What is the best treatment approach for a patient diagnosed with vestibular neuritis?

Treatment of Vestibular Neuritis

For acute vestibular neuritis, initiate corticosteroids within 3 days of symptom onset in otherwise healthy patients, combined with early vestibular rehabilitation therapy, while using vestibular suppressants only for the first few days to control severe symptoms. 1, 2

Acute Phase Management (First 72 Hours)

Corticosteroid Therapy

• Oral corticosteroids should be started within 3 days of symptom onset to accelerate recovery of vestibular function, with studies showing a 62% recovery rate within 12 months compared to lower rates without treatment 1, 3
• Withhold steroids in patients at higher risk for complications (diabetes, immunosuppression, significant cardiovascular disease) 1
• The evidence shows corticosteroids enhance earlier complete resolution, though long-term outcomes at 12 months may be equivalent to vestibular exercises alone 2

Symptomatic Control

• Vestibular suppressants (meclizine 25-100 mg daily in divided doses, antihistamines, or benzodiazepines) should be used only for the first several days to control severe vertigo, nausea, and vomiting 4, 1, 5
• Prolonged use of vestibular suppressants impedes central vestibular compensation and should be avoided beyond the acute phase 6, 1, 3
• Antiemetics may be added for severe nausea but should similarly be withdrawn quickly 1, 5

Vestibular Rehabilitation Therapy

Timing and Implementation

• Begin vestibular rehabilitation as soon as the acute symptoms subside (typically after the first few days), not waiting for complete symptom resolution 6, 1
• Early resumption of normal physical activity should be actively encouraged to promote central compensation 1, 3
• Vestibular rehabilitation appears equivalently effective to corticosteroids for long-term recovery, with 45-50% achieving complete resolution by 12 months 2

Components of Rehabilitation

• Include habituation exercises, adaptation exercises for gaze stabilization, and balance training 6, 7
• Physical activity is more important than any specific type of rehabilitation—patients with the most physical activity have better symptomatic outcomes long-term 8
• Customized vestibular exercises targeting both vestibulo-ocular reflex (VOR) and vestibulo-spinal function are recommended 5

Differential Diagnosis Considerations

Critical Red Flags

• Always evaluate for central causes (brainstem or cerebellar stroke) in patients with significant vascular risk factors, as vestibular neuritis is a diagnosis of exclusion 1, 3
• Central disorders can masquerade as vestibular neuritis—look for additional neurologic signs including gait dysfunction, speech abnormalities, or autonomic dysfunction 9, 3
• The presence of cochlear symptoms (hearing loss, tinnitus) suggests labyrinthitis or other pathology, not isolated vestibular neuritis 5, 3

Distinguishing Features

• Vestibular neuritis presents with acute-onset rotatory vertigo lasting more than 24 hours, horizontal-rotatory spontaneous nystagmus toward the unaffected ear, and positive head impulse test toward the affected ear 5, 3
• No cochlear symptoms or other neurological deficits should be present 5, 3

Follow-Up and Monitoring

Reassessment Timeline

• Reassess patients within 1 month after initial treatment to document resolution or persistence of symptoms 6, 7, 10
• For persistent symptoms, evaluate for incomplete compensation, coexisting vestibular disorders (Ménière's disease, migraine-associated vertigo), or central pathology 9, 6

Prognostic Factors

• Patients with absent cervical vestibular evoked myogenic potentials (cVEMP) have worse prognosis for vestibulo-ocular compensation 8
• Post-traumatic or post-infectious vestibular neuritis may be more refractory to treatment 9
• Recovery relies on three mechanisms: peripheral restoration (incomplete in most cases), sensory substitution, and central compensation 3

Patient Education and Safety

Fall Prevention

• Implement fall prevention strategies immediately, as vestibular dysfunction significantly increases fall risk 6, 7
• Elderly patients are at particularly high risk and may require home safety assessment 7
• Educate patients about the impact on balance, mobility, and driving safety during the acute and recovery phases 6, 7

Disease Course Education

• Inform patients that most recover well even without treatment, but recovery can take weeks to months 1, 3
• Explain that symptoms may persist despite normal vestibular testing, as compensation involves multiple systems 8
• Emphasize the importance of maintaining physical activity throughout recovery 1, 8

Common Pitfalls to Avoid

• Do not rely on vestibular suppressants as primary long-term treatment—they delay compensation and have significant side effects including drowsiness, cognitive deficits, and increased fall risk 6, 10
• Do not delay vestibular rehabilitation waiting for complete symptom resolution—early mobilization promotes compensation 6, 1
• Do not assume recovery based solely on vestibulo-ocular reflex testing—symptomatic and functional assessments are equally important 8
• Do not miss central causes in patients with vascular risk factors—any atypical features warrant neuroimaging 1, 3