What is the treatment for labyrinthitis?

Treatment of Labyrinthitis

The treatment of labyrinthitis should focus on symptom management with vestibular suppressants, antiemetics, and corticosteroids in cases with associated hearing loss, while antibiotics are reserved only for confirmed bacterial labyrinthitis.

Diagnosis and Classification

Before initiating treatment, it's essential to properly diagnose labyrinthitis, which is characterized by:

• Sudden onset of vertigo
• Hearing loss (sensorineural)
• Tinnitus
• Nausea and vomiting
• Balance problems

Labyrinthitis can be classified as:

1. Viral labyrinthitis - Most common form
2. Bacterial labyrinthitis - Rare, often a complication of otitis media or meningitis
3. Idiopathic labyrinthitis - Unknown cause

Treatment Algorithm

First-Line Treatment for Viral/Idiopathic Labyrinthitis

1. Vestibular suppressants for acute vertigo management:

   • Meclizine 25-50 mg every 4-6 hours as needed
   • Diazepam 2-5 mg every 6-8 hours as needed (short-term use only)

2. Antiemetics for nausea and vomiting:

   • Ondansetron 4-8 mg every 8 hours as needed
   • Promethazine 12.5-25 mg every 6 hours as needed

3. Corticosteroids for cases with sudden sensorineural hearing loss:

   • Prednisone 1 mg/kg/day (maximum 60 mg daily) for 10-14 days, followed by a taper over a similar period 1
   • Initiate within 14 days of symptom onset for optimal outcomes

4. Vestibular rehabilitation once acute symptoms begin to subside

Treatment for Bacterial Labyrinthitis

1. Intravenous antibiotics based on culture and sensitivity:

   • For Pseudomonas (common pathogen): Ceftazidime plus an aminoglycoside 2
   • Duration: 2-4 weeks of IV therapy followed by oral antibiotics

2. Corticosteroids to reduce inflammation:

   • IV methylprednisolone 1-2 mg/kg/day initially, then oral prednisone taper

3. Surgical intervention may be necessary if:

   • Mastoiditis is present
   • Temporal bone fracture with CSF leak
   • Cholesteatoma with labyrinthine fistula

Special Considerations

Monitoring and Follow-up

• Audiometric testing should be performed initially and at regular intervals to monitor hearing
• MRI may be indicated to rule out retrocochlear pathology and assess labyrinthine enhancement 2
• Follow-up vestibular testing to assess recovery of function

Prognosis and Expectations

• Viral labyrinthitis: Vertigo typically improves within 1-3 weeks, but residual imbalance may persist
• Bacterial labyrinthitis: Higher risk of permanent hearing loss and vestibular dysfunction
• Idiopathic labyrinthitis: Poor prognosis with 72.5% of patients experiencing persistent balance problems and only 20% achieving subjective hearing recovery 3

Prevention of Complications

• Monitor for development of labyrinthitis ossificans (pathological ossification of the labyrinth) 4
• Early cochlear implantation may be considered if profound hearing loss develops, before ossification occurs

Common Pitfalls to Avoid

1. Inappropriate antibiotic use: Antibiotics should not be routinely prescribed for presumed viral labyrinthitis 5

2. Delayed corticosteroid treatment: For cases with sudden hearing loss, corticosteroids should be initiated promptly (within 14 days of symptom onset) 1

3. Prolonged vestibular suppressant use: These medications should be used short-term only, as they may delay central vestibular compensation

4. Inadequate follow-up: Regular audiometric and vestibular testing is essential to monitor recovery and detect complications

By following this treatment approach, clinicians can effectively manage labyrinthitis while minimizing complications and optimizing outcomes for patients with this distressing condition.