Vestibular neuritis (VN) is among the leading causes of peripheral vestibular vertigo. The disorder is characterized by a sudden and severe attack of vertigo that occurs as a result of acute unilateral disruption in vestibular function. Intense nausea and vomiting follow the episode. The disorder affects organs innervated by superior vestibular nerve but not those innervated by inferior vestibular nerve. Hence, the central brainstem functions remain unaffected [1].
Presentation
The classical symptoms of VN comprise an abrupt, acute attack of severe, debilitating vertigo which worsens with head movement, persistent nausea and vomiting, sustained, horizontal, spontaneous nystagmus directed towards the unaffected ear, postural imbalance and complete absence of auditory and neurological symptoms. The symptoms typically last for 7 to 10 days. Within days to weeks, the episodes of VN slowly subside without treatment [10]. The entire period of illness typically lasts for 6 weeks but in some cases, may persist for more than 9 weeks [11] [12]. The hallmark of VN which distinguishes it from Meniere disease and Labyrinthitis is the complete absence of auditory symptoms (tinnitus and hearing loss) and other neurological symptoms (diplopia and dysarthria). Other symptoms of VN that might ensue due to underlying vestibular injury are presence of residual dysequilibrium and rapid head movements [10].
Entire Body System
- Inflammation
Nerve, Inflammations, Vestibular Nerve, Nerve Inflammation, Vestibular, Nerve Inflammations, Vestibular, Vestibular Nerve Inflammation, Vestibular Nerve Inflammations, Nerve Neuritides, Vestibular, Nerve Neuritis, Vestibular, Neuritides, Vestibular Nerve [fpnotebook.com]
Depending on the location of the inflammation or damage to the nerve determines whether the hearing is affected. [chop.edu]
These steroids work to reduce inflammation of the vestibular nerve and decrease direct damage to the nerve itself. [cornerstonephysio.com]
Vestibular neuronitis: Inflammation of the vestibular nerve, the nerve running to the vestibule. (The vestibule is in the inner ear. [medicinenet.com]
- Falling
[…] neuritis are acute onset of rotatory vertigo lasting several days, horizontal-rotatory peripheral vestibular spontaneous nystagmus toward the unaffected ear, a pathological head-impulse test, tilt of the subjective visual vertical, postural imbalance with falls [oxfordmedicine.com]
Second, your case history should always include a question about a history of falls or near falls. [canadianaudiologist.ca]
[…] several days, horizontal spontaneous nystagmus (with a rotational component) toward the unaffected ear, a pathologic head-impulse test toward the affected ear, a deviation of the subjective visual vertical toward the affected ear, postural imbalance with falls [ncbi.nlm.nih.gov]
Twenty-two patients in the UVHG (73.3%) had had falls during the preceding year. Seven patients (23.3%) of the CG reported suffering falls over this period. [scielo.br]
- Fatigue
Vertiginous symptoms showed relative improvement, but in the last medical examination 4 out of 11 cases (36.4%) complained of unsteadiness when their head was rotated and fatigued. [ncbi.nlm.nih.gov]
The symptoms can include: Vertigo Imbalance Visual disturbance Nausea and vomiting Fatigue Sensitivity to busy places Hearing Loss Tinnitus Inability to cope with normal activities Fuzz feeling in the head Pressure in the ears Anxiety or panic attacks [manchesterphysio.co.uk]
Severe, continuous vertigo (the sensation of spinning or tilting) Inability to balance or walk straight Nausea and vomiting, which can lead to dehydration and extreme fatigue Diagnosis of Labyrinthitis and Vestibular Neuritis Depending on the eye movement [hopkinsmedicine.org]
We ask about general symptoms (anxious mood, depressed mood, fatigue, pain, and stress) regardless of condition. Last updated: May 12, 2019 [patientslikeme.com]
- Asymptomatic
McAuley JR, Dickman D, Mustain W, Anand VK: Positional nystagmus in asymptomatic human subjects. Otolaryngol Head Neck Surgery. 1996, 114: 545-553. 10.1016/S0194-5998(96)70245-0. [bmcneurol.biomedcentral.com]
Even patients who become asymptomatic may experience discomfort months to years later, when their vestibular system is challenged, as when riding in a fast-moving car or boat. [aao.org]
The patient remains asymptomatic and disease-free at 18 months of follow up. Discussion VIPoma is a neuroendocrine tumor that secretes VIP described the first time by Verner and Morrison in 1958 (1). [scielo.isciii.es]
Twenty months postresection, the patient remains asymptomatic and has declined further workup or intervention. [mdmag.com]
Patients are asymptomatic at rest. BPPV is the most common condition that causes t- EVS. Spontaneous episodic vestibular syndrome (s- EVS)- recurrent episodes of dizziness lasting minutes to hours. [cancertherapyadvisor.com]
- Difficulty Walking
Increased night blindness; difficulty walking in the dark, Bouncing vision whilst walking, Fuzzy vision. This is not a complete list of symptoms. [dizzinessandvertigo.weebly.com]
Some difficulty walking, especially in busy environments. A feeling of fullness in your ears. Mild motion sensitivity. Anxiety. Keep in mind that vestibular neuritis symptoms vary from person to person. [my.clevelandclinic.org]
The key features of vestibular neuronitis include acute sustained severe dizziness associated with nausea and vomiting, and difficulty walking because of vertigo, although the actual ability to walk is intact. [cancertherapyadvisor.com]
Difficulty walking. Collapse, or periods of unconsciousness. Numbness in areas of your body. Chest pain. An abnormally slow or fast pulse. An irregular pulse. Any other symptom that you cannot explain. [patient.co.uk]
Respiratoric
- Dyspnea
Hyperventilation and hypocapnia may be accompanied by dyspnea, chest pain, palpitations, or paresthesias. [aafp.org]
Gastrointestinal
- Nausea
[…] symptoms of neuritis (severe sudden vertigo or dizziness, nausea/vomiting, imbalance, nystagmus) along with hearing loss. [chop.edu]
Symptoms and Signs Symptoms of vestibular neuronitis include a single attack of severe vertigo, with nausea and vomiting and persistent nystagmus toward the affected side, which lasts 7 to 10 days. [msdmanuals.com]
It most often begins with a rapid onset of vertigo accompanied by nausea and vomiting. [entaacare.com]
The onset of both conditions is typically abrupt over minutes to hours, and may involve vertigo, imbalance, jumping vision due to eye movements, nausea and vomiting. [hopkinsmedicine.org]
It may be associated with nausea, vomiting, and previous upper respiratory tract infections. It generally has no auditory symptoms, unlike labyrinthitis. Vestibular neuronitis may also be associated with eye nystagmus. [audiologicaldiagnostics.com]
- Vomiting
Symptoms and Signs Symptoms of vestibular neuronitis include a single attack of severe vertigo, with nausea and vomiting and persistent nystagmus toward the affected side, which lasts 7 to 10 days. [msdmanuals.com]
[…] symptoms of neuritis (severe sudden vertigo or dizziness, nausea/vomiting, imbalance, nystagmus) along with hearing loss. [chop.edu]
VN is characterized by prolonged episodes of nausea, vomiting and vertigo and is the second most common cause of peripheral vestibular vertigo. [symptoma.com]
It most often begins with a rapid onset of vertigo accompanied by nausea and vomiting. [entaacare.com]
Skin
- Macula
Benign Paroxysmal Positional Vertigo An initial event causes displacement of otoconia from the macula of the utricle. When the patient lies down the loose otoconia displace to the posterior canal. [entad.org]
There was loss of hair cells, "epithelialization" of the utricular maculae and semicircular canal cristae on the deafferented side, and reduced synaptic density in the ipsilateral vestibular nucleus (Baloh et al, 1996). [tchain.com]
S. (1965) The laminated cytoplasmic inclusions in the sensory epithelium of the human macula. Journal of Ultrastructural Research, 12, 92. Goodhill, V. (1979) Ear Diseases, Deafness and Dizziness, p. 532. Harper and Row, Hagerstown, Maryland. [cambridge.org]
Eyes
- Blurred Vision
This may cause you to feel nauseous or be sick, have difficulty concentrating and blurred vision. These symptoms can range from mild to severe, with some people feeling that they’re unable to remain upright for the first few days. [gateswaytohealth.com]
This may cause you to feel nauseous or be sick, have difficulty concentrating and blurred vision. These symptoms can range from mild to severe, with some people feeling that theyre unable to remain upright for the first few days. [zana.com]
Viral infection, usually related to the upper respiratory tract or the gastrointestinal tract Less commonly, bacteria infection of the inner ear Dizziness/vertigo lasting minutes to hours Nausea Oscillopsia if both ears are affected (blurred vision with [ktph.com.sg]
Ears
- Benign Paroxysmal Positional Vertigo
1 [Objective diagnostic possibility in the differentiation of idiopathic and secondary benign paroxysmal positional vertigo]. 61 32008350 2020 2 Results in caloric test, video head impulse test and inner ear MRI in patients with Ménière's disease. 61 [malacards.org]
paroxysmal positional vertigo Treatment Supportive, symptomatic, early ambulation. [medical-dictionary.thefreedictionary.com]
In 35 of 177 patients, the vertigo-like condition was due to peripheral causes: 10 sudden deafness, six vestibular neuronitis, three benign paroxysmal positional vertigo and three Meniere's disease. [ncbi.nlm.nih.gov]
Dix-Hallpike maneuver (used to diagnose benign paroxysmal positional vertigo). [aafp.org]
References:[2] Differential diagnoses for vertigo Differential diagnosis of vertigo-associated disorders DDx Ménière disease Benign paroxysmal positional vertigo Persistent postural-perceptual dizziness Vestibular neuritis Vertigo Vertigo lasts for minutes [amboss.com]
Neurologic
- Vertigo
In labyrinthitis, hearing may be reduced or distorted in tandem with vertigo. [tchain.com]
[…] symptoms of neuritis (severe sudden vertigo or dizziness, nausea/vomiting, imbalance, nystagmus) along with hearing loss. [chop.edu]
However vestibular neuronitis only presents with vertigo, while viral labyrinthitis is also accompanied by tinnitus, hearing loss, or both. Although etiology is unclear, a viral cause is suspected. [msdmanuals.com]
[…] vestibular neuronitis a sudden, severe attack of vertigo without symptoms of deafness or tinnitus. [medical-dictionary.thefreedictionary.com]
Vestibular neuritis is the third most common cause of peripheral vestibular vertigo. It has an annual incidence of 3.5 per 100,000 persons and accounts for 7% of the patients at outpatient clinics specializing in the treatment of vertigo. [oxfordmedicine.com]
- Dizziness
Labyrinthitis and vestibular neuritis must be differentiated from other forms of dizziness. [chop.edu]
The symptoms of both vestibular neuritis and labyrinthitis typically include dizziness or vertigo, disequilibrium or imbalance, and nausea. Acutely, the dizziness is constant. [tchain.com]
“Vertigo and Dizziness in the Emergency Department”. [cancertherapyadvisor.com]
You can do several things to minimise any remaining feelings of dizziness and vertigo. [your.md]
- Nystagmus
The absence of apogeotropic nystagmus with the right ear down in pat 1 and 2 and nystagmus within normal limits (6–8 degrees) in pat 3 also make this an unlikely assumption. [bmcneurol.biomedcentral.com]
The nystagmus is unidirectional, horizontal, and spontaneous, with fast-beat oscillations in the direction of the unaffected ear. [msdmanuals.com]
Abstract We evaluated the vestibular functions, especially for positional nystagmus and caloric nystagmus, in 43 cases of vestibular neuronitis for long periods after its onset. [ncbi.nlm.nih.gov]
- Stroke
“HINTS to diagnose stroke in the Acute Vestibular Syndrome”. Stroke. vol. 40. 2009. pp. 3504- 3510. [cancertherapyadvisor.com]
Strokes are more common in people who have a history of smoking, high blood pressure, high cholesterol, diabetes, or previous stroke or heart attack. [hopkinsmedicine.org]
[Journal Article] Tidsskr Nor Laegeforen 2019; 139(14)Weisshaar M, Mygland Å, Ljøstad UTN Acute dizziness may have a number of causes, including cerebrovascular stroke which can present as isolated acute vestibular syndrome. [unboundmedicine.com]
[…] risk factors, or focal neurologic symptoms to rule out a lateral medullary/cerebellar stroke! [amboss.com]
"HINTS to diagnose stroke in the Acute Vestibular Syndrome". Stroke. vol. 40. 2009. pp. 3504- 3510. [clinicaladvisor.com]
- Giddiness
Dizziness, Giddiness and Feeling Faint Dizziness is a common complaint and has a very broad list of possible underlying causes. Dizziness is a nonspecific term which can mean true vertigo, light-headedness, ... [evidence.nhs.uk]
[…] gradual return of balance occurs over approximately 6-weeks period Benign Paroxysmal Positional Vertigo (BPPV) may occur as a squealer in 15% of those diagnosed with vestibular neuritis Consult your general practitioner to ascertain if the cause of your giddiness [ktph.com.sg]
Dizziness can be classified into four groups: vertigo (spinning sensation) disequilibrium (feeling of imbalance) light-headedness (sensation of giddiness)3 presyncope (sensation of feeling faint). [racgp.org.au]
Workup
Patients with symptoms characteristic of VN are recommended a series of tests and assessments in order to establish a definite diagnosis of the disease. A complete history and thorough physical examination is performed which is followed by an audiologic assessment along with electronystagmography, caloric testing, imaging, laboratory studies and Hallpike maneuver.
MRI is performed to locate the vertigo and to rule out the presence of central vertigo. It is the preferred method of imaging compared to computed topography (CT) scan as the former method shows visible augmentation of the vestibular nerve and provides a vague image of internal auditory canals and. Imaging helps in ruling out other diagnoses and should therefore only be considered in patients suspected of suffering from other illnesses as well.
Laboratory studies are usually indicated to exclude other diagnoses and to differentiate among types of vertigo which may be found in other disease conditions. For instance, presence of abnormal serum glucose levels and anemia along with dizziness can be suggestive of cardiac dysrhythmia.
Another specific diagnostic test that helps in determining the cause of vertigo is Hallpike maneuver. The patient is instructed to turn the head in three different angles in a lied back supine position and is checked for the presence of nystagmus.
Treatment
As described earlier, determination of the type of vertigo and distinguishing the disorder from other forms with similar symptoms is of paramount importance in order to establish accurate diagnosis and initiate treatment. VN is a self-limiting condition and the symptoms often subside without treatment through physiological vestibular compensation. Management of VN is largely symptomatic with the use of anticholinergics, antiemetics, antihistamines, benzodiazepines and corticosteroids. Presence of dehydration due to severe vomiting must be corrected by starting an intravenous (IV) line. Physical therapy aimed at performing vestibular rehabilitation also helps in improving vestibular function.
In a study performed to determine possible treatment options that may help in protecting the vestibular apparatus and restoring vestibular function, it was found that administration of methylprednisolone in tapered doses can help in sustaining vestibular function. Furthermore, use of antiviral agent (valacyclovir) alone and in combination with methylprednisolone has also proved to be helpful [13].
Prognosis
The majority of patients suffering from VN typically recovers from episodes of severe vertigo and imbalance within a week without treatment. A small percentage of patients may experience recurrent, less severe attacks with prolonged symptoms [7]. The prognosis of VN is reported to be better in children than in adults [9]. In a clinical study conducted by Matsuo and Sekitani, it was reported that VN shows partial resolution in some cases with 15% of cases out of total 38 patients demonstrating recurrence of vestibular symptoms after 1 year [8].
Etiology
As described earlier, the definite cause of VN is not discovered yet. According to most researchers, underlying viral infection might lead to the development of VN by some uncertain mechanism. Another suspected cause that may precipitate VN is localized ischemia of the vestibular apparatus.
Presumably, viral infection of the vestibular nerve, vestibular ganglion or vestibular labyrinth is thought to be one of the most common causes of VN [3]. It is believed that VN may occur in children with preceding viral infection of the inner ear, viral infection caused by herpes virus in different parts of the body (cold sores, shingles, chicken pox) or other viral infections such as measles, flu, mumps, hepatitis and polio.
Epidemiology
The incidence rate of VN is reported to be approximately 3.5 cases among 100,000 people [5]. In the United States, about 5.6% cases of dizziness reported in emergency are due to VN [4]. The disease can occur in both males or females with no established gender predominance. Studies have shown that VN typically effects middle-aged individuals in between 30 and 60 years [5].
Pathophysiology
To date, the etiology and definite pathophysiology of VN largely remain unknown. However, certain theories claim that the reactivation of a previously latent neurotropic virus (for instance, herpes simplex virus) in the vestibular ganglia accounts for the onset of an inflammatory reaction, leading to sudden dysfunction of afferent neuronal input of the vestibular apparatus. The disruption leads to self-limited episodes of vertigo. The evidence of suspected herpetic viral infection in pathophysiology of VN is suggested by histologic evaluation of the temporal bone that shows visible changes. The lesions occurring in VN are limited to vestibular neurons only with no involvement of cochlear and vestibular elements of inner ear. Therefore, the vertigo occurs solely in the absence of hearing loss and central involvement, a distinctive feature of VN [6].
Prevention
Prevention of VN requires staying away from a possible viral infection as the disease is thought to occur due to such. Getting complete vaccination shots and following treatment regimen in patients who are already on antimicrobial therapy are also helpful measures in preventing VN.
Summary
Vestibular neuronitis (VN), also referred to as vestibular neuropathy or acute peripheral vestibulopathy is described as acute, persistent dysfunction of the peripheral vestibular system that occurs as a result of inflammation of the vestibular division of the 8th cranial nerve. VN is characterized by prolonged episodes of nausea, vomiting and vertigo and is the second most common cause of peripheral vestibular vertigo [1] [2]. The etiology of VN is not completely known but it is thought to emerge from inflammatory reaction provoked by the herpes simplex virus where that effects the vestibular ganglion and vestibular nerve [3]. Diagnosis of VN requires meticulous assessment to rule out other similar diagnoses. VN, primarily exhibiting a peripheral cause, must be differentiated from other conditions possessing central cause. Such can be cerebral stroke and hemorrhage, the latter possibly fatal. In cases when central signs are suspected or vertigo is undifferentiated from others forms of dizziness, magnetic resonance imaging (MRI) is suggested to establish a definite diagnosis. Other diagnostic tests of VN comprise audiologic assessment, caloric testing, electronystagmography and Hallpike maneuver. Recovery following an episode of VN often occurs without definite treatment although symptomatic management helps in alleviating symptoms and improving the overall condition. Prolonged use of vestibular suppressants in order to reduce episodes of VN should be avoided as the physiologic compensation might be disrupted. Commonly used drugs to reduce symptoms of VN are anticholinergics, antiemetics, antihistamines, benzodiazepines and corticosteroids. Because the definite cause of VN is unknown, no specific preventive measures of the disease are established. Avoiding viral infection, getting appropriate vaccination and following complete course of antimicrobial drugs can be helpful in preventing VN.
Patient Information
Vestibular neuronitis (VN) is a disorder of a part of the brain (called vestibular system) which results in a sudden, intensive episode of vertigo, (a type of dizziness in which the patient experiences false feeling of head spinning) followed by severe nausea and vomiting.
The definite cause of VN is not known but it is thought to occur from a viral infection. Herpes simplex virus, a type of virus belonging to the neurotropic group of viruses, is suspected to be involved in the disease. It is believed that after entering the body, the virus resides in the brain in an inactive state and becomes reactivated later to cause infection which then results in VN. Other viral infections that may precipitate VN include measles, flu, mumps, hepatitis and polio. An ischemic attack in the vestibular apparatus may also cause VN.
The characteristic signs and symptoms of VN is a single, severe attack of vertigo that may last several days and may be followed by additional milder vertigo attacks later for several weeks. Other symptoms are nausea and vomiting which last for 7 to 10 days. Usually the initial episode of vertigo is the most severe one. It has been estimated that in the US, about 3.5% cases of dizziness reported in the ER are found to occur from VN. The disease equally affects males and females with no gender predominance.
A series of hearing tests (audiologic assessment), tests for nystagmus (electronystagmography) and Hallpike maneuver are used to establish diagnosis. Laboratory studies and imaging (MRI scan) are performed to assure that the symptoms are characteristic of VN only and not caused by any other disease. Hallpike maneuver is a specific test used to identify the type of vertigo. In this test, the patient is instructed to lie down facing upwards three times with both eyes kept open. Throughout the assessment, the patient is checked for the appearance of nystagmus and symptoms of vertigo (appearance or worsening of symptoms).
VN often subsides itself without medicinal intervention. However, the severe and recurring symptoms can be managed by symptomatic treatment. When diagnosed correctly and treated appropriately, the outcome is usually positive. Commonly prescribed medicines used to control symptoms of VN are anticholinergics, antiemetics, antihistamines, benzodiazepines and corticosteroids. Physical therapy is also applied to improve brain function in VN. It is recommended to stay away from all forms of viral infections and follow complete course of antimicrobial therapy during infection in order to prevent VN.
References
- Aw ST, Fetter M, Cremer PD, Karlberg M, Halmagyi GM. Individual semicircular canal function in superior and inferior vestibular neuritis. Neurology. 2001;57(5):768-774.
- Cutfield NJ, Seemungal BM, Millington H, Bronstein AM. Diagnosis of acute vertigo in the emergency department. Emerg Med J. 2011;28(6):538-539.
- Schuknecht HF, Kitamura K. Second Louis H. Clerf Lecture. Vestibular neuritis. Ann Otol Rhinol Laryngol Suppl. 1981:1-19.
- Newman-Toker DE, Hsieh YH, Camargo CA Jr, Pelletier AJ, Butchy GT, Edlow JA. Spectrum of dizziness visits to US emergency departments: cross-sectional analysis from a nationally representative sample. Mayo Clin Proc. 2008;83(7):765-775.
- Sekitani T, Imate Y, Noguchi T, Inokuma T. Vestibular neuronitis: epidemiological survey by questionnaire in Japan. Acta Otolaryngol Suppl. 1993;503:9-12.
- Gacek RR, Gacek MR. Viral neuropathies in the temporal bone. Introduction. Adv Otorhinolaryngol. 2002;60:7-9.
- Mandalà M, Nuti D, Broman AT, Zee DS. Effectiveness of careful bedside examination in assessment, diagnosis, and prognosis of vestibular neuritis. Arch Otolaryngol Head Neck Surg. 2008;134(2):164-169.
- Matsuo T, Sekitani T. Vestibular neuronitis: neurotological findings and progress. ORL J Otorhinolaryngol Relat Spec. 1985;47(4):199-206.
- Tahara T, Sekitani T, Imate Y, Kanesada K, Okami M. Vestibular neuronitis in children. Acta Otolaryngol Suppl. 1993;503:49-52.
- Gacek RR. A Perspective on Recurrent Vertigo. ORL J Otorhinolaryngol Relat Spec. 2013;75(2):91-107.
- Clemis JD, Becker GW. Vestibular neuronitis. Otolaryngol Clin North Am. 1973;6(1):139-155.
- Worster-Drought C. An unusual epidemic. The Lancet. 1952;371.
- Strupp M, Zingler VC, Arbusow V, Niklas D, Maag KP, Dieterich M. Methylprednisolone, valacyclovir, or the combination for vestibular neuritis. N Engl J Med. 2004;351(4):354-361.