Disease Patterns

Vestibular Neuritis

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0:00Vestibular neuritis presents with sudden vertigo, lasting days to weeks, in a patient without auditory symptoms or central signs.

0:13The acute findings are unilateral: head impulse test positive to one side, caloric weakness on the same side, contralesional spontaneous nystagmus suppressed by visual fixation.

0:30Park and colleagues, in 2017, examined CDP findings in 87 patients with acute vestibular neuritis.

0:4370 percent had abnormality on condition five or six, or both. Falls were common on condition five.

0:57The classical vestibular pattern was the most frequent signature: selective C5 and C6 reduction with the remaining conditions intact.

1:1324 percent showed a visual-vestibular pattern — abnormalities extending to condition four. This is the second most common signature in acute neuritis.

1:29The remaining patients showed either compensated patterns with milder C5/C6 reduction, or unusual patterns that warranted further investigation.

1:45CDP supports the diagnosis but does not establish it. The head impulse test, caloric testing, and the absence of central signs are central.

2:01Over weeks to months, central compensation drives the SOT pattern back toward normal, even when caloric testing remains permanently asymmetric.

2:17A patient with persistent symptoms beyond three months but a now-normal CDP and normal HIT raises the question of PPPD — a different disorder entirely.

Signature on CDP

The figure below shows the archetypal Acute VN pattern across the six SOT conditions, MCT response, and ADT adaptation, compared against an age-matched normal reference.

SOT pattern vs normal

MCT — medium-amplitude backward translation

ADT — sway energy across five trials per direction

Teaching point. In acute VN, Park et al. (2017) found that ~70% of patients show abnormality on C5 and/or C6. The pattern is more severe than chronic compensated loss, with frequent falls on C5/C6 and high intertrial variability reflecting the uncompensated state.

Audiometric companion

The audiogram below shows the typical hearing signature for this disorder. Reading the audiometric and CDP signatures together is often more informative than either alone.

Vestibular neuritis — normal hearing despite acute peripheral vestibular loss.

Vestibular neuritis spares hearing — the inflammation affects the vestibular nerve but not the cochlear nerve. A normal audiogram alongside an acute peripheral CDP pattern (selective C5/C6 reduction with falls) supports the diagnosis. Hearing loss in this context should prompt consideration of labyrinthitis instead.

In this module

Acute vestibular neuritisFoundation · Trainee · Clinician
Typical CDP patternFoundation · Trainee · Clinician
Evolution of CDP findings over timeTrainee · Clinician

Acute vestibular neuritis

Vestibular neuritis is an acute peripheral vestibulopathy presenting with sudden severe vertigo lasting days to weeks, in a patient without auditory symptoms and without central neurological signs. It is most often attributed to inflammation of the vestibular nerve, possibly viral.

The acute findings are unilateral: a positive head impulse test to one side, caloric weakness on the same side, contralesional spontaneous nystagmus that is suppressed by visual fixation, and no hearing loss. The HINTS exam (head impulse, nystagmus, test of skew) reliably distinguishes neuritis from a posterior-circulation stroke in the acute setting.

Recovery is the rule, although a minority of patients develop PPPD or chronic dizziness even after the peripheral lesion has compensated. CDP can document the acute lesion and track its compensation.

Typical CDP pattern

Park and colleagues (2017) examined CDP in 87 patients with acute vestibular neuritis, all tested within 7 days of symptom onset. Seventy percent had abnormality on conditions 5 or 6, or both. Falls on condition 5 were common.

The most frequent SOT pattern was the classical vestibular pattern: selective reduction on C5 and C6 with C1–C4 intact (about 46% of patients). The second most frequent was the visual-vestibular pattern, with reduction extending to C4 (about 24% of patients).

MCT findings in acute neuritis are typically normal in latency and amplitude. The ADT is usually intact — adaptation is a central process and the lesion is peripheral. Findings outside this pattern, particularly prolonged MCT latency or non-adapting ADT, should prompt a search for central involvement.

Evolution of CDP findings over time

Over the first six weeks, the CDP pattern attenuates. The classical vestibular pattern softens as central compensation rebalances vestibular tone; condition 5 scores rise from near-zero into the 30s and 40s, then into the 50s and 60s by three months.

By six months, most uncomplicated neuritis patients have essentially normal CDPs even when caloric weakness persists. This dissociation between structural and functional recovery is the key reason CDP and calorics report complementary, not redundant, information.

Patients who do not show this trajectory — those still with a severe vestibular pattern at three months — warrant a careful re-look. Co-existing PPPD, fear-avoidance behaviour, central involvement, and incomplete rehabilitation are the principal possibilities.