Nervous System & Special Senses

Vestibular neuritis and labyrinthitis

Clinical Overview and When to Suspect Vestibular Neuritis/Labyrinthitis

— Key distinction: Vestibular neuritis = vertigo only. Labyrinthitis = vertigo PLUS unilateral hearing loss/tinnitus. Both lack brainstem signs.

— Continuous vertigo lasting days (not seconds like BPPV, not minutes-to-hours like Ménière, not a transient spell like TIA).

— Nausea, vomiting, gait instability — but the patient can still walk (falls toward affected side).

— Recent viral illness, no focal neurologic deficits, no headache, no new hearing loss (neuritis) or with hearing loss (labyrinthitis).

Definition: Acute peripheral vestibular syndrome caused by inflammation (presumed viral or post-viral reactivation of HSV-1) of the vestibular nerve (vestibular neuritis) or the entire labyrinth including cochlea (labyrinthitis).

Epidemiology: Third most common cause of peripheral vertigo after BPPV and Ménière disease. Peaks ages 30–60, no sex predilection. Often follows a viral URI by 1–2 weeks.

Pathophysiology: Selective inflammation of the superior vestibular nerve branch (innervates horizontal and anterior semicircular canals + utricle) is most common. The inferior branch and cochlea share blood supply with the vestibular nerve via the labyrinthine artery — explaining overlap with labyrinthitis.

When to suspect on Step 3:

Ambulatory framing: The vast majority are diagnosed and managed in primary care or urgent care. The clinician's main job is ruling out posterior circulation stroke, which mimics this presentation in up to 25% of acute vestibular syndrome cases over age 60.

Board pearl: Acute vestibular syndrome = acute, continuous vertigo >24 hours with nystagmus, nausea, and gait unsteadiness. Always apply HINTS exam before labeling it "peripheral." A "central HINTS" pattern in an ED patient mandates MRI, not symptomatic discharge.

Step 3 management: First decision point is central vs peripheral — not labs, not imaging in low-risk patients, but a structured bedside exam.

Presentation Patterns and Key History

— Hours 0–48: severe spinning, nausea, vomiting, photophobia-like aversion to motion, bedbound.

— Days 3–7: improvement at rest, residual motion-provoked imbalance.

— Weeks 2–6: central compensation; most return to baseline by 3 months. ~15% develop persistent postural-perceptual dizziness (PPPD).

— Constant vertigo (not episodic) — worsened by head movement but does not resolve when still. This separates it from BPPV.

— No tinnitus or hearing change → vestibular neuritis.

— Unilateral hearing loss, aural fullness, or tinnitus → labyrinthitis.

— Sudden onset thunderclap headache, neck pain (vertebral dissection).

— Diplopia, dysarthria, dysphagia, dysmetria, numbness, weakness — any of the "5 Ds."

— Vascular risk factors: age >60, HTN, DM, AFib, smoking, prior stroke/TIA.

— Bilateral or alternating hearing symptoms.

— Recent aminoglycosides, loop diuretics, cisplatin → ototoxicity mimic.

— Alcohol intoxication, benzodiazepine use → mimic and treatment confounders.

— Migraine history → vestibular migraine differential.

— Driving, occupational safety (pilots, roofers, surgeons), fall risk in elderly.

— Assess ability to maintain hydration PO; persistent vomiting drives ED disposition.

Classic prodrome: Viral URI, gastroenteritis, or otitis 1–3 weeks earlier in ~50%. Sudden or subacute onset over hours of relentless rotational vertigo, worst at onset, then gradual improvement over days to weeks.

Symptom timeline (high-yield):

Symptom quality cues:

Red flags in history (push toward central etiology):

Social/medication history:

Functional impact for Step 3:

Board pearl: A patient who says "the room spins ONLY when I roll over in bed and it lasts 30 seconds" is BPPV, not vestibular neuritis. Vestibular neuritis is continuous baseline vertigo, exacerbated (not triggered) by motion.

Key distinction: Recurrent episodic vertigo with hearing loss = Ménière. Single prolonged episode with hearing loss = labyrinthitis.

Physical Exam Findings and the HINTS Exam

— Unidirectional, horizontal with a torsional component, fast phase beats away from the affected ear.

— Suppressed by visual fixation; enhanced with Frenzel lenses or fixation removal.

— Obeys Alexander's law: intensifies on gaze toward the fast phase.

— Romberg: falls toward the affected (hypofunctioning) side.

— Can walk with assistance — inability to stand or walk unaided is a central red flag.

— No limb dysmetria, normal finger-to-nose, normal heel-to-shin.

— Head Impulse: Rapid 10–20° head turn while patient fixates on examiner's nose. Corrective saccade = peripheral (reassuring). Normal/absent saccade in an acutely vertiginous patient = central (worrisome).

— Nystagmus: Unidirectional horizontal = peripheral. Direction-changing or pure vertical/torsional = central.

— Test of Skew: Alternate cover test. Vertical skew deviation = central.

— Mnemonic "INFARCT" = Impulse Normal, Fast-phase Alternating, Refixation on Cover Test → stroke.

— Normal TM and canal in neuritis/labyrinthitis (rules out otitis media, cholesteatoma, zoster oticus).

— Vesicles in the ear canal + facial palsy + vertigo = Ramsay Hunt syndrome (HZ oticus) — treat with antivirals + steroids, ENT referral.

— Bedside Weber/Rinne: sensorineural pattern in labyrinthitis.

General appearance: Pale, diaphoretic, lying very still, eyes closed. Vital signs typically normal — abnormal vitals should prompt a search for alternative etiologies (sepsis, arrhythmia, dehydration).

Nystagmus characteristics (peripheral pattern):

Gait/coordination:

HINTS exam (Head Impulse, Nystagmus, Test of Skew) — the cornerstone bedside tool:

Otologic exam:

Board pearl: HINTS is more sensitive than early MRI for posterior circulation stroke in acute vestibular syndrome — but only valid in continuous vertigo with nystagmus AT THE TIME of exam. Do not apply HINTS to episodic or asymptomatic patients.

Step 3 management: A "peripheral HINTS" pattern + no red flags + ability to tolerate PO = outpatient management. No imaging needed.

Diagnostic Workup — Initial Evaluation

— Persistent vomiting, dehydration: BMP, glucose for electrolyte/AKI assessment.

— Elderly or atypical features: consider CBC, TSH (hypothyroid mimic), B12.

— Suspected infection: CBC with differential; consider Lyme serology in endemic areas with cranial neuropathy.

— Autoimmune inner ear disease workup (bilateral, recurrent, steroid-responsive): ANA, ESR, CRP — usually deferred to ENT.

— Any central HINTS finding, focal neuro deficit, severe headache, inability to walk, age >60 with vascular risk factors, or sudden isolated hearing loss with vertigo.

— MRI brain with DWI + MRA of head/neck is the test of choice — CT misses up to 80% of posterior circulation strokes in the first 24–48 hours.

— Initial CT is reasonable only to exclude hemorrhage if thrombolysis is being considered or if MRI is unavailable.

— Indicated when hearing loss is present (labyrinthitis) or suspected. Outpatient referral to audiology/ENT within 1–2 weeks.

— Sudden sensorineural hearing loss (>30 dB across 3 contiguous frequencies within 72 hours) is an otologic emergency — start oral steroids and refer urgently.

Vestibular neuritis and labyrinthitis are clinical diagnoses. There is no confirmatory blood test, and routine imaging is not indicated in the typical low-risk patient with a reassuring HINTS exam.

When to obtain labs (selective, not routine):

ECG: Obtain if any concern for arrhythmia-mediated presyncope being misinterpreted as vertigo, or in elderly with vascular risk factors before discharge.

Glucose: Bedside fingerstick — hypoglycemia mimics dizziness.

When to image (CT/MRI):

Audiometry:

Pregnancy test: In reproductive-age women before imaging contrast or pharmacotherapy.

Board pearl: Negative non-contrast head CT does NOT rule out cerebellar or brainstem stroke. In a patient with a central HINTS pattern, push for MRI/MRA even if CT is "normal."

Step 3 management: Order MRI brain with DWI and MRA neck — not CT — when acute vestibular syndrome has any central features. Admit or hold in observation pending results.

Diagnostic Workup — Advanced and Confirmatory Studies

— Videonystagmography (VNG/ENG): Caloric testing demonstrates unilateral hypofunction (reduced response to warm/cold water irrigation) on the affected side — confirms vestibular neuritis weeks later.

— Video Head Impulse Test (vHIT): Quantifies vestibulo-ocular reflex by canal. Superior canal involvement = classic neuritis pattern.

— Rotary chair testing: Useful for bilateral vestibular loss assessment, less for unilateral acute neuritis.

— Vestibular Evoked Myogenic Potentials (VEMPs): Cervical VEMP tests saccule/inferior nerve; ocular VEMP tests utricle/superior nerve. Helps localize partial nerve involvement.

— Pure-tone audiometry, speech discrimination, tympanometry. Expect unilateral sensorineural pattern.

— Repeat audiometry at 2 and 6 weeks to track recovery.

— MRI brain with gadolinium: May show enhancement of the vestibular nerve or labyrinth in neuritis/labyrinthitis but is not required for diagnosis. Primary role is excluding vestibular schwannoma, MS plaque, cerebellar infarct, or hemorrhage.

— MRA head and neck: Vertebral artery dissection workup in younger patients with neck pain or recent trauma/chiropractic manipulation.

— Bilateral or recurrent vestibulopathy → neurotology.

— Persistent symptoms >4–6 weeks → vestibular rehab + ENT.

— Atypical audiometric pattern, asymmetric SNHL → MRI IAC to exclude vestibular schwannoma.

Vestibular function testing (outpatient ENT/neurotology setting, not acute):

Audiologic workup (labyrinthitis):

Imaging when indicated:

Lumbar puncture: Rarely needed; consider if meningitis, neurosyphilis, or neurosarcoid is suspected (fever, meningismus, multiple cranial neuropathies).

Specialty referral triggers:

Key distinction: A unilateral caloric weakness on VNG distinguishes vestibular neuritis from vestibular migraine (which typically has normal interictal caloric testing).

Board pearl: Any patient with asymmetric sensorineural hearing loss after a presumed labyrinthitis episode needs MRI of the internal auditory canals to rule out acoustic neuroma — even months later.

Risk Stratification and Management Logic

— Peripheral pattern + tolerating PO + safe home environment → discharge home with symptomatic therapy and short-interval follow-up (48–72 hours).

— Peripheral pattern + intractable vomiting/dehydration → observation for IV fluids and antiemetics, often discharge within 24 hours.

— Any central features or diagnostic uncertainty → admit for MRI, neurology consult, stroke workup.

— Mild: Tolerating PO, ambulatory with support — outpatient.

— Moderate: Severe vomiting, unsteady — short observation.

— Severe with hearing loss (labyrinthitis): Add oral corticosteroids early (within 3 days for SSNHL benefit), urgent audiology referral.

— Symptom control: antiemetics, vestibular suppressants — short-term only (≤3 days).

— Prevent dehydration and falls.

— Initiate vestibular rehabilitation early (within first week) to promote central compensation.

— Identify and treat reversible mimics (otitis, herpes zoster oticus, drug toxicity).

— Don't continue meclizine for weeks — it delays central compensation.

— Don't reflexively order CT for every dizzy patient.

— Don't anticoagulate empirically without confirming stroke.

First fork: Central vs peripheral. The HINTS exam + neuro screen + gait + red-flag history drives this decision. Never skip it in acute vestibular syndrome.

ABCD2 score is for TIA, not acute vestibular syndrome — but vascular risk factors raise central probability. Threshold for MRI/MRA should be low in patients >60 with HTN, DM, AFib, smoking, prior stroke.

Disposition algorithm:

Severity grading of peripheral disease:

Goals of management (Step 3 voice):

What NOT to do:

Step 3 management: The single most impactful intervention beyond symptom control is early vestibular rehab referral — it shortens recovery and improves functional outcomes versus rest alone (Cochrane evidence).

Board pearl: In ambulatory practice, a structured 48-hour callback (phone or visit) catches missed central pathology and worsening dehydration — document it.

Pharmacotherapy — First-Line Regimens

— Meclizine 25–50 mg PO q6–8h PRN — H1 antihistamine with anticholinergic effect. First-line outpatient. Sedating; caution in elderly.

— Dimenhydrinate 50 mg PO/IM q4–6h — alternative antihistamine.

— Diazepam 2–5 mg PO/IV q6–8h or lorazepam 0.5–1 mg — benzodiazepines reserved for severe symptoms unresponsive to antihistamines; use sparingly, fall and dependence risk.

— Promethazine 12.5–25 mg PO/IM/PR q6h — combined antiemetic and vestibular suppressant; avoid in children <2 (black box: respiratory depression).

— Ondansetron 4–8 mg PO/IV/ODT q8h — first-line for nausea/vomiting. Check QTc in at-risk patients.

— Prochlorperazine 5–10 mg PO/IM — effective but extrapyramidal risk.

— Metoclopramide 10 mg — alternative; tardive dyskinesia warning with prolonged use.

— Evidence is mixed. Some trials (Strupp 2004) show faster caloric recovery with methylprednisolone, but functional outcomes at 12 months are similar. Current practice: may consider prednisone 60 mg/day × 5 days then taper over 15–20 days in severe early cases.

— Antivirals (valacyclovir) alone or with steroids: not recommended — no benefit demonstrated.

— Prednisone 60 mg/day × 7–14 days, then taper — initiate within 72 hours of hearing loss onset.

— Intratympanic dexamethasone is a salvage or alternative option via ENT.

Vestibular suppressants (short course, ≤72 hours):

Antiemetics:

Corticosteroids (vestibular neuritis):

Corticosteroids (labyrinthitis with SSNHL):

IV fluids: Normal saline for dehydration from emesis. K+, Mg replacement as needed.

Avoid: Long-term meclizine, scopolamine patches beyond 72 hours (delays compensation), and routine antibiotics (this is not bacterial).

Board pearl: Vestibular suppressants are a bridge, not a destination. Stopping them at 48–72 hours and starting vestibular exercises is the evidence-based path.

Step 3 management: For suspected bacterial (suppurative) labyrinthitis from otitis media — that's a different disease: IV antibiotics, ENT consult, possible mastoidectomy.

Vestibular Rehabilitation and Non-Pharmacologic Management

— Initiate within the first week of symptom onset once acute vomiting subsides.

— Referral to a physical therapist trained in vestibular rehab.

— Gaze stabilization (VOR ×1, ×2): Patient fixates on a target while moving the head — retrains vestibulo-ocular reflex.

— Habituation exercises (Brandt-Daroff–style positional movements): Repeated exposure to provocative head positions to desensitize.

— Balance and gait training: Standing on foam, tandem gait, dynamic head turns while walking — improves postural control.

— Substitution strategies: Train visual and somatosensory inputs to compensate for vestibular loss.

— Patients should perform exercises 3–5 times/day for 10–15 minutes even though they provoke mild symptoms — this is therapeutic, not harmful.

— Counseling: "Worsening with exercise is expected and necessary for recovery."

— Hydration, regular sleep, gradual return to activity.

— Driving restriction until symptom-free with head motion — typically 1–2 weeks; document the recommendation.

— Fall-proof home: remove rugs, night lighting, grab bars, especially elderly.

— Avoid alcohol and CNS depressants during recovery.

— Cognitive behavioral therapy for patients developing persistent postural-perceptual dizziness (PPPD) — anxiety amplifies symptoms.

— SSRIs (sertraline, escitalopram) for PPPD with comorbid anxiety/depression.

— Audiology follow-up, hearing aid evaluation if loss persists >3 months.

— Cochlear implant candidacy for profound bilateral loss (rare).

Vestibular rehabilitation therapy (VRT) is the definitive treatment for promoting central compensation and is more effective than medication alone for functional recovery.

Core exercise categories:

Home program:

Lifestyle and safety:

Adjuncts:

For labyrinthitis with hearing loss:

CCS pearl: On a simulated case, order "physical therapy — vestibular rehabilitation" early and reassess at 1 and 4 weeks; advance activity, taper meclizine. This trio mirrors the right ambulatory pathway.

Board pearl: VRT outperforms prolonged bed rest and prolonged vestibular suppressant therapy for time-to-recovery — the most cited Cochrane review supports this consistently.

Special Populations — Elderly and Renal/Hepatic Impairment

— Dizziness is a top-5 chief complaint in patients >65 and a leading cause of falls.

— Higher prior probability of central etiology — posterior circulation stroke risk in acute vestibular syndrome rises sharply with age and vascular risk factors. Lower threshold for MRI/MRA.

— Polypharmacy: Review for ototoxic drugs (aminoglycosides, loop diuretics, cisplatin, high-dose ASA), antihypertensives causing orthostasis, anticholinergics worsening cognition.

— Beers Criteria: Meclizine, diphenhydramine, promethazine, scopolamine, benzodiazepines all on the avoid/use-cautiously list in older adults due to fall risk, delirium, anticholinergic burden.

— If meclizine necessary, use lowest dose (12.5 mg) and shortest duration (≤48 h).

— Avoid benzodiazepines — STOPP/START criteria flag them as inappropriate.

— Ondansetron preferred antiemetic; check QTc and avoid in QT-prolonging regimens.

— Meclizine: no specific renal adjustment but use cautiously due to anticholinergic accumulation.

— Ondansetron: no adjustment needed for renal impairment; max 8 mg IV in hepatic dysfunction.

— Prednisone: no renal adjustment; monitor glucose closely in CKD with DM.

— Ondansetron: max 8 mg/day in severe hepatic dysfunction (Child-Pugh C).

— Diazepam, lorazepam: lorazepam preferred (glucuronidation, no active metabolites).

— Prednisone: caution; risk of fluid retention and encephalopathy precipitation in cirrhosis.

— Reconcile medications, screen for orthostatic hypotension, and assess gait/balance (Timed Up and Go) before discharge.

— Refer to fall-prevention program; home safety evaluation by OT.

Elderly considerations:

Pharmacologic adjustment in elderly:

Renal impairment:

Hepatic impairment:

Multimorbidity framing:

Step 3 management: In an 80-year-old with new acute vertigo, the default is MRI brain with DWI + MRA, admit for observation, not outpatient meclizine. Age plus continuous vertigo = stroke until proven otherwise.

Board pearl: Vestibular rehab is especially effective in elderly patients and reduces fall recurrence — refer aggressively.

Special Populations — Pregnancy, Pediatrics, and Comorbid Conditions

— Vestibular neuritis presentation is unchanged, but management is constrained by teratogenicity concerns.

— Safe antiemetics: Pyridoxine (B6) + doxylamine first-line; ondansetron acceptable after first trimester (mixed data on cleft palate risk in T1 — shared decision).

— Meclizine: Category B historically; commonly used for hyperemesis and considered safe.

— Promethazine: Use cautiously, especially near term.

— Avoid: Benzodiazepines (cleft palate, neonatal withdrawal), prolonged corticosteroids in T1.

— Imaging: MRI without gadolinium is preferred when imaging is necessary; gadolinium crosses placenta — avoid unless clearly needed.

— True vestibular neuritis is uncommon in children; consider alternatives:

— Benign paroxysmal vertigo of childhood — brief episodes, often migraine precursor.

— Otitis media with effusion/labyrinthitis — bacterial labyrinthitis is more common pediatric labyrinthitis and requires IV antibiotics + ENT.

— Vestibular migraine, posterior fossa tumor (medulloblastoma) — red flags include morning vomiting, ataxia, papilledema.

— Avoid promethazine in children <2 (respiratory depression black box).

— Meclizine approved ≥12 years; dimenhydrinate for younger children at weight-based dosing.

— Consider CMV labyrinthitis, herpes zoster oticus, cryptococcal or syphilitic involvement.

— Lower threshold for MRI and ID consult.

— Strongly consider vestibular migraine as a mimic — episodic, often with photophobia/phonophobia, family history of migraine.

— Return-to-duty requires symptom resolution with provocative head movement and normal vestibular testing — flight medicine grounding rules apply.

Pregnancy:

Pediatrics:

Immunocompromised patients (HIV, transplant, chemotherapy):

Patients with migraine:

Athletes/military/aviation:

Key distinction: A febrile child with otitis media, vertigo, and hearing loss has suppurative bacterial labyrinthitis — emergency ENT consult, IV ceftriaxone, possible myringotomy, NOT a simple viral labyrinthitis.

Board pearl: Vertigo + ataxia + morning headache in a child = posterior fossa tumor until imaging proves otherwise. Never dismiss pediatric vertigo as functional.

Complications and Adverse Outcomes

— Most common chronic complication; chronic non-vertiginous dizziness, unsteadiness, hypersensitivity to motion lasting >3 months.

— Risk factors: anxiety disorder, prolonged use of vestibular suppressants, avoidance behavior, lack of vestibular rehab.

— Management: VRT + SSRI/SNRI + CBT. Sertraline, venlafaxine, or escitalopram are first-line.

— Inflammation can dislodge otoconia → develops days to weeks after initial neuritis.

— Presents as brief positional vertigo superimposed on resolving baseline symptoms.

— Diagnosis: Dix-Hallpike. Treatment: Epley maneuver. Easy to miss — re-examine at follow-up.

— Up to 30–50% of patients have detectable caloric weakness years later, but most compensate centrally and are asymptomatic.

— Bilateral hypofunction (rare after unilateral neuritis) → oscillopsia, severe gait instability — requires intensive VRT.

— Sensorineural hearing loss may be permanent if not treated promptly with steroids.

— Tinnitus may persist; manage with sound therapy, hearing aids, CBT.

— Wrist fractures, hip fractures in elderly — link with fall prevention pathways.

— Anxiety, agoraphobia, depression — screen at follow-up with GAD-7 and PHQ-9.

— Most feared complication — misdiagnosed cerebellar/PICA infarction can progress to malignant edema, herniation, death. Mortality reduced with early posterior fossa decompression.

— Anticholinergic delirium (especially elderly), QT prolongation with ondansetron, benzodiazepine dependence, steroid-induced hyperglycemia and mood changes.

Persistent postural-perceptual dizziness (PPPD):

Secondary BPPV:

Permanent vestibular hypofunction:

Hearing loss (labyrinthitis):

Falls and injury:

Mental health sequelae:

Missed stroke:

Medication adverse effects:

Step 3 management: Persistent dizziness beyond 8–12 weeks → re-evaluate. Don't keep prescribing meclizine. Send to neurotology, screen for PPPD, BPPV, vestibular migraine, anxiety.

Board pearl: A patient with "neuritis" who returns weeks later with brief positional vertigo on rolling over has secondary BPPV — do an Epley, not another meclizine refill.

When to Escalate Care — ICU, Consult, or Inpatient Triage

— Any central HINTS finding or focal neurologic deficit.

— Inability to stand or walk even with assistance.

— Severe headache, neck pain (dissection), or altered mental status.

— Vascular risk factors + new acute vestibular syndrome in patient >60.

— Persistent intractable vomiting with dehydration or electrolyte derangement.

— Suspected posterior circulation stroke — activate stroke pathway if within tPA window (4.5 hours) and clinical suspicion is high.

— Cerebellar infarct or hemorrhage on imaging — admit to stroke unit or neuro ICU.

— Cerebellar infarct with mass effect, hemorrhage, or hydrocephalus → may need suboccipital decompression or EVD. Time-sensitive.

— Suspected suppurative (bacterial) labyrinthitis from otitis media or meningitis — IV antibiotics + possible surgical drainage.

— Sudden sensorineural hearing loss — start steroids, audiology and ENT within 24–72 hours; consider intratympanic dexamethasone if oral steroid failure.

— Ramsay Hunt syndrome — start valacyclovir + prednisone, ENT for ear exam.

— Recurrent vestibulopathy, suspected schwannoma, or autoimmune inner ear disease.

— Cerebellar stroke with deteriorating GCS, brainstem signs, hydrocephalus.

— Airway compromise from severe vomiting and aspiration risk.

— Vestibular rehab / physical therapy.

— Audiology for labyrinthitis follow-up.

— Neurology for recurrent or atypical vestibular symptoms.

— Psychiatry/CBT for PPPD or comorbid anxiety.

— Community hospitals without MRI or neurology coverage should transfer patients with acute vestibular syndrome and any central features to a stroke center.

Immediate ED/inpatient triage criteria:

Neurology/stroke consult:

Neurosurgery consult:

ENT/otology consult:

ICU criteria:

Outpatient referrals for stable patients:

Transfer considerations:

CCS pearl: In a CCS case with acute vertigo + abnormal HINTS, order MRI brain with DWI + MRA neck, neurology consult, NPO, IV access, admit to stroke unit — advance the clock and recheck neuro exam every 2–4 hours.

Board pearl: Cerebellar stroke can present with isolated vertigo in 10% of cases — peripheral mimic is real and dangerous.

Key Differentials — Other Causes of Vertigo (Same Category)

— Brief (seconds) positional vertigo triggered by head movement (rolling, looking up, lying down).

— Dix-Hallpike reveals upbeat-torsional nystagmus with latency, fatigability.

— Treated with Epley maneuver; no medications needed.

— Episodic vertigo (20 minutes to several hours), fluctuating low-frequency SNHL, tinnitus, aural fullness.

— Recurrent attacks; between attacks, patient is well.

— Management: low-salt diet, diuretics (HCTZ-triamterene), betahistine (outside US), intratympanic steroids, gentamicin, surgery for refractory.

— Vertigo episodes lasting minutes to days, often with migraine features (headache, photophobia, phonophobia, visual aura).

— Family history of migraine common; normal vestibular testing between attacks.

— Treatment: migraine prophylaxis (propranolol, topiramate, amitriptyline, venlafaxine), trigger avoidance.

— Vertigo and hearing loss after barotrauma, head injury, heavy lifting, or straining.

— Positive Hennebert sign (vertigo with pressure on tragus).

— ENT referral; may need surgical repair.

— Vertigo with loud sounds (Tullio phenomenon), autophony, hyperacusis to bone-conducted sounds.

— High-resolution CT of temporal bones diagnostic.

— Vertigo + ipsilateral facial palsy + vesicles in ear canal/auricle.

— Treat with valacyclovir 1 g TID × 7 days + prednisone 60 mg taper.

— Gradual, progressive unilateral SNHL + tinnitus + imbalance (not acute vertigo).

— MRI internal auditory canal diagnostic.

Benign paroxysmal positional vertigo (BPPV):

Ménière disease:

Vestibular migraine:

Perilymph fistula:

Superior semicircular canal dehiscence (Minor syndrome):

Ramsay Hunt syndrome (HZ oticus):

Vestibular schwannoma:

Key distinction: Duration is the master discriminator — seconds = BPPV, minutes-hours = Ménière/migraine, days = neuritis/stroke, progressive = schwannoma. Memorize this clock.

Board pearl: A patient with low-frequency hearing loss, episodic vertigo, and tinnitus has Ménière — start a low-salt diet and HCTZ-triamterene before reaching for advanced testing.

Key Differentials — Other-Category Causes

— AICA infarct can present with vertigo + ipsilateral SNHL (mimics labyrinthitis exactly — labyrinthine artery is a branch of AICA).

— Lateral medullary (Wallenberg): vertigo, ipsilateral Horner syndrome, dysphagia, hoarseness, crossed sensory loss.

— Diagnosis: MRI brain with DWI, MRA. Manage as acute ischemic stroke.

— Episodic vertigo with associated brainstem symptoms (diplopia, dysarthria). High risk for completed stroke — urgent workup.

— Young adult, optic neuritis history, INO, vertigo from brainstem demyelination. MRI with periventricular lesions.

— Patients describe "lightheadedness" or "near fainting," not true spinning. Confirm with orthostatic vitals. Causes: dehydration, antihypertensives, autonomic neuropathy.

— AFib with rapid ventricular response, bradyarrhythmia, AV block — presyncope mistaken for vertigo. ECG and rhythm monitoring.

— Ototoxicity (aminoglycosides, cisplatin, loop diuretics, salicylates).

— Anticonvulsants (phenytoin, carbamazepine) at toxic levels — vertical nystagmus.

— Alcohol intoxication and withdrawal.

— Chronic non-vertiginous dizziness exacerbated by upright posture and motion; often with anxiety. Diagnosis of exclusion with specific criteria.

— Progressive ataxia, downbeat nystagmus. MRI diagnostic.

— Insidious unilateral SNHL — not acute vertigo, but a key labyrinthitis mimic at follow-up.

Posterior circulation stroke (cerebellar, PICA, AICA, lateral medullary):

Vertebrobasilar TIA:

Multiple sclerosis:

Orthostatic hypotension/presyncope:

Cardiac arrhythmia:

Hypoglycemia, hyponatremia, anemia: Generalized dizziness; check basic labs.

Medication/toxin:

Psychogenic dizziness / PPPD:

Cerebellar degeneration, Chiari malformation, posterior fossa tumor:

Acoustic neuroma (vestibular schwannoma):

Key distinction: "Dizziness" is a vague term. Pin down: spinning (vertigo) vs lightheadedness (presyncope) vs unsteadiness (disequilibrium) vs floating (PPPD). Each has its own differential and workup.

Board pearl: Vertigo + isolated hearing loss + AICA territory deficits (facial weakness, Horner) = AICA stroke, not labyrinthitis. MRI is mandatory.

Secondary Prevention, Discharge Plan, and Long-Term Care

— Meclizine 25 mg PO q8h PRN × 3 days, then stop.

— Ondansetron 4–8 mg PO q8h PRN nausea × 3–5 days.

— IV fluids as needed before discharge; ensure tolerating PO.

— For labyrinthitis with SSNHL: prednisone 60 mg/day × 7 days, then taper over 7–14 days. PPI gastroprotection if risk factors. Glucose monitoring in diabetics.

— Warning signs prompting return: new headache, weakness, diplopia, slurred speech, worsening imbalance, fainting, inability to tolerate fluids.

— Driving restriction: until symptom-free with rapid head movement (typically 1–2 weeks).

— Fall precautions, hydration, gradual activity resumption.

— Vestibular exercises handout — start in 2–3 days.

— Vestibular physical therapy within 1 week.

— Audiology within 1–2 weeks if hearing involved.

— ENT for labyrinthitis or persistent symptoms.

— Primary care 48–72 hour callback or visit.

— Most patients fully recover by 8–12 weeks.

— Monitor for PPPD, secondary BPPV, persistent SNHL.

— Repeat audiometry at 2, 6, and 12 weeks in labyrinthitis to track recovery and identify hearing aid candidates.

— For older patients in whom stroke was ruled out, treat HTN, DM, dyslipidemia, AFib aggressively — primary prevention of posterior circulation stroke.

There is no proven primary prevention for vestibular neuritis/labyrinthitis — but recurrence is uncommon (<5%). Long-term care focuses on functional recovery and complication prevention.

Discharge medications (typical peripheral case):

Written discharge instructions:

Referrals at discharge:

Long-term plan:

Cardiovascular risk factor optimization:

Step 3 management: At discharge, schedule a structured 48–72 hour primary care follow-up — this is the single highest-value safety net in ambulatory practice for catching missed stroke or worsening dehydration.

Board pearl: Don't refill meclizine indefinitely. After 72 hours it impedes recovery — replace it with vestibular rehab.

Follow-Up, Monitoring Parameters, and Counseling

— 48–72 hours: phone or in-person check — symptom trajectory, hydration, medication tolerance, fall events, red-flag screen.

— 1–2 weeks: in-person — confirm vestibular rehab initiated, taper/stop suppressants, screen for secondary BPPV (Dix-Hallpike), audiometry if hearing involvement.

— 4–6 weeks: assess recovery, screen for PPPD using validated tools (Dizziness Handicap Inventory), reinforce exercises.

— 3 months: most have recovered. If symptoms persist, refer to neurotology and consider PPPD diagnosis.

— Symptom severity (vertigo, imbalance) — track with DHI or VAS.

— Functional measures: Timed Up and Go, gait speed, falls log.

— Audiometry trends (labyrinthitis).

— Medication side effects: sedation, anticholinergic burden, BP, glucose if on steroids.

— Expectation setting: "Most people recover completely in 6–8 weeks. You'll feel off-balance with head movements for a few weeks even as the vertigo resolves — that's normal."

— Activity: Encourage walking and head movement; bed rest worsens outcomes.

— Exercises provoke mild symptoms — that's how compensation works.

— Driving: Restrict until safe with head turns.

— Alcohol: Avoid during recovery; impairs central compensation.

— Smoking cessation, BP, glucose control if vascular risk factors.

— Provide written list. New neurologic deficits, severe headache, hearing change, persistent vomiting → seek immediate care.

— At 4–6 week visit: GAD-7, PHQ-9 — anxiety and depression are common and treatable contributors to chronic dizziness.

Follow-up cadence (ambulatory Step 3 framework):

Monitoring parameters:

Counseling points:

Patient education on red flags:

Mental health screening:

CCS pearl: Schedule follow-up, reorder physical therapy referral if not completed, and recheck audiogram at each labyrinthitis visit until stable — the simulator rewards continuity.

Board pearl: Persistent dizziness at 3 months with normal exam and imaging is PPPD — manage with VRT + SSRI + CBT, not more meclizine.

Ethical, Legal, and Patient Safety Considerations

— Document explicit counseling against driving until symptom-free with head motion. In many states, physicians have a duty (sometimes mandatory reporting, e.g., California, Oregon, Pennsylvania, New Jersey) to report medically impaired drivers. Know your state's law.

— For commercial drivers (CDL), pilots (FAA), train operators — disease-specific medical certification rules apply. Document grounding recommendations.

— Off-label corticosteroid use in vestibular neuritis: discuss equipoise, side effects (hyperglycemia, mood, infection risk), and lack of long-term functional benefit. Shared decision-making is required.

— Intratympanic steroid injection for SSNHL: invasive — consent for tympanic membrane perforation, infection, hearing loss progression.

— Cerebellar stroke misdiagnosed as peripheral vertigo is a leading cause of malpractice claims in emergency and primary care neurology.

— Risk mitigation: document HINTS exam findings explicitly, document gait assessment, document the 48–72 hour follow-up plan, and use teach-back for red flags.

— ED to primary care handoff is high-risk. Ensure the discharge summary lists pending tests, medications to taper, red flags, and follow-up appointments. Closed-loop referrals to vestibular rehab and ENT reduce dropout.

— Suspected child abuse if pediatric vertigo is explained by inflicted head trauma — report to CPS.

— Suspected elder abuse if recurrent unexplained falls in dependent elderly — report per state law.

— Vestibular rehab is unevenly available; lack of access predicts worse outcomes. Telehealth-based VRT and home exercise programs are equity-improving alternatives.

Driving and occupational safety:

Informed consent edge cases:

Missed stroke / diagnostic error:

Transitions of care:

Mandatory reporting:

Health equity and access:

Polypharmacy and Beers criteria in elderly: avoid long-term anticholinergic suppressants; document deprescribing.

Step 3 management: Always document the driving counseling, the red-flag teach-back, and the planned follow-up — these three items protect the patient and the clinician.

Board pearl: "The room spun, the CT was normal, I sent her home" without HINTS or follow-up plan is the prototypical malpractice vignette — don't be that clinician.

High-Yield Associations and Rapid-Fire Clinical Facts

Vestibular neuritis = vertigo without hearing loss. Labyrinthitis = vertigo with hearing loss.

Both are presumed viral or post-viral (HSV-1 reactivation hypothesis).

Symptoms peak in 24–48 hours, resolve over days to weeks.

Nystagmus: unidirectional, horizontal-torsional, fast phase away from affected ear, suppressed by fixation.

HINTS exam outperforms early MRI for detecting posterior circulation stroke in acute vestibular syndrome. Mnemonic INFARCT = central pattern.

Romberg falls toward affected side; gait possible with assistance.

Inability to walk unaided = central red flag.

Caloric testing shows unilateral hypofunction (cold water → nystagmus toward opposite ear normally; reduced response on affected side).

Superior vestibular nerve is most commonly affected → spares posterior canal, which is why posterior canal BPPV can develop later (otoconia displaced into preserved posterior canal).

Sudden SNHL with vertigo: start prednisone within 72 hours; refer ENT/audiology urgently.

Ramsay Hunt = HZ oticus = vesicles + facial palsy + vertigo → valacyclovir + prednisone.

AICA stroke can mimic labyrinthitis exactly — labyrinthine artery branches off AICA.

Bacterial (suppurative) labyrinthitis from otitis media or meningitis is an ENT emergency — IV antibiotics ± surgery.

Vestibular rehab > medication for long-term recovery.

Meclizine is a bridge ≤72 hours — long-term use delays compensation.

Beers criteria flag meclizine, diphenhydramine, scopolamine, benzodiazepines in elderly.

Secondary BPPV is common after neuritis — re-examine with Dix-Hallpike.

PPPD = persistent dizziness >3 months; treat with VRT + SSRI + CBT.

Vestibular schwannoma is the must-not-miss diagnosis in unilateral SNHL — MRI IAC.

Vertigo + headache + ataxia in a child = posterior fossa tumor until proven otherwise.

Pregnancy: pyridoxine + doxylamine first, ondansetron acceptable after T1, avoid benzodiazepines.

Key distinction: Duration is the master discriminator — seconds=BPPV, minutes-hours=Ménière/migraine, days=neuritis/stroke, progressive=schwannoma.

Board pearl: A "negative" non-contrast CT does not exclude cerebellar stroke — order MRI/MRA if central features are present.

Board Question Stem Patterns

Stem 1 (classic peripheral): A 42-year-old has 2 days of constant spinning vertigo, nausea, vomiting after a recent URI. Horizontal-torsional nystagmus beats left, corrective saccade on right head impulse, no skew, can walk with support. Next step? → Symptomatic care + vestibular rehab, no imaging. Reassuring HINTS pattern.

Stem 2 (must-not-miss central): A 68-year-old with HTN and AFib has acute vertigo. Direction-changing nystagmus, normal head impulse, skew deviation present. CT head normal. Next step? → MRI brain with DWI + MRA, admit, neurology consult — concern for posterior circulation stroke.

Stem 3 (labyrinthitis with SSNHL): A 35-year-old has vertigo, left ear fullness, and SNHL on audiometry. No prior episodes. Next step? → Prednisone 60 mg/day × 7 days within 72 hours, ENT and audiology referral.

Stem 4 (Ramsay Hunt): Vertigo + ipsilateral facial droop + vesicles in the auditory canal. → Valacyclovir + prednisone.

Stem 5 (BPPV mimic): Vertigo lasting 30 seconds when rolling over in bed, no continuous symptoms, Dix-Hallpike positive. → Epley maneuver, not meclizine. Not vestibular neuritis.

Stem 6 (Ménière): Recurrent 2-hour episodes of vertigo with low-frequency hearing loss, tinnitus, aural fullness. → Low-salt diet, HCTZ-triamterene.

Stem 7 (vestibular migraine): Episodic vertigo with photophobia, family history of migraine, normal exam between attacks. → Migraine prophylaxis (propranolol, topiramate).

Stem 8 (secondary BPPV after neuritis): 6 weeks post-neuritis, brief positional vertigo recurs. → Dix-Hallpike, Epley.

Stem 9 (PPPD): 4 months of persistent unsteadiness after resolved neuritis, normal exam. → VRT + SSRI + CBT.

Stem 10 (suppurative labyrinthitis): Febrile child with otitis media and new vertigo, SNHL. → IV ceftriaxone, ENT consult, not outpatient meclizine.

Stem 11 (driving counseling): Patient asks when she can drive after neuritis. → Until symptom-free with rapid head movement, document counseling.

Step 3 management: The recurring trap is outpatient peripheral vs admit-for-stroke — let the HINTS exam, gait, and red flags decide. If unsure, image and admit.

Board pearl: When a stem includes age >60 + vascular risk + vertigo, the answer is almost always MRI, not meclizine.

One-Line Recap

Vestibular neuritis (vertigo only) and labyrinthitis (vertigo + sensorineural hearing loss) are post-viral peripheral vestibulopathies diagnosed clinically using the HINTS exam to exclude posterior circulation stroke, managed with short-course vestibular suppressants and antiemetics, early vestibular rehabilitation, and — for labyrinthitis with sudden SNHL — prompt oral corticosteroids, with structured follow-up to catch secondary BPPV, persistent postural-perceptual dizziness, and missed central pathology.

— Diagnosis is clinical: continuous vertigo for days, unidirectional horizontal-torsional nystagmus, peripheral HINTS pattern (corrective saccade on head impulse, unidirectional nystagmus, no skew), preserved gait with support.

— Image (MRI brain with DWI + MRA neck), don't discharge when there are central features, age >60 with vascular risk, focal deficits, severe headache, or inability to walk — AICA stroke perfectly mimics labyrinthitis.

— Treat short, rehab long: meclizine + ondansetron ≤72 hours, then taper. Vestibular rehabilitation within the first week is the single most evidence-based intervention. For labyrinthitis with SSNHL, prednisone 60 mg × 7 days within 72 hours plus ENT/audiology referral.

— Follow-up safety net: 48–72 hour check, screen for secondary BPPV at 2–6 weeks (Dix-Hallpike → Epley), screen for PPPD at 3 months (treat with VRT + SSRI + CBT), document driving counseling and red-flag teach-back at every visit.

High-yield recap bullets:

Step 3 management: Outpatient supportive care + vestibular rehab + structured callback covers 80% of cases; the remaining 20% earn an MRI and a stroke workup — the HINTS exam and red-flag screen tell you which is which.

Board pearl: Duration discriminates — seconds=BPPV, minutes-hours=Ménière/migraine, days=neuritis/stroke, progressive=schwannoma — anchor every dizziness vignette to this clock first.