What is the recommended treatment for a patient diagnosed with labyrinthitis?

Treatment of Labyrinthitis

For acute labyrinthitis, initiate short-term vestibular suppressants (antihistamines or benzodiazepines for severe cases) combined with corticosteroids, followed by vestibular rehabilitation therapy once acute symptoms subside. 1

Acute Phase Management (First 24-72 Hours)

Pharmacological Treatment

Vestibular Suppressants - Use only for short-term symptom control during acute vertigo attacks, not as long-term therapy 1:

• Antihistamines are first-line to reduce vertigo severity 1
• Benzodiazepines may be used cautiously for severe symptoms with associated anxiety, but prescribe sparingly due to dependency risk 1
• Discontinue vestibular suppressants after 3-5 days to avoid delaying central compensation

Corticosteroids - Critical for reducing inflammation and improving hearing outcomes 2, 3:

• Prednisone 1 mg/kg/day (typically 60-70 mg daily) for 7-14 days 2
• Taper gradually over 1-2 weeks
• Evidence from COVID-19 labyrinthitis and bacterial labyrinthitis cases shows clinical recovery with corticosteroid therapy 2, 3

Antibiotic Considerations

Only if bacterial etiology is suspected or confirmed 3, 4:

• If associated with acute otitis media or purulent otorrhea, obtain culture and initiate broad-spectrum IV antibiotics 3
• Adjust based on culture results (e.g., 25 days total for Pseudomonas labyrinthitis) 3
• For syphilitic labyrinthitis specifically: ampicillin combined with prednisone maintains useful hearing in 28 of 29 ears, superior to ampicillin alone 5

Common Pitfall: Do not routinely prescribe antibiotics for presumed viral labyrinthitis without evidence of bacterial infection 1

Subacute Phase (Days to Weeks)

Vestibular Rehabilitation

Initiate vestibular rehabilitation therapy once acute symptoms improve 1, 3:

• Can be self-administered or clinician-guided 1
• Improves compensation and functional outcomes 3
• Essential for patients with persistent imbalance

Dietary and Lifestyle Modifications

If symptoms persist or suggest progression to Ménière's disease 1:

• Sodium restriction: 1500-2300 mg daily 1
• Limit caffeine and alcohol consumption 1
• Identify and manage stress triggers 1

Diagnostic Workup During Treatment

Essential Testing

Audiogram - Obtain promptly to document hearing loss and establish baseline 2, 3, 4:

• Distinguishes sensorineural from conductive hearing loss
• Guides prognosis and treatment intensity

MRI with FLAIR and CISS sequences - When diagnosis is uncertain 2, 3:

• Identifies labyrinthine enhancement confirming inflammation 2, 3
• Excludes cholesteatoma, vestibular schwannoma, and central causes 2, 3
• Particularly valuable in atypical presentations 4

Etiologic Investigation 2:

• Syphilis serologies (RPR, FTA-ABS) given excellent treatment outcomes when identified 5
• Viral studies if indicated by clinical context
• Culture of otorrhea if present 3

Follow-Up Protocol

Reassess within 1 month after initial treatment 1:

• Document resolution, improvement, or persistence of symptoms 1
• Repeat audiogram to assess hearing recovery 4

If symptoms persist beyond 4 weeks 1:

• Evaluate for unresolved labyrinthitis, underlying peripheral vestibular disorders, or central nervous system pathology 1
• Consider additional imaging or subspecialty referral

Prognosis Considerations

Hearing outcomes vary by etiology and treatment timing 5, 3, 4:

• Viral/serous labyrinthitis: hearing may return to normal with prompt corticosteroid treatment 4
• Bacterial labyrinthitis: deafness often persists despite resolution of vertigo 3
• Syphilitic labyrinthitis: combined ampicillin and prednisone prevents progression to profound deafness in most cases 5

Vertigo typically resolves with treatment and vestibular rehabilitation, but hearing loss may be permanent 3, 4

Critical Pitfall: Failing to provide patient education about potential disease recurrence and the importance of follow-up increases risk of permanent disability 1