Is there a role for steroids in the treatment of vestibular neuritis?

Role of Steroids in Vestibular Neuritis

Corticosteroids should be offered to patients with acute vestibular neuritis who present within 24-72 hours of symptom onset, as they provide statistically significant short-term benefit in vestibular function recovery, though long-term benefits remain uncertain. 1, 2

Evidence Supporting Steroid Use

Short-Term Benefits

• Oral corticosteroids accelerate recovery of vestibular function in the acute phase with an odds ratio of 3.1 (95% CI 1.2-7.8) for good outcome, translating to a number needed to treat (NNT) of 6. 1
• Restoration of vestibular function at follow-up shows an OR of 2.4 (95% CI 1.3-4.4) favoring steroid treatment with NNT of 7. 1
• Timing matters critically: 100% of patients treated within 24 hours achieved normal caloric test results at 3 months, compared to only 58% of those treated between 25-72 hours (p < 0.05). 2

Long-Term Outcomes

• At 12 months, no statistically significant difference exists between corticosteroid treatment, vestibular rehabilitation therapy (VRT), or combination therapy in terms of caloric lateralization, vestibular myogenic potential amplitude, or Dizziness Handicap Inventory scores. 3
• Corticosteroids show significantly better caloric recovery at 1 month (95% CI -16.33 to -0.32), but this advantage disappears by 12 months. 4
• Subjective recovery does not differ between steroid and control groups at any time point. 4

Treatment Algorithm

Patient Selection Criteria

• Treat if: Patient presents within 3 days (ideally within 24 hours) of symptom onset AND is otherwise healthy without significant vascular risk factors. 5, 2
• Withhold if: Patient has significant cardiovascular risk factors requiring stroke evaluation, presents >72 hours after onset, or has contraindications to corticosteroids. 5

Dosing Regimen

• Oral prednisolone 50 mg daily for 5 days, then taper over the next 5 days. 2
• For patients with severe nausea/vomiting: Consider initial intravenous betamethasone 8 mg for 1-2 days, then transition to oral prednisolone. 2

Adjunctive Management

• Antiemetics and vestibular suppressants should be used only for the first several days, as prolonged use impedes central vestibular compensation. 5
• Early resumption of normal activity must be encouraged to promote compensation, regardless of steroid use. 5
• Directed vestibular rehabilitation therapy can be offered as an alternative or adjunct, with equivalent long-term efficacy to steroids. 3

Important Caveats and Pitfalls

Risk-Benefit Considerations

• The number needed to harm (NNH) is 4 (95% CI 3-19), with adverse effects occurring significantly more often in steroid-treated patients (OR 10.9,95% CI 1.3-93.8). 1
• Most patients recover well from vestibular neuritis even without treatment, making the absolute benefit modest. 5

Critical Diagnostic Exclusion

• Any patient with significant vascular risk factors thought to have vestibular neuritis must be evaluated for possible brainstem or cerebellar stroke, as definitive central signs are not always present and missing this diagnosis could be life-threatening. 5

Evidence Quality Limitations

• Eight of 15 studies in the most recent meta-analysis were judged at high risk of bias, with broad heterogeneity and low-grade quality limiting confidence in the findings. 1
• The evidence supports only "careful judgement of some benefit" rather than definitive superiority. 1

Practical Approach

• For patients presenting within 24 hours: Strong consideration for steroid treatment given 100% normalization rate. 2
• For patients presenting 25-72 hours: Reasonable to offer steroids but counsel that benefit is less certain. 2
• For patients presenting >72 hours: Steroids unlikely to provide benefit; focus on vestibular rehabilitation. 5