What is the treatment for viral labyrinthitis?

Treatment of Viral Labyrinthitis

Viral labyrinthitis should be treated with short-term vestibular suppressants during the acute phase, followed by vestibular rehabilitation exercises once acute symptoms subside, while avoiding antibiotics and antiviral medications which have no proven benefit. 1

Acute Phase Management (First 12-36 Hours)

Vestibular Suppressants

• Administer vestibular suppressants only during acute vertigo attacks for short-term symptom control 1
• Antihistamines (meclizine, dimenhidrinato) are first-line options for acute rotational vertigo 1
• Benzodiazepines may be used cautiously for severe symptoms to address both vertigo and associated anxiety, but only briefly due to dependency risk 1
• Discontinue vestibular suppressants after 3-5 days as prolonged use delays central vestibular compensation 2

Supportive Care

• Provide generalized supportive care including hydration and antiemetics for nausea/vomiting 3
• Ensure patient safety during the acute phase when severe vertigo is present 2

What NOT to Do

Avoid Antibiotics

• Do not prescribe antibiotics for typical viral labyrinthitis as most cases are self-limited and antibiotics are ineffective against viral pathogens 1

Avoid Antiviral Therapy

• Do not routinely prescribe antiviral agents (aciclovir, valacyclovir) for viral labyrinthitis 4
• Multiple randomized controlled trials have failed to demonstrate benefit when antivirals are added to standard therapy 4, 5
• A prospective, randomized, double-blind trial of aciclovir combined with prednisolone showed no beneficial effect on hearing recovery in sudden sensorineural hearing loss compared to prednisolone alone 5
• Antivirals carry potential side effects including nausea, vomiting, photosensitivity, and rarely reversible neurologic reactions 4

Avoid Vestibular Rehabilitation During Acute Phase

• Do not initiate vestibular rehabilitation during acute vertigo attacks as it is ineffective and poorly tolerated 1

Recovery Phase Management (After 1-3 Weeks)

Vestibular Rehabilitation

• Offer self-administered or clinician-guided vestibular rehabilitation for chronic imbalance following the acute phase 1
• Most patients experience significant improvement of acute vertigo symptoms within 1-3 weeks, at which point rehabilitation should begin 1
• Vestibular exercises promote central compensation and reduce fall risk 1

Lifestyle Modifications

• Identify and manage potential triggers including stress, caffeine, and alcohol consumption 1
• Provide patient education about the natural course and potential for recovery 1

Clinical Pearls and Monitoring

Expected Timeline

• Acute severe rotational vertigo typically lasts 12-36 hours with decreasing disequilibrium over the next 4-5 days 1
• Unlike Ménière's disease or BPPV, labyrinthitis typically presents as a single event rather than recurring episodes 1
• If vertigo persists beyond 3-4 weeks, further evaluation is warranted to rule out other conditions 1

Red Flags Requiring Further Evaluation

• Any new or worsening neurological symptoms should prompt immediate attention to rule out central causes (stroke, multiple sclerosis) 1
• Presence of severe headache, diplopia, dysarthria, or ataxia suggests central rather than peripheral pathology 2

Prognostic Factors

• Advanced age may delay central vestibular compensation 1
• Presence of comorbidities affecting balance may prolong recovery 1

Corticosteroid Controversy

While corticosteroids are sometimes used in clinical practice for labyrinthitis, the evidence base is primarily from sudden sensorineural hearing loss studies rather than labyrinthitis specifically 4. The guidelines reviewed do not make a strong recommendation for routine corticosteroid use in viral labyrinthitis, distinguishing it from conditions like vestibular neuritis where steroids may have a role 3.