Vestibular NeuronitisMANAGEMENT

ENT AND MAXILLOFACIAL PRESENTATIONS · 12 SECTIONS

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337 items

☷ Legend

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Cardiovascular Presentations71▾

Respiratory Presentations52▾

Neurological Presentations83▾

Gastrointestinal Presentations74▾

Genitourinary and Reproductive Presentations48▾

Infectious Disease Presentations148▾

Trauma Presentations89▾

Toxicologic Presentations80▾

Psychiatric Presentations26▾

Musculoskeletal and Rheumatologic Presentations96▾

Dermatology Presentations23▾

Environmental and Exposure Presentations27▾

Hematologic and Oncologic Presentations36▾

Pediatric-Specific Presentations19▾

Endocrine and Metabolic Presentations45▾

ENT and Maxillofacial Presentations27▾

Acute laryngitis Acute pharyngitis Auricular hematoma Bezold's Abscess Cerumen impaction Dry socket Ear foreign body Epistaxis (anterior)Epistaxis (Posterior)Labyrinthitis Ludwig's Angina Malignant Otitis Externa Marcus Gunn Pupil Mastoiditis Meniere's Disease Nasal Bone Fracture Nasal foreign body Nasal Septal Hematoma Otitis externa Otitis Media Post-tonsillectomy hemorrhage Sialolithiasis and sialadenitis Sinusitis Sudden Sensorineural Hearing Loss TMJ dislocation Tympanic membrane perforation Vestibular Neuronitis

Ophthalmologic Presentations19▾

Obstetric Presentations23▾

Systemic and Miscellaneous Presentations17▾

01Approach to the Critical Patient/attcp15

Red Flags and Immediate Actions

›Acute Vestibular Syndrome (AVS) triage priorities

›HINTS exam mandatory in all AVS presentations to exclude posterior circulation stroke

›Central features on HINTS mandate immediate neurology consult and MRI

›Inability to stand or walk independently requires urgent stroke workup

›Posterior fossa stroke may present with peripheral-appearing nystagmus in up to 64% of cases

PITFALLS

›Critical diagnostic pitfalls in vestibular emergencies

›CT head is NOT an adequate stroke screen in AVS — sensitivity for posterior fossa stroke less than 50%

›HINTS superior to early MRI-DWI in first 24–48 hours of symptom onset

›Negative head impulse test (normal VOR) in AVS is a red flag for central etiology

›Do not reassure and discharge without further workup if HIT is negative

PEARLS

›Key clinical pearls for vestibular neuronitis

›Peripheral HINTS (abnormal HIT, unidirectional nystagmus, no skew) has sensitivity greater than 95% for excluding stroke

›Vestibular suppressants must be limited to 3–5 days maximum — prolonged use impairs central compensation

›All patients benefit from vestibular rehabilitation therapy referral at discharge

›Earlier initiation within 1–2 weeks associated with significantly better outcomes

02History/hx47

Presenting Symptoms

›Symptom characterization

›Acute onset severe continuous rotatory vertigo lasting hours to days, not seconds

›Maximal intensity reached within minutes to hours of onset

›True spinning sensation (room or self-spinning), not lightheadedness or presyncope

Temporal Course

›Timeline of illness

›Acute phase lasting 1–3 days followed by progressive improvement

›Residual imbalance and motion sensitivity may persist weeks to months

›Recurrent episodes atypical — if recurrent, consider Meniere disease or vestibular migraine

Aggravating and Precipitating Factors

›Symptom modifiers

›Worsened by head movement

›Not triggered by positional changes (distinguishes from BPPV)

›Viral prodrome (upper respiratory infection) in days to weeks prior

Associated Symptoms

›Accompanying features

›Severe nausea and vomiting

›Oscillopsia (visual illusion of environmental movement)

›Gait unsteadiness with falling toward the affected side

Important Negatives

›Absence of these features supports vestibular neuronitis over central or other peripheral causes

›No hearing loss

›No tinnitus or aural fullness

›No diplopia, dysarthria, dysphagia, or dysphonia

›No limb weakness or sensory changes

›No severe headache or neck stiffness

03Physical Exam/exam31

Vital Signs

›Hemodynamic and vital sign assessment

›Blood pressure — hypertension may suggest stroke rather than vestibular neuronitis

›Orthostatic hypotension — alternative cause of dizziness

›Pulse regularity — arrhythmia as alternative diagnosis

HINTS Exam

›Head Impulse, Nystagmus, Test of Skew — mandatory bedside test in all AVS presentations

›Head Impulse Test (HIT): positive catch-up saccade toward affected side = peripheral, supports vestibular neuronitis

›Negative HIT (no catch-up saccade) in AVS is a red flag for central cause

›Nystagmus: unidirectional horizontal-torsional, fast phase beating away from affected ear

›Direction-changing nystagmus with gaze = central pattern

›Vertical or pure torsional nystagmus = central pattern

›Test of Skew: negative (no vertical misalignment on alternate cover test)

›Positive skew deviation = central sign, concerning for brainstem lesion

›All three peripheral on HINTS: sensitivity greater than 95% for ruling out stroke, superior to early MRI

Gait and Balance

›Postural and locomotor assessment

›Romberg test: falls toward the affected ear

›Gait deviation toward the affected side

›Inability to stand independently — escalate to urgent stroke workup

Positional Testing

›Positional maneuver findings

›Dix-Hallpike test: negative in vestibular neuronitis (no typical BPPV nystagmus elicited)

Hearing Assessment

›Auditory function

›Grossly normal hearing on finger rub test

›Weber and Rinne tests for lateralization

›Hearing loss = labyrinthitis, AICA stroke, or central cause — not vestibular neuronitis

04Differential Diagnosis/ddx21

Cannot-Miss Diagnoses

›Life-threatening conditions that must be excluded

›Posterior circulation stroke (cerebellar or brainstem infarction) — ICD-10 I63.x

›Up to 25% of AVS presentations may be posterior circulation stroke

›Up to 64% may present with peripheral-appearing nystagmus mimicking vestibular neuronitis

›Labyrinthine infarction — ICD-10 H83.8

›Hyperacute onset, no viral prodrome, hearing loss may be present

›Can mimic vestibular neuronitis clinically including on HINTS exam

Peripheral Vestibular Conditions

›Peripheral conditions in the differential

›Labyrinthitis — vestibular neuronitis plus hearing loss — ICD-10 H83.0

›Meniere disease — recurrent episodes, hearing loss, tinnitus, aural fullness — ICD-10 H81.0

›BPPV — brief episodes lasting under 1 minute, positionally triggered, positive Dix-Hallpike — ICD-10 H81.1

›Ramsay Hunt syndrome (herpes zoster oticus) — vesicular rash on ear, facial palsy, severe vestibular loss — ICD-10 B02.21

Central Conditions

›Central nervous system etiologies

›Vestibular migraine — episodic vertigo, migraine history, may lack nystagmus between attacks — ICD-10 G43.d

›Demyelinating disease (multiple sclerosis) — subacute onset, other CNS signs — ICD-10 G35

›Cerebellopontine angle tumor (vestibular schwannoma) — insidious onset, hearing loss, facial palsy — ICD-10 D33.3

Other Conditions

›Additional diagnostic considerations

›Ototoxicity from aminoglycosides, cisplatin, loop diuretics

›Autoimmune inner ear disease

›Cardiogenic dizziness — arrhythmia, orthostatic hypotension

›Psychogenic dizziness — anxiety or panic disorder coexisting with vestibular pathology

05Laboratory Tests/lt15

Routine Investigations

›Standard laboratory workup

›Routine labs generally not required for classic vestibular neuronitis presentation

›Basic metabolic panel if dehydrated from vomiting or IV fluids required

›Electrolytes, creatinine, blood urea nitrogen for hydration status

›Glucose — to exclude hypoglycemia as contributing cause

Targeted Investigations

›Condition-specific laboratory tests

›CBC if infection clinically suspected

›Thyroid-stimulating hormone if chronic dizziness or atypical presentation

›RPR and FTA-ABS if risk factors for syphilitic labyrinthitis

Cardiac Investigations

›Cardiac workup considerations

›Troponin only if cardiac symptoms are present — routine troponin in dizzy patients not recommended due to high false-positive rate

›ECG if palpitations, syncope, presyncope, irregular pulse, or suspicion of cardiogenic dizziness

›Atrial fibrillation is both a stroke risk factor and alternative dizziness etiology

›Prolonged QTc if using ondansetron or promethazine — monitor

›Holter or event monitoring if episodic dizziness with palpitations — wearable ECG patch 72-hour monitoring comparable to conventional Holter

06Diagnostic Tests/dt39

Scoring Systems

›HINTS exam — primary bedside diagnostic tool for AVS

›Head Impulse Test component: positive catch-up saccade = peripheral (vestibular neuronitis)

›Negative HIT in AVS has high specificity for central cause

›Nystagmus component: unidirectional = peripheral; direction-changing = central

›Test of Skew component: no vertical misalignment = peripheral; positive skew = central

›All peripheral HINTS: sensitivity greater than 95%, specificity greater than 85% for excluding posterior circulation stroke

›Cochrane meta-analysis 2023 supports HINTS superiority over early MRI-DWI in first 24–48 hours

›HINTS Plus: add hearing test (finger rub or audiometry) to increase sensitivity for AICA stroke

MRI

›Magnetic resonance imaging indications and interpretation

›MRI with diffusion-weighted imaging (DWI) is the imaging of choice when central cause is suspected

›Indicated for any central sign on HINTS exam

›Indicated for inability to stand or walk independently

›Indicated for vascular risk factors with diagnostic uncertainty

›Indicated for no improvement within 48 hours

›MRI-DWI sensitivity for posterior fossa stroke in first 24–48 hours is 80–83% — may miss early infarct

›False-negative DWI rate approximately 17–20% in first 24 hours

›Peripheral HINTS in experienced hands outperforms early MRI-DWI for stroke exclusion

›ACR Appropriateness Criteria 2024: imaging usually not appropriate in isolated AVS with peripheral HINTS findings

›Computed tomography considerations

›CT of the head is NOT recommended for routine AVS workup

›Sensitivity for posterior fossa stroke less than 50%

›Posterior fossa bony artifact severely limits evaluation of brainstem and cerebellum

›CT angiography of head and neck: consider if vertebral artery dissection is suspected

›Neck pain, trauma history, or young patient with stroke presentation

›CT appropriateness: ACR Appropriateness Criteria 2024 rates CT as usually not appropriate in isolated AVS

07Disposition/dispo20

Discharge Criteria

›Criteria supporting safe discharge

›Peripheral HINTS exam with no central features

›Able to stand and ambulate (even if unsteady)

›Tolerating oral fluids and medications

›Adequate home support available

›Follow-up arranged within 1–2 weeks

Admission and Observation Criteria

›Indications for admission or observation

›Intractable vomiting with inability to tolerate oral intake despite ED treatment

›Severe dehydration requiring ongoing IV fluid resuscitation

›Inability to stand or walk independently — MRI required to exclude stroke

›Any central sign on HINTS exam or neurologic examination

›Diagnostic uncertainty in patients with high vascular risk

Specialist Consultation Triggers

›Consultation indications

›Neurology: any concern for central etiology, atypical features, or failure to improve within expected timeframe

›ENT or neurotology: hearing loss, recurrent episodes, suspected Meniere disease

›Vestibular physical therapy: all patients for vestibular rehabilitation therapy referral at discharge

Follow-up Planning

›Outpatient follow-up requirements

›Primary care or ENT follow-up within 1–2 weeks

›Vestibular rehabilitation therapy referral at discharge — earlier initiation within 1–2 weeks associated with better outcomes

›Return to driving only when vertigo resolves and balance is stable

08Treatment/t44

Immediate ED Management

›Initial stabilization priorities

›IV fluid resuscitation for dehydration from vomiting

›Normal saline or lactated Ringer's solution based on clinical status

›Antiemetic therapy for acute nausea and vomiting

›Promethazine 25 mg IM or IV — first-line for acute severe vomiting

›Prochlorperazine 10 mg IM or IV — add if vomiting persists or refractory

›Ondansetron 4 mg IV — antiemetic alternative, monitor QTc

›Reassurance and explanation of expected disease course

Vestibular Suppressants

›Short-term vestibular suppressant therapy (limit to 3–5 days maximum)

›Meclizine 25 mg orally every 6–8 hours as needed

›First-line oral vestibular suppressant once tolerating oral intake

›Dimenhydrinate 50 mg orally every 6–8 hours as needed

›Alternative oral suppressant

›Diazepam 5 mg orally as needed — for refractory acute vestibular symptoms

›Lorazepam 0.5–1 mg as needed — benzodiazepine alternative for refractory cases

›Discontinue all vestibular suppressants as soon as tolerable

›Antihistamines, antiemetics, and benzodiazepines all block central vestibular compensation

›Prolonged use beyond 3–5 days significantly impairs recovery

Corticosteroids

›Steroid therapy — shared decision-making approach

›Indication: consider in patients presenting within 3 days of onset

›GRACE-3 guideline 2023: conditional recommendation, very low certainty evidence

›Evidence shows improved caloric recovery but uncertain symptomatic benefit

›Methylprednisolone: starting dose 100 mg daily, tapered over approximately 3 weeks

›Prednisone: equivalent taper regimen may be used as alternative

›Contraindications to corticosteroids

09Special Populations/sp31

Pregnancy

›Vestibular neuronitis in pregnancy

›Medication safety considerations

›Meclizine: FDA category B — generally considered safe, use minimum effective dose

›Promethazine: FDA category C — use with caution, avoid in first trimester if possible

›Ondansetron: FDA category B — preferred antiemetic; monitor QTc

›Benzodiazepines: avoid — associated with neonatal withdrawal and cleft palate risk

›Corticosteroids: use with caution — associated with gestational diabetes and preeclampsia risk in pregnancy

›Hydration critical — IV fluids preferred over oral rehydration if vomiting is severe

›Fetal monitoring considerations if symptoms are severe or prolonged

›Vestibular rehabilitation therapy safe in pregnancy — preferred long-term approach

Geriatric

›Vestibular neuronitis in elderly patients

›Higher baseline fall risk requires early physical therapy referral and home safety assessment

›Vascular risk factors common — lower threshold for MRI to exclude posterior circulation stroke

›Medication considerations

›Meclizine and promethazine are Beers Criteria medications — use with caution in elderly

›Increased sensitivity to anticholinergic effects — confusion, urinary retention, falls

›Benzodiazepines strongly discouraged in elderly — fall risk, paradoxical agitation, cognitive effects

›Ondansetron preferred antiemetic in elderly patients to minimize anticholinergic burden

›Dehydration risk is higher — lower threshold for IV fluid administration

›Higher rates of incomplete vestibular compensation — more likely to benefit from structured VRT

Pediatrics

›Vestibular neuronitis in pediatric patients

›Less common in children — consider other diagnoses including posterior fossa tumors

›Pediatric AVS without clear peripheral features warrants lower threshold for MRI

›Viral prodrome more commonly identified compared to adults

›Weight-based antiemetic dosing

10Background/b33

Epidemiology

›Epidemiologic features of vestibular neuronitis

›Annual incidence approximately 3.5 per 100,000 population

›Second most common cause of peripheral vestibular vertigo after BPPV

›Peak incidence in patients aged 30–50 years

›No strong hereditary predisposition identified

›Seasonal variation with clustering during viral epidemics

›Up to 50% of patients may develop persistent symptoms including imbalance or motion sensitivity

›Approximately 80% still have caloric paresis at 6 months despite clinical improvement

›Some patients (10–15%) develop secondary BPPV after vestibular neuronitis

Pathophysiology

›Underlying mechanisms

›Presumed viral inflammation of the vestibular portion of cranial nerve VIII

›HSV-1 reactivation in vestibular ganglia is the leading hypothesis

›HSV-1 DNA found in vestibular ganglia and endolymphatic sac at post-mortem

›Superior vestibular nerve division most commonly affected

›Inferior division involvement less common and less well characterized

›Unilateral vestibular deafferentation causes acute tonic imbalance

›Explains spontaneous nystagmus beating away from the affected ear

›Explains falling tendency toward the affected side

›Central compensation involves cerebellar and brainstem neuroplasticity

›Compensation process takes weeks to months

›Vestibular suppressant medications impair this central compensation

›ICD-10 code: H81.2 — vestibular neuronitis

Therapeutic Considerations

›Evidence base for management decisions

›Corticosteroid evidence: RCT by Strupp et al. 2004 (NEJM) — methylprednisolone improved caloric recovery at 12 months

›Cochrane review 2011: insufficient evidence to recommend corticosteroids routinely

11Patient Discharge Instructions/pdi25

copy discharge instructions

›Vestibular Neuronitis (inner ear inflammation) — Discharge Instructions

›Your diagnosis is vestibular neuronitis, an inflammation of the balance nerve in your inner ear

›This is not a stroke — but we have confirmed that your symptoms are due to an inner ear problem

›The severe dizziness usually improves significantly within 2–3 days

›Some imbalance and motion sensitivity may last for several weeks to months

›You have been prescribed medications to help with nausea and dizziness

›Take these medications for no more than 3–5 days only

›Stopping these medications sooner helps your brain recover faster

›Avoid alcohol while you are recovering — it worsens dizziness

›Do not drive until your vertigo has completely resolved and your balance is stable

›Do not operate heavy machinery until your symptoms have fully resolved

›You have been referred to vestibular physiotherapy — this is an important part of recovery

›The exercises may initially cause brief dizziness — this is expected and necessary for recovery

›Start exercises once your severe nausea and vomiting have settled

›Follow up with your family doctor or ENT specialist within 1–2 weeks

Return to Emergency Department Red Flags

›Return to the emergency department immediately if you develop any of the following

›New or worsening headache, especially sudden or severe

›Double vision or any change in vision

›Slurred speech, difficulty swallowing, or facial drooping

›Weakness or numbness in any limb

›Worsening vertigo after initial improvement

›Inability to keep fluids down — severe dehydration

›New hearing loss or severe ear pain

›Falls or inability to walk at all

›Chest pain, palpitations, or fainting

12References/r16

Guidelines and Key Sources

›Primary clinical guidelines

›Edlow JA, Carpenter C, Akhter M, et al. Guidelines for Reasonable and Appropriate Care in the Emergency Department 3 (GRACE-3): Acute Dizziness and Vertigo in the Emergency Department. Academic Emergency Medicine. 2023. https://onlinelibrary.wiley.com/doi/10.1111/acem.14728

›Rogers TS, Noel MA, Garcia B. Dizziness: Evaluation and Management. American Family Physician. 2023. https://www.aafp.org/link_out?pmid=37192077

›Hall CD, Herdman SJ, Whitney SL, et al. Vestibular Rehabilitation for Peripheral Vestibular Hypofunction: An Updated Clinical Practice Guideline. Journal of Neurologic Physical Therapy. 2022. https://pubmed.ncbi.nlm.nih.gov/34864777

›Wang LL, Thompson TA, Shih RY, et al. ACR Appropriateness Criteria Dizziness and Ataxia: 2023 Update. Journal of the American College of Radiology. 2024. https://linkinghub.elsevier.com/retrieve/pii/S1546-1440(24)00259-X

Landmark Trials and Systematic Reviews

›Key evidence sources

›Strupp M, Zingler VC, Arbusow V, et al. Methylprednisolone, Valacyclovir, or the Combination for Vestibular Neuritis. New England Journal of Medicine. 2004. https://www.nejm.org/doi/full/10.1056/NEJMoa033280

›Gottlieb M, Peksa GD, Carlson JN. Head Impulse, Nystagmus, and Test of Skew Examination for Diagnosing Central Causes of Acute Vestibular Syndrome. Cochrane Database of Systematic Reviews. 2023. https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD015089.pub2/full

›McDonnell MN, Hillier SL. Vestibular Rehabilitation for Unilateral Peripheral Vestibular Dysfunction. Cochrane Database of Systematic Reviews. 2015. https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD005397.pub4/full

›Fishman JM, Burgess C, Waddell A. Corticosteroids for the Treatment of Idiopathic Acute Vestibular Dysfunction. Cochrane Database of Systematic Reviews. 2011. https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD008607.pub2/full

›Tokle G, Morkved S, Brathen G, et al. Efficacy of Vestibular Rehabilitation Following Acute Vestibular Neuritis: A Randomized Controlled Trial. Otology and Neurotology. 2020. https://pubmed.ncbi.nlm.nih.gov/31789800

›Nham B, Wang C, Reid N, et al. Modern Vestibular Tests Can Accurately Separate Stroke and Vestibular Neuritis. Journal of Neurology. 2023. https://pubmed.ncbi.nlm.nih.gov/36566345

›Baloh RW. Vestibular Neuritis. New England Journal of Medicine. 2003. https://www.nejm.org/doi/full/10.1056/NEJMcp021154

›Jeong SH, Kim HJ, Kim JS. Vestibular Neuritis. Seminars in Neurology. 2013. https://pubmed.ncbi.nlm.nih.gov/24057821

›Oliveira J E Silva L, Khoujah D, Naples JG, et al. Corticosteroids for Patients With Vestibular Neuritis: Evidence Synthesis for GRACE-3. Academic Emergency Medicine. 2023. https://pubmed.ncbi.nlm.nih.gov/35975654

›Muncie HL, Sirmans SM, James E. Dizziness: Approach to Evaluation and Management. American Family Physician. 2017. https://pubmed.ncbi.nlm.nih.gov/28145669

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