How is vestibular neuritis managed?

Management of Vestibular Neuritis

Vestibular neuritis should be managed with a combination of early corticosteroid therapy and vestibular rehabilitation exercises, with vestibular suppressants used only for short-term symptomatic relief during the acute phase. This approach optimizes recovery of vestibular function while promoting central compensation.

Diagnostic Approach

When evaluating a patient with suspected vestibular neuritis, focus on these key features:

• Acute onset of rotatory vertigo lasting several days
• Horizontal spontaneous nystagmus toward the unaffected ear
• Positive head-impulse test toward the affected ear
• Normal hearing (distinguishes from labyrinthitis)
• Absence of neurological symptoms (distinguishes from central causes)

The HINTS examination (Head-Impulse, Nystagmus, Test of Skew) is essential to rule out central causes, as it is more sensitive than early MRI for detecting stroke when performed correctly 1.

Treatment Algorithm

Acute Phase (First 3-7 Days)

1. Corticosteroids

   • Start oral prednisolone within first 3 days of symptom onset
   • Typical regimen: 10-day course of prednisolone 2
   • Evidence shows corticosteroids accelerate recovery of vestibular function 3

2. Vestibular Suppressants

   • Use only for short-term symptomatic relief (first few days)
   • Options include meclizine (FDA-approved for vertigo associated with vestibular system diseases) 4
   • Important: Discontinue as soon as possible (preferably after first several days) as prolonged use may impede central vestibular compensation 5

3. Antiemetics

   • Prokinetic antiemetics (e.g., metoclopramide) can manage nausea without significantly interfering with vestibular compensation 1

Recovery Phase (Beyond First Week)

1. Vestibular Rehabilitation Therapy (VRT)

   • Begin as early as possible after diagnosis
   • Individualized, supervised exercise therapy with home exercise program
   • Significantly reduces perception of dizziness and improves daily function compared to standard care alone 2
   • Promotes central vestibular compensation

2. Physical Activity

   • Encourage early resumption of normal activity to promote compensation
   • Regular physical activity improves symptomatic outcomes over the long term 6

Evidence for Treatment Efficacy

Recent evidence shows complementary benefits of different treatment approaches:

• Corticosteroids enhance earlier objective improvement in canal paresis 7
• Vestibular rehabilitation provides earlier subjective improvement in dizziness handicap 7
• A 2020 randomized controlled trial demonstrated that vestibular rehabilitation started early after diagnosis, combined with standard care (including corticosteroids), reduces dizziness perception and improves daily function more effectively than standard care alone at both 3 and 12 months 2

Monitoring and Follow-up

• Reassess at 1 month to evaluate recovery
• If symptoms persist, consider:
  1. Re-evaluation for alternative diagnoses
  2. Intensification of vestibular rehabilitation
  3. Assessment for complications or comorbidities

Important Considerations

• Avoid prolonged use of vestibular suppressants as they delay central compensation
• Rule out stroke in patients with vascular risk factors, as central vertigo can mimic vestibular neuritis
• Patient education about expected recovery timeline and importance of compliance with vestibular exercises is crucial
• Fall prevention strategies should be discussed, particularly with elderly patients

Prognosis

Most patients recover well from vestibular neuritis, though complete peripheral vestibular function recovery occurs in only about 62% of patients within 12 months 3. Recovery depends on a combination of peripheral restoration of labyrinthine function, sensory substitution, and central compensation. Early intervention with both corticosteroids and vestibular rehabilitation optimizes outcomes.