What is the recommended treatment for an adult with acute vestibular neuritis presenting with sudden prolonged vertigo, nausea, and gait instability after a viral upper‑respiratory infection, without hearing loss, tinnitus, or focal neurologic signs?

Treatment of Vestibular Neuritis

For an adult with acute vestibular neuritis presenting with sudden prolonged vertigo, nausea, and gait instability after a viral upper-respiratory infection, initiate oral corticosteroids within 3 days of symptom onset, provide short-term vestibular suppressants (≤3 days) for severe symptoms only, and begin early vestibular rehabilitation therapy as soon as the acute phase subsides.

Pharmacologic Management

Corticosteroid Therapy (Primary Treatment)

• Oral corticosteroids accelerate recovery of vestibular function when initiated within 3 days of symptom onset and should be prescribed for otherwise healthy adults presenting early 1.
• The evidence for long-term benefit remains uncertain, but steroids are reasonable for patients without contraindications who present acutely 1.
• Withhold steroids from patients at higher risk of steroid-related complications (e.g., uncontrolled diabetes, severe hypertension, active infection) 1.

Symptomatic Medications (Acute Phase Only)

• Vestibular suppressants (e.g., meclizine) and antiemetics are useful acutely but must be withdrawn after the first several days because prolonged use impedes central vestibular compensation 1, 2.
• Meclizine is FDA-approved for vertigo associated with vestibular system diseases in adults 3.
• Limit symptomatic medications to the acute phase only—typically the first 2–3 days—to relieve severe vertigo, nausea, and vomiting 1, 4.
• Generalized supportive care includes hydration and antiemetics during the acute phase 2.

Antiviral and Vasodilator Therapy

• Antiviral therapy and vasodilator therapy have been reported as specific drug options, though evidence for routine use is limited 2.
• The pathogenesis likely involves reactivation of herpes simplex virus affecting the vestibular ganglion or nerve, but antiviral efficacy requires further validation 1, 4.

Vestibular Rehabilitation Therapy

• Early resumption of normal activity should be encouraged immediately to promote central vestibular compensation 1.
• Directed vestibular rehabilitation therapy accelerates recovery and should begin as soon as the acute phase subsides (typically after 2–3 days) 1, 2, 4.
• Vestibular rehabilitation includes generalized vestibular exercises and customized vestibular exercises tailored to the patient's deficits 2.
• Prolonged use of vestibular suppressants delays compensation; discontinue them early and transition to active rehabilitation 1, 4.

Diagnostic Confirmation and Red Flags

Confirming Vestibular Neuritis

• Characteristic features include abrupt true-whirling vertigo lasting >24 hours, horizontal-torsional spontaneous nystagmus beating away from the lesion side, and absence of cochlear symptoms (no hearing loss, tinnitus, or aural fullness) 2, 4.
• Abnormal head impulse test for the involved semicircular canals, ipsilesional caloric paresis, and unsteadiness with falling toward the lesion side confirm the diagnosis 4.
• Vestibular neuritis preferentially involves the superior vestibular labyrinth; the posterior semicircular canal and saccule are usually spared 4.

When to Obtain Brain Imaging

• Brain imaging (MRI preferred) is indicated when the patient has unprecedented severe headache, negative head impulse test, severe imbalance disproportionate to vertigo, or no recovery within 1–2 days 4.
• Any focal neurological deficits (dysarthria, dysphagia, visual disturbances, limb weakness/numbness, Horner's syndrome) mandate immediate MRI to exclude posterior circulation stroke 5.
• Direction-changing nystagmus without head position changes, downbeating nystagmus, or baseline nystagmus without provocative maneuvers are red flags requiring emergency imaging 5.
• Patients with significant vascular risk factors (age >50, hypertension, diabetes, atrial fibrillation, prior stroke) should be evaluated for possible stroke even with typical vestibular neuritis features 1, 6.

Prognosis and Follow-Up

• Most patients recover well from vestibular neuritis even without treatment, though steroids may accelerate recovery 1.
• Vertigo typically peaks within 6–8 hours, gradually subsides over 7 days, and becomes tolerable by 10 days 7.
• Despite proper treatment and rehabilitation, signs of dynamic vestibular imbalances may persist for months to a year in some patients 7.
• Recurrence is possible, and patients should be counseled about the natural history and expected recovery timeline 2.

Common Pitfalls to Avoid

• Do not prescribe vestibular suppressants beyond the first 2–3 days; prolonged use delays central compensation and prolongs recovery 1, 4.
• Do not dismiss central causes in patients with atypical features (negative head impulse test, severe imbalance, no improvement after 1–2 days, or vascular risk factors) 4, 5.
• Do not confuse vestibular neuritis with labyrinthitis; labyrinthitis includes profound hearing loss, whereas vestibular neuritis has no cochlear symptoms 8, 4.
• Do not delay imaging if red flags are present; 75–80% of posterior circulation strokes presenting with acute vestibular syndrome lack focal deficits on initial examination 6.