Approach

Labyrinthitis can be managed with vestibular suppressants, anti-emetics, corticosteroids, antivirals or antibiotics (to treat the underlying viral/bacterial infection), and vestibular rehabilitation. Tinnitus can be managed with masking, tinnitus retraining, amplification with hearing aids, and anxiolytics and/or antidepressants in the setting of active anxiety and depression.[66] Management of vestibular neuritis is similar to that of viral labyrinthitis; treatment options include vestibular suppressants, anti-emetics, corticosteroids, and vestibular rehabilitation.[18]

Most acute episodes of labyrinthitis are short-lived and self-limited, and patients can be treated on an outpatient basis. Advise patients to seek further medical care if the symptoms do not improve or if they develop neurological symptoms (e.g., diplopia, slurred speech, gait disturbances, or localised weakness or numbness). Long-term therapy may typically involve use of vestibular rehabilitation and stopping vestibular suppressants.

Treatment for underlying conditions

Viral infections are the most common cause of labyrinthitis and the main aim of management is the symptomatic control of vertigo, nausea, and vomiting. It should be recognised that viral testing may not yield positive results at the time of illness and that there is no role for empirical antiviral therapy in the treatment of labyrinthitis and vestibular neuritis in the absence of other indications.

A variety of auditory and vestibular complaints including labyrinthitis have been reported in patients with AIDS. The relative importance of the HIV infection itself as opposed to its associated opportunistic infections requires further study.

Patients with bacterial labyrinthitis following otitis media (middle ear infection) or bacterial meningitis may require antibiotics in addition to treatments for vertigo and possible nausea and vomiting. If the history and exam are consistent with otitis media, such as otalgia (ear pain) and an abnormal ear exam suggesting fluid, redness, or pus behind the ear drum, without systemic signs of infection (i.e., fever, chills), then topical antibiotics should be prescribed. Oral antibiotics are not typically indicated unless the patient has systemic signs of infection (i.e., fever, chills). See Acute otitis media.

If meningitis is suspected, prompt treatment with intravenous systemic antibiotics is indicated. Topical antibiotics are recommended if otorrhoea is also present. Corticosteroids may be prescribed to reduce the severity of hearing loss. See Bacterial meningitis.

Patients with positive syphilis serology should be treated with an appropriate course of antibiotics and may warrant a thorough evaluation by an infectious disease specialist.[3]​ See Syphilis infection.

Symptomatic management

Treatment is in response to symptoms. Acute vertigo episodes can be treated with vestibular suppressants and anti-emetics. Much of the effect is from the sedating action of these drugs, therefore warn patients about driving and operating equipment while being treated. Only one agent should be used at a time.

Vestibular suppressants include antihistamines with anticholinergic properties (e.g., promethazine, dimenhydrinate, cyclizine) and anti-emetics (e.g., prochlorperazine, metoclopramide, ondansetron).[67]​ Use of all vestibular suppressant drugs should be limited to 3-5 days to avoid interfering with central compensation and adaptation.[68]​ Metoclopramide should be used for up to 5 days only to minimise the risk of neurological and other adverse effects. It is not recommended for this indication in children.[69]​ Benzodiazepines have been used historically, but dependency and delayed vestibular compensation are significant concerns with these agents. Meclozine, an antihistamine with anticholinergic properties, has also been used historically, but is less effective than benzodiazepines.

Acute vertigo symptoms typically resolve over 72 hours. Consider fluid and electrolyte imbalances, particularly if the patient has had prolonged nausea and vomiting. Obtaining a basic metabolic panel before and after treatment, and initiating intravenous hydration, may be necessary in these patients.

Corticosteroids may be prescribed to reduce the intensity of symptoms in the first 72 hours.[68] They should be prescribed only when there is no medical contraindication. One meta-analysis has reported a benefit of corticosteroids in patients with vestibular neuritis, compared with control therapies.[70]​ One randomised trial found that methylprednisolone significantly improved the recovery of peripheral vestibular function in patients with vestibular neuritis (number needed to treat = 6).[71]​ An​other meta-analysis found that corticosteroids improved the caloric extent and recovery of canal paresis, but no difference was seen in the Dizziness Handicap Inventory score, compared with controls.[72]​ However, the evidence to support the use of corticosteroids for vestibular neuritis treatment is insufficient and more trials are required.[68][73][74][75]​​​​ The National Institute for Health and Care Excellence (NICE) in the UK suggests the use of corticosteroids for the management of idiopathic sudden sensorineural hearing loss in adults.[76] For patients with sudden sensorineural hearing loss, a short course of oral corticosteroids is considered the standard of care.[77]

Intratympanic corticosteroid injections (e.g., dexamethasone) may be used in patients with viral labyrinthitis due to the presence of sudden sensorineural hearing loss. Intratympanic corticosteroid injections have been found to improve intra-labyrinthine corticosteroid concentrations and reduce adverse effects associated with systemic corticosteroids.[78][79][80]​​​​​​​​​​ They are not indicated in patients with vestibular neuritis. Efficacy data for use of intratympanic corticosteroid injections in labyrinthitis have been extrapolated from studies demonstrating promise of intratympanic therapy in patients with idiopathic sudden sensorineural hearing loss.[79][81]​​​​​​​​[82]​ Some studies report no advantage of intratympanic corticosteroid injections over systemic corticosteroids.[83][84][85][86]​​​ Adverse effects associated with intratympanic injection, including tympanic membrane perforation, pain, dizziness, and vertigo, must be taken into consideration while choosing this therapy.[84][87]

Vestibular rehabilitation

In vestibular disorders, the brain undergoes a complex set of changes that allow it to adapt to the altered vestibular function. This process is called vestibular compensation. Compensation may occur naturally over time, but if patients continue to have an altered vestibular function, a course of vestibular rehabilitation therapy can promote compensation.[88][89]​​ Patients with persistent vestibular symptoms after treatment may require vestibular rehabilitation.​[88][90]​​ Early initiation of vestibular rehabilitation may be associated with improved clinical outcomes.[91]

Vestibular rehabilitation uses specialised exercises to manage dizziness, vertigo, gaze instability, nausea, anxiety, and balance issues. The treatment aims to enhance gaze stability, enhance postural stability, improve vertigo, and improve daily functioning.[92]​ Gaze stability and habituation exercises may be prescribed. If balance is also affected, prescribe balance training exercises. 

One Cochrane review found moderate to strong evidence that vestibular rehabilitation (i.e., physical [repositioning] manoeuvres, exercise-based movements) is safe and effective in unilateral peripheral vestibular dysfunction. This was based on a number of high‐quality randomised controlled trials, although a quarter of the studies may have had some risk of bias due to non-blinding of outcome assessors and selective reporting.[88] One non-blinded, randomised controlled trial found that a vestibular rehabilitation programme started early (after a confirmed vestibular neuritis diagnosis) when combined with standard care (including a corticosteroid, general information, and counselling) reduced the perception of dizziness and improved functions of daily life more effectively than standard care alone.[93]

Vestibular rehabilitation and/or corticosteroid is the first-line treatment option for patients with vestibular neuritis.[94][95][96]​​​​​ Choice of treatment can be made based on the patient's condition.[94]​ One prospective, single-blind, randomised clinical trial reported that corticosteroids and vestibular rehabilitation were equally effective for the treatment of acute vestibular neuritis. A faster, complete disease resolution was seen with corticosteroids, compared with vestibular rehabilitation (P >0.05), but this did not affect the long-term prognosis.[97]​ One meta-analysis of 12 studies found that combination therapy of vestibular rehabilitation plus corticosteroids was more effective than corticosteroids alone in patients with vestibular neuritis.[95]​ Another meta-analysis of four studies found that mecobalamin (a form of vitamin B12) plus vestibular rehabilitation was more effective than vestibular rehabilitation alone in improving vertigo and other symptoms in patients with vestibular neuritis.[96]​ Further, one meta-analysis showed that combination therapy of vestibular rehabilitation plus anti-vertigo drugs may reduce vestibular dysfunction symptoms and improve daily activities.[98]​ However, the included studies lacked data on long-term follow-up and had varying frequency and duration of treatment.[98]

The Academy of Neurologic Physical Therapy of the American Physical Therapy Association recommends offering vestibular rehabilitation to individuals with unilateral and bilateral vestibular hypofunction with the intention of improving quality of life.[99]​ Gaze stabilisation exercises may be prescribed for optimal time intervals, depending on whether the hypofunction is unilateral or bilateral.[99]

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