What is the management of vestibular neuritis?

Management of Vestibular Neuritis

Vestibular neuritis should be managed with early corticosteroids (if presenting within 3 days), immediate vestibular rehabilitation, and short-term vestibular suppressants only during the acute phase, with avoidance of prolonged suppressant use that delays central compensation. 1, 2

Acute Phase Management (First 3 Days)

Corticosteroid Therapy

• Oral corticosteroids should be initiated within 3 days of symptom onset in otherwise healthy patients to accelerate recovery of vestibular function. 2
• A 10-day course of prednisolone is the standard regimen, though the long-term benefit remains uncertain. 2, 3
• Withhold corticosteroids in patients at higher risk of complications (uncontrolled diabetes, immunosuppression, significant cardiovascular disease). 2

Symptomatic Control

• Antiemetics like prochlorperazine may be used for severe nausea and vomiting during the acute phase only. 1
• Vestibular suppressants (meclizine, antihistamines, benzodiazepines) should be withdrawn after the first several days, as prolonged use impedes central vestibular compensation. 1, 2
• If meclizine worsens symptoms or causes excessive drowsiness, discontinue immediately. 1

Vestibular Rehabilitation

Early Initiation

• Vestibular rehabilitation should be started early after diagnosis, as it reduces perceived dizziness and improves daily function more effectively than standard care alone. 3
• Early resumption of normal activity should be encouraged to promote central compensation. 2
• Visual fixation exercises can be initiated even while the patient is bed-ridden to accelerate recovery. 4

Evidence for Effectiveness

• A randomized controlled trial demonstrated that vestibular rehabilitation combined with standard care significantly reduced overall perceived dizziness at 3 months (p=0.007) and 12 months (p=0.001) compared to standard care alone. 3
• At 12 months, vestibular rehabilitation also showed significant improvements in anxiety/depression scores (p=0.039) and dizziness handicap inventory (p=0.049). 3
• Vestibular exercises appear equivalently effective as corticosteroid therapy for clinical, caloric, and otolith recovery in the long term. 5

Rehabilitation Components

• Supervised exercise therapy should be individually tailored and supported by home exercises. 3
• Most patients undergo spontaneous vestibular compensation, but directed rehabilitation accelerates this process. 4, 2

Critical Diagnostic Considerations

Red Flags Requiring Brain Imaging

• Patients with significant vascular risk factors should be evaluated for possible stroke, as cerebellar strokes can present similarly to vestibular neuritis. 1, 2
• Brain imaging is indicated when the patient has: 6
  • Unprecedented severe headache
  • Negative head impulse test (suggests central pathology)
  • Severe unsteadiness out of proportion to typical vestibular neuritis
  • No recovery within 1-2 days

Central Warning Signs

• Central signs requiring urgent brain imaging include: 1
  • Downbeating nystagmus
  • Direction-changing nystagmus without head position changes
  • Gaze-evoked nystagmus
  • Dysarthria, dysmetria, or dysphagia
  • Sensory or motor deficits

Common Pitfalls to Avoid

Medication Errors

• Continuing vestibular suppressants beyond the acute phase is a critical error that delays recovery by interfering with the brain's natural compensation mechanisms. 1, 2
• Do not prescribe vestibular suppressants as primary long-term treatment. 1

Delayed Rehabilitation

• Failing to initiate early vestibular rehabilitation results in prolonged symptoms and impaired quality of life. 3
• Patients who remain anxious or have persistent instability are particularly strong candidates for formal vestibular rehabilitation programs. 4

Missed Central Pathology

• Inferior vestibular neuritis (rare subtype) lacks typical features and may be misdiagnosed as central vestibular disorder. 6
• Any patient with atypical features or significant vascular risk factors warrants imaging to exclude stroke. 6, 2

Treatment Algorithm Summary

1. Day 0-3: Initiate oral corticosteroids if presenting within 3 days and no contraindications exist 2
2. Acute phase (first few days): Use antiemetics and vestibular suppressants for severe symptoms only 1, 2
3. Day 3 onward: Discontinue vestibular suppressants 1, 2
4. Early (within first week): Begin vestibular rehabilitation exercises, encourage normal activity 2, 3
5. Ongoing: Continue supervised vestibular rehabilitation with home exercises for optimal recovery 3