Treatment and Diagnosis of Vestibular Neuritis
Diagnosis
Vestibular neuritis presents as acute, prolonged continuous vertigo with nausea, vomiting, and imbalance, typically lasting days to weeks, and is diagnosed clinically by identifying spontaneous horizontal-torsional nystagmus beating away from the affected ear, positive head impulse test toward the affected side, and absence of auditory symptoms or central neurological signs. 1
Key Diagnostic Features to Identify:
- Acute vestibular syndrome: Continuous vertigo lasting >24 hours with spontaneous nystagmus, postural instability, nausea/vomiting, and head motion intolerance 1
- Peripheral vestibular pattern: Horizontal-torsional nystagmus that is unidirectional, suppressed by visual fixation, and increases with gaze in the direction of the fast phase 1
- Positive head impulse test: Corrective saccade when head is rapidly turned toward the affected side 1
- Absence of hearing loss: This distinguishes vestibular neuritis from labyrinthitis 1
Critical Pitfall - Excluding Central Causes:
Any patient with significant vascular risk factors (hypertension, diabetes, age >50, smoking) must be evaluated for posterior circulation stroke, as central causes can mimic vestibular neuritis and may be life-threatening. 1
- Red flags requiring neuroimaging: severe headache, focal neurological deficits, vertical or direction-changing nystagmus, negative head impulse test (normal vestibulo-ocular reflex), severe truncal ataxia out of proportion to vertigo 1
Acute Phase Treatment (First 72 Hours)
Corticosteroids - Primary Treatment
Initiate oral corticosteroids within 72 hours of symptom onset, ideally within 24 hours, as this significantly improves recovery of peripheral vestibular function. 2, 3
Dosing Protocol:
- Methylprednisolone or prednisone 1 mg/kg/day (typically 50-100 mg daily) for 5 days, then taper over 10-15 days 2, 4
- If patient is severely nauseous: Consider initial IV betamethasone 8 mg for 1-2 days, then transition to oral steroids 3
Evidence Supporting Steroids:
- Methylprednisolone improves vestibular function recovery by 62.4% compared to 39.6% with placebo at 12 months (P<0.001) 2
- Treatment within 24 hours results in 100% normalization of caloric testing at 3 months, versus only 58% when treated between 25-72 hours 3
- Earlier recovery of vestibular function occurs at 1 and 3 months with steroid treatment 4
Antivirals - NOT Recommended
Do not prescribe antiviral medications (valacyclovir, acyclovir) for vestibular neuritis, as they provide no benefit. 2
- Valacyclovir showed no significant effect on vestibular recovery (P=0.43) in randomized controlled trials 2
- Combination of methylprednisolone plus valacyclovir was not superior to corticosteroid monotherapy 2
- Despite the suspected herpes simplex virus etiology, antivirals do not improve outcomes 1, 2
Symptomatic Management - Short-Term Only
Use vestibular suppressants (antihistamines, benzodiazepines) and antiemetics only for the first 2-3 days to control severe nausea and vertigo, then discontinue immediately. 1, 5
Appropriate Short-Term Options:
- Meclizine 25 mg three times daily for acute vertigo (maximum 3 days) 5
- Prochlorperazine 5-10 mg for severe nausea/vomiting (maximum 3 days) 6
- Diazepam or lorazepam for severe anxiety with vertigo (maximum 3 days) 7
Critical Warning:
Prolonged use of vestibular suppressants beyond 3 days impedes central vestibular compensation and delays recovery. 1, 5
- These medications interfere with the brain's natural adaptation mechanisms 5
- They increase fall risk, especially in elderly patients 5, 6
- They should never be used as primary or definitive treatment 7
Recovery Phase (After Acute Symptoms Subside)
Vestibular Rehabilitation - Essential for Recovery
Encourage early resumption of normal activity and head movements as soon as the acute phase resolves (typically after 3-5 days) to promote central vestibular compensation. 1, 8
Rehabilitation Protocol:
- Begin visual fixation exercises while still symptomatic: Focus on stationary objects while moving head side-to-side and up-down 8
- Progress to gaze stabilization exercises: Read text or focus on targets while walking or turning head 1
- Advance to balance and gait training: Standing on foam, tandem walking, turning exercises 8
When to Refer for Formal Vestibular Rehabilitation:
- Persistent instability beyond 2-3 weeks 8
- Significant anxiety or fear of movement limiting recovery 8
- Elderly patients or those with increased fall risk 1
Follow-Up and Monitoring
Reassess patients within 1 month after initial treatment to document symptom resolution or identify treatment failure. 7
Assessment at Follow-Up:
- Resolution of spontaneous nystagmus and vertigo 1
- Improvement in balance and gait 1
- Return to normal activities without significant disability 8
If Symptoms Persist Beyond 1 Month:
- Consider formal vestibular function testing (caloric testing, video head impulse test) 2, 4
- Evaluate for incomplete compensation or bilateral vestibular loss 1
- Rule out alternative diagnoses (BPPV, Meniere's disease, central lesions) 1
- Refer for specialized vestibular rehabilitation 8
Prognosis
Most patients (60-80%) achieve complete recovery within 3-6 months, even without treatment, though corticosteroids accelerate this process. 1, 4