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vestibular neuronitis (acoustic neuritis)

Unilateral vestibular dysfunction without hearing loss. Etiology: (hypotheses) 1) may follow an upper respiratory tract infection in prior 2-3 weeks 2) reactivation of Herpes simplex Pathology: - vestibular dysfunction due to inflammation of the vestibular nerve (may be unilateral) Clinical manifestations: 1) acute onset of severe of severe constant vertigo - vertigo may be exacerbated by head movements 2) non-positional* peripheral vertigo 3) postural imbalance, positive Rhomberg test 4) dizziness 5) nausea, vomiting 6) no hearing loss 7) no photophonophobia 8) tinnitus may be noted 9) ear pain or fullness in the ear may be noted 10) symptoms generally last for hours, > 1-2 days [5] - symptoms resolve in days to weeks [9] - residual symptoms may persist for days to months to years 11) head-thrust test may be positive 12) Dix-Hallpike maneuver* results in delayed (~6 seconds) nystagmus with severe vertigo lasting < 1 minute * non-positional does not preclude patient from preferring to lie in bed with eyes closed [4] * non-positional apparently does not apply to head-thrust test * Dix-Hallpike maneuver does not constitute rapid positional change Special laboratory: - Weber test: midline - Rinne test: positive (air conduction > bone conduction) Differential diagnosis: - Meniere's disease: associated with hearing loss - labyrinthitis: associated with hearing loss - benign positional vertigo: - duration of vertigo < 24 hours - may be caused by head trauma - rotatory nystagmus provoked by rapid positional change lasts < 1 minute - Rhomberg test positive would be positive only during episodes of vertigo Management: 1) meclizine (Antivert) 25-50 mg PO every 6 hours 2) dimenhydrinate (Dramamine) 50 mg PO every 6 hours 3) promethazine (Phenergan) 25-50 mg PO every 6 hours 4) methylprednisolone taper over 3 weeks [3] -> begin 100 mg PO QD 5) valacyclovir no better than placebo [3]

General

vestibular disorder (vestibulopathy)

References

  1. Saunders Manual of Medical Practice, Rakel (ed), WB Saunders, Philadelphia, 1996, pg 1013
  2. Harrison's Principles of Internal Medicine, 14th ed. Fauci et al (eds), McGraw-Hill Inc. NY, 1998, pg 106
  3. Journal Watch 24(17):133, 2004 Strupp M, Zingler VC, Arbusow V, Niklas D, Maag KP, Dieterich M, Bense S, Theil D, Jahn K, Brandt T. Methylprednisolone, valacyclovir, or the combination for vestibular neuritis. N Engl J Med. 2004 Jul 22;351(4):354-61. PMID: 15269315 - Johnson RT. Vestibular neuritis, or driving dizzily through Donegal. N Engl J Med. 2004 Jul 22;351(4):322-3. No abstract available. PMID: 15269310
  4. Medical Knowledge Self Assessment Program (MKSAP) 14, 15, 16, 17, 18. American College of Physicians, Philadelphia 2006, 2009, 2012, 2015, 2018
  5. Geriatric Review Syllabus, 8th edition (GRS8) Durso SC and Sullivan GN (eds) American Geriatrics Society, 2013
  6. Jeong SH, Kim HJ, Kim JS. Vestibular neuritis. Semin Neurol. 2013 Jul;33(3):185-94. Review. PMID: 24057821
  7. Baloh RW. Clinical practice. Vestibular neuritis. N Engl J Med 2003 Mar 15; 348:1027 PMID: 12637613 https://www.nejm.org/doi/full/10.1056/NEJMcp021154
  8. NEJM Knowledge+ Otolaryngology - Le TN, Westerberg BD, Lea J. Vestibular Neuritis: Recent Advances in Etiology, Diagnostic Evaluation, and Treatment. Adv Otorhinolaryngol. 2019;82:87-92. PMID: 30947184 Review.
  9. NEJM Knowledge+ Question ot the Week. August 15, 2023 https://knowledgeplus.nejm.org/question-of-week/1380/ - Baloh RW. Clinical practice. Vestibular neuritis. N Engl J Med 2003 Mar 15; 348:1027 PMID: 12637613 https://www.nejm.org/doi/full/10.1056/NEJMcp021154
  10. Young AS, Rosengren SM, Welgampola MS. Disorders of the inner-ear balance organs and their pathways. Handb Clin Neurol. 2018;159:385-401. PMID: 30482329 Review.
  11. Baron R, Steenerson KK, Alyono J. Acute Vestibular Syndrome and ER Presentations of Dizziness. Otolaryngol Clin North Am. 2021 Oct;54(5):925-938. PMID: 34294435 Review.