Vestibular Labyrinthitis: Definition and Treatment Guidelines
Definition
Vestibular labyrinthitis is an inner ear infection affecting the membranous labyrinth, characterized by the simultaneous onset of acute vertigo AND hearing loss, distinguishing it from vestibular neuritis which affects only balance function. 1, 2
Key diagnostic features include:
- Sudden onset of vertigo with concurrent hearing loss (the hearing loss component is what differentiates labyrinthitis from vestibular neuritis) 1, 2
- Associated symptoms: nausea, vomiting, tinnitus, and gait instability 1, 3
- Vestibular weakness demonstrable on testing 2
- Symptoms persist for days or longer 3
Treatment Guidelines
Acute Phase Management
Vestibular suppressant medications (antihistamines like meclizine or benzodiazepines) should be used ONLY for short-term management of severe nausea and vomiting during the acute phase, then discontinued as soon as possible. 4, 5
- Use PRN (as-needed) dosing rather than scheduled dosing to minimize interference with vestibular compensation 5
- These medications interfere with central vestibular compensation and prolong recovery if used beyond the acute phase 6, 4, 5
- They increase fall risk, cause drowsiness, and cognitive deficits, especially in elderly patients 4, 5
Early medical treatment with corticosteroids should be initiated promptly based on the pathophysiology of inner ear inflammation 1, 7
Vestibular Rehabilitation Therapy (VRT)
VRT is the cornerstone of treatment and should be offered to all patients with unilateral vestibular hypofunction presenting with impairments and activity limitations (Grade A recommendation). 4
Key principles:
- Initiate VRT after the acute phase subsides - do NOT perform VRT during active, fluctuating vestibular attacks as this may worsen symptoms 4
- VRT improves motion sensitivity, subjective symptoms, and accelerates central compensation 4
- Withdraw vestibular suppressants before starting VRT as they interfere with the compensation process 4
- Both supervised outpatient therapy and independent home therapy are acceptable options 4
Follow-Up and Monitoring
Reassess patients within 1 month to confirm symptom resolution and transition to appropriate rehabilitation. 6, 5
- Regular audiovestibular follow-up is essential 1
- Monitor for persistent balance problems (72.5% of patients still experience balance issues at long-term follow-up) 2
- Hearing recovery occurs in only 20% of cases, indicating poor prognosis for auditory function 2
Treatment Algorithm
Acute phase (first 24-72 hours):
Subacute phase (after acute symptoms subside):
Chronic phase (persistent symptoms beyond 1 month):
Critical Pitfalls to Avoid
Do not mistake labyrinthitis for other vestibular disorders - the presence of hearing loss distinguishes it from vestibular neuritis, BPPV, or Ménière's disease, which require different treatment approaches 4, 8
Do not continue vestibular suppressants beyond the acute phase - this is the most common error that delays recovery and increases fall risk 4, 5
Do not delay VRT - early initiation after the acute phase improves outcomes, but avoid during active fluctuating symptoms 4
Prognosis
Patients with idiopathic labyrinthitis have a poor prognosis for both hearing and balance function, with the majority experiencing persistent balance problems at long-term follow-up 2. Vestibular compensation typically takes 6-12 months depending on treatment timing 9. Despite the guarded prognosis, comprehensive treatment including early medical intervention, VRT, and regular monitoring optimizes functional outcomes 1, 7.