Management of Vestibular Neuritis
For acute vestibular neuritis, initiate oral corticosteroids within 3 days of symptom onset in otherwise healthy patients, provide short-term vestibular suppressants (3 days maximum), and begin early vestibular rehabilitation therapy as soon as the acute phase subsides.
Acute Phase Management (First 72 Hours)
Corticosteroid Therapy
- Oral corticosteroids should be started within 3 days of symptom onset in patients without contraindications, as they accelerate recovery of vestibular function and promote better long-term vestibular compensation 1, 2.
- Withhold steroids in patients at higher risk for complications (uncontrolled diabetes, severe hypertension, immunocompromised states) 1.
- The evidence shows long-term beneficial effects for vestibular function recovery when corticosteroids are used in the acute phase 2.
Symptomatic Medication Management
- Vestibular suppressants (such as meclizine) and antiemetics should be used only during the first 3 days and then discontinued, as prolonged use impedes central vestibular compensation 1, 3.
- Meclizine is FDA-approved for vertigo associated with vestibular system diseases at doses of 25-100 mg daily in divided doses 4.
- Antiemetics like prochlorperazine may be used for severe nausea and vomiting during the acute phase only 5.
- Critical pitfall: Continuing vestibular suppressants beyond the acute phase delays recovery by interfering with the brain's natural compensation mechanisms 6, 1.
Supportive Care
- Provide generalized supportive care including hydration and rest during the first 24-48 hours 7.
- Patients should avoid alcohol while taking vestibular suppressants due to increased CNS depression 4.
Early Mobilization Phase (Days 3-7)
Discontinuation of Suppressants
- Withdraw vestibular suppressants after the first several days to allow central compensation to begin 1, 3.
- If meclizine worsens symptoms or causes excessive drowsiness, discontinue immediately 6.
Activity Resumption
- Encourage early resumption of normal physical activity as soon as tolerable to promote vestibular compensation 1, 8.
- Physical activity is more beneficial than extended rehabilitation sessions for long-term symptomatic improvement 8.
- Begin simple visual fixation exercises even while bed-ridden to accelerate recovery 2.
Vestibular Rehabilitation Phase (Week 1 Onward)
Initiation Timing
- Start directed vestibular rehabilitation therapy within the first week after acute symptoms subside 1, 7.
- Do not delay rehabilitation with prolonged waiting periods, as this does not improve outcomes 8.
Rehabilitation Components
- Implement both generalized vestibular exercises and customized vestibular exercises based on specific deficits 7.
- Include vestibulo-ocular reflex (VOR) rehabilitation exercises 8.
- Include vestibulo-spinal function exercises, as VOR rehabilitation alone is insufficient 8.
- Most patients undergo spontaneous compensation, but directed therapy accelerates this process 1, 2.
Diagnostic Confirmation Requirements
Essential Clinical Features
- Abrupt onset of true whirling vertigo lasting more than 24 hours 7.
- Absence of cochlear symptoms (hearing loss, tinnitus) 7.
- Absence of other neurological symptoms or signs 7.
- Spontaneous horizontal-torsional nystagmus beating away from the lesion side 3.
Red Flags Requiring Brain Imaging
- Obtain urgent brain imaging if the patient has: unprecedented severe headache, negative head impulse test (suggesting central pathology), severe unsteadiness disproportionate to nystagmus, or no recovery within 1-2 days 3.
- Patients with significant vascular risk factors should be evaluated for possible stroke, as 10% of cerebellar strokes can present similarly to vestibular neuritis 9.
- Central signs include: downbeating nystagmus, direction-changing nystagmus without head position changes, gaze-evoked nystagmus, dysarthria, dysmetria, dysphagia, or sensory/motor deficits 9.
Prognostic Factors
Favorable Outcomes
- Most patients recover well even without treatment, though steroids accelerate recovery 1.
- Higher levels of daily physical activity correlate with better long-term symptomatic outcomes 8.
Poor Prognostic Indicators
- Absent cervical vestibular evoked myogenic potentials (cVEMP) indicate worse prognosis for vestibulo-ocular compensation 8.
- Inferior vestibular neuritis (rare subtype) may be misdiagnosed as central disorder due to atypical presentation 3.
Follow-Up Strategy
Reassessment Timing
- Evaluate patients within 1-2 days if no improvement occurs 3.
- Patients with persistent instability, excessive anxiety, or those requesting additional support are candidates for formal vestibular rehabilitation programs 2.