Overview
Vestibular Neuritis
1. Clinical Overview
Summary
Vestibular Neuritis is an Acute, Peripheral Vestibular Disorder characterised by Sudden Onset of Severe, Prolonged Rotational Vertigo, Nausea and Vomiting, Postural Imbalance, and Horizontal-Torsional Nystagmus beating away from the affected ear. It is caused by Viral Inflammation (Or Reactivation) of the Vestibular Nerve, most commonly attributed to Herpes Simplex Virus Type 1 (HSV-1). Crucially, Hearing is Preserved (Unlike Labyrinthitis, Which involves the cochlea and causes hearing loss). Vestibular Neuritis is one of the most common causes of Acute Vestibular Syndrome (AVS) and must be differentiated from Central Causes (Posterior Circulation Stroke) using the HINTS Exam. The acute vertigo typically lasts 24-72 hours, with gradual improvement over 1-6 weeks as Central Vestibular Compensation occurs. Treatment is Supportive (Vestibular Suppressants short-term, Antiemetics), with Vestibular Rehabilitation being crucial for recovery. [1,2,3]
Clinical Pearls
"Vertigo WITHOUT Hearing Loss = Vestibular Neuritis. WITH Hearing Loss = Labyrinthitis.": Key distinction.
"HINTS Exam Beats MRI in Acute Phase": More sensitive than early MRI for detecting posterior stroke. Learn the HINTS exam.
"Nystagmus Beats AWAY from the Lesion": The fast phase beats towards the healthy side.
"Vestibular Rehab is Key": Early mobilisation and vestibular exercises promote central compensation.
2. Epidemiology
Demographics
| Factor | Notes |
|---|---|
| Incidence | ~3.5 per 100,000 per year. |
| Age | Peak 30-60 years. |
| Sex | Equal. |
| Seasonality | Some studies suggest increased incidence in spring/Summer (Viral link). |
Aetiology
| Cause | Notes |
|---|---|
| Viral (Most Likely) | HSV-1 reactivation (Strongest evidence). Other viruses: VZV, CMV, EBV, Adenovirus, Influenza. |
| Post-Viral Inflammation | Following URTI. |
| Vascular (Rare, Consider) | Ischaemia of vestibular nerve (Uncommon but important differential). |
3. Anatomy and Pathophysiology
Vestibular Nerve
- Superior Division: Innervates Superior SCC, Horizontal SCC, Utricle.
- Inferior Division: Innervates Posterior SCC, Saccule.
- Usually Superior Division Affected: Hence Posterior SCC often spared.
Mechanism
- Viral Infection / Reactivation: HSV-1 in vestibular ganglion (Scarpa's ganglion).
- Inflammation and Oedema: Of vestibular nerve within bony canal.
- Unilateral Vestibular Hypofunction: Sudden loss of input from one labyrinth.
- Tonic Imbalance: Brain perceives asymmetric vestibular input → Sensation of rotation (Vertigo).
- Nystagmus: Slow phase towards affected (Hypoactive) side, Fast phase away (Towards healthy side).
- Central Compensation: Over days to weeks, Brain recalibrates to asymmetric input.
4. Clinical Presentation
Symptoms
| Symptom | Notes |
|---|---|
| Acute Severe Rotational Vertigo | Sustained. Lasts hours to days. Worsened by head movement. |
| Nausea and Vomiting | Prominent. Can be severe. |
| Postural Instability / Imbalance | Difficulty walking. Falls towards affected side. |
| Oscillopsia | Visual blurring with head movement (Due to VOR impairment). |
| NO Hearing Loss | Key distinction from Labyrinthitis. |
| NO Tinnitus | Key distinction from Labyrinthitis. |
| NO Neurological Symptoms | No weakness, Numbness, Dysarthria, Diplopia (Would suggest central cause). |
| Preceding URTI | In ~50%. |
Examination Findings
| Finding | Notes |
|---|---|
| Horizontal-Torsional Nystagmus | Fast phase AWAY from affected ear. Unidirectional. Increased with gaze towards fast phase (Alexander's Law). Suppressed by visual fixation. |
| Positive Head Impulse Test (HIT) | Key finding. Quick head turn towards affected side → Corrective saccade (Catch-up eye movement). Indicates peripheral lesion. |
| Romberg | Falls towards affected side. |
| Gait | Unsteady. Veers towards affected side. |
| Hearing | Normal (Weber/Rinne normal). |
| Neurological Exam | Normal. No cerebellar signs, Cranial nerve palsies. |
HINTS Exam (Head Impulse, Nystagmus, Test of Skew)
| Test | Peripheral (Vestibular Neuritis) | Central (Stroke) |
|---|---|---|
| Head Impulse (HIT) | Abnormal (Corrective saccade) | Normal (Or abnormal) |
| Nystagmus | Unidirectional, Horizontal-Torsional, Suppressed by fixation | Direction-changing, Vertical, Not suppressed by fixation |
| Test of Skew (Alternate Cover) | Negative (No vertical deviation) | Positive (Vertical deviation – Skew deviation) |
HINTS Rule: If HIT is Normal, Nystagmus is Direction-Changing/Vertical, OR Skew Deviation is Present → Suspect Central Cause (Stroke). Refer urgently.
5. Differential Diagnosis
Acute Vestibular Syndrome Differentials
| Condition | Key Features |
|---|---|
| Posterior Circulation Stroke | HINTS exam central pattern. Risk factors (Age, HTN, AF, DM). Neurological signs. |
| Labyrinthitis | Similar to VN BUT with Hearing Loss ± Tinnitus (Cochlear involvement). |
| BPPV | Brief episodes (less than 1 min) triggered by specific head positions. Dix-Hallpike positive. |
| Meniere's Disease | Recurrent episodes. Hearing loss (Fluctuating), Tinnitus, Aural fullness. |
| Vestibular Migraine | Recurrent. History of migraine. Other migraine features. |
| Multiple Sclerosis | Young patient. Other neurological episodes/Signs. MRI lesions. |
6. Investigations
Diagnosis is Clinical
- Based on history and examination (Especially HINTS exam).
Investigations (When Indicated)
| Investigation | Notes |
|---|---|
| MRI Brain (DWI) | If central cause suspected (HINTS central pattern, Risk factors, Atypical features). Note: Early MRI (less than 48h) can be falsely negative for posterior stroke. HINTS is more sensitive acutely. |
| Audiometry | Normal in Vestibular Neuritis. Hearing loss → Labyrinthitis. |
| Caloric Testing / VNG (Videonystagmography) | Confirms peripheral vestibular hypofunction. Shows reduced caloric response on affected side. Not needed acutely. |
| Blood Tests | Generally not helpful for VN. Consider if other diagnoses. |
7. Management
Management Algorithm
ACUTE VESTIBULAR SYNDROME
(Sudden Onset Prolonged Vertigo, Nystagmus, Imbalance)
↓
PERFORM HINTS EXAM
(Head Impulse, Nystagmus type, Test of Skew)
┌────────────────┴────────────────┐
HINTS PERIPHERAL HINTS CENTRAL PATTERN
(Positive HIT, Uni-directional (Normal HIT, Direction-changing/
Nystagmus, No Skew) Vertical Nystagmus, Skew +)
↓ ↓
**VESTIBULAR NEURITIS** **SUSPECT STROKE**
(Or Labyrinthitis if HL) → Urgent MRI/CT
→ Stroke pathway
↓
VESTIBULAR NEURITIS MANAGEMENT
┌──────────────────────────────────────────────────────────┐
│ **ACUTE PHASE (First 24-72 hours)** │
│ │
│ **SUPPORTIVE CARE** │
│ - Rest in quiet, Dark environment │
│ - IV Fluids if unable to tolerate orally │
│ │
│ **VESTIBULAR SUPPRESSANTS (Short-Term Only)** │
│ - Prochlorperazine 5mg TDS PO/Buccal/IM (Stemetil) │
│ - Cyclizine 50mg TDS PO/IM (Valoid) │
│ - Cinnarizine 15-30mg TDS PO (Stugeron) │
│ - Betahistine 16mg TDS PO (May help, Limited evidence) │
│ - **LIMIT TO 3-5 DAYS**: Prolonged use impairs central │
│ compensation │
│ │
│ **ANTIEMETICS** │
│ - As above (Antihistamines/Anticholinergics) │
│ - Ondansetron 4-8mg PO/IV (Less sedating) │
│ │
│ **CORTICOSTEROIDS (Controversial)** │
│ - Some evidence for faster recovery of vestibular │
│ function if given early (Within 3 days) │
│ - Methylprednisolone or Prednisolone tapering course │
│ - Not universally recommended. │
│ │
│ **ANTIVIRALS (Not Routinely Recommended)** │
│ - No proven benefit for vestibular neuritis. │
└──────────────────────────────────────────────────────────┘
↓
RECOVERY PHASE (Days to Weeks)
┌──────────────────────────────────────────────────────────┐
│ **EARLY MOBILISATION** │
│ - Encourage movement as soon as tolerated │
│ - Promotes central compensation │
│ │
│ **VESTIBULAR REHABILITATION (Key Intervention)** │
│ - Referral to Vestibular Physiotherapist │
│ - Gaze Stabilisation Exercises (VOR exercises) │
│ - Habituation Exercises │
│ - Balance Training │
│ - Cawthorne-Cooksey Exercises │
│ - Significantly improves outcomes and speeds recovery │
│ │
│ **STOP VESTIBULAR SUPPRESSANTS** │
│ - After 3-5 days. Impair compensation if prolonged. │
│ │
│ **REASSURANCE** │
│ - Symptoms typically improve over 1-6 weeks │
│ - Some residual imbalance may persist (Especially with │
│ rapid head movements) │
└──────────────────────────────────────────────────────────┘
8. Complications
| Complication | Notes |
|---|---|
| Prolonged Symptoms | Some patients have persistent unsteadiness. |
| Incomplete Compensation | Chronic dizziness. Associated with anxiety, Avoidance behaviours. |
| Benign Paroxysmal Positional Vertigo (BPPV) | Can develop post-VN (~15%). Treat with Epley manoeuvre. |
| Persistent Postural-Perceptual Dizziness (PPPD) | Functional dizziness syndrome. Chronic non-vertiginous dizziness. |
| Anxiety / Depression | Common. |
| Falls | During acute phase. |
9. Prognosis and Outcomes
| Factor | Notes |
|---|---|
| Acute Symptoms | Peak severity 24-48h. Gradual improvement. |
| Recovery | Most patients significantly better by 1-3 weeks. Full recovery over 1-3 months. |
| Vestibular Function | ~50% have persistent vestibular hypofunction on caloric testing, But symptoms compensate. |
| Vestibular Rehab | Patients who do vestibular rehab have faster and more complete recovery. |
| Recurrence | Rare (~2-5%). |
10. Evidence and Guidelines
Key Guidelines
| Guideline | Notes |
|---|---|
| NICE CKS / Cochrane | Vestibular suppressants short-term. Early mobilisation. Vestibular rehab. Steroids controversial. |
Key Evidence
- HINTS Exam: More sensitive than early MRI for posterior stroke (Sensitivity ~100% vs ~80% for DWI MRI less than 48h).
- Vestibular Rehab: Strong evidence for benefit.
- Corticosteroids: Some RCTs show improved vestibular function recovery, But clinical benefit less clear.
11. Patient and Layperson Explanation
What is Vestibular Neuritis?
Vestibular Neuritis is inflammation of the nerve that connects your inner ear (Balance organ) to your brain. This causes sudden, Severe dizziness (Vertigo).
What are the symptoms?
- Sudden, Intense spinning sensation (Vertigo).
- Feeling sick (Nausea) and vomiting.
- Difficulty balancing and walking.
- Eyes may jump (Nystagmus).
- Hearing is NOT affected (If your hearing is affected, It may be a related condition called Labyrinthitis).
What causes it?
It is usually caused by a viral infection affecting the balance nerve, Often following a cold or flu.
How is it treated?
- In the first few days: Medications to reduce dizziness and sickness. Rest.
- After a few days: It is important to start moving around, Even if you feel unsteady. This helps your brain adapt.
- Vestibular Rehabilitation: Special exercises (Often with a physiotherapist) to help your balance system recover.
How long does it last?
The severe dizziness usually lasts 1-3 days. You will gradually improve over 1-6 weeks. Some people feel slightly off-balance for longer, But this usually gets better with exercises.
When should I seek help urgently?
- New weakness, Numbness, Or difficulty speaking.
- Double vision.
- Severe headache.
- If the dizziness is very different from typical vertigo (e.g., You feel like you're going to pass out).
- If you have risk factors for stroke (High blood pressure, Diabetes, Heart problems) – See a doctor promptly.
12. References
Primary Sources
- Strupp M, Brandt T. Vestibular neuritis. Semin Neurol. 2009;29(5):509-519. PMID: 19834862.
- Kattah JC, et al. HINTS to diagnose stroke in the acute vestibular syndrome. Stroke. 2009;40(11):3504-3510. PMID: 19762709.
- Hillier S, McDonnell M. Vestibular rehabilitation for unilateral peripheral vestibular dysfunction. Cochrane Database Syst Rev. 2011;2011(2):CD005397. PMID: 21328277.
13. Examination Focus
Common Exam Questions
- HINTS Exam: "What are the three components of the HINTS exam?"
- Answer: Head Impulse Test (HIT), Nystagmus type, Test of Skew (Alternate Cover Test).
- Peripheral vs Central: "What HINTS findings suggest a peripheral cause like vestibular neuritis?"
- Answer: Positive (Abnormal) HIT (Corrective saccade), Unidirectional Horizontal-Torsional Nystagmus (Suppressed by fixation), Negative Skew Test.
- Hearing: "What distinguishes Vestibular Neuritis from Labyrinthitis?"
- Answer: Vestibular Neuritis = No Hearing Loss. Labyrinthitis = Hearing Loss ± Tinnitus.
- Key Treatment: "What is the key intervention for recovery in vestibular neuritis?"
- Answer: Vestibular Rehabilitation (Physiotherapy-led exercises).
Viva Points
- Nystagmus Fast Phase Beats Away from Lesion: Towards healthy side.
- Limit Vestibular Suppressants to 3-5 Days: Prolonged use impairs central compensation.
- HINTS More Sensitive Than Early MRI: For posterior stroke.
- Usually Superior Division Affected: Posterior SCC often spared (May lead to post-VN BPPV).
Medical Disclaimer: MedVellum content is for educational purposes and clinical reference. Clinical decisions should account for individual patient circumstances. Always consult appropriate specialists.