What is the treatment for labyrinthitis?

Treatment of Labyrinthitis

For acute labyrinthitis, use short-term vestibular suppressants (antihistamines like meclizine or dimenhydrinate, or benzodiazepines for severe cases) for symptom control during the first few days, followed by early vestibular rehabilitation exercises once the acute phase subsides—typically within 1-3 weeks. 1, 2

Acute Phase Management (First 12-72 Hours)

Pharmacological Treatment

Vestibular suppressants should be used only for short-term management of acute vertigo attacks, not as definitive or long-term therapy. 1, 3

• Antihistamines (first-line): Meclizine or dimenhydrinate work by suppressing the hyperstimulated labyrinthine function and central emetic center 3, 4

  • Use primarily as-needed (PRN) rather than scheduled to avoid interfering with vestibular compensation 3
  • Typical duration: 2-3 days maximum 1

• Benzodiazepines (for severe symptoms): May be used cautiously when vertigo is severe and accompanied by significant anxiety 1, 2

  • Provides dual benefit for both vertigo and psychological anxiety 3
  • Critical caveat: Significant risk of dependency, falls (especially in elderly), drowsiness, and cognitive deficits 3
  • Should be discontinued as soon as tolerable to allow central compensation 3

• Antiemetics (for severe nausea/vomiting): Prochlorperazine 5-10 mg orally or intravenously, maximum three doses per 24 hours 3

  • Use only for short-term management of autonomic symptoms 1

What NOT to Use

Do not routinely prescribe antibiotics for typical viral labyrinthitis, as most cases are self-limited and antibiotics are ineffective against viral pathogens. 1

Do not routinely prescribe antiviral agents (aciclovir or valacyclovir), as multiple randomized controlled trials have failed to demonstrate benefit, and they carry potential side effects including nausea, vomiting, photosensitivity, and rarely reversible neurologic reactions. 1

Subacute to Chronic Phase (After 3-5 Days)

Vestibular Rehabilitation

Self-administered or clinician-guided vestibular rehabilitation should be offered for chronic imbalance following the acute phase of labyrinthitis. 1, 2

• Do NOT perform vestibular rehabilitation during acute vertigo attacks 1
• Begin exercises as early as possible after the acute phase subsides (typically 3-5 days) 5
• Slower exercises are more effective than faster ones because they depend more on the vestibular system 5
• Strong evidence shows vestibular exercises improve vestibulo-spinal compensation 5

Lifestyle Modifications

• Identify and manage triggers: stress, caffeine, alcohol consumption 1, 2
• Dietary considerations: If symptoms suggest progression to Ménière's disease, sodium restriction (1500-2300 mg daily) may be beneficial 2
• Adequate hydration, regular exercise, and sufficient sleep 3

Follow-Up and Monitoring

Reassess patients within 1 month after initial treatment to document resolution or persistence of symptoms. 3, 2

• Most patients experience significant improvement of acute vertigo symptoms within 1-3 weeks 1
• If vertigo symptoms persist beyond 3-4 weeks, further evaluation is warranted to rule out other conditions 1
• Transition from medication to vestibular rehabilitation when appropriate to promote long-term recovery 3

Prognosis Considerations

• The acute phase typically involves severe rotational vertigo lasting 12-36 hours with decreasing disequilibrium for the next 4-5 days 1
• Poor prognosis indicators: Advanced age (delays central vestibular compensation), presence of comorbidities affecting balance 1
• Research shows 72.5% of patients may still experience balance problems at long-term follow-up, and subjective hearing recovery occurs in only 20% of cases 6
• Any new or worsening neurological symptoms should prompt immediate medical attention to rule out central causes 1

Critical Pitfalls to Avoid

• Prolonged use of vestibular suppressants: Interferes with central compensation and delays recovery 3
• Starting vestibular rehabilitation too early: Wait until acute vertigo subsides 1
• Polypharmacy in elderly patients: Vestibular suppressants are an independent risk factor for falls, especially when combined with other medications 7, 3
• Failing to distinguish from other vestibular disorders: Must differentiate from BPPV (positional), vestibular neuritis (no hearing loss), and Ménière's disease (episodic/fluctuating) 1