eMedicine Specialties > Emergency Medicine > Neurology
Vestibular Neuronitis: Treatment & Medication
Updated: Nov 6, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
Treatment
Emergency Department Care
- ED physicians must first distinguish true vertigo from other types of dizziness. Then, after determining that the patient truly has vertigo, central vertigo must be ruled out through a careful history, physical examination, and, if still uncertain, imaging studies.
- Regardless of the vertigo's etiology, ED physicians should attempt to alleviate patient suffering. An intravenous (IV) line often is started to rehydrate the patient, who should be allowed to lie still in bed as desired. Parenteral medicines then are administered.
Consultations
In cases refractory to acute medical treatment, ED physicians may wish to consult with a neurologist or otolaryngologist.
Medication
Several types of medications have been used to treat vestibular neuronitis. Treatment generally has been based on responses of patients with motion sickness, a related condition. Few controlled studies exist; treatment is often empiric. However, recent data suggest a 3-week course of methylprednisolone tapered from 100 mg down to 10 mg daily may reduce long-term loss of vestibular function. Despite the evidence of viral infection in at least some patients, valacyclovir was found not to be helpful alone or in combination with methylprednisolone in the same study.8
H1-receptor antagonists
These agents may suppress vestibular responses through an effect on the CNS, although their mechanism remains unknown. Some investigators believe this action is mediated primarily by central anticholinergic activity.
Dimenhydrinate (Dramamine, Dimetabs, Dymenate)
A 1:1 salt of 8 chlorotheophylline and diphenhydramine thought to be useful in treatment of vertigo. Diminishes vestibular stimulation and depresses labyrinthine function through central anticholinergic effects. However, prolonged treatment may decrease rate of recovery of vestibular injuries.
Adult
50-100 mg PO q4-6h not to exceed 400 mg/24 h
50 mg IV in 10 mL NaCl given over 2 min; do not inject intra-arterially
50 mg IM prn
Pediatric
<2 years: Not established
2-5 years: Up to 12.5-25 mg q6-8h; not to exceed 75 mg/d
6-12 years: 25-50 mg PO q6-8h; not to exceed 150 mg/d
1.25 mg/kg or 37.5 mg/m2 IM qid; not to exceed 300 mg/d
Alcohol or other CNS depressants may have additive effect; take concurrently with antibiotics that may cause ototoxicity, may mask ototoxic symptoms and irreversible damage may result
Documented hypersensitivity; do not administer to neonates; IV products may contain benzyl alcohol, which has been associated with fatal "gasping syndrome" in premature infants and low-birth-weight infants
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Do not treat severe emesis with antiemetic drugs alone; may contain either sulfites or tartrazine, which may cause allergic-type reactions in susceptible persons; may impede diagnosis of conditions such as brain tumors, intestinal obstruction, and appendicitis; may obscure signs of toxicity from overdosage of other drugs
Diphenhydramine (Benadryl, Bydramine, Hyrexin)
For treatment and prophylaxis of vestibular disorders that may cause nausea and vomiting.
Adult
25-50 mg PO q6-8h prn; not to exceed 400 mg/d
10-100 mg IV/IM if required; not to exceed 400 mg/d
Pediatric
12.5-25 mg PO divided tid/qid, or 5 mg/kg/d, or 150 mg/m2/d; 5 mg/kg/d or 150 mg/m2/d IV/IM divided qid; not to exceed 300 mg/d
Potentiates effects of CNS depressants; alcohol in syrup form—do not give to patients taking medications that can cause disulfiramlike reactions
Documented hypersensitivity; MAOIs
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
May exacerbate angle-closure glaucoma, hyperthyroidism, peptic ulcer, and urinary tract obstruction
Meclizine (Antivert)
Decreases excitability of middle ear labyrinth and blocks conduction in middle ear vestibular-cerebellar pathways. These effects associated with relief of nausea and vomiting.
Adult
25-50 mg PO q12-24h; not to exceed 100 mg/d
Pediatric
<12 years: Not established
>12 years: Administer as in adults
May increase toxicity of CNS depressants, neuroleptics, and anticholinergics
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Caution in angle-closure glaucoma, prostatic hypertrophy, pyloric or duodenal obstruction, and bladder neck obstruction
Promethazine (Phenergan)
For symptomatic treatment of nausea in vestibular dysfunction.
Adult
12.5 mg PO/PR tid and 25 mg hs
25 mg IV/IM, repeat in 2 h prn; switch to PO as soon as possible
Pediatric
<2 years: Contraindicated
0.25-1 mg/kg PO/IV/IM/PR 4-6 times/d prn
CNS depressants or anticonvulsants; epinephrine may cause hypotension
Documented hypersensitivity; children <2 y (incidences of death due to respiratory depression)
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in cardiovascular disease, impaired liver function, seizures, sleep apnea, and asthma; not to administer SC or intra-arterially since necrotic lesions may develop; causes sedation and may have anticholinergic adverse effects
Benzodiazepines
These agents centrally inhibit vestibular responses, presumably by potentiating inhibitory GABA receptors.
Diazepam (Valium, Diastat, Diazemuls)
Probably most commonly used benzodiazepine to treat vertigo, its CNS duration is relatively short as it is highly lipophilic and undergoes rapid redistribution after administration.
Adult
5-10 mg PO/IV/IM q3-4h; not to exceed 30 mg in 8 h; repeat q2-4h prn
Pediatric
0.12-0.8 PO mg/kg/d divided q6-8h
0.05-0.3 mg/kg/dose IV/IM over 2-3 min; not to exceed 10 mg/dose; repeat q2-4h prn
Phenothiazines, barbiturates, alcohol, and MAOIs increase toxicity in CNS
Documented hypersensitivity; narrow-angle glaucoma
Pregnancy
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Caution with other CNS depressants, low albumin levels, or hepatic disease (may increase toxicity)
Lorazepam (Ativan)
Sedative hypnotic with short onset of effects and relatively long half-life. By increasing action of GABA, which is major inhibitory neurotransmitter in brain, may depress all levels of CNS, including limbic and reticular formation.
Adult
1-10 mg/d PO/IV/IM divided bid/tid
Pediatric
0.05 mg/kg/dose PO/IV/IM q4-8h
Alcohol, phenothiazines, barbiturates, and MAOIs increase toxicity in CNS
Documented hypersensitivity; preexisting CNS depression; hypotension; narrow-angle glaucoma
Pregnancy
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Caution in renal or hepatic impairment, myasthenia gravis, organic brain syndrome, or Parkinson disease
Anticholinergics
These agents are thought to work centrally by suppressing conduction in vestibular cerebellar pathways.
Scopolamine (Scopace, Transderm Scop)
Blocks action of acetylcholine at parasympathetic sites in smooth muscle, secretory glands, and CNS. Antagonizes histamine and serotonin action. Transdermal scopolamine may be most effective agent for motion sickness. Use in vestibular neuronitis limited by its slow onset of action.
Adult
0.3-0.65 mg IM/SC/IV and repeat q4-6h
2.5 cm2 transdermal patch to hairless area behind ear qod
Pediatric
6 mcg/kg/dose IM/SC/IV; not to exceed 0.3 mg/dose or 0.2 mg/m2/ dose; repeat q6-8h
May decrease antipsychotic effectiveness of phenothiazines; may increase anticholinergic adverse effects of phenothiazines (adjust dose as necessary); TCAs may increase anticholinergic adverse effects (eg, dry mouth, constipation, urinary retention) due to additive effect (TCAs with less anticholinergic activity may be beneficial)
Documented hypersensitivity; primary glaucoma (including initial stages); pyloric obstruction; toxic megacolon; hepatic disease; paralytic ileus; severe ulcerative colitis; renal disease; obstructive uropathy; myasthenia gravis
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in elderly because of increased incidence of glaucoma; large doses may suppress intestinal motility and precipitate or aggravate toxic megacolon; may aggravate hiatal hernia associated with reflux esophagitis; patients with prostatism can have dysuria and may require catheterization; use cautiously in patients with asthma or allergies; reduction in bronchial secretions can lead to inspissation and formation of bronchial plugs
Corticosteroids
Have anti-inflammatory properties and cause profound and varied metabolic effects. Modify the body's immune response to diverse stimuli.
Prednisone (Deltasone, Orasone)
Anti-inflammatory properties may reduce inflammation and edema of the vestibular nerve and associated apparatus, leading to faster recovery and less permanent damage.
Adult
100 mg per day PO tapered down to 10 mg per day PO over a 3-wk period
Pediatric
Uncertain for this condition
Coadministration with estrogens may decrease prednisone clearance; concurrent use with digoxin may cause digitalis toxicity secondary to hypokalemia; phenobarbital, phenytoin, and rifampin may increase metabolism of glucocorticoids (consider increasing maintenance dose); monitor for hypokalemia with coadministration of diuretics
Documented hypersensitivity; viral, fungal, tubercular skin, or connective tissue infections; peptic ulcer disease; hepatic dysfunction; GI disease
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Abrupt discontinuation of glucocorticoids may cause adrenal crisis; hyperglycemia, edema, osteonecrosis, myopathy, peptic ulcer disease, hypokalemia, osteoporosis, euphoria, psychosis, myasthenia gravis, growth suppression, and infections may occur with glucocorticoid use
More on Vestibular Neuronitis |
| Overview: Vestibular Neuronitis |
| Differential Diagnoses & Workup: Vestibular Neuronitis |
 Treatment & Medication: Vestibular Neuronitis |
| Follow-up: Vestibular Neuronitis |
| References |
| « Previous Page | Next Page » |
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Further Reading
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
