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Vestibular Neuritis and Labyrinthitis

Vestibular neuritis causes an acute vestibular syndrome of prolonged vertigo, nausea and imbalance without hearing loss; labyrinthitis adds hearing loss and/or tinnitus, but both diagnoses are made only after urgent assessment for posterior-circulation stroke and other dangerous causes.

In a nutshell

Vestibular neuritis causes acute continuous vertigo, nausea and imbalance without hearing loss; labyrinthitis adds hearing loss and/or tinnitus. Treat acute continuous vertigo as acute vestibular syndrome: exclude posterior-circulation stroke with trained HINTS or immediate stroke-pathway referral, urgently refer sudden sensorineural hearing loss, use antiemetics/antihistamines only briefly, then mobilise and rehabilitate.

Classic presentation

Sudden continuous vertigo with vomiting and unsteadiness lasting days, often after a viral illness, with a peripheral eye-movement pattern and no hearing loss in neuritis; hearing loss/tinnitus suggests labyrinthitis or another inner-ear diagnosis.

Key points

  • Acute vestibular syndrome is a clinical syndrome, not a diagnosis; posterior-circulation stroke is the critical mimic.
  • HINTS is appropriate only when performed by a healthcare professional trained and experienced in the test.
  • Normal head impulse, direction-changing nystagmus or skew deviation are central warning signs requiring immediate neuroimaging.
  • Vestibular neuritis has no hearing loss or tinnitus; labyrinthitis adds hearing symptoms.
  • Sudden sensorineural hearing loss within 3 days and within the last 30 days needs immediate ENT or emergency assessment.
  • Use antiemetics/antihistamines for no more than about 3 days, then mobilise and arrange vestibular rehabilitation if symptoms persist.

First-line investigation

Assess the acute vestibular syndrome clinically; use trained HINTS when available, and refer immediately via the stroke pathway if it is unavailable or central features are present. Check hearing and otoscopy, with audiometry for hearing loss.

Management

Treat acute vestibular syndrome as a possible stroke

  • Use trained HINTS where appropriate; refer immediately for stroke-pathway assessment and neuroimaging if the test is unavailable or central signs are present.1

Do not miss sudden hearing loss

  • Sudden hearing loss over 3 days or less within the previous 30 days needs immediate ENT or emergency assessment; specialist teams consider steroid treatment for idiopathic sudden sensorineural loss.3,2

Relieve severe symptoms briefly

  • Use an appropriate antiemetic or antihistamine/motion-sickness medicine for up to about 3 days, checking the BNF, contraindications and route when vomiting prevents oral treatment.2,4

Mobilise and avoid hazards

  • Stop suppressants as the acute phase settles, mobilise gradually and do not drive, cycle, use machinery or work at height while dizzy or unsteady.2,4

Rehabilitate persistent imbalance

  • Arrange vestibular physiotherapy or audiovestibular review for persistent symptoms and reconsider stroke, BPPV, Ménière's disease, vestibular migraine and other mimics if recovery stalls or the pattern changes.2,3

Safety-net infection and neurological deterioration

  • Urgently reassess new neurological symptoms, worsening gait, sudden hearing loss, severe headache, fever, meningism, facial weakness, severe ear pain or discharge.1,3,2

Exam traps

  • A negative head-impulse test in acute vestibular syndrome is concerning for stroke; it is not a reassuring result when the rest of the syndrome is present.
  • Do not use HINTS in a patient without continuous acute vestibular syndrome or without examiner training and experience.
  • Hearing loss means the presentation is not uncomplicated vestibular neuritis; sudden sensorineural loss needs immediate assessment.
  • Vestibular suppressants beyond the acute phase can delay central compensation.
  • Vertigo with focal neurology, direction-changing/vertical nystagmus or skew is central until proven otherwise.
  • Vertigo lasting seconds with positional triggers suggests BPPV, while recurrent attacks with fluctuating hearing symptoms suggest Ménière's disease.

Illustrations

Abnormal video head-impulse test in unilateral vestibular lossVideo head-impulse testing showing reduced vestibulo-ocular reflex gain and corrective saccades during leftward impulses in unilateral peripheral vestibular loss. HINTS interpretation requires a trained examiner and the correct acute vestibular syndrome context.Life 2024, CC-BY-4.0 · CC-BY-4.0

Key sources

  1. NICE NG127, Suspected neurological conditions: recognition and referral (NG127)Updated 1 Jul 2019
  2. NHS, Labyrinthitis and vestibular neuritis (NHS labyrinthitis and vestibular neuritis)Updated 17 Feb 2023
  3. NICE NG98, Hearing loss in adults: assessment and management (NG98)Updated 2 Oct 2023
  4. British National Formulary, online prescribing information (BNF)
  5. NHS, Vertigo (NHS vertigo)Updated 2 May 2023

This page is exam revision material, not medical advice, and must not be used for patient care. Always check drug doses against the BNF and current guidance. Full disclaimer.