What is the treatment approach for a patient presenting with symptoms of labyrinthitis versus vestibular neuronitis, including vertigo, nausea, and hearing loss?

Labyrinthitis vs Vestibular Neuronitis: Diagnosis and Treatment

Key Clinical Distinction

The presence or absence of hearing loss is the definitive differentiator: labyrinthitis presents with acute vertigo PLUS sensorineural hearing loss, while vestibular neuronitis causes identical vertigo but WITHOUT hearing involvement. 1

Clinical Presentation

Vestibular Neuronitis

• Acute onset of severe, continuous rotatory vertigo lasting days to weeks with severe nausea, vomiting, and intolerance to head motion 1, 2
• No hearing loss, tinnitus, or aural fullness 3
• Horizontal-torsional spontaneous nystagmus beating away from the affected side 4, 2
• Positive head impulse test toward the affected ear 4, 2
• Falls and postural imbalance toward the lesion side 2
• Severe rotational vertigo typically lasts 12-36 hours with decreasing disequilibrium over 4-5 days 3

Labyrinthitis

• Identical presentation to vestibular neuronitis BUT with profound sensorineural hearing loss on the affected side 3, 1
• Sudden severe vertigo with prolonged duration (>24 hours) 3
• Vertigo, nausea with hearing loss—not episodic, not fluctuating 3
• May present with severe otalgia and fever if infectious etiology 3

Diagnostic Workup

Essential Testing

• Comprehensive audiologic examination is mandatory to distinguish between the two conditions 1
• Head impulse test to confirm peripheral vestibular dysfunction 4, 2
• Caloric testing shows ipsilateral canal paresis 4, 2
• Vestibular-evoked myogenic potentials (VEMPs) show decreased responses on affected side 4

Critical Red Flags Requiring Immediate MRI

Do not assume peripheral vestibular disease if any of the following are present—approximately 25% of acute vestibular syndrome cases are actually cerebellar or brainstem strokes: 1

• Severe postural instability out of proportion to symptoms 1
• Direction-changing or purely vertical nystagmus 1
• Negative head impulse test (suggests central pathology) 4
• Additional neurologic symptoms (dysarthria, dysmetria, sensory/motor deficits) 5
• Significant vascular risk factors 1, 6
• Unprecedented severe headache 4
• No improvement within 1-2 days 4

No imaging is needed for typical presentations with normal neurologic exam and no red flags 1

Treatment Approach

Acute Phase Management (First 3 Days)

For Vestibular Neuronitis:

• Oral corticosteroids within 3 days of onset: methylprednisolone 100mg daily for 3 days, then taper over 7-10 days 1, 7
• This regimen significantly improves recovery of peripheral vestibular function (62% recovery vs 40% with placebo at 12 months) 7
• Antiviral agents (valacyclovir) provide NO benefit and should not be used 7

For Labyrinthitis:

• Same corticosteroid regimen as vestibular neuronitis 1
• If infectious etiology suspected (fever, otalgia), consider appropriate antimicrobial therapy 3
• Vasodilators and steroids for sudden hearing loss component 3

Symptomatic Management

Antiemetics (use sparingly):

• Prochlorperazine 5-10mg orally or IV, maximum 3 doses per 24 hours for severe nausea/vomiting 5
• Use only during acute phase when symptoms are most severe 5, 6

Vestibular Suppressants (critical limitations):

• Meclizine is FDA-approved for vertigo associated with vestibular disease 8
• However, vestibular suppressants should be discontinued after 3 days maximum 1, 6
• Prolonged use causes significant harm: impedes central vestibular compensation, increases fall risk, causes cognitive impairment 5, 6
• These medications do not address underlying pathophysiology 5

Recovery Phase (After First Week)

Vestibular Rehabilitation:

• Early resumption of normal activity should be encouraged immediately to promote central compensation 6, 2
• Directed vestibular rehabilitation therapy accelerates recovery 6, 2
• Most patients recover well even without specific treatment, but steroids and rehabilitation optimize outcomes 6, 2

Hearing Rehabilitation (Labyrinthitis Only)

• Audiometry follow-up to assess for permanent hearing loss 3
• Hearing aids if amplification beneficial 3
• Cochlear implants for profound deafness 3
• Bone-anchored devices for single-sided deafness 3

Follow-Up

Reassess within 1 month to document:

• Resolution or persistence of vertigo 5
• Hearing status (labyrinthitis) 3
• Quality of life changes 3
• Need for vestibular rehabilitation 3

Persistent symptoms require re-evaluation for:

• Alternative diagnoses including central causes 5
• Incomplete recovery requiring intensified rehabilitation 3

Common Pitfalls to Avoid

• Missing central stroke in patients with vascular risk factors—up to 75-80% of stroke patients with vertigo may lack focal neurologic deficits 5
• Prolonged vestibular suppressant use—discontinue after 3 days to avoid impeding compensation 1, 6
• Failing to obtain audiometry—this is the only way to definitively distinguish labyrinthitis from vestibular neuronitis 1
• Prescribing antiviral medications—these provide no benefit for vestibular neuronitis 7
• Delaying corticosteroids beyond 3 days—efficacy diminishes significantly after this window 1, 7