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 exercises once the acute vertigo subsides. 1, 2
Acute Phase Management (First 12-36 Hours)
Pharmacological Treatment
Vestibular suppressants are the cornerstone of acute management and should be used for short-term symptom control only, not as long-term therapy. 1, 2
Antihistamines (such as meclizine or dimenhydrinate) are first-line agents to reduce vertigo severity during the acute attack. 1
Benzodiazepines may be used cautiously for severe symptoms to alleviate both vertigo and associated anxiety, but prescribe with awareness of dependency risk and limit duration to a few days. 1, 2
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 routinely prescribe antiviral agents (aciclovir or valacyclovir), as multiple randomized controlled trials have failed to demonstrate benefit, and antivirals carry potential side effects including nausea, vomiting, photosensitivity, and rarely reversible neurologic reactions. 2
Critical Timing Consideration
The acute phase is characterized by severe rotational vertigo lasting 12-36 hours with decreasing disequilibrium over the next 4-5 days. 2
Vestibular suppressants should be discontinued after the acute phase (typically 3-5 days) to avoid delaying central vestibular compensation. 2
Subacute to Chronic Phase Management (After Acute Vertigo Resolves)
Vestibular Rehabilitation
Self-administered or clinician-guided vestibular rehabilitation should be offered to improve outcomes and facilitate central compensation. 1, 2
Do NOT perform vestibular rehabilitation during acute vertigo attacks—wait until the severe rotational vertigo subsides. 2
Vestibular rehabilitation is particularly important as most patients (72.5%) still experience balance problems at long-term follow-up. 3
Lifestyle Modifications
Identify and manage potential triggers including stress, caffeine, and alcohol consumption. 1, 2
Consider sodium restriction (1500-2300 mg daily) if labyrinthitis is related to or progresses to Ménière's disease. 1
Follow-Up Protocol
Reassess patients 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 conditions such as vestibular schwannoma, Ménière's disease, or central causes. 2
Provide patient education about the condition's natural course and potential for incomplete recovery—only 20% of patients experience subjective hearing recovery. 3
Common Pitfalls to Avoid
Prolonged use of vestibular suppressants delays central compensation and worsens long-term outcomes. 2
Failing to initiate vestibular rehabilitation after the acute phase—this is essential for recovery despite poor overall prognosis. 2, 3
Neglecting audiometric evaluation—all patients should have hearing testing as labyrinthitis causes concurrent hearing loss that rarely recovers. 3
Missing red flags for central causes—any new or worsening neurological symptoms should prompt immediate evaluation to rule out stroke or other central pathology. 2