The disorder

Clinical features

A patient who is suddenly, continuously spinning for days, veering to one side, with a steady beat of the eyes — and, in pure neuritis, hearing that is entirely normal.

The cardinal features

Trainee

Vestibular neuritis is the acute vestibular syndrome: acute, sustained vertigo with nausea, gait imbalance and a unidirectional spontaneous nystagmus.1 The 2022 Bárány criteria require acute/subacute sustained spinning, a peripheral spontaneous nystagmus and an ipsilesional head-impulse deficit, with central signs excluded.3 Tap each feature:

Acute sustained vertigo. Sudden, continuous spinning vertigo lasting days, with nausea and vomiting — the acute vestibular syndrome. Unlike Ménière's or BPPV it is a single prolonged attack, not recurrent spells, and is present at rest (not purely positional).

The peripheral nystagmus

The nystagmus is horizontal-torsional and unidirectional, beating away from the affected ear. Its peripheral signature is that visual fixation suppresses it — remove fixation (Frenzel goggles or the dark) and it grows. Toggle fixation below:

R (affected)L
Peripheral nystagmus is unidirectional and horizontal-torsional, beating away from the affected ear. Crucially it is suppressed by visual fixation and grows when fixation is removed — the opposite of most central nystagmus, which fixation does not damp.

For the full taxonomy of nystagmus and its localising value, see the Nystagmus chapter; for how it is recorded, see VNG.

The course of recovery

The acute crisis settles over days; the static deficit then compensates over weeks, and the dynamic deficit recovers over months. Step through the trajectory:

Acute · days

Severe continuous vertigo, nausea and vomiting, prostrate with spontaneous nystagmus. Symptomatic relief and short-course steroids belong here; bed rest beyond a day or two is counter-productive.

Around half of patients report some residual imbalance.2 Two sequelae deserve active follow-up: a secondary BPPV in the spared posterior canal, and persistent postural-perceptual dizziness when symptoms outlast the deficit — see BPPV and the planned PPPD chapter.

Key points

  • The acute vestibular syndrome: acute, continuous vertigo lasting days, present at rest.
  • Unidirectional horizontal-torsional nystagmus beating away from the lesion, suppressed by fixation.
  • Gait veers and the head impulse is abnormal toward the affected side; hearing is spared in neuritis.
  • Recovery runs acute → subacute compensation → chronic; watch for secondary BPPV and PPPD.