Disorders · Introduction
Vestibular neuritis & labyrinthitis
One prolonged attack of spinning that lasts days — the prototypical acute vestibular syndrome. The whole skill is telling this benign peripheral illness from the stroke that can imitate it.
What it is
Vestibular neuritis is a sudden, severe, continuous dizziness that comes on over hours and lasts several days, usually after a viral-type illness. It affects the balance nerve of one ear, so balance is off and the eyes drift — but hearing is normal. When hearing is affected too, it is called labyrinthitis.
Vestibular neuritis is an acute, sustained unilateral peripheral vestibulopathy — the commonest cause of the acute vestibular syndrome after stroke. It presents with days of continuous vertigo, unidirectional spontaneous nystagmus and a positive head-impulse test, with hearing spared.2 Add cochlear symptoms and it becomes labyrinthitis.
It is a diagnosis of bedside reasoning, not a test: in a patient with continuous vertigo and spontaneous nystagmus, HINTS separates the peripheral neuritis from a posterior-circulation stroke more reliably than early MRI. Mechanistically it is a selective superior-divisionvestibulopathy, presumed to follow reactivation of latent virus in Scarpa’s ganglion.3
By the numbers
Vestibular neuritis is the third commonest cause of peripheral vertigo, after BPPV and Ménière’s disease; onset peaks in midlife and the superior division is affected in most cases.1
Division affected
superior inferior / total
Age of onset
peak onset in the thirties–fifties; no clear sex difference
How this chapter is organised
- Pathophysiology & anatomy — viral reactivation, and why the superior division is the one that fails.
- Clinical features — the acute vestibular syndrome, the nystagmus, and the recovery trajectory.
- Diagnosis & HINTS — an interactive HINTS interpreter and the localising battery.
- Differential diagnosis — above all, separating it from stroke.
- Treatment & recovery — steroids, why antivirals fail, and rehabilitation as the mainstay.
Key points
- A single prolonged attack of continuous vertigo lasting days — the acute vestibular syndrome, not recurrent spells.
- Hearing is spared in neuritis; cochlear involvement (hearing loss, tinnitus) defines labyrinthitis.
- HINTS distinguishes peripheral neuritis from stroke — and a normal head impulse, direction-changing nystagmus or skew is the dangerous pattern.
- The superior division is usually affected; the spared posterior canal can later cause a secondary BPPV.
- Recovery is driven by central compensation — rehabilitate early and keep suppressants brief.