Vestibular Neuritis and Labyrinthitis

Let's Begin With Definitions

Vestibular neuritis

• Vestibular neuritis is inflammation limited to the vestibular nerve, which connects the inner ear’s balance sensors to the brainstem. This disrupts balance signals, causing vertigo without affecting hearing.

• It causes vertigo but typically no hearing loss.

• Vestibular neuritis is the third most common cause of peripheral vertigo, after benign paroxysmal positional vertigo (BPPV) and vestibular migraine. Read more about vertigo here.

• It affects approximately 3.5 to 4 cases per 100,000 people annually.

• It is more commonly observed in adults, with a peak incidence between 40 and 50 years of age. Children are less frequently affected.

Labyrinthitis

• Involves inflammation of the labyrinth, the inner ear structure housing both balance and hearing organs. It leads to vertigo with hearing loss or tinnitus. 

• Viral labyrinthitis is less common than vestibular neuritis but still accounts for a significant proportion of inner ear disorders.

• It is most frequently observed in adults aged 30–60 years, and slightly more common in women.

• Bacterial labyrinthitis is rare in our modern antibiotic age but can occur in individuals with untreated middle ear infections or meningitis.

What Causes Neuritis and Labyrinthitis?

Both conditions are predominantly caused by viral infections, such as:

• Herpes viruses (e.g., HSV-1, varicella-zoster).

• Respiratory viruses (e.g., influenza, adenovirus).
  These viruses may reactivate from prior infections or spread from nearby areas like the respiratory tract.

In vestibular neuritis, the virus targets the vestibular nerve, causing swelling and impaired signal transmission. In labyrinthitis, inflammation spreads to the cochlea, disrupting both balance and sound processing.

Bacterial labyrinthitis is less common and typically arises from:

• Untreated middle ear infections (otitis media) spreading to the inner ear.

• Meningitis, where bacteria invade the labyrinth via the cerebrospinal fluid.

Clinical Presentation

Unfortunately, I often see patients mistakenly diagnosed with neuritis or labyrinthitis after they had an unexplained vertigo episode, or because they have persistent imbalance. Emergency doctors or primary care providers sometimes jump to this conclusion. In my experience, the term is used too freely without careful consideration of the specific criteria, because it makes for an easier diagnosis. If you have a "vertigo" that lasts for weeks or months, or have had multiple episodes in the past year, you probably do NOT suffer from a neuritis or labyrinthitis. If you do not have hearing loss, you do not have a labyrinthitis. The physical examination (see below) should not only allow to confirm the diagnosis, but also pinpoint exactly which ear is affected by the inflammation. If your doctor cannot tell you which ear is affected (or at least suggest which ear might be causing the issue), the diagnosis is probably being made loosely.

For these reasons, it is important to carefully evaluate the symptoms, because they help us make the right diagnosis. Symptoms for these two conditions overlap but differ in key ways:

Vestibular Neuritis

• Severe vertigo lasting days. The vertigo is truly spinning, not just a swaying sensation. There is extreme sensitivity to head movements.

• The vertigo is very intense at the beginning (24-72H) but gets better with time, although some imbalance will persist for a few weeks.

• Vertigo is associated wth nausea, vomiting, and imbalance.

• Recurrent spells would be very uncommon, but they can happen. 
  
  

• No hearing loss or tinnitus (unlike labyrinthitis)

Labyrinthitis

• The vertigo is similar to what is seen in neuritis, BUT there is associated hearing loss and/or ringing (tinnitus).

  • This is a critical distinction to understand. If you do not have hearing loss, you do not have a labyrinthitis. 

• After the acute vertigo spell resolves, there is remaining sensitivity to head movements and imbalance, similar to neuritis.

• Possible ear fullness or pain if bacterial.

• Recurrences would be very rare.

What Medical Evaluation Is Needed? 

Shared Diagnostic Steps

1. History: Focus on symptom onset, recent infections, and hearing changes. Read more about vertigo here.

2. Physical Exam: The physical exam is crucial. It not only allows the doctor to confirm that there is in fact an inflammation of the inner ear or balance nerve (as opposed to other causes such as BPPV), but also allows the identification of which ear is affected. 

   • Head Impulse Test: Rapid head turns to detect impaired eye stabilization (seen in inner ear inflammation). There will be a catch-up eye movement when the head is turned towards the affected ear.

   • Nystagmus Observation: Involuntary eye movements typically horizontal and torsional in vestibular neuritis and labyrinthitis. The direction of the nystagmus is towards the healthy ear.

Differentiating Tests

• Audiometry: Probably the most important test to order urgently. Confirms hearing loss in labyrinthitis (absent in vestibular neuritis). Read more about audiograms here.

• MRI or CT Scan: Ordered if stroke or tumor is suspected (e.g., sudden one-sided weakness, atypical nystagmus). This is usually done in the emergency room.

• Videonystagmography (VNG) and video head-impulse test (vHIT): Measure eye movements to assess vestibular function, can help identify which ear is weaker. Read more about VNGs here, and learn more about vHIT here.

Treatment Approaches

Vestibular Neuritis

1. Acute Phase (First 5-7 Days):

   • Corticosteroids: Prednisone reduces inflammation of the balance nerve and helps quicken recovery time.
     
     
   • Antivirals: Controversial, not much evidence to support their use. I generally do not prescribe them.
     
     

   • Antihistamines: Meclizine (Antivert and certain version of Dramamine) or dimenhydrinate (Gravol) to reduce vertigo and nausea. This is supportive medication to help get through the episode.

***Should only be used for a few days (max 5) to avoid prolonging the recovery of the vestibular injury. Anti-histamines numb the balance system, which is good during the initial episode, but long-term use will prevent the brain from compensating and recovering.

1. • Anti-emetics: Ondansetron for severe vomiting. This is also supportive medication to help get through the episode.

2. Recovery Phase:

   • Vestibular Rehabilitation Therapy (VRT): Custom exercises like gaze stabilization and balance training to promote brain adaptation.

Labyrinthitis

1. Viral Cases:

   • Corticosteroids: Prednisone (1 mg/kg/day for 7–10 days) to reduce inflammation.

   • Antivirals: Controversial, not much evidence to support they use. I generally do not prescribe them.

   • Anti-histamines and anti-emetics just like for neuritis. See above for cautious use.
     
     

2. Bacterial Cases:

   • Antibiotics: Oral or intravenous treatment are required, especially if there is spread to a meningitis.

3. Recovery Phase:

   • Vestibular Rehabilitation Therapy for prolonged dizziness.

   • Hearing aids if hearing loss persists.

   • If there is complete loss in the affected ear, an emergency cochlear implant should be considered. This should be done very quickly before the inner ear ossified (gets filled with bone) from the inflammation.

Prognosis and Long-Term Outcomes

• Vestibular Neuritis:

  • 80–90% recover fully within 3–6 weeks. By 3 months, most patients will have recovered almost fully.

  • Some experience persistent imbalance during quick head turns, improving with continued VRT.

  • Some individuals may develop a prolonged recovery course leading to chronic dizziness, a condition called PPPD. You can learn more about it here.
    
    
  • Risk of recurrence: 

    Most cases occur as a single episode; however, recurrence is possible. Studies estimate a recurrence rate of up to 10%, though subsequent episodes are often less severe than the initial attack. In some patients, recurrent vertigo may be due to secondary conditions like BPPV, which develops in about 15% of patients following vestibular neuritis.

• Labyrinthitis:

  • Hearing can return to normal or near-normal within few weeks or months with appropriate therapy, but unfortunately many patients lose their hearing permanently.

  • Chronic dizziness affects up to 10% (sometimes more) of patients, requiring extended VRT. 

  • Similar to neuritis, some individuals may develop a prolonged recovery course leading to chronic dizziness, a condition called PPPD. You can learn more about it here.
    
    

  • Bacterial cases may result in permanent hearing loss if treatment is delayed.

  • Risk of recurrence: 
    

    Viral labyrinthitis is typically a one-time event. Recurrence rates are not well-documented but are thought to be lower than those for vestibular neuritis.

Summary Table: Vestibular Neuritis vs. Labyrinthitis