Vestibular neuritis, also known as vestibular neuronitis, is a disease of the inner ear typically caused by a viral infection. It is believed that inflammation of the vestibular part of the eighth cranial nerve causes the condition.1 This nerve carries balance information through the inner ear to the brain and its inflammation frequently causes vertigo, dizziness, nausea, and problems with balance and coordination.2 While the symptoms might be upsetting, appropriate evaluation and treatment, such as medication, vestibular rehabilitation exercises, and modifications to one's lifestyle, can help effectively manage the disease.
Vestibular neuritis is a condition characterised by inflammation of the vestibular nerve, which links the inner ear to the brain and is essential for balance.3 The syndrome usually appears unexpectedly and is caused by a viral infection. Severe vertigo is the primary symptom, which is accompanied by dizziness, nausea, and difficulty with balance and coordination, lack of auditory symptoms or findings. It usually occurs in the middle-aged population, equally affecting both sexes and is associated with recent or present upper respiratory infection.4 While the symptoms can be incapacitating, most patients recover gradually over many weeks to months with the assistance of medicines to control symptoms, vestibular rehabilitation activities to improve compensation, and lifestyle changes to eliminate triggers and promote recovery. Seeking medical treatment and advice from healthcare specialists is critical for determining an accurate diagnosis and managing vestibular neuritis.
Causes of vestibular neuritis
According to current studies, the most prevalent cause of vestibular neuritis is an inner ear viral infection. Viral infections, most often the herpes simplex virus or the varicella-zoster virus infections, are the primary causes of vestibular neuritis.2 These viruses commonly infect the vestibular nerve, causing inflammation and dysfunction. The virus particles are thought to infiltrate the nerve, prompting an immunological response that leads to inflammation. The precise process by which the virus penetrates the nerve and induces inflammation is unknown. Other possible causes of vestibular neuritis include autoimmune illnesses, bacterial infections, and vascular events, albeit these are rather uncommon.5
Signs and symptoms of vestibular neuritis
Vestibular neuritis is classified into acute and chronic stages, each with its own set of symptoms. Here's a brief description of the symptoms associated with each stage:
- Vertigo: The acute phase is characterised by severe vertigo, typically lasting a few days to a few weeks. Vertigo is frequently characterised as a spinning or whirling sensation, and it can be severe, impairing balance and everyday tasks. Vertigo during the acute phase of vestibular neuritis frequently causes nausea and, in rare cases, vomiting
- Imbalance and Unsteadiness: Individuals may report issues with balance and coordination, feeling shaky or off-balance. This can make walking and performing ordinary chores difficult.
- Nystagmus: Nystagmus, or involuntary rhythmic eye movements, may be present2
- Persistent dizziness: After the initial phase has passed, some people may feel persistent dizziness or unsteadiness. This sensation might last for several weeks to months following the original vertigo attack
- Imbalance and instability: Imbalance issues and a feeling of insecurity may remain in the chronic phase. Individuals may feel shaky, especially in difficult or crowded situations
- Anxiety and emotional distress: The chronic symptoms of vestibular neuritis can lead to increased anxiety and emotional distress, as the ongoing dizziness and balance issues may affect daily functioning and quality of life
Management and treatment for vestibular neuritis
The goal of vestibular neuritis management and treatment is to relieve symptoms, promote healing, and restore balance and function.
Treatment for vestibular neuritis includes
- Symptomatic treatment with antivertiginous drugs (e.g. dimenhydrinate, scopolamine) to reduce vertigo, dizziness, and nausea/vomiting
- Causal treatment with corticosteroids to improve recovery of peripheral vestibular function.
- Physical therapy (vestibular exercises and balance training) to improve central vestibular compensation2
When nausea is severe for the first 1 to 3 days, medications may be administered to control symptoms such as vertigo, nausea, and dizziness. Antivertigo (e.g. meclizine) and anti-nausea (e.g. promethazine) drugs are often used. Corticosteroids may be administered in some circumstances to decrease inflammation and facilitate speedier healing.
Vestibular rehabilitation therapy (VRT)
VRT is a specialised exercise programme aimed at increasing vestibular system compensation and adaptability. It consists of a variety of exercises and procedures designed to improve balance, reduce dizziness, and increase the brain's capacity to interpret sensory information. VRT is often adjusted to the particular needs of each individual and may be guided by a physical therapist.
Making specific lifestyle changes can help control symptoms and reduce triggers. Avoiding rapid head movements, getting lots of rest, lowering stress levels, and making adjustments to the surroundings to increase safety and minimise fall risks are all great examples.
Canalith repositioning manoeuvres
Techniques such as the Epley or Semont manoeuvres, are specialised head and body positioning strategies used to treat benign paroxysmal positional vertigo (BPPV), which can occasionally accompany vestibular neuritis. These manoeuvres are designed to relocate misplaced calcium crystals in the inner ear, alleviating vertigo symptoms associated with BPPV.
During the acute phase, rest and self-care practices, such as staying hydrated and avoiding activities that aggravate symptoms, can be beneficial. Additionally, because vestibular neuritis can induce anxiety and mental discomfort, emotional support and counselling may be useful.
Diagnosis of vestibular neuritis
Vestibular neuritis is normally diagnosed using a combination of collecting the medical history, physical examination, and specialised testing.2
- Medical history: The healthcare professional will begin by inquiring about the type and length of symptoms, any recent viral infections or illnesses, medications being taken, and any past ear-related difficulties
- A physical examination will be undertaken to examine overall health, balance, and coordination, as well as any evidence of irregular eye movements (nystagmus) that may be related to vestibular dysfunction
- Vestibular Function Tests:Several tests may be performed to assess the function of the vestibular system, which aids in determining if the symptoms are caused by vestibular neuritis. Among these tests are:
- Videonystagmography (VNG): This test examines eye movements to determine the vestibular system's integrity
- Caloric testing: rrigating the ear canal with warm or cold water to stimulate the inner ear and then observing the associated eye movements
- Vestibular evoked myogenic potentials (VEMP): VEMP studies assess how specific muscles in the neck or eyes respond to sound or vibration stimulation
- Hearing Evaluation: An audiometry test may be performed to examine hearing sensitivity and rule out any hearing loss or other auditory disorders
- Imaging studies such as magnetic resonance imaging (MRI), may be conducted in certain circumstances to rule out other potential causes of symptoms, particularly if there are abnormal findings or concerns about other underlying illnesses
Although the actual cause of vestibular neuritis is viral infections, some risk factors may enhance the probability of acquiring this disease. These may include;
- Viral infections: Individuals who have recently had viral infections or who have a compromised immune system may be more vulnerable
- Age: Vestibular neuritis may affect people of any age, although it is more frequent in adults, particularly those between the ages of 30 and 60
- Previous ear infections or illnesses: People who have had repeated ear infections or other ear illnesses, such as otitis media or Meniere's disease, are more likely to develop vestibular neuritis.
- Chronic stress and exhaustion can impair the immune system, leaving people more susceptible to infections, including those that cause vestibular neuritis
- Smoking and secondhand smoke exposure are also possible risk factors for vestibular neuritis
While most people with vestibular neuritis recover completely over time, there may be some difficulties. Here are a few potential complications:
- Recurrent vertigo
- Persistent dizziness and imbalance
- Anxiety and emotional distress
- Impact on daily functioning like driving, work, social or recreational activities
- Impact on mental health
Can vestibular neuritis be prevented?
Unfortunately, no proven way of preventing vestibular neuritis exists since it is frequently caused by viral infections that are difficult to detect or avoid. However, several precautions might potentially lower the likelihood of getting the illness or lessen its severity:
- Good hygiene practices
- Reducing virus exposure: avoiding close contact with people who have active respiratory or viral diseases, practising respiratory hygiene (covering mouth and nose while coughing or sneezing), and avoiding crowded venues during periods of high viral activity
- Lifestyle modification: maintaining a healthy lifestyle that includes regular exercise, a well-balanced diet, appropriate sleep, and stress management might help to promote general immune function and perhaps minimise susceptibility to viral infections
How common is vestibular neuritis?
Around 3 to 15 out of every 100,000 persons suffer from vestibular neuritis. It is the third most prevalent cause of vertigo in the peripheral ear.
When should I see a doctor?
Call your doctor if you experience severe vertigo, dizziness, or balance problems as a result of vestibular neuritis. If you've already had vestibular neuritis therapy but your symptoms aren't improving, contact your doctor.
Vestibular neuritis is an inflammation of the vestibular nerve, which links the inner ear to the brain and plays an important role in balance. It usually presents as vertigo, dizziness, and balance issues. The most common causes are viral infections, specifically herpes simplex or varicella-zoster viruses. While the symptoms might be upsetting, with adequate therapy, including medicines, vestibular rehabilitation exercises, and lifestyle changes, most patients recover gradually over time.
- Smith T, Rider J, Cen S, Borger J. Vestibular neuronitis. [Updated 2023 Jul 21]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK549866/
- Strupp M, Brandt T. Vestibular neuritis. Semin Neurol [Internet]. 2009 Nov 1;29(5):509–19. Available from: https://pubmed.ncbi.nlm.nih.gov/19834862/
- Strupp M, Brandt T. Peripheral vestibular disorders. Curr Opin Neurol [Internet]. 2013 Feb;26(1):81–9. Available from: https://journals.lww.com/co-neurology/fulltext/2013/02000/peripheral_vestibular_disorders.13.aspx
- Nadol JB Jr. Vestibular neuritis. Otolaryngol Head Neck Surg [Internet]. 1995 Jan;112(1):162-72. Available from: https://aao-hnsfjournals.onlinelibrary.wiley.com/doi/10.1016/S0194-59989570316-0
- Greco A, Macri GF, Gallo A, Fusconi M, De Virgilio A, Pagliuca G, Marinelli C, et al. Is vestibular neuritis an immune related vestibular neuropathy inducing vertigo? J Immunol Res [Internet]. 2014;2014:459048. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3987789/