What is the initial treatment for a patient presenting with vestibular neuritis?

Management of Vestibular Neuritis: Presentation and Treatment

For patients presenting with vestibular neuritis, the initial treatment should include a short course of oral corticosteroids combined with vestibular rehabilitation therapy, while vestibular suppressant medications should be limited to the first few days of symptoms only. 1, 2

Clinical Presentation

Vestibular neuritis typically presents with:

• Prolonged continuous vertigo (hours to days)
• Nausea and vomiting
• Imbalance with falling tendency toward the lesion side
• Spontaneous horizontal-torsional nystagmus beating away from the affected side
• Abnormal head impulse test for the involved semicircular canals
• Ipsilesional caloric paresis
• No auditory symptoms (distinguishing it from labyrinthitis)
• No central neurological signs

Initial Assessment

• Rule out central causes (stroke, hemorrhage) especially in patients with vascular risk factors
• Look for diagnostic hallmarks:
  • Spontaneous horizontal-torsional nystagmus
  • Positive head impulse test
  • Normal hearing
  • No other neurological deficits

Treatment Algorithm

Immediate Management (0-3 days)

1. Corticosteroids:

   • Start within 3 days of symptom onset 1
   • Oral prednisone or methylprednisolone
   • Studies show accelerated recovery of vestibular function with early steroid administration 2

2. Symptomatic relief (first few days only):

   • Vestibular suppressants for severe symptoms:
     • Meclizine 25-100 mg daily in divided doses 3
     • Benzodiazepines for severe distress (use lowest effective dose, especially in elderly) 4
   • Antiemetics for nausea/vomiting
   • Important: Discontinue vestibular suppressants after 2-3 days to avoid impeding central compensation 1

Short-term Management (Days 3-14)

1. Vestibular Rehabilitation Therapy (VRT):

   • Begin as soon as acute vertigo begins to subside
   • Includes adaptation exercises, habituation exercises, and balance training 5
   • Significantly improves dizziness and balance ability 5
   • Promotes central vestibular compensation 1

2. Discontinue vestibular suppressants:

   • Prolonged use impedes central compensation 1
   • The American Academy of Otolaryngology-Head and Neck Surgery recommends against routine use of vestibular suppressant medications 6, 4

Long-term Management (Beyond 2 weeks)

1. Continue Vestibular Rehabilitation:

   • Home-based exercises
   • Consider formal therapy if symptoms persist
   • Studies show VRT is equally effective as corticosteroids for long-term outcomes 7, 2

2. Patient Education:

   • Encourage early resumption of normal activities to promote compensation 1
   • Maintain a symptom journal to track triggers and patterns 4
   • Implement fall prevention strategies 4

Evidence on Treatment Efficacy

• Corticosteroids: Accelerate early recovery of vestibular function but may not significantly affect long-term outcomes 7, 2
• Vestibular Rehabilitation: Improves subjective symptoms (DHI scores) earlier than corticosteroids alone 2
• Combination Therapy: Provides better early recovery than either treatment alone 2
• Long-term Outcomes: No significant difference between treatment approaches after 12 months 7, 2

Common Pitfalls and Caveats

1. Misdiagnosis: Don't miss central causes of vertigo (stroke, hemorrhage)

   • Consider brain imaging when patient has:
     • Unprecedented headache
     • Negative head impulse test
     • Severe unsteadiness
     • No recovery within 1-2 days 8

2. Prolonged medication use: Avoid extended use of vestibular suppressants as they delay central compensation 1

3. Delayed rehabilitation: Early initiation of vestibular exercises promotes faster recovery 5

4. Inferior vestibular neuritis: This rare subtype may be misdiagnosed as a central disorder due to atypical presentation 8

5. Steroid contraindications: Consider patient-specific factors before prescribing corticosteroids (diabetes, hypertension, etc.)

By following this evidence-based approach, most patients with vestibular neuritis will experience significant improvement in symptoms and balance function.