Acute peripheral vestibulopathy

Condition

• Acute peripheral vestibulopathy 

Definition 

• Acute vestibular failure is the sudden loss of function in one balance organ 
• The presumptive cause of acute peripheral vestibulopathy is vestibular neuritis (also known as vestibular neuronitis). Recent evidence suggests reactivation of herpes simplex type 1 virus in the vestibular ganglion is responsible 

History 

• Mainly in young adults and middle aged people
• Single attack of vertigo 
• Abrupt onset of persistent vertigo
• Often follows a flu-like illness
• Accompanied by nausea and vomiting
• No hearing loss or tinnitus
• Gradual recovery over days to weeks
• Spontaneous horizontal nystagmus 
• Caloric stimulation confirms impaired vestibular function 

Examination 

• Spontaneous horizontal nystagmus 
• Check ear to exclude suppuration in the middle ear or mastoid cavity 
• Head impulse test (positive test points towards acute vestibular syndrome, click on it to watch a video on youtube) 
• Hallpike maneuvre
• Rhomberg test
• Positive Romberg indicates loss of proprioceptive or vestibular input, support the diagnosis of Romberg test
• Bedside assessment of hearing
• Assessment of gait and preponderance to veer to one or other side

Diagnostic triad

• acute vertigo + nausea + vomiting = vestibular neuritis
• same symptoms + hearing loss +/- tinnitus = acute labyrinthitis

Differential diagnoses

• stroke
• Meniere disease
• BPPV
• Vestibula migraine

Red flags

• acute unaccustomed headache
• inability to stand or walk
• the presence of spontaneous direction changing nystagmus
• spontaneous vertical nystagmus
• a normal head impulse
• the presence of additional focal neurological signs

Treatment

• Short term
• Education: spontaneous resolution usually after 1 week
• Prochlorperazine 12.5 mg 
• Short course of corticosteroids such as prednisolone often helps
• Medium
• vestibular physiotherapy could be considered

Reference:

John Murtagh 5th edition p. 497
Check program ENT Case 4 2011