What is the role of steroids, such as prednisone, in treating vertigo associated with inflammatory conditions?

Role of Steroids in Treating Vertigo Associated with Inflammatory Conditions

Intratympanic steroids are recommended for patients with active Ménière's disease not responsive to noninvasive treatments, while oral steroids have limited evidence supporting their use for vertigo control in inflammatory conditions. 1

Intratympanic Steroids for Ménière's Disease

Efficacy and Mechanism

• Intratympanic (IT) steroid therapy stabilizes the vascular endothelium and improves cochlear blood flow through anti-inflammatory effects, as well as effects on cochlear ion and fluid homeostasis 1
• IT steroid therapy shows greater improvement in vertigo symptoms (85%-90%) compared to placebo or conventional medical therapy (57%-80%) 1
• IT steroids appear to have significantly less risk of treatment-associated hearing loss (0-8%) compared to IT gentamicin therapy (12.5-15.4%) 1

Dosing Recommendations

• Dexamethasone sodium phosphate: 4-24 mg/mL, inject 0.4-0.8 mL into middle ear space 1
• Methylprednisolone sodium succinate: 30-62.5 mg/mL, inject 0.4-0.8 mL into middle ear space 1
• Treatment frequency: From once only up to 3-4 sessions every 3-7 days depending on clinical response 1

Oral Steroids for Vertigo

Limited Evidence for Ménière's Disease

• Oral steroids showed overall improvement in vertigo in one small pilot study, while another cited no hearing improvement 1
• A small randomized controlled trial found that oral prednisone (0.35 mg/kg daily) reduced frequency and duration of vertigo episodes by 50% and 30%, respectively, in patients with refractory Ménière's disease 2
• Current clinical practice guidelines do not strongly recommend oral steroids as first-line therapy for Ménière's disease 3

Evidence for Vestibular Neuritis

• A Cochrane review found insufficient evidence to support the administration of corticosteroids to patients with idiopathic acute vestibular dysfunction (vestibular neuritis) 4
• However, a small double-blind, prospective, placebo-controlled study found methylprednisolone to be more effective than placebo in reducing vertiginous symptoms in patients with acute vestibular vertigo 5

Treatment Algorithm for Vertigo in Inflammatory Conditions

First-Line Approach

• For acute vertigo attacks in Ménière's disease, offer a limited course of vestibular suppressants 1, 3
• Consider underlying diagnosis - rule out vestibular migraine, benign paroxysmal positional vertigo, and other causes of vertigo 1

For Refractory Cases

• Consider IT steroid therapy for patients with active Ménière's disease not responsive to noninvasive treatment 1, 3
• Dexamethasone or methylprednisolone can be administered intratympanically according to dosing guidelines 1
• For severe cases not responding to IT steroids, consider IT gentamicin as the next step 1

Special Considerations

• IT steroid therapy may have a role in salvaging hearing secondary to a Ménière's disease flare 1
• Combining IT steroid therapy with oral betahistine may improve vertigo control (73% vs 44% with IT steroids alone) 1
• For patients with diabetes who cannot tolerate systemic corticosteroids, IT steroids may be a viable alternative 1

Cautions and Limitations

• Most evidence for steroid use in vertigo comes from small studies with methodological limitations 4
• Adverse effects of oral steroids include elevated blood sugar, increased thirst, and sleep or appetite changes 1
• Adverse effects of IT steroids include transient pain at the injection site and brief caloric vertigo 1
• Long-term efficacy of steroid therapy for vertigo control remains uncertain 1, 4