GP - Vestibular neuronitis and Labyrinthitis

Question 1

What is vestibular neuronitis?

Answer 1

Acute vertigo of peripheral origin

Question 2

What ‘s the difference between vestibular neuronitis and viral labyrinthitis?

Answer 2

Vestibular neuronitis is inflammation of the vestibular nerve and often occurs following a viral infection. Associated with vertigo only! Viral labyrinthitis is inflammation of the membranous labyrinth, affecting both the vestibular and cochlear end organs. Associated with both vertigo and hearing loss!

Vestibular neuronitis has an insidious onset while viral labyrinthitis has a more acute onset

Question 3

What age group does vestibular neuronitis/ labyrinthitis affect?

Answer 3

30-60 yrs old

Question 4

Give 3 complications of vestibular neuronitis/ labyrinthitis

Answer 4

BPPV

Falls

Affects ability to drive

Chronic hearing loss (in viral labyrinthitis only)

Question 5

What’s the most common cause of vestibular neuronitis and viral labyrinthitis?

Answer 5

Viral infections - Herpes simplex virus or influenza virus

Question 6

How long does it take for vestibular neuronitis to resolve?

Answer 6

Although Initial severe symptoms usually last 2-3 days, most people will recover gradually after 6 weeks

Question 7

What symptoms does a patient with vestibular neuronitis present with?

Answer 7

Symptoms

• Acute, rotational vertigo that is NOT triggered by movement, but is exacerbated by movement (changes of head position)
• N&V + autonomic symptoms e.g. sweating, pallor
• Poor balance and unsteadiness –> falls
• Hearing loss + tinnitus (only in viral labyrinthitis, absent in vestibular neuronitis)
• Recent Hx of URTI

Question 8

What signs does a patient with vestibular neuronitis have?

Answer 8

Signs

• HINTS examination
  
  • Abnormal head impulse test indicating impaired vestibulo-ocular reflex
  • Spontaneous unidirectional horizontal nystagmus towards the unaffected side
  • Normal skew test (no vertical skew) - tested by the cover/uncover test
  • Sensorineural hearing loss
    
    • If unilateral:
      
      • Rinne’s test - lateralises to the bad ear
      • Weber’s test - lateralises to the good ear
  • Gait disturbance - patient may fall towrads the affected side

Question 9

What advice should you give to the patient who has vestibular neuronitis?

Answer 9

• Reassure that severe symptoms tend to settle within 2-3 days and most people will recover gradually over 6 weeks if no treatment is given
• Advise to stay away from alcohol
• Advise not to drive if they feel dizzy
• Advise to inform employer if symptoms likely affect their ability to work
• Advise to return if symptoms deteriorate or have not fully resolved after 1 week

Question 10

What is the management for vestibular neurontis/ viral labyrinthitis?

Answer 10

To rapidly relieve N&V - give buccal/ IM prochlorperazine

For less severe N&V, give a short oral course of prochlorperazine

Vestibular rehabilitation exercises are the preferred treatment for patients who have chronic symptoms

Question 11

When should you refer patients?

Answer 11

Hospital admission if severe N&V and cannot tolerate oral fluids or medications

Refer to an ENT specialist if:

• Symptoms are not typical of vestibular neuronitis
• Symptoms don’t improve after 1 week despite treatment
• Symptoms persist for > 6 weeks