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Vestibular Neuronitis

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Overview

Vestibular neuronitis is the inflammation of the vestibular nerve often following a viral infection leading to problems with balance. Vestibular neuronitis is where only the vestibular nerve is affected i.e. there is no hearing loss involved, only balance problems. Labyrinthitis is where both the vestibular nerve and labyrinth are affected.

Epidemiology

  • Prevalence highest in 40-50 years
  • Incidence is 3.5 cases per 100,000

Risk Factors

Presentation

Patients classically have episodes of vertigo lasting hours to days following a recent upper respiratory tract infection. Features are:

  • No hearing loss or tinnitus
  • Vertigo – this is worsened with movement but not triggered by it
  • Nausea and vomiting associated with the vertigo
  • Horizontal nystagmus towards the unaffected side
  • Gait abnormalities – patients usually fall to the affected side

Differential Diagnoses

Labyrinthitis

  • There is vertigo but hearing loss is present
  • Can also follow a recent viral infection

Meniere’s disease

  • Recurrent episodes of hearing loss, tinnitus, vertigo, and a sensation of aural fullness
  • There is usually no preceding viral infection

Benign paroxysmal positional vertigo

  • Episodes of vertigo are triggered by changes in head position
  • There is usually no preceding viral infection

Vestibular schwannoma

  • Sensorineural hearing loss, vertigo, and tinnitus present with potential cranial nerve involvement e.g. absent corneal reflex is CN V is involved

Posterior stroke

  • Ataxia
  • Romberg’s test negative
  • Facial paralysis/dysphagia
  • Contralateral lower extremity weakness

Diagnosis and Referal

All patients

  • Clinical diagnosis – based on history and examination

Referral

Refer to a neurologist or balance specialist if:

  • Symptoms are atypical e.g. additional neurological symptoms
  • Urgent referral if symptoms persist >1 week without improvement despite treatment
  • Symptoms >6 weeks

Management

All patients

  • 1st-line: reassurance – symptoms usually settle over several weeks
  • Severe nausea/vomiting: short-term buccal prochlorperazine/IM prochlorperazine or cyclizine
    • This rapidly relieves these symptoms
  • Less severe nausea/vomiting/vertigo: short-course oral prochlorperazine or antihistamines (cyclizine/promethazine/cinnarizine)
    • Short courses should be used as these can delay recovery

Monitoring

  • Patients should return if their symptoms worsen or have not fully resolved after a week

Patient Advice

  • Patients should be reassured that symptoms usually resolve over several weeks
  • Patients should not drive/operate heavy machinery if they are dizzy or likely to experience vertigo when driving
  • Patients should take measures to reduce the risk of falls in the home
  • Patients should avoid alcohol and should be offered help with this if need be

Complications

Prognosis

  • Most patients recover within 6 weeks
  • Recurrence is unlikely and if it occurs, alternate diagnoses should be considered

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