrinthitis can lead to significant hearing impairment 2

Anti-emetics

• For nausea and vomiting: ondansetron 4-8mg every 8 hours as needed

Vestibular Rehabilitation

• Should be initiated once acute symptoms begin to resolve
• Includes:
  • Gaze stabilization exercises
  • Balance retraining
  • Habituation exercises
  • Graduated activity program

Monitoring and Follow-up

• Regular audiometric testing to monitor hearing function
• MRI may be helpful to identify inflammatory changes in the membranous labyrinth 3
• Follow-up visits at 2 weeks, 1 month, and 3 months to assess recovery

Advanced Interventions for Refractory Cases

Intratympanic Gentamicin

• For persistent vertigo unresponsive to medical therapy
• Caution: Risk of hearing loss; should be used only in patients with non-functional hearing or when vertigo severely impacts quality of life 4
• Success rate for relieving vertigo is high, but hearing preservation is variable

Surgical Options

• Labyrinthectomy:
  • Reserved for patients with:
    • Unilateral disease
    • Non-usable hearing (PTA >60 dB and speech discrimination <50%)
    • Failed less invasive therapies
  • Success rate for vertigo control is approximately 95% 4
  • Contraindicated in bilateral disease or vestibular hypofunction in the contralateral ear

Prognosis and Expectations

• Patients should be counseled that:
  • Complete recovery may take weeks to months
  • Approximately 72.5% of patients may experience persistent balance problems 5
  • Only about 20% achieve subjective hearing recovery 5
  • Risk factors for poor prognosis include advanced age, severe initial symptoms, and delayed treatment

Important Considerations

• Bacterial labyrinthitis is often associated with other complications including meningitis (21%), facial paralysis (21%), and mastoiditis (21%) 2
• Early diagnosis and treatment are essential to prevent permanent hearing loss
• MRI plays an important role in definitive diagnosis during the acute phase 2

The treatment approach should be adjusted based on the severity of symptoms, underlying cause, and patient response to initial therapy. Close monitoring is essential as labyrinthitis can lead to significant long-term hearing and balance impairment if not properly managed.