Labyrinthitis and vestibular neuritis
- Overview
- Theory
- Diagnosis
- Management
- Follow up
- Resources
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
labyrinthitis
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.
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]Soto E, Vega R. Neuropharmacology of vestibular system disorders. Curr Neuropharmacol. 2010 Mar;8(1):26-40. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2866460 http://www.ncbi.nlm.nih.gov/pubmed/20808544?tool=bestpractice.com Use of all vestibular suppressant drugs should be limited to 3-5 days to avoid interfering with central compensation and adaptation.[68]Viola P, Gioacchini FM, Astorina A, et al. The pharmacological treatment of acute vestibular syndrome. Front Neurol. 2022;13:999112. https://www.frontiersin.org/journals/neurology/articles/10.3389/fneur.2022.999112/full http://www.ncbi.nlm.nih.gov/pubmed/36158968?tool=bestpractice.com 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]European Medicines Agency. European Medicines Agency recommends changes to the use of metoclopramide. July 2013 [internet publication]. https://www.ema.europa.eu/en/news/european-medicines-agency-recommends-changes-use-metoclopramide#:~:text=The%20Committee%20recommended%20that%20metoclopramide,have%20been%20considered%20or%20tried
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
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]Chandrasekhar SS, Tsai Do BS, Schwartz SR, et al. Clinical practice guideline: sudden hearing loss (update). Otolaryngol Head Neck Surg. 2019 Aug;161(suppl 1):S1-45. https://journals.sagepub.com/doi/full/10.1177/0194599819859885?url_ver=Z39.88-2003&rfr_id=ori%3Arid%3Acrossref.org&rfr_dat=cr_pub++0pubmed http://www.ncbi.nlm.nih.gov/pubmed/31369359?tool=bestpractice.com 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]National Institute for Health and Care Excellence. Suspected neurological conditions: recognition and referral. NG127. Oct 2023 [internet publication]. https://www.nice.org.uk/guidance/ng127 [79]Lai D, Zhao F, Jalal N, et al. Intratympanic glucocorticosteroid therapy for idiopathic sudden hearing loss: meta-analysis of randomized controlled trials. Medicine (Baltimore). 2017 Dec;96(50):e8955. https://journals.lww.com/md-journal/fulltext/2017/12150/intratympanic_glucocorticosteroid_therapy_for.38.aspx http://www.ncbi.nlm.nih.gov/pubmed/29390288?tool=bestpractice.com [80]Rauch SD. Intratympanic steroids for sensorineural hearing loss. Otolaryngol. Clin. N. Am. 2004 Oct; 37(5):1061-74. 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]Lai D, Zhao F, Jalal N, et al. Intratympanic glucocorticosteroid therapy for idiopathic sudden hearing loss: meta-analysis of randomized controlled trials. Medicine (Baltimore). 2017 Dec;96(50):e8955. https://journals.lww.com/md-journal/fulltext/2017/12150/intratympanic_glucocorticosteroid_therapy_for.38.aspx http://www.ncbi.nlm.nih.gov/pubmed/29390288?tool=bestpractice.com [81]Ng JH, Ho RC, Cheong CS, et al. Intratympanic steroids as a salvage treatment for sudden sensorineural hearing loss? a meta-analysis. Eur Arch Otorhinolaryngol. 2015 Oct;272(10):2777-82. http://www.ncbi.nlm.nih.gov/pubmed/25217083?tool=bestpractice.com [82]Qiang Q, Wu X, Yang T, et al. A comparison between systemic and intratympanic steroid therapies as initial therapy for idiopathic sudden sensorineural hearing loss: a meta-analysis. Acta Otolaryngol. 2017 Jun;137(6):598-605. http://www.ncbi.nlm.nih.gov/pubmed/27921520?tool=bestpractice.com Some studies report no advantage of intratympanic corticosteroid injections over systemic corticosteroids.[83]Mirsalehi M, Ghajarzadeh M, Farhadi M, et al. Intratympanic corticosteroid injection as a first-line treatment of the patients with idiopathic sudden sensorineural hearing loss compared to systemic steroid: a systematic review and meta-analysis. Am J Otolaryngol. 2022 Sep-Oct;43(5):103505. http://www.ncbi.nlm.nih.gov/pubmed/35714500?tool=bestpractice.com [84]Plontke SK, Meisner C, Agrawal S, et al. Intratympanic corticosteroids for sudden sensorineural hearing loss. Cochrane Database Syst Rev. 2022 Jul 22;7(7):CD008080. http://www.ncbi.nlm.nih.gov/pubmed/35867413?tool=bestpractice.com [85]Chrysouli K, Kollia P, Papanikolaou V, et al. The effectiveness of intratympanic steroid injection in addition to systemic corticosteroids in the treatment of idiopathic sudden sensorineural hearing loss. Am J Otolaryngol. 2023 Jul-Aug;44(4):103872. http://www.ncbi.nlm.nih.gov/pubmed/37060782?tool=bestpractice.com [86]Sialakis C, Iliadis C, Frantzana A, et al. Intratympanic versus systemic steroid therapy for idiopathic sudden hearing loss: a systematic review and meta-analysis. Cureus. 2022 Mar;14(3):e22887. https://www.cureus.com/articles/85262-intratympanic-versus-systemic-steroid-therapy-for-idiopathic-sudden-hearing-loss-a-systematic-review-and-meta-analysis#! http://www.ncbi.nlm.nih.gov/pubmed/35399426?tool=bestpractice.com Adverse effects associated with intratympanic injection, including tympanic membrane perforation, pain, dizziness, and vertigo, must be taken into consideration while choosing this therapy.[84]Plontke SK, Meisner C, Agrawal S, et al. Intratympanic corticosteroids for sudden sensorineural hearing loss. Cochrane Database Syst Rev. 2022 Jul 22;7(7):CD008080. http://www.ncbi.nlm.nih.gov/pubmed/35867413?tool=bestpractice.com [87]Jin MC, Qian ZJ, Cooperman SP, et al. Trends in use and timing of intratympanic corticosteroid injections for sudden sensorineural hearing loss. Otolaryngol Head Neck Surg. 2021 Jul;165(1):166-73. http://www.ncbi.nlm.nih.gov/pubmed/33287664?tool=bestpractice.com
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
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]Chan YM, Adams DA, Kerr AG. Syphilitic labyrinthitis: an update. J Laryngol Otol. 1995 Aug;109(8):719-25. http://www.ncbi.nlm.nih.gov/pubmed/7561492?tool=bestpractice.com See Syphilis infection.
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]Soto E, Vega R. Neuropharmacology of vestibular system disorders. Curr Neuropharmacol. 2010 Mar;8(1):26-40. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2866460 http://www.ncbi.nlm.nih.gov/pubmed/20808544?tool=bestpractice.com Use of all vestibular suppressant drugs should be limited to 3-5 days to avoid interfering with central compensation and adaptation.[68]Viola P, Gioacchini FM, Astorina A, et al. The pharmacological treatment of acute vestibular syndrome. Front Neurol. 2022;13:999112. https://www.frontiersin.org/journals/neurology/articles/10.3389/fneur.2022.999112/full http://www.ncbi.nlm.nih.gov/pubmed/36158968?tool=bestpractice.com 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]European Medicines Agency. European Medicines Agency recommends changes to the use of metoclopramide. July 2013 [internet publication]. https://www.ema.europa.eu/en/news/european-medicines-agency-recommends-changes-use-metoclopramide#:~:text=The%20Committee%20recommended%20that%20metoclopramide,have%20been%20considered%20or%20tried
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
vestibular rehabilitation
Vestibular rehabilitation is the first-line treatment option for patients with vestibular neuritis.[94]Hidayati HB, Imania HAN, Octaviana DS, et al. Vestibular rehabilitation therapy and corticosteroids for vestibular neuritis: a systematic review and meta-analysis of randomized controlled trials. Medicina (Kaunas). 2022 Sep 5;58(9):1221. https://www.mdpi.com/1648-9144/58/9/1221 http://www.ncbi.nlm.nih.gov/pubmed/36143898?tool=bestpractice.com [95]Huang HH, Chen CC, Lee HH, et al. Efficacy of vestibular rehabilitation in vestibular neuritis: a systematic review and meta-analysis. Am J Phys Med Rehabil. 2024 Jan 1;103(1):38-46. http://www.ncbi.nlm.nih.gov/pubmed/37339059?tool=bestpractice.com [96]Sun X, Li X, Yang D. Efficacy and safety of mecobalamin combined with vestibular rehabilitation training for acute vestibular neuritis: a systematic review and meta-analysis. Ann Palliat Med. 2022 Feb;11(2):480-9. https://apm.amegroups.org/article/view/85168/html http://www.ncbi.nlm.nih.gov/pubmed/35249325?tool=bestpractice.com Early initiation of vestibular rehabilitation may be associated with improved clinical outcomes.[91]Agger-Nielsen HE, Grøndberg TS, Berg-Beckhoff G, et al. Early vestibular rehabilitation training of peripheral acute vestibular syndrome-a systematic review and meta-analysis. Front Neurol. 2024;15:1396891. https://www.frontiersin.org/journals/neurology/articles/10.3389/fneur.2024.1396891/full http://www.ncbi.nlm.nih.gov/pubmed/38872828?tool=bestpractice.com
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]Han BI, Song HS, Kim JS. Vestibular rehabilitation therapy: review of indications, mechanisms, and key exercises. J Clin Neurol. 2011 Dec;7(4):184-96. https://www.thejcn.com/DOIx.php?id=10.3988/jcn.2011.7.4.184 http://www.ncbi.nlm.nih.gov/pubmed/22259614?tool=bestpractice.com 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]McDonnell MN, Hillier SL. Vestibular rehabilitation for unilateral peripheral vestibular dysfunction. Cochrane Database Syst Rev. 2015 Jan 13;(1):CD005397. http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD005397.pub4/full http://www.ncbi.nlm.nih.gov/pubmed/25581507?tool=bestpractice.com 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]Tokle G, Mørkved S, Bråthen G, et al. Efficacy of vestibular rehabilitation following acute vestibular neuritis: a randomized controlled trial. Otol Neurotol. 2020 Jan;41(1):78-85. http://www.ncbi.nlm.nih.gov/pubmed/31789800?tool=bestpractice.com
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]Hall CD, Herdman SJ, Whitney SL, et al. Vestibular rehabilitation for peripheral vestibular hypofunction: an updated clinical practice guideline from the academy of neurologic physical therapy of the American Physical Therapy Association. J Neurol Phys Ther. 2022 Apr 1;46(2):118-77. https://journals.lww.com/jnpt/fulltext/2022/04000/vestibular_rehabilitation_for_peripheral.7.aspx http://www.ncbi.nlm.nih.gov/pubmed/34864777?tool=bestpractice.com Gaze stabilisation exercises may be prescribed for optimal time intervals, depending on whether the hypofunction is unilateral or bilateral.[99]Hall CD, Herdman SJ, Whitney SL, et al. Vestibular rehabilitation for peripheral vestibular hypofunction: an updated clinical practice guideline from the academy of neurologic physical therapy of the American Physical Therapy Association. J Neurol Phys Ther. 2022 Apr 1;46(2):118-77. https://journals.lww.com/jnpt/fulltext/2022/04000/vestibular_rehabilitation_for_peripheral.7.aspx http://www.ncbi.nlm.nih.gov/pubmed/34864777?tool=bestpractice.com
systemic corticosteroid
Treatment recommended for ALL patients in selected patient group
A systemic corticosteroid should be used in combination with vestibular rehabilitation exercises.[94]Hidayati HB, Imania HAN, Octaviana DS, et al. Vestibular rehabilitation therapy and corticosteroids for vestibular neuritis: a systematic review and meta-analysis of randomized controlled trials. Medicina (Kaunas). 2022 Sep 5;58(9):1221. https://www.mdpi.com/1648-9144/58/9/1221 http://www.ncbi.nlm.nih.gov/pubmed/36143898?tool=bestpractice.com [95]Huang HH, Chen CC, Lee HH, et al. Efficacy of vestibular rehabilitation in vestibular neuritis: a systematic review and meta-analysis. Am J Phys Med Rehabil. 2024 Jan 1;103(1):38-46. http://www.ncbi.nlm.nih.gov/pubmed/37339059?tool=bestpractice.com [96]Sun X, Li X, Yang D. Efficacy and safety of mecobalamin combined with vestibular rehabilitation training for acute vestibular neuritis: a systematic review and meta-analysis. Ann Palliat Med. 2022 Feb;11(2):480-9. https://apm.amegroups.org/article/view/85168/html http://www.ncbi.nlm.nih.gov/pubmed/35249325?tool=bestpractice.com Choice of treatment can be made based on the patient’s condition.[94]Hidayati HB, Imania HAN, Octaviana DS, et al. Vestibular rehabilitation therapy and corticosteroids for vestibular neuritis: a systematic review and meta-analysis of randomized controlled trials. Medicina (Kaunas). 2022 Sep 5;58(9):1221. https://www.mdpi.com/1648-9144/58/9/1221 http://www.ncbi.nlm.nih.gov/pubmed/36143898?tool=bestpractice.com
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]Goudakos JK, Markou KD, Psillas G, et al. Corticosteroids and vestibular exercises in vestibular neuritis. Single-blind randomized clinical trial. JAMA Otolaryngol Head Neck Surg. 2014 May;140(5):434-40. https://jamanetwork.com/journals/jamaotolaryngology/fullarticle/1835393 http://www.ncbi.nlm.nih.gov/pubmed/24604142?tool=bestpractice.com 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]Huang HH, Chen CC, Lee HH, et al. Efficacy of vestibular rehabilitation in vestibular neuritis: a systematic review and meta-analysis. Am J Phys Med Rehabil. 2024 Jan 1;103(1):38-46. http://www.ncbi.nlm.nih.gov/pubmed/37339059?tool=bestpractice.com 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]Sun X, Li X, Yang D. Efficacy and safety of mecobalamin combined with vestibular rehabilitation training for acute vestibular neuritis: a systematic review and meta-analysis. Ann Palliat Med. 2022 Feb;11(2):480-9. https://apm.amegroups.org/article/view/85168/html http://www.ncbi.nlm.nih.gov/pubmed/35249325?tool=bestpractice.com
Primary options
dexamethasone sodium phosphate: children and adults: consult specialist for guidance on intravenous dose
More dexamethasone sodium phosphateSwitch to oral therapy (e.g., prednisolone) when clinically appropriate. May be used in combination with mecobalamin.
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]Soto E, Vega R. Neuropharmacology of vestibular system disorders. Curr Neuropharmacol. 2010 Mar;8(1):26-40. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2866460 http://www.ncbi.nlm.nih.gov/pubmed/20808544?tool=bestpractice.com Use of all vestibular suppressant drugs should be limited to 3-5 days to avoid interfering with central compensation and adaptation.[68]Viola P, Gioacchini FM, Astorina A, et al. The pharmacological treatment of acute vestibular syndrome. Front Neurol. 2022;13:999112. https://www.frontiersin.org/journals/neurology/articles/10.3389/fneur.2022.999112/full http://www.ncbi.nlm.nih.gov/pubmed/36158968?tool=bestpractice.com 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]European Medicines Agency. European Medicines Agency recommends changes to the use of metoclopramide. July 2013 [internet publication]. https://www.ema.europa.eu/en/news/european-medicines-agency-recommends-changes-use-metoclopramide#:~:text=The%20Committee%20recommended%20that%20metoclopramide,have%20been%20considered%20or%20tried
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
with persistent vestibular symptoms post-treatment
vestibular rehabilitation
Patients with persistent vestibular symptoms after treatment may require vestibular rehabilitation.[88]McDonnell MN, Hillier SL. Vestibular rehabilitation for unilateral peripheral vestibular dysfunction. Cochrane Database Syst Rev. 2015 Jan 13;(1):CD005397. http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD005397.pub4/full http://www.ncbi.nlm.nih.gov/pubmed/25581507?tool=bestpractice.com [90]Cohen HS, Kimball KT. Decreased ataxia and improved balance after vestibular rehabilitation. Otolaryngol Head Neck Surg. 2004 Apr;130(4):418-25. http://www.ncbi.nlm.nih.gov/pubmed/15100637?tool=bestpractice.com
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]McDonnell MN, Hillier SL. Vestibular rehabilitation for unilateral peripheral vestibular dysfunction. Cochrane Database Syst Rev. 2015 Jan 13;(1):CD005397. http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD005397.pub4/full http://www.ncbi.nlm.nih.gov/pubmed/25581507?tool=bestpractice.com [89]Joshua A.M., Pai S. Vestibular rehabilitation. In: Joshua, A.M., ed. Physiotherapy for adult neurological conditions. Singapore: Springer; 2022:495-538
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]Han BI, Song HS, Kim JS. Vestibular rehabilitation therapy: review of indications, mechanisms, and key exercises. J Clin Neurol. 2011 Dec;7(4):184-96. https://www.thejcn.com/DOIx.php?id=10.3988/jcn.2011.7.4.184 http://www.ncbi.nlm.nih.gov/pubmed/22259614?tool=bestpractice.com 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]McDonnell MN, Hillier SL. Vestibular rehabilitation for unilateral peripheral vestibular dysfunction. Cochrane Database Syst Rev. 2015 Jan 13;(1):CD005397. http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD005397.pub4/full http://www.ncbi.nlm.nih.gov/pubmed/25581507?tool=bestpractice.com 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]Tokle G, Mørkved S, Bråthen G, et al. Efficacy of vestibular rehabilitation following acute vestibular neuritis: a randomized controlled trial. Otol Neurotol. 2020 Jan;41(1):78-85. http://www.ncbi.nlm.nih.gov/pubmed/31789800?tool=bestpractice.com
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]Hall CD, Herdman SJ, Whitney SL, et al. Vestibular rehabilitation for peripheral vestibular hypofunction: an updated clinical practice guideline from the academy of neurologic physical therapy of the American Physical Therapy Association. J Neurol Phys Ther. 2022 Apr 1;46(2):118-77. https://journals.lww.com/jnpt/fulltext/2022/04000/vestibular_rehabilitation_for_peripheral.7.aspx http://www.ncbi.nlm.nih.gov/pubmed/34864777?tool=bestpractice.com Gaze stabilisation exercises may be prescribed for optimal time intervals, depending on whether the hypofunction is unilateral or bilateral.[99]Hall CD, Herdman SJ, Whitney SL, et al. Vestibular rehabilitation for peripheral vestibular hypofunction: an updated clinical practice guideline from the academy of neurologic physical therapy of the American Physical Therapy Association. J Neurol Phys Ther. 2022 Apr 1;46(2):118-77. https://journals.lww.com/jnpt/fulltext/2022/04000/vestibular_rehabilitation_for_peripheral.7.aspx http://www.ncbi.nlm.nih.gov/pubmed/34864777?tool=bestpractice.com
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