Treatment algorithm

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

ACUTE

labyrinthitis

1st line – treatment of underlying condition

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ACUTE
|
labyrinthitis
|
viral
1st line – 

treatment of underlying condition

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 in the absence of other indications.

Patients with HIV-associated labyrinthitis should be referred to a physician with experience in managing patients with HIV. See HIV in adults.

Plus – vestibular suppressant/anti-emetic

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ACUTE
|
labyrinthitis
|
viral
Plus – 

vestibular suppressant/anti-emetic

Treatment recommended for ALL patients in selected patient group

Symptoms of 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]

The 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.

Primary options

promethazine: children ≥2 years of age: 0.25 to 1 mg/kg orally/intravenously every 4-6 hours when required, maximum 25 mg/dose; adults: 12.5 to 25 mg orally/intravenously every 4-6 hours when required

OR

dimenhydrinate: children 2-5 years of age: 12.5 to 25 mg orally every 6-8 hours when required, maximum 75 mg/day; children 6-11 years of age: 25-50 mg orally every 6-8 hours when required, maximum 150 mg/day; children ≥12 years of age and adults: 50-100 mg orally/intravenously/intramuscularly every 4-6 hours when required, maximum 600 mg/day

OR

cyclizine: children 6-11 years of age: 25 mg orally every 6-8 hours when required, maximum 75 mg/day; children ≥12 years of age and adults: 50 mg orally every 4-6 hours when required, maximum 200 mg/day

OR

prochlorperazine: children 2-12 years of age and 9-13 kg body weight: 2.5 mg orally every 12-24 hours when required, maximum 7.5 mg/day; children 2-12 years of age and 14-17 kg body weight: 2.5 mg orally every 8-12 hours when required, maximum 10 mg/day; children 2-12 years of age and 18-39 kg body weight: 2.5 mg orally every 8 hours when required, maximum 15 mg/day; children 2-12 years of age and ≥40 kg body weight: 5 mg orally every 6-8 hours when required, maximum 20 mg/day; adults: 5-10 mg orally every 6-8 hours when required, maximum 40 mg/day

OR

metoclopramide: adults: 5-10 mg orally/intravenously every 8 hours when required for a maximum of 5 days, maximum 30 mg/day

OR

ondansetron: children: consult specialist for guidance on dose; adults: 4-8 mg orally/intravenously/intramuscularly every 4-8 hours when required

Plus – systemic or intratympanic corticosteroid

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ACUTE
|
labyrinthitis
|
viral
Plus – 

systemic or intratympanic corticosteroid

Treatment recommended for ALL patients in selected patient group

For patients with non-HIV associated labyrinthitis with sudden sensorineural hearing loss, oral corticosteroids (e.g., prednisolone) are considered the standard of care.[77]​ The treatment course is typically 10-14 days of oral therapy with a 5-day taper.

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]​ 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]​ 

Intratympanic corticosteroid injections may be considered first line as monotherapy, or in combination with an oral corticosteroid. They may also be given as salvage therapy after failure of oral corticosteroids. The decision depends on clinical factors and local practice.

Primary options

prednisolone: children: 1 mg/kg/day orally; adults: 60 mg/day orally

and/or

dexamethasone sodium phosphate: children and adults: consult specialist for guidance on intratympanic dose

1st line – treatment of underlying condition

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ACUTE
|
labyrinthitis
|
bacterial
1st line – 

treatment of underlying condition

If the history and examination are consistent with otitis media, such as otalgia (ear pain) and an abnormal ear examination 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 intracranial infection (e.g., 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.

Plus – vestibular suppressant/anti-emetic

Back
ACUTE
|
labyrinthitis
|
bacterial
Plus – 

vestibular suppressant/anti-emetic

Treatment recommended for ALL patients in selected patient group

Symptoms of 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]

The 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.

Primary options

promethazine: children ≥2 years of age: 0.25 to 1 mg/kg orally/intravenously every 4-6 hours when required, maximum 25 mg/dose; adults: 12.5 to 25 mg orally/intravenously every 4-6 hours when required

OR

dimenhydrinate: children 2-5 years of age: 12.5 to 25 mg orally every 6-8 hours when required, maximum 75 mg/day; children 6-11 years of age: 25-50 mg orally every 6-8 hours when required, maximum 150 mg/day; children ≥12 years of age and adults: 50-100 mg orally/intravenously/intramuscularly every 4-6 hours when required, maximum 600 mg/day

OR

cyclizine: children 6-11 years of age: 25 mg orally every 6-8 hours when required, maximum 75 mg/day; children ≥12 years of age and adults: 50 mg orally every 4-6 hours when required, maximum 200 mg/day

OR

prochlorperazine: children 2-12 years of age and 9-13 kg body weight: 2.5 mg orally every 12-24 hours when required, maximum 7.5 mg/day; children 2-12 years of age and 14-17 kg body weight: 2.5 mg orally every 8-12 hours when required, maximum 10 mg/day; children 2-12 years of age and 18-39 kg body weight: 2.5 mg orally every 8 hours when required, maximum 15 mg/day; children 2-12 years of age and ≥40 kg body weight: 5 mg orally every 6-8 hours when required, maximum 20 mg/day; adults: 5-10 mg orally every 6-8 hours when required, maximum 40 mg/day

OR

metoclopramide: adults: 5-10 mg orally/intravenously every 8 hours when required for a maximum of 5 days, maximum 30 mg/day

OR

ondansetron: children: consult specialist for guidance on dose; adults: 4-8 mg orally/intravenously/intramuscularly every 4-8 hours when required

vestibular neuritis

1st line – vestibular rehabilitation

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ACUTE
|
vestibular neuritis
1st line – 

vestibular rehabilitation

Vestibular rehabilitation is the first-line treatment option for patients with vestibular neuritis.[94][95][96]​​ 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]

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]

Plus – systemic corticosteroid

Back
ACUTE
|
vestibular neuritis
Plus – 

systemic corticosteroid

Treatment recommended for ALL patients in selected patient group

A systemic corticosteroid should be used in combination with vestibular rehabilitation exercises.[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] 

Primary options

dexamethasone sodium phosphate: children and adults: consult specialist for guidance on intravenous dose

More

Plus – vestibular suppressant/anti-emetic

Back
ACUTE
|
vestibular neuritis
Plus – 

vestibular suppressant/anti-emetic

Treatment recommended for ALL patients in selected patient group

Symptoms of 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 antiemetics (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]

The 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.

Primary options

promethazine: children ≥2 years of age: 0.25 to 1 mg/kg orally/intravenously every 4-6 hours when required, maximum 25 mg/dose; adults: 12.5 to 25 mg orally/intravenously every 4-6 hours when required

OR

dimenhydrinate: children 2-5 years of age: 12.5 to 25 mg orally every 6-8 hours when required, maximum 75 mg/day; children 6-11 years of age: 25-50 mg orally every 6-8 hours when required, maximum 150 mg/day; children ≥12 years of age and adults: 50-100 mg orally/intravenously/intramuscularly every 4-6 hours when required, maximum 600 mg/day

OR

cyclizine: children 6-11 years of age: 25 mg orally every 6-8 hours when required, maximum 75 mg/day; children ≥12 years of age and adults: 50 mg orally every 4-6 hours when required, maximum 200 mg/day

OR

prochlorperazine: children 2-12 years of age and 9-13 kg body weight: 2.5 mg orally every 12-24 hours when required, maximum 7.5 mg/day; children 2-12 years of age and 14-17 kg body weight: 2.5 mg orally every 8-12 hours when required, maximum 10 mg/day; children 2-12 years of age and 18-39 kg body weight: 2.5 mg orally every 8 hours when required, maximum 15 mg/day; children 2-12 years of age and ≥40 kg body weight: 5 mg orally every 6-8 hours when required, maximum 20 mg/day; adults: 5-10 mg orally every 6-8 hours when required, maximum 40 mg/day

OR

metoclopramide: adults: 5-10 mg orally/intravenously every 8 hours when required for a maximum of 5 days, maximum 30 mg/day

OR

ondansetron: children: consult specialist for guidance on dose; adults: 4-8 mg orally/intravenously/intramuscularly every 4-8 hours when required

ONGOING

with persistent vestibular symptoms post-treatment

1st line – vestibular rehabilitation

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ONGOING
|
with persistent vestibular symptoms post-treatment
1st line – 

vestibular rehabilitation

Patients with persistent vestibular symptoms after treatment may require vestibular rehabilitation.​[88][90]

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]​ 

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]

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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Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer

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