Introduction: What is vestibular neuritis?

Vestibular neuritis is an inner ear condition which affects the superior vestibulocochlear nerve. This nerve is responsible for sending messages to the brain to control your hearing and balance.¹ When the vestibulocochlear nerve becomes irritated, it disturbs the brain's ability to process information for hearing and balance, resulting in symptoms of nausea, vomiting, sudden dizziness, vertigo and troubles with balance. The symptoms vary from each person; however, it is believed the condition is triggered by a recent viral infection, such as a cold or chickenpox. Quick head movements can commonly trigger the symptoms for a few days or weeks. The exact cause of the condition is unclear, and in this article, we will explore nystagmus in vestibular neuritis and how the conditions are diagnosed and treated. 

Understanding Nystagmus

Nystagmus is a condition which causes your eyes to make rapid, uncontrolled movements. Your eyes may move in various directions:

• Side to side (horizontal nystagmus)
• Up and down (vertical nystagmus)
• In a circle (rotary or torsional nystagmus)

Clinical features of vestibular neuritis 

Signs and symptoms

Although the symptoms may be intense, they are usually short-lived, and the initial symptoms last up to 2-3 days. In some people, the symptoms may last a few weeks but gradually improve. The initial signs and symptoms include:

• Sudden onset of dizziness 
• Intense balance problems
• Vertigo (a room spinning like sensation)
• Nausea and/or Vomiting
• Nystagmus - usually fine horizontal, but may be mixed horizontal-torsional³
• Symptoms aggravated by head movement 
• You should not have any hearing loss 

Diagnosis

How vestibular neuritis is diagnosed

For the condition to be diagnosed, a full clinical history, including the symptoms and physical examination, must be carried out, and this may indicate vestibular neuritis if symptoms last more than 24 hours. 

Sudden spontaneous dizziness and vertigo, which is worsened by changes to head position, but can remain even when your head is still.

To differentiate the condition, hearing loss and tinnitus (noises that do not come from an outside source heard in the ears) are not features of vestibular neuritis; they are usually present in other inner ear conditions such as labyrinthitis or Meniere's disease.

Horizontal and/or torsional nystagmus are usually present in Vestibular Neuritis, and they move away from the affected ear.³

A test known as the “head impulse test” is done to confirm the diagnosis by a healthcare professional. The test is carried out by following the instructions below:

• The healthcare professional will ask you to sit upright, and they will gently tilt your head from side to side using both hands, making sure that your neck muscles are relaxed and your eyes are fixated on them
• They will then ask you to keep looking at their nose whilst they turn their head left and right
• They will then turn your head about 10-20 degrees to each side rapidly and then back to the midpoint whilst they watch your eye movements³

If the test is positive, it means there is a disturbance with the vestibulocochlear nerve. You will have difficulty focusing on the healthcare professional's nose, and your eyes will move as your head moves, rather than fixating on the healthcare professional. This test should be avoided if you have neck or upper spine issues.

If the test is negative, this can indicate another cause of your symptoms, and this must be excluded. If you develop sudden-onset vertigo with hearing loss for the first time, this requires urgent medical assistance, and you will need to go to the emergency department for assessment. Whilst there, they are required to perform a scan to ensure these symptoms are not caused by an interruption to the blood supply of the inner ear.⁴ 

Treatment and management

Managing vestibular neuritis 

Usually, the symptoms of Vestibular neuritis resolve on their own; however, in many cases, the symptoms are treated using different management options. You may also be advised to avoid factors that can worsen your symptoms, such as alcohol and lack of sleep. In addition, minimising exposure to repeated viral infections may help reduce symptom flare-ups.³

You must also not drive if you are feeling dizzy or have a likely chance of having such an episode whilst driving.³

Treating Vestibular neuritis is often done with a symptomatic approach, and this is done with oral medication. You may be given oral anti-sickness medication to help with nausea or vomiting. Medications such as prochlorperazine are used to help quieten the nerve messages from the inner ear and may provide relief from vertigo and balance disturbances.⁴

Vestibular rehabilitation therapy

If your symptoms do not clear within a few weeks despite treatment, then you may be referred to a specialist in physical therapy, known as a physiotherapist or audiologist, and they may recommend vestibular rehabilitation. This uses exercises and occupational therapy techniques to treat vertigo and restore balance disorders. 

If symptoms deteriorate or have not improved after 1 week, you should see a healthcare professional again for further management.⁴

Depending on how long the symptoms are ongoing, they can have a significant impact on daily life. In such cases, psychological support can be offered and used to ensure you are receiving the right support.

Symptoms can often be so severe that you are having intense periods of vomiting and are unable to tolerate any oral foods or fluids, which can lead to severe dehydration. This requires hospital admission for IV fluid therapy (receiving fluids through a vein).

• If symptoms persist for more than a week despite treatment, you should be referred to a balance specialist known as an audiovestibular physician or neurologist 
• If symptoms persist for longer than 6 weeks, a different diagnosis may need to be considered, and further investigations are necessary to understand the cause of your symptoms³

Differential diagnosis

Conditions to rule out:

Labyrinthitis

This is another type of inner ear disorder caused by inflammation of the labyrinth of the ear (also responsible for your hearing and balance). Inflammation can usually be caused by a bacterial or viral infection. It has very similar features to vestibular neuritis as it also causes nausea, vomiting, dizziness, nystagmus and disturbances with balance. The main difference is that it involves tinnitus and hearing loss. If labyrinthitis is suspected, you may be referred for other investigations such as a hearing test.

Ménière's disease

A rare disorder of the inner ear, which is also characterised by vertigo, tinnitus, nausea, vomiting and troubles with balance. The cause of the condition is still unknown, and unfortunately, there is no definitive cure, so the condition is purely symptomatic management. 

• It is characterised by having 2 or more episodes of vertigo lasting 20 minutes to 12 hours⁹
• Usually have sensorineural hearing loss (type of hearing loss that occurs due to damage to the inner ear or nerve) in one ear at least on one occasion before, during, or after an episode of vertigo
• Varying ear symptoms such as reduced hearing, deafness, tinnitus, or ear fullness in the affected ear⁵

Benign paroxysmal positional vertigo (BPPV)

Another type of inner ear disorder, which is another cause of vertigo and dizziness, especially in the elderly.⁷ In the inner ear, there are small calcium carbonate crystals called otoliths, which aid your balance and spatial awareness. They line up the inner ear, and when these crystals shift, i.e due to a head injury or ear infection, they can cause you to feel dizzy and aggravate your vertigo.⁹

BPPV is the most common cause of vertigo. It can be caused by head injury, sitting for long periods in a horizontal position (for example, at the dentist or a hairdresser) or following another inner ear condition such as vestibular neuritis, labyrinthitis or Meniere's disease.⁸

Symptoms of vertigo are often short-lived and typically last for 20-30 seconds and not longer than 60 seconds.⁷ It can also be accompanied by signs and symptoms of occasional nystagmus, nausea and vomiting. This is often relieved by keeping your head still as the vertigo is triggered by a change in head position, including getting up from lying to standing position (i.e from your bed) or rolling over in bed.⁷

Summary

Vestibular Neuritis is a self-resolving condition that can impact your daily life due to sudden dizziness, nystagmus, and difficulties with balance. It can be scary, but over time, it does get better. It is diagnosed mainly by history, examination, and key signs like a positive head impulse test. The main differentiating factor is that it does not cause hearing loss. Many medications can be used to help your recovery, and knowing the difference between other inner conditions like Labyrinthitis, Meniere's disease, or BPPV can ensure you receive an accurate diagnosis and treatment.

Comparison of differential diagnoses

FAQs

Q. How long does recovery take?

1.  Most people usually start feeling better after 2-3 days; however, full recovery may take weeks. Some may experience ongoing issues with their balance, but this can be improved with vestibular rehabilitation. 

Q. Can it recur?

1. Unfortunately, although uncommon, there is a possibility that the symptoms may return. 

Q. Is there any permanent damage?

1. No, typically the inner ear nerve can recover, and symptoms gradually improve with time. Persistent symptoms will need to be reviewed by a specialist.