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Vestibular Neuronitis

Vestibular Neuritis

Vestibular neuritis (VN) is among the leading causes of peripheral vestibular vertigo. The disorder is characterized by a sudden and severe attack of vertigo that occurs as a result of acute unilateral disruption in vestibular function. Intense nausea and vomiting follow the episode. The disorder affects organs innervated by superior vestibular nerve but not those innervated by inferior vestibular nerve. Hence, the central brainstem functions remain unaffected [1].


Presentation

The classical symptoms of VN comprise an abrupt, acute attack of severe, debilitating vertigo which worsens with head movement, persistent nausea and vomiting, sustained, horizontal, spontaneous nystagmus directed towards the unaffected ear, postural imbalance and complete absence of auditory and neurological symptoms. The symptoms typically last for 7 to 10 days. Within days to weeks, the episodes of VN slowly subside without treatment [10]. The entire period of illness typically lasts for 6 weeks but in some cases, may persist for more than 9 weeks [11] [12]. The hallmark of VN which distinguishes it from Meniere disease and Labyrinthitis is the complete absence of auditory symptoms (tinnitus and hearing loss) and other neurological symptoms (diplopia and dysarthria). Other symptoms of VN that might ensue due to underlying vestibular injury are presence of residual dysequilibrium and rapid head movements [10].

Hunting
  • In cases of Hunt's syndrome with CSF pleocytosis, intrathecal IgG synthesis was detected.[ncbi.nlm.nih.gov]
  • Herpes zoster oticus (Ramsay Hunt syndrome) : Occurs when varicella-zoster virus is reactivated in the facial nerve. It causes facial paralysis, loss of taste, vestibulocochlear dysfunction and pain.[patient.info]
  • The varacella zoster virus (the cause of Ramsey Hunt) is also thought to be a common source of vestibular neuritis.[dizziness-and-balance.com]
Impaired Balance
  • Viral infection is suspected to be the most common cause and symptoms are sudden onset of vertigo, nausea, vomiting, impaired balance and horizontal nystagmus. This case report describes a three-year-old boy diagnosed with NV.[ncbi.nlm.nih.gov]
  • Symptoms of the disorder include impaired balance, nausea, vomiting, visual difficulties, dizziness and a spinning sensation that can range from mild to severe.[livestrong.com]
  • balance after rapid head movement.[jamanetwork.com]
Nausea
  • Vestibular neuronitis is an interesting condition characterized by the acute onset of vertigo, nausea and vomiting, in the absence of hearing loss or tinnitus. There is often evidence of a recent or concurrent upper respiratory tract infection.[ncbi.nlm.nih.gov]
  • It causes severe vertigo and is of a sudden onset, with or without nausea or vomiting, but without neurological signs or hearing loss. The symptoms of vestibular neuritis may seem highly bothersome, but it is indeed a benign disease.[health.ccm.net]
  • Vestibular neuritis (neuronitis) 2017-04-24T13:17:58 00:00 Vestibular neuritis or vestibular neuronitis is characterized by the sudden onset of spinning vertigo and nausea in a patient.[lmhofmeyr.co.za]
  • Vestibular neuronitis (VN) is a relatively common condition characterized by the acute onset of vertigo, nausea and vomiting, in the absence of auditory or central nervous system involvement. The exact aetiology (inflammatory, viral or vascular?)[ncbi.nlm.nih.gov]
Vomiting
  • Nausea and vomiting may be relieved by pills or suppositories containing the drug prochlorperazine .[msdmanuals.com]
  • Vestibular neuronitis is an interesting condition characterized by the acute onset of vertigo, nausea and vomiting, in the absence of hearing loss or tinnitus. There is often evidence of a recent or concurrent upper respiratory tract infection.[ncbi.nlm.nih.gov]
  • It causes severe vertigo and is of a sudden onset, with or without nausea or vomiting, but without neurological signs or hearing loss. The symptoms of vestibular neuritis may seem highly bothersome, but it is indeed a benign disease.[health.ccm.net]
  • Medications are given for nausea, vomiting and dizziness. If onset of VN is recent then oral steroids may help to decrease the severity of dizziness. If vomiting is uncontrollable, admission into a hospital is required for intravenous rehydration.[earassociates.com]
  • Symptoms and Signs Symptoms of vestibular neuronitis include a single attack of severe vertigo , with nausea and vomiting and persistent nystagmus toward the affected side, which lasts 7 to 10 days.[msdmanuals.com]
Vertigo
  • In 35 of 177 patients, the vertigo-like condition was due to peripheral causes: 10 sudden deafness, six vestibular neuronitis, three benign paroxysmal positional vertigo and three Meniere's disease.[ncbi.nlm.nih.gov]
  • So BPPV may occur soon after the disappearance of severe vertigo.[ncbi.nlm.nih.gov]
  • Since NB is tractable, all patients visiting the ENT clinic, especially those with vertigo, should be screened.[ncbi.nlm.nih.gov]
  • The main subjective complaint was vertigo (whirling; 93%). The remaining subjects noticed a floating sensation and unsteadiness of gait.[ncbi.nlm.nih.gov]
  • Vertigo Vertigo is the feeling of dizziness and disorientation, often associated with fear of heights. Learn about vertigo and how to treat it at Patient.[evidence.nhs.uk]
Dizziness
  • In 50% of the cases, vertigo subsided by the end of the 3-month period, but 6 subjects suffered from an intractable dizzy sensation for over 1 year. Even after 3 years, 3 of these 6 cases were bothered by dizzy sensations.[ncbi.nlm.nih.gov]
  • After Dizzy, life is more of an effort. Before Dizzy, life was calm. After Dizzy, life is unsteady. Before Dizzy, the ground was solid. After Dizzy, the ground is marshmallow. Before Dizzy, life was “normal.”[mysocalleddizzylife.wordpress.com]
  • A key component of successful adaptation is a dedicated effort to keep moving, despite the symptoms of dizziness and imbalance.[daganmd.com]
  • In general the best way to improve the dizziness due to vestibular neuronitis is to remain active (take a 30 minute walk every day) and avoid taking tablets for dizziness.[earandbalance.co.uk]
Nystagmus
  • In the case with a short period before the second attack, the direction of nystagmus was unchanged throughout the clinical course. It is suggested that the direction of nystagmus depends upon the severity of each vestibular dysfunction.[ncbi.nlm.nih.gov]
  • In 23 of these patients, central nervous disorders (CND) were suspected from the result of tests of positional and positioning nystagmus, smooth pursuit, optokinetic nystagmus or auditory brainstem response.[ncbi.nlm.nih.gov]
  • All cases were examined for critical head position which provoked vertigo, non-gaze nystagmus, positional and positioning nystagmus and caloric nystagmus. No characteristic signs and symptoms could be observed.[ncbi.nlm.nih.gov]
  • We evaluated the vestibular functions, especially for positional nystagmus and caloric nystagmus, in 43 cases of vestibular neuronitis for long periods after its onset.[ncbi.nlm.nih.gov]
  • The tests used for evaluation in this series were the following: spontaneous nystagmus, head positional nystagmus, a caloric test and a computed galvanic body sway test (GBST) conducted by Yamaguchi University.[ncbi.nlm.nih.gov]

Workup

Patients with symptoms characteristic of VN are recommended a series of tests and assessments in order to establish a definite diagnosis of the disease. A complete history and thorough physical examination is performed which is followed by an audiologic assessment along with electronystagmography, caloric testing, imaging, laboratory studies and Hallpike maneuver.

MRI is performed to locate the vertigo and to rule out the presence of central vertigo. It is the preferred method of imaging compared to computed topography (CT) scan as the former method shows visible augmentation of the vestibular nerve and provides a vague image of internal auditory canals and. Imaging helps in ruling out other diagnoses and should therefore only be considered in patients suspected of suffering from other illnesses as well. 

Laboratory studies are usually indicated to exclude other diagnoses and to differentiate among types of vertigo which may be found in other disease conditions. For instance, presence of abnormal serum glucose levels and anemia along with dizziness can be suggestive of cardiac dysrhythmia. 

Another specific diagnostic test that helps in determining the cause of vertigo is Hallpike maneuver. The patient is instructed to turn the head in three different angles in a lied back supine position and is checked for the presence of nystagmus

Intermittent Slow Activity

Treatment

As described earlier, determination of the type of vertigo and distinguishing the disorder from other forms with similar symptoms is of paramount importance in order to establish accurate diagnosis and initiate treatment. VN is a self-limiting condition and the symptoms often subside without treatment through physiological vestibular compensation. Management of VN is largely symptomatic with the use of anticholinergics, antiemetics, antihistamines, benzodiazepines and corticosteroids. Presence of dehydration due to severe vomiting must be corrected by starting an intravenous (IV) line. Physical therapy aimed at performing vestibular rehabilitation also helps in improving vestibular function.

In a study performed to determine possible treatment options that may help in protecting the vestibular apparatus and restoring vestibular function, it was found that administration of methylprednisolone in tapered doses can help in sustaining vestibular function. Furthermore, use of antiviral agent (valacyclovir) alone and in combination with methylprednisolone has also proved to be helpful [13].

Prognosis

The majority of patients suffering from VN typically recovers from episodes of severe vertigo and imbalance within a week without treatment. A small percentage of patients may experience recurrent, less severe attacks with prolonged symptoms [7]. The prognosis of VN is reported to be better in children than in adults [9]. In a clinical study conducted by Matsuo and Sekitani, it was reported that VN shows partial resolution in some cases with 15% of cases out of total 38 patients demonstrating recurrence of vestibular symptoms after 1 year [8]. 

Etiology

As described earlier, the definite cause of VN is not discovered yet. According to most researchers, underlying viral infection might lead to the development of VN by some uncertain mechanism. Another suspected cause that may precipitate VN is localized ischemia of the vestibular apparatus.

Presumably, viral infection of the vestibular nerve, vestibular ganglion or vestibular labyrinth is thought to be one of the most common causes of VN [3]. It is believed that VN may occur in children with preceding viral infection of the inner ear, viral infection caused by herpes virus in different parts of the body (cold sores, shingles, chicken pox) or other viral infections such as measles, flu, mumps, hepatitis and polio.

Epidemiology

The incidence rate of VN is reported to be approximately 3.5 cases among 100,000 people [5]. In the United States, about 5.6% cases of dizziness reported in emergency are due to VN [4]. The disease can occur in both males or females with no established gender predominance. Studies have shown that VN typically effects middle-aged individuals in between 30 and 60 years [5].

Sex distribution
Age distribution

Pathophysiology

To date, the etiology and definite pathophysiology of VN largely remain unknown. However, certain theories claim that the reactivation of a previously latent neurotropic virus (for instance, herpes simplex virus) in the vestibular ganglia accounts for the onset of an inflammatory reaction, leading to sudden dysfunction of afferent neuronal input of the vestibular apparatus. The disruption leads to self-limited episodes of vertigo. The evidence of suspected herpetic viral infection in pathophysiology of VN is suggested by histologic evaluation of the temporal bone that shows visible changes. The lesions occurring in VN are limited to vestibular neurons only with no involvement of cochlear and vestibular elements of inner ear. Therefore, the vertigo occurs solely in the absence of hearing loss and central involvement, a distinctive feature of VN [6].

Prevention

Prevention of VN requires staying away from a possible viral infection as the disease is thought to occur due to such. Getting complete vaccination shots and following treatment regimen in patients who are already on antimicrobial therapy are also helpful measures in preventing VN. 

Summary

Vestibular neuronitis (VN), also referred to as vestibular neuropathy or acute peripheral vestibulopathy is described as acute, persistent dysfunction of the peripheral vestibular system that occurs as a result of inflammation of the vestibular division of the 8th cranial nerve. VN is characterized by prolonged episodes of nausea, vomiting and vertigo and is the second most common cause of peripheral vestibular vertigo [1] [2]. The etiology of VN is not completely known but it is thought to emerge from inflammatory reaction provoked by the herpes simplex virus where that effects the vestibular ganglion and vestibular nerve [3]. Diagnosis of VN requires meticulous assessment to rule out other similar diagnoses. VN, primarily exhibiting a peripheral cause, must be differentiated from other conditions possessing central cause. Such can be cerebral stroke and hemorrhage, the latter possibly fatal. In cases when central signs are suspected or vertigo is undifferentiated from others forms of dizziness, magnetic resonance imaging (MRI) is suggested to establish a definite diagnosis. Other diagnostic tests of VN comprise audiologic assessment, caloric testing, electronystagmography and Hallpike maneuver. Recovery following an episode of VN often occurs without definite treatment although symptomatic management helps in alleviating symptoms and improving the overall condition. Prolonged use of vestibular suppressants in order to reduce episodes of VN should be avoided as the physiologic compensation might be disrupted. Commonly used drugs to reduce symptoms of VN are anticholinergics, antiemetics, antihistamines, benzodiazepines and corticosteroids. Because the definite cause of VN is unknown, no specific preventive measures of the disease are established. Avoiding viral infection, getting appropriate vaccination and following complete course of antimicrobial drugs can be helpful in preventing VN. 

Patient Information

Vestibular neuronitis (VN) is a disorder of a part of the brain (called vestibular system) which results in a sudden, intensive episode of vertigo, (a type of dizziness in which the patient experiences false feeling of head spinning) followed by severe nausea and vomiting

The definite cause of VN is not known but it is thought to occur from a viral infection. Herpes simplex virus, a type of virus belonging to the neurotropic group of viruses, is suspected to be involved in the disease. It is believed that after entering the body, the virus resides in the brain in an inactive state and becomes reactivated later to cause infection which then results in VN. Other viral infections that may precipitate VN include measles, flu, mumps, hepatitis and polio. An ischemic attack in the vestibular apparatus may also cause VN.

The characteristic signs and symptoms of VN is a single, severe attack of vertigo that may last several days and may be followed by additional milder vertigo attacks later for several weeks. Other symptoms are nausea and vomiting which last for 7 to 10 days. Usually the initial episode of vertigo is the most severe one. It has been estimated that in the US, about 3.5% cases of dizziness reported in the ER are found to occur from VN. The disease equally affects males and females with no gender predominance. 

A series of hearing tests (audiologic assessment), tests for nystagmus (electronystagmography) and Hallpike maneuver are used to establish diagnosis. Laboratory studies and imaging (MRI scan) are performed to assure that the symptoms are characteristic of VN only and not caused by any other disease. Hallpike maneuver is a specific test used to identify the type of vertigo. In this test, the patient is instructed to lie down facing upwards three times with both eyes kept open. Throughout the assessment, the patient is checked for the appearance of nystagmus and symptoms of vertigo (appearance or worsening of symptoms). 

VN often subsides itself without medicinal intervention. However, the severe and recurring symptoms can be managed by symptomatic treatment. When diagnosed correctly and treated appropriately, the outcome is usually positive. Commonly prescribed medicines used to control symptoms of VN are anticholinergics, antiemetics, antihistamines, benzodiazepines and corticosteroids. Physical therapy is also applied to improve brain function in VN. It is recommended to stay away from all forms of viral infections and follow complete course of antimicrobial therapy during infection in order to prevent VN. 

References

Article

  1. Aw ST, Fetter M, Cremer PD, Karlberg M, Halmagyi GM. Individual semicircular canal function in superior and inferior vestibular neuritis. Neurology. 2001;57(5):768-774.
  2. Cutfield NJ, Seemungal BM, Millington H, Bronstein AM. Diagnosis of acute vertigo in the emergency department. Emerg Med J. 2011;28(6):538-539.
  3. Schuknecht HF, Kitamura K. Second Louis H. Clerf Lecture. Vestibular neuritis. Ann Otol Rhinol Laryngol Suppl. 1981:1-19.
  4. Newman-Toker DE, Hsieh YH, Camargo CA Jr, Pelletier AJ, Butchy GT, Edlow JA. Spectrum of dizziness visits to US emergency departments: cross-sectional analysis from a nationally representative sample. Mayo Clin Proc. 2008;83(7):765-775.
  5. Sekitani T, Imate Y, Noguchi T, Inokuma T. Vestibular neuronitis: epidemiological survey by questionnaire in Japan. Acta Otolaryngol Suppl. 1993;503:9-12.
  6. Gacek RR, Gacek MR. Viral neuropathies in the temporal bone. Introduction. Adv Otorhinolaryngol. 2002;60:7-9.
  7. Mandalà M, Nuti D, Broman AT, Zee DS. Effectiveness of careful bedside examination in assessment, diagnosis, and prognosis of vestibular neuritis. Arch Otolaryngol Head Neck Surg. 2008;134(2):164-169.
  8. Matsuo T, Sekitani T. Vestibular neuronitis: neurotological findings and progress. ORL J Otorhinolaryngol Relat Spec. 1985;47(4):199-206.
  9. Tahara T, Sekitani T, Imate Y, Kanesada K, Okami M. Vestibular neuronitis in children. Acta Otolaryngol Suppl. 1993;503:49-52.
  10. Gacek RR. A Perspective on Recurrent Vertigo. ORL J Otorhinolaryngol Relat Spec. 2013;75(2):91-107.
  11. Clemis JD, Becker GW. Vestibular neuronitis. Otolaryngol Clin North Am. 1973;6(1):139-155.
  12. Worster-Drought C. An unusual epidemic. The Lancet. 1952;371.
  13. Strupp M, Zingler VC, Arbusow V, Niklas D, Maag KP, Dieterich M. Methylprednisolone, valacyclovir, or the combination for vestibular neuritis. N Engl J Med. 2004;351(4):354-361.

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Last updated: 2018-06-22 01:22