eMedicine Specialties > Emergency Medicine > Neurology

Vestibular Neuronitis

Author: Keith A Marill, MD, Faculty, Department of Emergency Medicine, Massachusetts General Hospital
Contributor Information and Disclosures

Updated: Nov 6, 2009

Introduction

Background

Vestibular neuronitis may be described as acute, sustained dysfunction of the peripheral vestibular system with secondary nausea, vomiting, and vertigo. As this condition is not clearly inflammatory in nature, neurologists often refer to it as vestibular neuropathy.

Pathophysiology

Its etiology remains largely unknown, yet vestibular neuronitis appears to be a sudden disruption of afferent neuronal input from 1 of the 2 vestibular apparatuses. This imbalance in vestibular neurologic input to the central nervous system (CNS) causes symptoms of vertigo. At least some cases are thought to be due to reactivation of latent herpes simplex virus type 1 in the vestibular ganglia.

Frequency

United States

Dizziness is the primary ED complaint in 3.3% of US ED visits, and approximately 5.6% of these patients are diagnosed with vestibular neuritis or labyrinthitis. Thus, the annual incidence of these two diagnoses in US EDs is approximately 150,000 patients.1

Mortality/Morbidity

Most patients experience complete recovery within a few weeks. A minority have recurrent vertiginous episodes following rapid head movement for years after onset.2

Sex

Studies have shown no consistent male or female predominance.3

Age

This syndrome occurs most commonly in middle-aged adults; mean age of onset is 41 years.3

Clinical

History

  • Patients usually complain of abrupt onset of severe, debilitating vertigo with associated unsteadiness, nausea, and vomiting.
    • They often describe their vertigo as a sense that either they or their surroundings are spinning.
    • Vertigo increases with head movement.

Physical

  • Spontaneous, unidirectional, horizontal nystagmus is the most important physical finding.4
    • Fast phase oscillations beat toward the healthy ear.
    • Nystagmus may be positional and apparent only when gazing toward the healthy ear, or during Hallpike maneuvers.
    • Patients may suppress their nystagmus by visual fixation.
  • Patient tends to fall toward his or her affected side when attempting ambulation or during Romberg tests.
  • Affected side has either unilaterally impaired or no response to caloric stimulation.
  • Vestibular neuronitis is unlikely if any of the following findings are present. The following symptoms should be absent:
    • Multidirectional, nonfatiguing nystagmus suggesting vertigo of central origin
    • Hearing loss
    • Other cranial nerve deficits
    • Truncal ataxia (suggests cerebellar disease or another CNS process)
    • Inflamed tympanic membrane
    • Mastoid tenderness
    • High fever
    • Nuchal rigidity
  • The head impulse test is a test for normal ocular fixation in association with rapid passive head rotation. An abnormal response is indicated by an inability to maintain fixation during head rotation with a corrective gaze shift after the head stops moving. An abnormal test seems to be sensitive, but not perfectly specific, for a peripheral vestibular disorder.5,6

Causes

  • Viral infection of the vestibular nerve and/or labyrinth is believed to be the most common cause of vestibular neuronitis.
  • Acute localized ischemia of these structures also may be an important cause.
  • Especially in children, vestibular neuritis may be preceded by symptoms of a common cold. However, the causative mechanism remains uncertain.

More on Vestibular Neuronitis

Overview: Vestibular Neuronitis
Differential Diagnoses & Workup: Vestibular Neuronitis
Treatment & Medication: Vestibular Neuronitis
Follow-up: Vestibular Neuronitis
References
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References

  1. 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. Jul 2008;83(7):765-75. [Medline].

  2. Huppert D, Strupp M, Theil D, Glaser M, Brandt T. Low recurrence rate of vestibular neuritis: a long-term follow-up. Neurology. Nov 28 2006;67(10):1870-1. [Medline].

  3. Sekitani T, Imate Y, Noguchi T, Inokuma T. Vestibular neuronitis: epidemiological survey by questionnaire in Japan. Acta Otolaryngol Suppl. 1993;503:9-12. [Medline].

  4. Hotson JR, Baloh RW. Acute vestibular syndrome. N Engl J Med. Sep 3 1998;339(10):680-5. [Medline].

  5. Newman-Toker DE, Kattah JC, Alvernia JE, Wang DZ. Normal head impulse test differentiates acute cerebellar strokes from vestibular neuritis. Neurology. Jun 10 2008;70(24 Pt 2):2378-85. [Medline].

  6. Kattah JC, Talkad AV, Wang DZ, Hsieh YH, Newman-Toker DE. HINTS to diagnose stroke in the acute vestibular syndrome: three-step bedside oculomotor examination more sensitive than early MRI diffusion-weighted imaging. Stroke. Nov 2009;40(11):3504-10. [Medline].

  7. Lee H, Sohn SI, Cho YW, Lee SR, Ahn BH, Park BR, et al. Cerebellar infarction presenting isolated vertigo: frequency and vascular topographical patterns. Neurology. Oct 10 2006;67(7):1178-83. [Medline].

  8. Strupp M, Zingler VC, Arbusow V, Niklas D, Maag KP, Dieterich M. Methylprednisolone, valacyclovir, or the combination for vestibular neuritis. N Engl J Med. Jul 22 2004;351(4):354-61. [Medline].

  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. Feb 2008;134(2):164-9. [Medline].

  10. Savitz SI, Caplan LR, Edlow JA. Pitfalls in the diagnosis of cerebellar infarction. Acad Emerg Med. Jan 2007;14(1):63-8. [Medline].

  11. Babe KS Jr, Serafin WE. Histamine, bradykinin, and their antagonists. In: Goodman & Gilman's The Pharmacological Basis of Therapeutics. 1996. 581-600.

  12. Baloh RW. Clinical practice. Vestibular neuritis. N Engl J Med. Mar 13 2003;348(11):1027-32. [Medline].

  13. Baloh RW, Ishyama A, Wackym PA, Honrubia V. Vestibular neuritis: clinical-pathologic correlation. Otolaryngol Head Neck Surg. Apr 1996;114(4):586-92. [Medline].

  14. Bohmer A. Acute unilateral peripheral vestibulopathy. In: Disorders of the Vestibular System. 1996:318-27.

  15. Cohen B, DeJong JM. Meclizine and placebo in treating vertigo of vestibular origin. Relative efficacy in a double-blind study. Arch Neurol. Aug 1972;27(2):129-35. [Medline].

  16. Division of Drugs and Toxicology. Drugs used for motion disorders and vomiting. Drug Evaluations Annual. 1995:465-92.

  17. El-Kashlan HK, Telian SA. Diagnosis and initiating treatment for peripheral system disorders: imbalance and dizziness with normal hearing. Otolaryngol Clin North Am. Jun 2000;33(3):563-78. [Medline].

  18. Froehling DA, Silverstein MD, Mohr DN. Does this dizzy patient have a serious form of vertigo?. JAMA. Feb 2 1994;271(5):385-8. [Medline].

  19. Gizzi M, Riley E, Molinari S. The diagnostic value of imaging the patient with dizziness. A Bayesian approach. Arch Neurol. Dec 1996;53(12):1299-304. [Medline].

  20. Marill KA, Walsh MJ, Nelson BK. Intravenous lorazepam versus dimenhydrinate for treatment of vertigo in the emergency department: A randomized clinical trial. Ann Emerg Med. 2000;36:310-9. [Medline].

  21. Peppard SB. Effect of drug therapy on compensation from vestibular injury. Laryngoscope. Aug 1986;96(8):878-98. [Medline].

  22. Philpot SJ, Archer JS. Herpes encephalitis preceded by ipsilateral vestibular neuronitis. J Clin Neurosci. Nov 2005;12(8):958-9. [Medline].

  23. Rascol O, Hain TC, Brefel C. Antivertigo medications and drug-induced vertigo. A pharmacological review. Drugs. Nov 1995;50(5):777-91. [Medline].

  24. Ryu JH, McCabe BF. effects of diazepam and dimenhydrinate on the resting activity of the vestibular neuron. Aerosp Med. Oct 1974;45(10):1177-9. [Medline].

  25. Schwaber MK. Vestibular Disorders. Clinical Otology. 1997:345-65.

  26. Troost BT. Dizziness and Vertigo. Neurology in Clinical Practice. 1996;1:219-32.

  27. Troost BT, Waller MA. Neuro-Otology. Neurology in Clinical Practice. 1996;1:647-57.

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Further Reading

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Keywords

vestibular neuronitis, vestibular neuropathy, inflammation of the vestibular nerve, vertigo, dizziness, reactivation of latent herpes simplex virus type 1, herpes simplex virus, vertiginous episodes, rapid head movement  

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Contributor Information and Disclosures

Author

Keith A Marill, MD, Faculty, Department of Emergency Medicine, Massachusetts General Hospital
Keith A Marill, MD is a member of the following medical societies: American Academy of Emergency Medicine and Society for Academic Emergency Medicine
Disclosure: Medtronic Ownership interest None; Cambridge Heart, Inc. Ownership interest None

Medical Editor

Peter MC DeBlieux, MD, Professor of Clinical Medicine and Pediatrics, Section of Pulmonary and Critical Care Medicine, Program Director, Department of Emergency Medicine, Louisiana State University Health Sciences Center
Peter MC DeBlieux, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, Radiological Society of North America, and Society of Critical Care Medicine
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

J Stephen Huff, MD, Associate Professor, Emergency Medicine and Neurology, Department of Emergency Medicine, University of Virginia Health Sciences Center
J Stephen Huff, MD is a member of the following medical societies: American Academy of Emergency Medicine, American Academy of Neurology, American College of Emergency Physicians, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

Rick Kulkarni, MD, Assistant Professor of Surgery, Section of Emergency Medicine, Yale-New Haven Hospital
Rick Kulkarni, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: WebMD Salary Employment

 
 
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