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The sudden and persistent onset of vertigo, often accompanied by hearing loss, caused by acute inflammation or infection of the labyrinth
Labyrinthitis is a clinical diagnosis in absence of neurologic deficits.
Typically presents with false sense of motion or room-spinning vertigo lasting for hours or days and often sudden unilateral hearing loss
Often associated with vestibular hypofunction of the involved ear. Peripheral vertigo improves over time with central compensation.
System(s) affected: nervous, special sensory (auditory and vestibular)
Synonym(s): acute peripheral vestibulopathy; vestibular neuronitis (vertigo/dizziness only); vestibular neuritis (vertigo/dizziness only)
“Vertigo” and “dizziness” are commonly used terms. Clarify symptoms by giving options of alternative descriptions such as light-headedness, disequilibrium, room-spinning vertigo, or imbalance.
Hearing loss and duration of symptoms can help narrow the differential diagnosis in patients with vertigo.
Benign paroxysmal positional vertigo (BPPV) is the most common cause of vertigo. Unlike labyrinthitis, BPPV is episodic, with severe symptoms lasting ≪1 minute. BPPV is diagnosed using the Dix-Hallpike maneuver. Unlike labyrinthitis, it is not associated with hearing loss.
Ménière disease presents with the classic triad of episodic vertigo, tinnitus, and sensorineural hearing loss that is often fluctuant 1[C].
Elderly are less likely to compensate fully and may report symptoms of disequilibrium lasting weeks to months after resolution of the acute vertigo.
Avoid excessive use of scopolamine, meclizine, and other vestibular suppressants following the initial event, as this will delay central compensation.
Benzodiazepines are preferred vestibular suppressant treatment but do increase the risk of falls in older persons.
10% of all patients seen for dizziness
Most common in 30 to 50 years of age 3
Predominant sex: female = male
Viral labyrinthitis is the most common etiology.
Suppurative or serous labyrinthitis secondary to otitis media is increasingly rare.
Acute inflammation or damage to the inner ear, involving both branches of the vestibulocochlear nerve
Viruses pass via hematogenous spread into the labyrinth or directly from the middle ear to labyrinth via the round/oval window.
Bacterial toxins and host inflammatory mediators from a middle ear infection may reach the inner ear.
Ischemia: Ischemic or thromboembolic events involving the labyrinthine artery can cause symptoms that mimic acute labyrinthitis; often presents with associated neurologic symptoms
Autoimmune: Local or systemic inflammatory processes may affect the inner ear via autoantibodies vasculitis of the labyrinthine artery.
Ototoxic drugs (e.g., aspirin, aminoglycosides, loop diuretics, cisplatin)
Viral upper respiratory infection
History of allergies
Other risk factors include autoimmune disease, herpes zoster infection, excessive alcohol consumption, and smoking.
Scheduled immunizations (to prevent common viral pathogens)
Prevent maternal transmission of pathogens, including syphilis and HIV.
Vertigo AND (often) hearing loss in one ear
Vertigo is acute in onset and lasts days to weeks.
Nausea and vomiting are common.
Fullness of affected ear
Tinnitus of affected ear (roaring, ringing)
Upper respiratory tract infection symptoms
Otorrhea or otalgia (not common with viral causes)
Severe headache, fever, and nuchal rigidity in the setting of meningitis
Recurrent symptoms should raise suspicion for autoimmune causes.
Profound imbalance or associated focal neurologic signs are not typical and should prompt imaging.
Symptoms abate in supine position and with eyes closed or with visual fixation.
Otologic exam may be unremarkable in the setting of viral labyrinthitis.
Serous/purulent effusion may be present in the middle ear.
Retraction of the tympanic membrane and keratinaceous debris may be present with cholesteatoma.
Vestibular neuritis/neuronitis (vertigo without hearing loss)
BPPV: episodic, vertigo lasting seconds/minutes, worse when lying down or looking up
Ménière disease: episodic vertigo lasting minutes to hours, associated with the triad of episodic vertigo, tinnitus, and hearing loss
Autoimmune inner ear disease
Acute otitis media
Cardiovascular accident (CVA)/brainstem infarct
Cerebellopontine-angle tumors (e.g., vestibular schwannoma)
Less common etiologies: parainfectious encephalomyelitis or cranial polyneuritis, Ramsay Hunt syndrome, HIV infection, syphilis, temporal lobe epilepsy, perilymphatic fistula, superior canal dehiscence, idiopathic sudden single-sided deafness, multiple sclerosis, vasculitis (cerebral or systemic)
Routine lab studies are not helpful in making the diagnosis unless an autoimmune cause is highly suspected.
Consider culture of otorrhea or middle ear fluid to direct antibiotic choice.
Consider lumbar puncture only if meningitis is suspected.
Consider screening for syphilis or HIV when clinically indicated by risk factors or clinical history.
Imaging is not required for the diagnosis of acute labyrinthitis.
If associated neurologic symptoms or sensorineural hearing loss are present, an MRI and MR angiography of brain and brainstem are recommended.
Vertigo usually spontaneously resolves, and there is a low risk of developing Ménière disease or migraines.
Audiogram should be obtained.
Vestibular tests are not typically indicated in the acute setting. If vertigo and dizziness persist after expected resolution of symptoms, electronystagmography should be used.
Audiogram may show varying degrees of both hearing loss and discrimination.
Caloric testing may show relative weakness of the horizontal semicircular canal of the affected side. Sensitivity and specificity of this test are variable within literature.
Symptom management and reassurance
Vestibular rehabilitation is the mainstay of treatment and has been shown to be safe and effective management for unilateral peripheral vestibular dysfunction 5[A].
Patients should begin exercises as soon as the acute phase resolves and movement is tolerable, generally within 2 to 3 days of onset.
Vestibular suppressants as needed (see “Medication”) for severe acute attacks of vertigo only. Patients should be advised NOT to use these medications as scheduled medications or for prophylaxis without symptoms.
Sudden single-sided hearing loss (onset within 2 weeks) should be managed with high-dose oral steroids as soon as possible.
Auricular acupuncture and Ginkgo biloba may be emerging adjunctive therapies to reduce vertiginous symptoms, although research is limited.
For suppurative labyrinthitis, appropriate antibiotics to eradicate infection
Benzodiazepines, which are better vestibular suppressants, are preferred over antihistamine/anticholinergics such as meclizine. Sublingual benzodiazepines are very effective for vertigo and should be considered first-line therapy.
Urgent steroid treatment in acute setting
Consider neuro-otology referral for other peripheral causes of vertigo or unremitting vertigo.
Consider neurology referral for suspected central causes of vertigo or dizziness.
Consider otolaryngology referral for progressive bilateral hearing loss and vertigo after preliminary laboratory workup excluding rheumatologic causes.
Patients with systemic infection, young age, or intractable vertigo with nausea and vomiting may need to be hospitalized for intravenous fluids and medications.
Usually outpatient management
Lee HK, Ahn SK, Jeon SY, et al. Clinical characteristics and natural course of recurrent vestibulopathy: a long-term follow-up study. Laryngoscope. 2012;122(4):883–886.
Romoli M, Allais G, Airola G, et al. Ear acupuncture and fMRI: a pilot study for assessing the specificity of auricular points. Neurol Sci. 2014;35(Suppl 1):189–193.
Sokolova L, Hoerr R, Mishchenko T. Treatment of vertigo: a randomized, double-blind trial comparing efficacy and safety of Ginkgo biloba extract EGb 761 and betahistine. Int J Otolaryngol. 2014;2014:682439.
H83.09 Labyrinthitis, unspecified ear
H83.01 Labyrinthitis, right ear
H83.02 Labyrinthitis, left ear
H83.03 Labyrinthitis, bilateral
386.30 Labyrinthitis, unspecified
386.31 Serous labyrinthitis
386.33 Suppurative labyrinthitis
386.35 Viral labyrinthitis
386.34 Toxic labyrinthitis
386.32 Circumscribed labyrinthitis
23919004 Labyrinthitis (disorder)
41674001 Serous labyrinthitis
24817009 Suppurative labyrinthitis
409711008 Viral labyrinthitis
61794006 Circumscribed labyrinthitis
3344003 Toxic labyrinthitis
Ask patients to describe symptoms in their own words; alternative symptoms include lightheadedness, vertigo, disequilibrium, or imbalance.
Benzodiazepines are better vestibular suppressants and are preferred over antihistamine/anticholinergics such as meclizine.
Episodic vertigo tends to be caused by BPPV or Ménière disease, whereas persistent vertigo is more consistent with labyrinthitis.