eMedicine Specialties > Neurology > Neuro-otology
Inner Ear, Labyrinthitis: Treatment & Medication
Updated: Jan 14, 2010
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
- Multimedia
Treatment
Medical Care
- The initial treatment of viral labyrinthitis consists of bed rest and hydration. Most patients can be treated on an outpatient basis. However, they should be cautioned to seek further medical care for worsening symptoms, especially neurologic symptoms (eg, diplopia, slurred speech, gait disturbances, localized weakness or numbness).
- Patients with severe nausea and vomiting may benefit from intravenous fluid and antiemetic medications. Diazepam or other benzodiazepines are occasionally helpful as a vestibular suppressant. A short course of oral corticosteroids may be helpful. Currently, the role of antiviral therapy is not established.
- Steroids (methylprednisolone) were found to be more effective than antiviral agents (valacyclovir) for recovery of peripheral vestibular function in patients with vestibular neuritis in a randomized controlled trial by Strupp et al.19 This may also apply to the treatment of viral labyrinthitis.
- The antiviral drugs acyclovir, famciclovir, and valacyclovir shorten the duration of viral shedding in persons with herpes zoster oticus and may prevent some auditory and vestibular damage if started early in the clinical course. Administer corticosteroids to reduce inflammation and edema in the facial canal and labyrinth.
- For bacterial labyrinthitis, antibiotic treatment is selected based on culture and sensitivity results. Antibiotic treatment should consist of a broad-spectrum antibiotic or combination therapy with CNS penetration until culture results are available. Treat the vertigo symptomatically as indicated. The use of steroids in meningogenic hearing loss is controversial.
- Recent studies have shown that antioxidant therapy and cochlear microperfusion may be useful adjuvant treatments.20,21
Surgical Care
- In cases of labyrinthitis resulting from otitis media, perform a myringotomy and evacuate the effusion. A ventilation tube also may be indicated. Middle ear effusion should be sent for microscopic evaluation as well as culture and sensitivity.
- Mastoiditis and cholesteatoma are handled best with surgical drainage and debridement by way of a mastoidectomy.
Consultations
- Consult a neurosurgeon in the event of suppurative intracranial complications.
- Consultation with an infectious disease specialist may be warranted in the presence of systemic infection or unusual or atypical infections.
Medication
Medications may be indicated in persons with viral labyrinthitis to treat the symptoms of vertigo and nausea/vomiting. These medications include benzodiazepines and antiemetics and are typically used for a few days, until symptoms are relieved.
Corticosteroids should, in theory, reduce labyrinthine inflammation and prevent the sequelae of labyrinthitis due to infectious or inflammatory causes. Definitive evidence is lacking, however, for the efficacy of corticosteroids in the treatment of labyrinthitis and sudden sensorineural hearing loss.22 Intratympanic steroids may be more effective than systemic steroids in the treatment of sudden hearing loss, either alone or in combination with systemic steroids.23,24
Antiviral agents may play a role in the treatment of labyrinthitis due to presumed viral infections. However, recent studies have not shown improvement in treatment outcomes when antivirals are combined with systemic steroids in the treatment of labyrinthitis.25
Antibiotic therapy for bacterial causes of labyrinthitis must be directed at the most likely causative organisms. A complete discussion of all the antibiotics available for the treatment of suppurative or toxic bacterial labyrinthitis is beyond the scope of this article.
Benzodiazepines
These agents are used for the symptomatic treatment of vertigo.
Diazepam (Valium)
Depresses all levels of CNS (eg, limbic and reticular formation), possibly by increasing activity of GABA. Individualize dosage and increase cautiously to avoid adverse effects.
Adult
2-10 mg PO tid or 5-10 mg IV/IM in an acute setting
Pediatric
1-2.5 mg PO tid
Increases toxicity of benzodiazepines in CNS with coadministration of phenothiazines, barbiturates, alcohols, and MAOIs
Documented hypersensitivity; narrow-angle glaucoma; history of addiction, alcohol intoxication, myasthenia gravis
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)
By increasing action of GABA, which is a major inhibitory neurotransmitter in the brain, may depress all levels of CNS, including limbic and reticular formation.
Adult
1-2 mg PO/IV/IM tid
Pediatric
Not established
CNS toxicity of benzodiazepines increases when used concurrently with alcohol, phenothiazines, barbiturates, and MAOIs
Documented hypersensitivity; preexisting CNS depression, hypotension, and 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
Antiemetics
These agents are used for relief of nausea and vomiting.
Prochlorperazine (Compazine)
May relieve nausea and vomiting by blocking postsynaptic mesolimbic dopamine receptors through anticholinergic effects and depressing reticular activating system.
In addition to antiemetic effects, it has the advantage of augmenting hypoxic ventilatory response, acting as a respiratory stimulant at high altitude.
Adult
PO: 10 mg q6h
IV: 2.5-10 mg slow push q6h
PR: 25 mg q12h
Pediatric
<2 years: Not established
2-12 years: 2.5 mg PO bid/tid
>12 years: Administer as in adults
Coadministration with other CNS depressants or anticonvulsants may cause additive effects; with epinephrine, may cause hypotension
Documented hypersensitivity; bone marrow suppression, narrow-angle glaucoma, and severe liver or cardiac disease
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
Drug-induced Parkinson syndrome or pseudoparkinsonism occurs quite frequently; akathisia is most common extrapyramidal reaction in elderly persons; lowers seizure threshold; caution with history of seizures
Antiviral drugs
Nucleoside analogs are initially phosphorylated by viral thymidine kinase to eventually form a nucleoside triphosphate. These molecules inhibit HSV polymerase with 30-50 times the potency of human alpha-DNA polymerase.
Famciclovir (Famvir)
Prodrug that, when biotransformed into active metabolite (penciclovir), may inhibit viral DNA synthesis/replication.
Adult
500 mg PO tid for 7 d
Pediatric
Not established
Coadministration with probenecid or cimetidine may increase toxicity; coadministration increases bioavailability of digoxin
Documented hypersensitivity; impaired renal function
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Caution in renal failure or coadministration of nephrotoxic drugs
Valacyclovir (Valtrex)
Prodrug rapidly converted to the active drug acyclovir. More expensive but has a more convenient dosing regimen than acyclovir.
Adult
1000 mg PO tid for 7 d
Pediatric
Not established
Probenecid, zidovudine, or cimetidine coadministration prolongs half-life and increases CNS toxicity
Documented hypersensitivity; renal transplantation or renal failure
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Caution in renal failure and coadministration of nephrotoxic drugs; associated with onset of hemolytic uremic syndrome
Acyclovir (Zovirax)
Has affinity for viral thymidine kinase and, once phosphorylated, causes DNA chain termination when acted upon by DNA polymerase. Compliance problem; requires 5 daily doses.
Adult
800 mg PO 5 times/d for 7 d or 15 mg/kg IV divided tid for 5-10 d
Pediatric
Not established
Concomitant use of probenecid or zidovudine prolongs half-life and increases CNS toxicity
Documented hypersensitivity; renal failure or impairment
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Caution in renal failure or when using nephrotoxic drugs
Corticosteroids
Have anti-inflammatory properties and cause profound and varied metabolic effects. Modify the body's immune response to diverse stimuli.
Prednisone (Deltasone, Orasone, Meticorten)
Standard agents administered in cases of sudden hearing loss and may play a role in the treatment of viral labyrinthitis. Their role in treatment of bacterial labyrinthitis and meningogenic hearing loss is controversial.
Adult
40-60 mg PO qd for 5 d, then taper over 5 d
Pediatric
Not established
Coadministration with estrogens may decrease clearance; concurrent use with digoxin may cause digitalis toxicity secondary to hypokalemia; phenobarbital, phenytoin, and rifampin may increase metabolism (consider increasing maintenance dose); monitor for hypokalemia with coadministration of diuretics
Documented hypersensitivity; viral infection, peptic ulcer disease, hepatic dysfunction, connective tissue infections, and fungal or tubercular skin infections; GI disease
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Abrupt discontinuation may cause adrenal crisis; hyperglycemia, edema, osteonecrosis, myopathy, peptic ulcer disease, hypokalemia, osteoporosis, euphoria, psychosis, myasthenia gravis, growth suppression, and infections may occur
More on Inner Ear, Labyrinthitis |
| Overview: Inner Ear, Labyrinthitis |
| Differential Diagnoses & Workup: Inner Ear, Labyrinthitis |
 Treatment & Medication: Inner Ear, Labyrinthitis |
| Follow-up: Inner Ear, Labyrinthitis |
| Multimedia: Inner Ear, Labyrinthitis |
| References |
| « Previous Page | Next Page » |
References
Schuknecht HF, Kitamura K. Second Louis H. Clerf Lecture. Vestibular neuritis. Ann Otol Rhinol Laryngol Suppl. Jan-Feb 1981;90(1 Pt 2):1-19. [Medline].
Kuhweide R, Van de Steene V, Vlaminck S, Casselman JW. Ramsay Hunt syndrome: pathophysiology of cochleovestibular symptoms. J Laryngol Otol. Oct 2002;116(10):844-8. [Medline].
Hato N, Kisaki H, Honda N, Gyo K, Murakami S, Yanagihara N. Ramsay Hunt syndrome in children. Ann Neurol. Aug 2000;48(2):254-6. [Medline].
Schraff SA, Schleiss MR, Brown DK, Meinzen-Derr J, Choi KY, Greinwald JH, et al. Macrophage inflammatory proteins in cytomegalovirus-related inner ear injury. Otolaryngol Head Neck Surg. Oct 2007;137(4):612-8. [Medline].
Gulya AJ. Infections of the labyrinth. In: Bailey BJ, Johnson JT, Pillsbury HC, Tardy ME, Kohut RI, eds. Head and Neck Surgery-Otolaryngology. Vol 2. Philadelphia, Pa: JB Lippincott; 1993:1769-81.
Berlow SJ, Caldarelli DD, Matz GJ, Meyer DH, Harsch GG. Bacterial meningitis and sensorineural hearing loss: a prospective investigation. Laryngoscope. Sep 1980;90(9):1445-52. [Medline].
Jang CH, Park SY, Wang PC. A case of tympanogenic labyrinthitis complicated by acute otitis media. Yonsei Med J. Feb 28 2005;46(1):161-5. [Medline].
Harris JP, Ryan AF. Fundamental immune mechanisms of the brain and inner ear. Otolaryngol Head Neck Surg. Jun 1995;112(6):639-53. [Medline].
Broughton SS, Meyerhoff WE, Cohen SB. Immune-mediated inner ear disease: 10-year experience. Semin Arthritis Rheum. Oct 2004;34(2):544-8. [Medline].
Bovo R, Ciorba A, Martini A. The diagnosis of autoimmune inner ear disease: evidence and critical pitfalls. Eur Arch Otorhinolaryngol. Jan 2009;266(1):37-40. [Medline].
Byl FM. Seventy-six cases of presumed sudden hearing loss occurring in 1973: prognosis and incidence. Laryngoscope. May 1977;87(5 Pt 1):817-25. [Medline].
Baloh RW, Honrubia V, Jacobson K. Benign positional vertigo: clinical and oculographic features in 240 cases. Neurology. Mar 1987;37(3):371-8. [Medline].
Nadol JB Jr. Hearing loss as a sequela of meningitis. Laryngoscope. May 1978;88(5):739-55. [Medline].
Woolley AL, Kirk KA, Neumann AM Jr, McWilliams SM, Murray J, Freind D. Risk factors for hearing loss from meningitis in children: the Children's Hospital experience. Arch Otolaryngol Head Neck Surg. May 1999;125(5):509-14. [Medline].
Bohr V, Paulson OB, Rasmussen N. Pneumococcal meningitis. Late neurologic sequelae and features of prognostic impact. Arch Neurol. Oct 1984;41(10):1045-9. [Medline].
Kutz JW, Simon LM, Chennupati SK, Giannoni CM, Manolidis S. Clinical predictors for hearing loss in children with bacterial meningitis. Arch Otolaryngol Head Neck Surg. Sep 2006;132(9):941-5. [Medline].
Mark AS, Seltzer S, Nelson-Drake J, Chapman JC, Fitzgerald DC, Gulya AJ. Labyrinthine enhancement on gadolinium-enhanced magnetic resonance imaging in sudden deafness and vertigo: correlation with audiologic and electronystagmographic studies. Ann Otol Rhinol Laryngol. Jun 1992;101(6):459-64. [Medline].
Maire R, van Melle G. Diagnostic value of vestibulo-ocular reflex parameters in the detection and characterization of labyrinthine lesions. Otol Neurotol. Jun 2006;27(4):535-41. [Medline].
Strupp M, Zingler VC, Arbusow V, Niklas D, Maag KP, Dieterich M, et al. Methylprednisolone, valacyclovir, or the combination for vestibular neuritis. N Engl J Med. Jul 22 2004;351(4):354-61. [Medline].
Barkdull GC, Vu C, Keithley EM, Harris JP. Cochlear microperfusion: experimental evaluation of a potential new therapy for severe hearing loss caused by inflammation. Otol Neurotol. Jan 2005;26(1):19-26. [Medline].
Klein M, Koedel U, Pfister HW, Kastenbauer S. Meningitis-associated hearing loss: protection by adjunctive antioxidant therapy. Ann Neurol. Oct 2003;54(4):451-8. [Medline].
Wei BP, Mubiru S, O'Leary S. Steroids for idiopathic sudden sensorineural hearing loss. Cochrane Database Syst Rev. Jan 25 2006;CD003998. [Medline].
Battaglia A, Burchette R, Cueva R. Combination therapy (intratympanic dexamethasone + high-dose prednisone taper) for the treatment of idiopathic sudden sensorineural hearing loss. Otol Neurotol. Jun 2008;29(4):453-60. [Medline].
Plontke SK, Löwenheim H, Mertens J, Engel C, Meisner C, Weidner A, et al. Randomized, double blind, placebo controlled trial on the safety and efficacy of continuous intratympanic dexamethasone delivered via a round window catheter for severe to profound sudden idiopathic sensorineural hearing loss after failure of systemic therapy. Laryngoscope. Feb 2009;119(2):359-69. [Medline].
Westerlaken BO, Stokroos RJ, Dhooge IJ, Wit HP, Albers FW. Treatment of idiopathic sudden sensorineural hearing loss with antiviral therapy: a prospective, randomized, double-blind clinical trial. Ann Otol Rhinol Laryngol. Nov 2003;112(11):993-1000. [Medline].
Cohen HS, Kimball KT. Decreased ataxia and improved balance after vestibular rehabilitation. Otolaryngol Head Neck Surg. Apr 2004;130(4):418-25. [Medline].
Lee H, Kim HJ, Koo JW, Kim JS. Progression of acute cochleovestibulopathy into anterior inferior cerebellar artery infarction. J Neurol Sci. Mar 15 2009;278(1-2):119-22. [Medline].
Further Reading
Keywords
labyrinthitis of the inner ear, labyrinthitis, viral labyrinthitis, serous labyrinthitis, bacterial labyrinthitis, suppurative labyrinthitis, sudden sensorineural hearing loss, neurolabyrinthitis, vestibulocochleitis, vestibulocochlearis, sudden hearing loss, ear infection, inner ear infection, ear labyrinth infection, hearing disorder, hearing disturbance, balance disorder, balance disturbance, vertigo, dysequilibrium, hearing loss, vestibular neuritis, herpes zoster oticus, Ramsay-Hunt syndrome, varicella-zoster virus, varicella reactivation, zoster reactivation, rubella, cytomegalovirus, CMV, mumps, measles, SNHL, herpes oticus, labyrinthine inflammation, labyrinthine disease, labyrinthine disorder, labyrinthine infection
