AKT · ENT/Vertigo & balance

Vestibular neuritis / labyrinthitis

Inflammation of the vestibular nerve (± labyrinth), often post-viral

Overview

Acute inflammation of the vestibular nerve (vestibular neuritis) or the whole labyrinth (labyrinthitis), usually post-viral. A SINGLE, PROLONGED episode of severe constant vertigo with nausea lasting days. Labyrinthitis additionally causes hearing loss (the cochlea is involved); vestibular neuritis spares hearing.

Recognise

Acute-onset, severe, CONSTANT vertigo with nausea/vomiting lasting DAYS (worse on head movement but present at rest)
Horizontal nystagmus (away from the affected side); unsteadiness
Labyrinthitis: + hearing loss/tinnitus; vestibular neuritis: hearing SPARED. Often after a viral URTI

Red flags

Central features (HINTS exam suggesting stroke — direction-changing nystagmus, normal head-impulse test, skew deviation), other neurology, or vascular risk factors → posterior-circulation stroke

Differentials & how to tell them apart

BPPVBRIEF positional attacks, not a single prolonged constant episode

Ménière diseaserecurrent episodes lasting HOURS with hearing loss/tinnitus/fullness — neuritis is a single prolonged episode

Posterior-circulation strokethe dangerous mimic — central HINTS, other neurology, vascular risk; image

Migrainous vertigoheadache/migraine history, photophobia

Investigations

Clinical; the HINTS examination helps separate peripheral from central (stroke). MRI if central features. Audiometry if hearing involved.

Management

Short-course vestibular sedative for the acute phase, then vestibular rehab

1Reassure; a short course (≤3 days) of a vestibular sedative (prochlorperazine/cyclizine) for severe acute vertigo and vomiting; encourage early mobilisation.Gate: Stop the vestibular sedative after a FEW DAYS — prolonging it prevents central compensation and worsens chronic dizziness; and use HINTS/red flags to exclude a posterior-circulation STROKE before settling on neuritis
2Vestibular rehabilitation exercises for persistent imbalance; central features → urgent imaging/stroke pathway.

Short course of a vestibular sedative (prochlorperazine or an antihistamine) — for severe acute symptoms only — limit to a few days

Vestibular rehabilitation exercises — promote central compensation once the acute phase settles

Key points

A single prolonged (days) constant vertigo = neuritis/labyrinthitis (hearing loss → labyrinthitis). The trap is missing a cerebellar stroke — use HINTS and red flags. Sedatives are short-term only.

Monitor & prognosis

Recovery over days–weeks; persistent imbalance → rehab.

Usually self-limiting with gradual compensation.

Source: NICE CKS Vestibular neuronitis