What is the difference in diagnosis and treatment between acute labyrinthitis and vestibular neuritis?

Acute Labyrinthitis vs Vestibular Neuritis

The key difference is that labyrinthitis presents with hearing loss while vestibular neuritis does not—both cause acute, continuous vertigo lasting days to weeks, but only labyrinthitis affects the cochlea in addition to the vestibular system. 1, 2

Clinical Presentation

Shared Features (Acute Vestibular Syndrome)

Both conditions present as an acute vestibular syndrome characterized by: 1

• Acute onset of severe, continuous rotatory vertigo lasting days to weeks 1, 3
• Horizontal-torsional spontaneous nystagmus beating away from the affected ear 3
• Severe nausea and vomiting 1, 4
• Postural imbalance with falls toward the affected ear 3
• Intolerance to head motion 1
• Abnormal head-impulse test toward the affected ear 3, 5

The Critical Distinguishing Feature

Labyrinthitis includes sudden profound hearing loss, tinnitus, or aural symptoms, while vestibular neuritis has NO hearing loss, tinnitus, or aural fullness. 1, 2

• Labyrinthitis: Vertigo PLUS hearing loss (cochlear involvement) 1
• Vestibular neuritis: Isolated vestibular symptoms without any auditory symptoms 1, 3

Diagnostic Approach

History and Timing

Focus on the timing and triggers rather than vague descriptions of dizziness: 1, 6

• Duration: Both present with continuous symptoms lasting days (typically peaking at 24-48 hours, then gradually improving over 7 days) 4, 5
• Onset: Acute, spontaneous (not positional or triggered) 1
• Auditory symptoms: The presence or absence of hearing loss is the key differentiator 1

Physical Examination

Perform these specific maneuvers: 3, 5

• Head-impulse test: Abnormal toward affected ear in both conditions 3, 5
• Spontaneous nystagmus: Horizontal-torsional, beating away from affected ear, present without provocation 3
• Dix-Hallpike maneuver: Should NOT produce the characteristic BPPV pattern (helps exclude BPPV) 6
• Neurologic examination: Must be normal (any focal deficits suggest central cause like stroke) 6, 4

Audiometry

Obtain comprehensive audiologic examination to definitively distinguish between the two conditions: 6

• Labyrinthitis: Demonstrates sensorineural hearing loss on the affected side 1
• Vestibular neuritis: Normal hearing bilaterally 1, 3

When to Image

No imaging is indicated for typical vestibular neuritis or labyrinthitis IF the neurologic exam is normal and there are no red flags. 6 However, obtain MRI brain without contrast if: 6, 4

• Any focal neurologic deficits present 6
• Significant vascular risk factors (stroke risk) 4, 3
• Severe postural instability with inability to stand or walk 6, 7
• Downbeating or purely vertical nystagmus (suggests central cause) 6, 7
• New severe headache accompanying vertigo 6
• Failure to improve over expected timeframe 6

Critical Differential: Ruling Out Stroke

This is the most important clinical decision—approximately 25% of patients with acute vestibular syndrome have cerebellar or brainstem stroke, not peripheral vestibular disease. 7 The challenge is that 75-80% of posterior circulation stroke patients have NO focal neurologic deficits. 6

Red Flags Demanding Immediate MRI

• Severe postural instability with falling (cannot stand unassisted) 6, 7
• Direction-changing nystagmus or purely vertical nystagmus 7
• Any additional neurologic symptoms (dysarthria, diplopia, dysphagia, limb weakness) 7
• New severe headache 6
• High vascular risk factors (age >60, hypertension, diabetes, prior stroke) 4

Treatment

Acute Phase (First 3-7 Days)

For vestibular neuritis, oral corticosteroids within 3 days of onset accelerate recovery of vestibular function: 4, 3

• Methylprednisolone 100mg daily for 3 days, then taper over 7-10 days (or equivalent steroid regimen) 4, 3
• Corticosteroids improve recovery rate to 62% within 12 months 3
• Withhold steroids in patients with significant comorbidities (diabetes, immunosuppression) 4

For labyrinthitis, the same steroid approach may be used, though evidence is less robust. 4

Symptomatic management (use sparingly): 4, 3

• Antiemetics (ondansetron, promethazine) for severe nausea 4
• Vestibular suppressants (meclizine, diazepam) ONLY for first 2-3 days 4, 3
• Discontinue vestibular suppressants after 3 days maximum—prolonged use impedes central compensation 4, 3

Recovery Phase (After First Week)

Early mobilization and vestibular rehabilitation are essential for optimal recovery: 4, 3

• Encourage return to normal activity as soon as tolerated (promotes central compensation) 4, 3
• Formal vestibular rehabilitation therapy if symptoms persist beyond 2 weeks 4, 3
• Recovery occurs through three mechanisms: peripheral restoration (often incomplete), somatosensory/visual substitution, and central compensation 3

Common Pitfalls to Avoid

Do not assume normal neurologic exam excludes stroke—most posterior circulation strokes present without focal deficits. 6 Any patient with vascular risk factors and acute vestibular syndrome should be evaluated for stroke. 4

Do not continue vestibular suppressants beyond 3 days—they delay central compensation and prolong recovery. 4, 3

Do not rely on patient's description of "spinning" versus "dizziness"—focus instead on timing (acute continuous), triggers (spontaneous, not positional), and associated symptoms (hearing loss present or absent). 1, 6

Do not order routine imaging for typical cases—imaging is only indicated when red flags are present or the diagnosis is uncertain. 6

Do not miss bilateral vestibular neuritis—rare but can present with severe imbalance without prominent vertigo (oscillopsia with head movement is the key clue). 2