Vestibular neuritis
Overview
Summary
Acute unilateral vestibulopathy producing the prototypical acute vestibular syndrome: severe vertigo, nausea/vomiting, gait imbalance, and spontaneous nystagmus lasting days. The cochlear division is spared (preserved hearing distinguishes it from labyrinthitis).
Diagnostic criteria
See the Bárány Society / clinical practice guideline papers[13] listed on the references page for the consensus diagnostic framework used in this profile.
Epidemiology
Annual incidence 3.5/100,000. Adults 30–60. Often preceded by viral URI.
Pathophysiology
Presumed reactivation of latent HSV-1 in the vestibular (Scarpa's) ganglion causing inflammation and partial axonal degeneration of the superior vestibular nerve in most cases.
Prognosis
Vertigo resolves over 1–3 weeks via central compensation; ~50% have lasting subjective imbalance. Caloric paresis often persists on testing.
Key examination findings
- ◆Spontaneous horizontal-torsional jerk nystagmus beating AWAY from affected ear
- ◆Suppressed by visual fixation; enhanced under Frenzel/VNG
- ◆Alexander's law: intensity ↑ on gaze toward fast phase
- ◆Abnormal (catch-up saccade) head impulse test toward the affected ear
- ◆No skew deviation; no other central signs
- ◆Falls or veers toward affected side on Romberg/Fukuda
Investigations
- ▸Bedside HINTS: typically benign pattern (abnormal HIT, direction-fixed nystagmus, no skew)
- ▸Caloric testing: unilateral weakness ≥25% on the affected side
- ▸vHIT: reduced VOR gain with overt/covert catch-up saccades
- ▸MRI not routinely needed if HINTS clearly peripheral
Management
- ●Symptomatic: vestibular suppressants (e.g., dimenhydrinate, prochlorperazine) for <3 days only
- ●Steroids (methylprednisolone) within 3 days may improve recovery of caloric function (Strupp 2004)
- ●EARLY vestibular rehabilitation accelerates central compensation
- ●Avoid prolonged suppressant use — impairs compensation
Clinical pearls
- ★If hearing loss accompanies the syndrome, it is labyrinthitis, not neuritis.
- ★Direction-CHANGING nystagmus or skew deviation = STROKE until proven otherwise.