In labyrinthitis, does the vertiginous (vertigo) attack always occur at the beginning of the condition or can it occur later?

Timing of Vertigo in Labyrinthitis

In labyrinthitis, the vertiginous attack typically presents as an initial symptom, but it can also occur later in the course of the disease after other symptoms like tinnitus and hearing loss have already developed, as demonstrated in your patient's case. 1

Clinical Presentation of Labyrinthitis

• Labyrinthitis is characterized by sudden severe vertigo with profound hearing loss and prolonged vertigo (lasting >24 hours), distinguishing it from other vestibular disorders 1
• The vertigo in labyrinthitis is typically accompanied by nausea and hearing loss, and is not episodic or fluctuating like in Ménière's disease 1
• Severe rotational vertigo in vestibular neuritis (a related condition) typically lasts 12 to 36 hours with decreasing disequilibrium for the next 4 to 5 days 1

Sequence of Symptoms in Labyrinthitis

• While vertigo often occurs as the initial presenting symptom in labyrinthitis, the sequence can vary, with some patients experiencing auditory symptoms first 2
• In your patient's case with tinnitus and decreased hearing for a week followed by a 12-hour vertigo episode, this presentation is consistent with labyrinthitis, as inflammation can progress through different parts of the labyrinth at different rates 2
• A retrospective study of patients with idiopathic labyrinthitis found that all patients had vestibular weakness at presentation, but the timing of symptom onset varied among patients 2

Distinguishing Features from Other Vestibular Disorders

• Unlike Benign Paroxysmal Positional Vertigo (BPPV), which causes positional vertigo lasting less than a minute, labyrinthitis causes prolonged vertigo not primarily triggered by position changes 1
• Unlike Ménière's disease, which presents with episodic vertigo attacks and fluctuating hearing loss, labyrinthitis typically causes a single prolonged vertigo attack with more persistent hearing loss 1
• Unlike vestibular neuritis, which affects only the vestibular portion of the inner ear (causing vertigo without hearing loss), labyrinthitis affects both the vestibular and cochlear portions, resulting in both vertigo and hearing symptoms 1, 3

Prognosis and Long-term Outcomes

• Labyrinthitis has a relatively poor prognosis for both hearing and balance function recovery 2
• After a median follow-up of 61 months, 72.5% of patients still experienced balance problems, and subjective hearing recovery occurred in only 20% of cases 2
• Acute labyrinthitis should be considered when sudden onset vertigo and/or imbalance presents in patients outside of the perioperative period of ear surgeries 4

Red Flags Requiring Immediate Medical Attention

• Vertigo accompanied by speech difficulties, dysphagia, visual disturbances, or motor/sensory deficits requires urgent evaluation for possible central causes 5
• Severe imbalance disproportionate to the vertigo or symptoms lasting more than 24 hours without improvement are red flags requiring immediate attention 5
• New-onset severe headache, particularly occipital headache with vertigo, is a red flag for central vertigo 5

In summary, while vertigo is a hallmark symptom of labyrinthitis, its timing can vary in relation to other symptoms. The presentation of tinnitus and hearing loss followed by a vertigo attack is consistent with the diagnosis of labyrinthitis, as the inflammatory process can affect different parts of the inner ear at different times.