Approach Considerations
Viral labyrinthitis
The initial treatment for 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 (IV) fluid and antiemetic medications.
Bacterial labyrinthitis
For bacterial labyrinthitis, antibiotic treatment is selected based on culture and sensitivity results. Treatment of suppurative labyrinthitis is aimed at eradicating the underlying infection, providing supportive care to the patient, draining middle ear effusions or mastoid infections, and preventing the spread of infection.
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.
Inpatient care
Most patients with labyrinthitis can be evaluated and treated in the emergency department and then discharged. Some patients with intractable vertigo and vomiting may require admission.
For patients with a possible severe, underlying condition (eg, vertebrobasilar ischemia or brainstem tumor), admission to the hospital may be appropriate under the direction of a neurologist, a neurosurgeon, or both.
Pharmacologic Therapy
Viral labyrinthitis
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.
In a randomized, controlled trial by Strupp et al, steroids (methylprednisolone) were found to be more effective than antiviral agents (valacyclovir) for recovery of peripheral vestibular function in patients with vestibular neuritis. [24] 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.
Bacterial labyrinthitis
For bacterial labyrinthitis, antibiotic treatment is selected based on culture and sensitivity results. Antibiotic treatment should consist of 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.
Studies have shown that antioxidant therapy and cochlear microperfusion may be useful adjuvant treatments. [25, 26]
Outpatient Care
Patients with persistent vestibular symptoms may be candidates for vestibular rehabilitation. For many patients with chronic vertigo due to a peripheral vestibular etiology, a simple home program of vestibular habituation head movement exercises reduces symptoms of imbalance during stance and gait. [27]
A follow-up audiogram should be performed in all patients with hearing loss and in patients who were not tested at presentation. An auditory brainstem response test is indicated for younger children.
-
Anatomy of the labyrinth.
