What is the recommended treatment for a patient diagnosed with vestibular neuronitis?

Treatment of Vestibular Neuronitis

For acute vestibular neuronitis, initiate corticosteroids immediately (within 3 days of symptom onset) and begin vestibular rehabilitation exercises early, while avoiding routine use of vestibular suppressants beyond the first 2-3 days. 1, 2

Immediate Pharmacologic Management

Corticosteroids: Primary Treatment

• Start corticosteroids as soon as possible within the first 72 hours of symptom onset to improve peripheral vestibular recovery. 2
• Corticosteroid therapy achieves a 62% recovery rate of labyrinthine function within 12 months, compared to incomplete recovery without treatment. 2
• This represents the only evidence-based specific drug therapy that improves long-term vestibular function outcomes. 2

Vestibular Suppressants: Limited Short-Term Use Only

• Avoid benzodiazepines for routine treatment as they impede central vestibular compensation, which is critical for recovery. 1
• Meclizine (25-100 mg daily) may be used for severe nausea and vomiting during the first 2-3 days only. 3
• Prolonged use of vestibular suppressants (antihistamines, benzodiazepines) interferes with the brain's natural compensation mechanisms and delays recovery. 4, 1
• These medications cause significant adverse effects including drowsiness, cognitive deficits, increased fall risk (particularly in elderly patients), and anticholinergic effects. 5

Antiemetics for Symptomatic Relief

• Antiemetics (promethazine, ondansetron) may be used for severe nausea and vomiting during the acute phase (first 2-3 days). 4, 6
• Discontinue as soon as tolerable to avoid delaying central compensation. 4

Antiviral Therapy: Not Recommended

• Do not prescribe antiviral agents, as they have not been shown to improve outcomes in vestibular neuronitis. 7
• Despite evidence of HSV-1 DNA in vestibular ganglia suggesting viral reactivation as the likely cause, antiviral therapy has failed to demonstrate clinical benefit. 7, 2

Vestibular Rehabilitation: Essential Component

Early Initiation

• Begin vestibular exercises as soon as the acute severe vertigo subsides (typically after 2-3 days), even while symptoms persist. 6, 2
• Early vestibular rehabilitation accelerates central compensation and improves functional outcomes. 2

Exercise Types

• Implement generalized vestibular exercises including gaze stabilization exercises and balance training. 6
• Progress to customized vestibular exercises based on specific deficits identified during examination. 6
• These exercises promote somatosensory and visual substitution for the impaired vestibular function. 2

Diagnostic Confirmation Before Treatment

Clinical Features Required

• Acute onset of continuous rotatory vertigo lasting more than 24 hours (typically several days). 6, 8, 2
• Horizontal spontaneous nystagmus with rotational component beating toward the unaffected ear. 2
• Positive head-impulse test toward the affected ear. 2
• Absence of cochlear symptoms (no hearing loss or tinnitus) and absence of other neurological symptoms. 6, 8

Critical Red Flags Requiring Imaging

• Patients with significant cardiovascular risk factors (hypertension, diabetes, hyperlipidemia, smoking) presenting with acute vestibular syndrome should be evaluated for posterior circulation stroke. 1
• Downbeating nystagmus without torsional component, direction-changing nystagmus, or baseline nystagmus without provocative maneuvers suggest central pathology. 5
• Any additional neurological signs (hemiparesis, sensory loss, ataxia, cranial nerve palsies) indicate brainstem or cerebellar lesions, not vestibular neuronitis. 4

Follow-Up and Reassessment

Timing

• Reassess all patients within 1 month after initial treatment to document symptom resolution or persistence. 1
• Recovery typically occurs over 2 days to 6 weeks for the acute phase. 8
• Mild transitory dizziness episodes may recur over 12-18 months following the acute attack. 8

Persistent Symptoms

• If symptoms persist beyond expected timeframe, reconsider the diagnosis and evaluate for:
  • Vestibular pseudoneuritis from pontomedullary brainstem lesions or cerebellar nodular infarctions. 2
  • Vestibular migraine or monosymptomatic Ménière's disease. 2
  • Central nervous system pathology masquerading as peripheral vestibular disease. 1

Recovery Mechanisms

Recovery from vestibular neuronitis occurs through three mechanisms: 2

• Peripheral restoration of labyrinthine function (usually incomplete, improved by early corticosteroids)
• Somatosensory and visual substitution (promoted by vestibular exercises)
• Central compensation (impaired by vestibular suppressants, enhanced by early mobilization)

Common Pitfalls to Avoid

• Do not prescribe prolonged courses of meclizine or benzodiazepines, as this delays recovery and increases fall risk. 4, 1
• Do not delay corticosteroid initiation beyond 72 hours, as efficacy decreases significantly. 2
• Do not prescribe antiviral medications, as they provide no benefit despite viral etiology. 7
• Do not assume the diagnosis without confirming absence of auditory symptoms and other neurological findings. 6, 8
• Do not fail to assess cardiovascular risk factors that increase stroke probability in acute vestibular syndrome. 1