Disease 05.3

Vestibular Neuritis

The condition where VEMP earns its keep — by allowing topographic diagnosis of superior, inferior, or total nerve involvement.

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Foundation

What is vestibular neuritis?

Vestibular neuritis is an acute unilateral inflammation of part of the vestibular nerve, most often presumed post-viral. Patients present with severe vertigo, nausea, and characteristic spontaneous nystagmus lasting days to weeks. Hearing is preserved (distinguishing it from labyrinthitis).

AudiogramThe pure-tone signature

Hearing is preserved in vestibular neuritis — the cochlear branch of the eighth nerve is spared. Symmetric normal audiogram in someone with severe acute vertigo is itself a clue: it argues against labyrinthitis (which would show hearing loss) and against schwannoma (asymmetric loss).

In superior neuritis the affected oVEMP is absent or severely reduced while the cVEMP remains preserved.

Trainee

Topographic patterns

Variant	oVEMP	cVEMP	Caloric
Superior division	Abnormal	Normal	Abnormal
Inferior division	Normal	Abnormal	Normal
Total	Abnormal	Abnormal	Abnormal

Clinician

Inferior neuritis — the variant easily missed

A patient with isolated inferior vestibular neuritis presents with vertigo but has a normal head-impulse test of the horizontal canal and a normal caloric — both of which test the superior division. Without VEMP the diagnosis can be missed entirely, the patient labelled "psychogenic" or "BPPV without a positive test." An absent cVEMP on the affected side, with preserved oVEMP and caloric, is the signature.^[7]

Recovery and prognosis

VEMPs often remain abnormal in the affected division long after subjective recovery, consistent with the central compensation that drives clinical improvement. Serial VEMPs can document persistent peripheral asymmetry that helps interpret late-onset residual symptoms or recurrent episodes.