Acute vestibulopathy (vestibular failure)

Question 1

Acute vestibulopathy (vestibular failure) definition / Causes:

Answer 1

1). Vestibular neuritis

This term covers both vestibular neuritis and labyrinthitis,

which are considered to be:

• a viral infection of the vestibular nerve and labyrinth respectively,
• causing a prolonged attack of vertigo that can last for several days.

2). Stroke—of the inferior cerebellar arteries, AICA or PICA

Question 2

Vestibular neuritis

Answer 2

It is analogous to a viral infection of the 7th nerve causing Bell palsy.

The attack is similar to Ménière syndrome except that there is no hearing disturbance

Question 3

Vestibular neuritis triad

Answer 3

acute vertigo + nausea + vomiting

Question 4

Viral labyrinthitis

Answer 4

it is basically the same as vestibular neuronitis, except that:

• the whole of the inner ear is involved
• so that deafness and tinnitus arise simultaneously with severe vertigo.

Question 5

Acute labyrinthitis triad

Answer 5

acute vertigo + nausea + vomiting (same vestibular neuritis symptoms) + hearing loss ± tinnitus

Question 6

Main clinical features

Answer 6

It is basically a diagnosis of exclusion

• single attack of vertigo without tinnitus or deafness
• often follows a ‘flu-like’ illness
• mainly in young adults and middle age
• abrupt onset with vertigo, ataxia, nausea and vomiting
• Horizontal nystagmus (in acute phase)
• No hearing loss or tinnitus
• generally lasts days to weeks
• lateral or unidirectional nystagmus—rapid component away from side of lesion
• caloric stimulation confirms impaired vestibular function

Question 7

Treatment

Answer 7

1. Rest in bed, lying very still
2. Gaze in the direction that eases symptoms
3. Encourage patients to mobilise as early as possible
4. Drugs to lessen vertigo

Question 8

The following drugs can be used to lessen vertigo:

Answer 8

Promethazine 10–25 mg IM or IV (slow) then 10–25 mg (ο) for 48 hrs or

Prochlorperazine (Stemetil) 12.5 mg IM (if severe vomiting) or (recommended) / 5 mg PO, TDS daily

Scopolamine patches (not funded for this indication, cost is around $25 to $27 for 2 patches, each patch lasts 72 hours).

Diazepam (which decreases brain-stem response to vestibular stimuli) 5–10 mg IM for the acute severe attack then 5 mg (o) tds for 3 days

A short course of corticosteroids can promote recovery, e.g. prednisolone 1 mg/kg (up to 100 mg) ο mane for 5 d then taper over 15 d

Question 9

Outcome

Answer 9

Both are self-limiting disorders and usually settle

• over several days (e.g. 5–7) or weeks.

Review if vertigo persists after 2 weeks.

Labyrinthitis usually lasts longer and during

• recovery rapid head movements may bring on transient vertigo.

Some will have recurrent attacks and may need self-administered antiemetics e.g.

• buccal prochlorperazine.

Often short-lived but if not, consider requesting non-acute ENT/Otolaryngology assessment.

Question 10

Recurrent vestibulopathy

Answer 10

Episodic vertigo ± vomiting of similar duration to Meniere

• No hearing loss, tinnitus or focal neurological signs
• Peak age 30–50 yrs, M = F
• Aetiology unknown—possibly migraine variant

Treatment is symptomatic.