Vestibular Neuritis: Diagnosis and Treatment
Diagnosis
Vestibular neuritis presents as acute, continuous rotatory vertigo lasting more than 24 hours with horizontal-torsional nystagmus toward the unaffected ear, without hearing loss or other neurological symptoms. 1, 2
Key Clinical Features to Identify
- Acute onset of severe, continuous vertigo lasting several days (not brief positional episodes) 2
- Horizontal spontaneous nystagmus with rotational component beating toward the unaffected ear 2
- Positive head-impulse test toward the affected ear (corrective saccade when head is rapidly turned toward affected side) 2
- Nausea, vomiting, and postural imbalance with falls toward the affected ear 2
- Absence of hearing loss, tinnitus, or cochlear symptoms (critical distinguishing feature) 3, 4
- No other neurological signs such as dysarthria, dysmetria, dysphagia, or sensory/motor deficits 5
Critical Red Flags Requiring Stroke Evaluation
Any patient with significant cardiovascular risk factors presenting with acute vestibular syndrome must be evaluated for posterior circulation stroke, as 10% of cerebellar strokes can mimic peripheral vestibular disorders. 5, 6
- Downbeating nystagmus without torsional component 5
- Direction-changing nystagmus without head position changes 5
- Additional neurological signs indicating brainstem or cerebellar lesions 6
- Sudden onset (more abrupt than typical neuritis) 5
Diagnostic Testing
- Head-impulse test and caloric irrigation show ipsilateral vestibuloocular reflex deficit 2
- Vestibular-evoked myogenic potential testing can confirm vestibular nerve involvement 3
- Imaging is not routinely needed unless atypical features or vascular risk factors are present 6, 7
Treatment Algorithm
Acute Phase (First 3-5 Days)
Corticosteroids should be initiated within 3 days of symptom onset in otherwise healthy patients, as they accelerate recovery of vestibular function with a 62% recovery rate within 12 months. 1, 2
- Oral corticosteroids for patients presenting within 3 days of onset who lack contraindications 1
- Antiemetics for severe nausea/vomiting during acute phase only 6
- Vestibular suppressants (meclizine 25-100 mg daily) for short-term symptomatic relief only 8, 9
Critical Medication Warnings
Prolonged use of vestibular suppressants and benzodiazepines interferes with central compensation mechanisms and delays recovery—discontinue after 3-5 days maximum. 8, 6
- Avoid benzodiazepines for routine treatment due to impaired central vestibular compensation 6
- Withdraw vestibular suppressants as soon as tolerable (preferably after first several days) 1
- Antivirals have not been shown to improve outcomes and are not recommended 10
Recovery Phase (After Acute Symptoms Subside)
Early mobilization and resumption of normal activity should be encouraged immediately after the acute phase to promote central compensation. 1
- Vestibular rehabilitation therapy for persistent symptoms or incomplete recovery 8, 7
- Habituation exercises, gaze stabilization, and balance training 7
- Self-administered or therapist-directed exercises depending on severity 7
Follow-Up Protocol
Reassess patients within 1 month after initial treatment to document resolution or identify persistent vestibular dysfunction requiring further intervention. 8, 6
- Evaluate for incomplete recovery or underlying central nervous system disorders 7
- Screen for fall risk using CDC-recommended questions, particularly in elderly patients 7
- Counsel on potential recurrence and when to seek care 7
Common Pitfalls to Avoid
- Do not use vestibular suppressants as primary treatment—they delay compensation 6
- Do not miss central causes—always evaluate vascular risk factors 6, 1
- Do not withhold steroids in appropriate candidates—they improve recovery rates 1, 2
- Do not prolong bed rest—early mobilization is essential for compensation 1