Initial Treatment for Labyrinthitis
For acute labyrinthitis, initiate short-term vestibular suppressants (antihistamines or benzodiazepines) for symptom control during the acute phase, followed by early vestibular rehabilitation once severe vertigo subsides. 1, 2
Acute Phase Management (First 12-72 Hours)
Pharmacological Treatment
Vestibular suppressants should be prescribed for short-term use only during the acute vertigo attack, typically limiting use to the first several days 1, 2, 3
Antihistamines (such as meclizine) are first-line agents to reduce vertigo severity 1
Benzodiazepines may be used cautiously for severe symptoms when antihistamines are insufficient, providing relief of both vertigo and associated anxiety, but prescribe with awareness of dependency risk 1, 2
Antiemetics are useful acutely for nausea and vomiting but should be withdrawn as soon as possible, as prolonged use impedes central vestibular compensation 3
Critical Pitfall: Duration of Suppressant Use
Vestibular suppressants must be discontinued after the first several days (preferably within 3-5 days) because prolonged use delays the brain's natural compensation process and worsens long-term outcomes 3, 2. The acute severe rotational vertigo typically lasts 12-36 hours with decreasing disequilibrium over the next 4-5 days 2.
What NOT to Prescribe
Do not routinely prescribe antibiotics for typical viral labyrinthitis, as most cases are self-limited and antibiotics are ineffective against viral pathogens 2
Do not prescribe antiviral agents (aciclovir or valacyclovir) routinely, as multiple randomized controlled trials have failed to demonstrate benefit, and these carry potential side effects including nausea, vomiting, and photosensitivity 2
Note: Bacterial labyrinthitis (such as from Pseudomonas complicating acute otitis media) is exceptional and requires targeted antibiotic therapy based on culture results, but this represents a different clinical entity 4
Corticosteroids: Consider in Select Cases
While the evidence provided focuses primarily on sudden sensorineural hearing loss rather than labyrinthitis specifically, oral corticosteroids may be considered in otherwise healthy individuals presenting within 3 days of onset, as studies suggest they may accelerate recovery of vestibular function 3. However, withhold steroids from patients at higher risk of complications (diabetes, immunosuppression, psychiatric disorders) 3.
Subacute Phase (Days 4-21)
Vestibular Rehabilitation
Early resumption of normal activity should be encouraged immediately after the acute phase to promote central compensation 3
Self-administered or clinician-guided vestibular rehabilitation should be offered for chronic imbalance following the acute phase 1, 2
Do NOT perform vestibular rehabilitation during acute vertigo attacks as it is contraindicated when severe vertigo is present 2
Lifestyle Modifications and Patient Education
Identify and manage potential triggers including stress, caffeine, and alcohol consumption 1, 2
Provide patient education about the condition's natural course (most patients improve significantly within 1-3 weeks), potential for persistent symptoms (72.5% still experience balance problems at long-term follow-up), and poor prognosis for hearing recovery (only 20% subjective recovery) 2, 5
If labyrinthitis progresses to or is related to Ménière's disease, recommend sodium restriction (1500-2300 mg daily) 1
Follow-Up Protocol
Reassess within 1 month after initial treatment to document resolution or persistence of symptoms 1
If vertigo persists beyond 3-4 weeks, further evaluation is warranted to rule out other vestibular disorders or central causes 2
Any new or worsening neurological symptoms should prompt immediate evaluation to exclude central nervous system pathology 2
Differential Diagnosis Considerations
Distinguish labyrinthitis from other vestibular disorders: 2
- Benign paroxysmal positional vertigo (BPPV): Positional, brief episodes
- Vestibular neuritis: Vertigo without hearing loss
- Ménière's disease: Episodic vertigo with fluctuating hearing loss
- Labyrinthitis: Single event with sudden severe vertigo AND profound hearing loss lasting 12-36 hours 2