Treatment of Vestibular Neuronitis in Adults
For a previously healthy adult aged 30-60 with vestibular neuronitis, limit vestibular suppressants to only the first 1-3 days for severe nausea/vomiting, then discontinue them immediately and begin early mobilization with vestibular rehabilitation exercises to promote central compensation. 1
Acute Phase Management (First 72 Hours)
Symptomatic Control
- Antiemetics (such as ondansetron or promethazine) may be used only during the acute phase for severe nausea and vomiting, but should be discontinued as soon as tolerable to avoid delaying central compensation. 1
- Vestibular suppressants like meclizine (25-100 mg daily in divided doses) are FDA-approved for vertigo associated with vestibular system diseases 2, but prolonged use interferes with the brain's natural compensation mechanisms and delays recovery, causing significant adverse effects. 1
- Avoid benzodiazepines for routine treatment due to their potential to impede central vestibular compensation and increase fall risk. 1
Corticosteroid Therapy
- Early corticosteroid treatment improves peripheral vestibular function recovery, with a 62% recovery rate within 12 months compared to incomplete recovery without treatment. 3
- Corticosteroids should be initiated as soon as possible during the acute phase for optimal benefit. 3, 4
Critical Diagnostic Exclusions
Before confirming vestibular neuronitis, rule out central causes that require urgent intervention:
- Patients with significant cardiovascular risk factors (hypertension, diabetes, hyperlipidemia, smoking) presenting with acute vestibular syndrome should be evaluated for posterior circulation stroke. 1, 5
- Any additional neurological signs (vertical nystagmus, vertical diplopia, head tilt, hemiparesis, sensory loss, ataxia, Horner's syndrome, cranial nerve palsies, internuclear ophthalmoplegia) indicate brainstem or cerebellar lesions requiring urgent MRI with and without contrast. 5, 6
- Pure vestibular neuronitis presents with horizontal (not vertical) spontaneous nystagmus toward the unaffected ear, positive head-impulse test toward the affected ear, and no auditory symptoms or other neurological deficits. 3, 4
Recovery Phase (After 72 Hours)
Vestibular Rehabilitation
- Recovery from vestibular neuronitis occurs through central compensation, which is impaired by vestibular suppressants and enhanced by early mobilization. 1
- Begin vestibular exercises as soon as the acute vertigo subsides (typically after 2-3 days). 3, 4
- Vestibular rehabilitation can be generalized exercises or customized programs, both showing significant improvement in dizziness handicap inventory scores and objective vestibular function testing. 7, 4
- Recovery combines peripheral restoration (often incomplete), somatosensory and visual substitution, and central compensation improved by vestibular exercise. 3
Follow-Up and Monitoring
- Reassess patients within 1 month after initial treatment to document resolution or persistence of symptoms. 1
- The natural course typically involves resolution over 2 days to 6 weeks, with mild transitory episodes potentially recurring over 12-18 months. 8
- Persistent symptoms beyond expected recovery warrant re-evaluation for alternative diagnoses or complications. 1
Common Pitfalls to Avoid
- Do not prescribe vestibular suppressants beyond the first few days, as they significantly delay recovery by preventing central compensation mechanisms. 1
- Do not assume peripheral vestibular neuronitis in patients with cardiovascular risk factors without excluding stroke, as approximately 4% of isolated dizziness cases are due to stroke, with 70% in the posterior circulation. 6
- Do not continue antiemetics once nausea is controlled, as prolonged use interferes with compensation. 1
- Be aware that benzodiazepines increase fall risk, cognitive dysfunction, and drug interactions, particularly problematic in this population who already has balance impairment. 5