What is the recommended diagnostic work‑up and management for a patient with acute onset vertigo, nausea, vomiting, gait instability, no hearing loss, no focal neurologic deficits, and no recent head trauma suggestive of vestibular neuronitis?

Management of Vestibular Neuronitis

Immediate Diagnostic Confirmation

The first priority is to confirm the diagnosis of vestibular neuronitis and exclude stroke, which mimics this presentation in 25% of acute vestibular syndrome cases. 1

Key Clinical Features Supporting Vestibular Neuronitis

• Acute onset of severe, continuous rotatory vertigo lasting days to weeks with severe nausea, vomiting, and intolerance to head motion 1, 2
• Complete absence of hearing loss, tinnitus, or aural fullness—this is the critical differentiator from labyrinthitis 2
• Horizontal spontaneous nystagmus with a rotational component beating toward the unaffected (healthy) ear 3
• Positive head-impulse test toward the affected ear, indicating ipsilateral vestibuloocular reflex deficit 3
• Postural imbalance with falls toward the affected ear 3

Mandatory Stroke Exclusion

You must obtain urgent MRI brain without contrast if ANY of the following red flags are present: 1

• Age >50 years with vascular risk factors (hypertension, diabetes, atrial fibrillation, prior stroke)—even with normal neurologic exam, because 11–25% harbor posterior circulation stroke 1
• Severe postural instability with inability to stand or walk 1
• Direction-changing nystagmus or purely vertical nystagmus without torsional component 1, 4
• Normal head-impulse test (suggests central cause) 1
• Any focal neurologic deficits (dysarthria, limb weakness, diplopia, Horner's syndrome) 1, 4
• New severe headache 1
• Failure to improve after 3–5 days 1

Critical pitfall: 75–80% of posterior circulation strokes present without focal neurologic deficits, so a normal neurologic exam does NOT exclude stroke in high-risk patients 1

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Pharmacologic Treatment

Corticosteroids (First-Line Disease-Modifying Therapy)

Initiate oral corticosteroids within 3 days of symptom onset—ideally within 24 hours—to accelerate recovery of vestibular function. 2, 5

• Regimen: Methylprednisolone 100 mg daily for 3 days, then taper over 7–10 days 2
• Alternative: Prednisolone 50 mg daily for 5 days, then taper over next 5 days 5
• Evidence: 100% of patients treated within 24 hours achieved normal caloric testing at 3 months, versus only 58% treated between 25–72 hours 5
• Mechanism: Steroids promote peripheral restoration of labyrinthine function, achieving 62% recovery rate within 12 months 3

Withhold steroids in patients with significant vascular risk factors or those presenting >3 days after onset, as the risk-benefit ratio becomes unfavorable. 6

Symptomatic Management (Short-Term Only)

Use antiemetics and vestibular suppressants sparingly and discontinue after 3 days maximum—prolonged use impedes central vestibular compensation. 2, 6

• Antiemetics: Metoclopramide 10 mg IV or prochlorperazine 10 mg IV for severe nausea/vomiting 1
• Vestibular suppressants: Meclizine or diazepam only for the first 2–3 days 2, 6
• Rationale: These medications delay the brain's natural compensation process and prolong recovery 2, 6

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Rehabilitation and Recovery

Early Mobilization (Essential)

Encourage early resumption of normal activity as soon as the acute phase subsides (typically after 3–5 days) to promote central vestibular compensation. 6, 3

• Recovery occurs through three mechanisms: (1) peripheral labyrinthine restoration (incomplete), (2) somatosensory and visual substitution, and (3) central compensation 3
• Bed rest beyond the acute phase delays compensation and worsens outcomes 6

Vestibular Rehabilitation Therapy

Refer for formal vestibular rehabilitation therapy if symptoms persist beyond 2–3 weeks or if balance deficits remain significant. 1, 6

• VRT significantly improves gait stability compared to medication alone 1
• Particularly beneficial for elderly patients or those with heightened fall risk 1
• Includes habituation exercises, gaze stabilization, balance retraining, and fall prevention 1

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Diagnostic Testing

When Imaging Is NOT Indicated

No imaging is required for typical vestibular neuronitis if: 1, 2

• Neurologic exam is completely normal
• No red-flag features present
• Low vascular risk profile
• Clinical presentation fits classic vestibular neuronitis pattern

CT head has <1% diagnostic yield and misses most posterior circulation strokes—never substitute CT for MRI when stroke is suspected. 1

Audiometric Testing

Obtain comprehensive audiologic examination to definitively exclude labyrinthitis. 2

• Vestibular neuronitis: normal audiometry 2
• Labyrinthitis: sensorineural hearing loss on affected side 2
• This distinction is critical because labyrinthitis carries risk of permanent hearing loss 2

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Expected Clinical Course

• Acute phase: Severe continuous vertigo lasting 12–36 hours 2, 3
• Subacute phase: Gradual improvement in disequilibrium over 4–5 days 2, 3
• Recovery phase: Mild transitory dizziness episodes may recur over 12–18 months 7
• Long-term: Most patients recover well, even without treatment, though steroids accelerate recovery 6

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Common Diagnostic Pitfalls

• Assuming vestibular neuronitis without performing head-impulse testing—this bedside test is essential for confirming peripheral vestibulopathy 3
• Missing central causes (stroke, MS, cerebellar hemorrhage) that mimic vestibular neuronitis—always maintain high suspicion in patients >50 years or with vascular risk factors 1, 8
• Prolonging vestibular suppressants beyond 3 days—this is the most common treatment error and significantly delays recovery 2, 6
• Failing to obtain audiometry—you cannot definitively diagnose vestibular neuronitis without excluding hearing loss 2