What are the discharge criteria for vestibular neuritis?

Discharge Criteria for Vestibular Neuritis

Patients with vestibular neuritis can be safely discharged from the emergency department or acute care setting once central causes of vertigo (particularly stroke) have been excluded, symptomatic treatment has been initiated, and they demonstrate adequate oral intake and ambulation with assistance.

Immediate Assessment Before Discharge

Rule Out Central Causes

• Any patient with significant vascular risk factors must be evaluated for possible brainstem or cerebellar stroke before attributing symptoms to vestibular neuritis, as definitive central signs are not always present and missing a stroke could be life-threatening 1
• Confirm the absence of neurologic red flags including dysphagia, dysphonia, visual disturbances, or other focal neurologic symptoms that would suggest stroke rather than peripheral vestibular dysfunction 2
• Vestibular neuritis presents with severe rotational vertigo lasting 12-36 hours with decreasing disequilibrium over the next 4-5 days, without hearing loss, tinnitus, or aural fullness 2

Confirm Clinical Stability

• Patient must tolerate oral intake sufficiently to prevent dehydration, as nausea and vomiting are prominent features 1, 3
• Patient should be able to ambulate with assistance, even if unsteady, as complete immobility suggests a more severe process 1
• Vital signs should be stable without orthostatic hypotension

Symptomatic Management Initiated

Acute Medications Prescribed

• Antiemetics and vestibular suppressants should be prescribed for acute symptom control but must be limited to the first several days only, as prolonged use impedes central vestibular compensation 1
• Consider oral corticosteroids (prednisolone for 10 days) if the patient presents within 3 days of symptom onset and has no contraindications, as steroids accelerate recovery of vestibular function 1, 4

Patient Education Provided

• Inform patients that severe vertigo typically lasts 12-36 hours, with gradual improvement over 4-5 days, though full recovery may take 2 days to 6 weeks 2, 3
• Emphasize early resumption of normal physical activity to promote vestibular compensation, as this is more important than any specific rehabilitation technique 1, 5
• Warn that mild transitory episodes of dizziness may recur over 12-18 months after the acute attack 3

Discharge Instructions and Follow-Up

Activity Recommendations

• Encourage immediate return to normal daily activities as tolerated, as physical activity is the most critical factor for symptomatic recovery 5
• Patients should avoid prolonged bed rest and gradually increase activity levels despite initial discomfort 1

Medication Instructions

• Discontinue vestibular suppressants after 3-5 days maximum to avoid impeding compensation 1
• Complete the full course of corticosteroids if prescribed 4

Scheduled Follow-Up

• Arrange outpatient follow-up within 1-2 weeks to assess recovery trajectory 4
• Refer for formal vestibular rehabilitation therapy if symptoms persist beyond 2-3 weeks, as early supervised exercise therapy significantly reduces dizziness at 3 and 12 months compared to standard care alone 4
• Patients with absent cervical vestibular evoked myogenic potentials (cVEMP) have worse prognosis and may benefit from earlier rehabilitation referral 5

Red Flags Requiring Admission or Further Evaluation

• Inability to maintain hydration due to intractable vomiting 1
• Inability to ambulate even with maximal assistance 1
• Any central neurologic signs suggesting stroke 1
• Significant vascular risk factors without adequate stroke evaluation 1
• Loss of consciousness, which is never a feature of vestibular neuritis and demands alternative diagnosis 6