Vestibular neuritis

Background

• Benign, self-limited disorder associated with complete recovery in most pts
  • Must distinguish from acute vascular lesions of the CNS
• Pathophysiology
  • May be viral or postviral inflammatory disorder affecting vestibular portion of CN VIII

Clinical Features

• Acute, rapid onset of severe vertigo w/ N/V and gait instability
• Nystagmus
  • Unilateral, horizontal or horizontal-torsional that is suppressed w/ visual fixation
  • Does not change direction with gaze
• Unlike BPPV and Meniere lasts several days and does not recur

Diagnosis

• HINTS Exam can reliably distinguish peripheral cause from cerebellar/brain stem CVA
  • 1. Head Impulse Testing
    • Tests vestibulo-ocular reflex
    • Have pt fix their eyes on your nose
    • Move their head in the horizontal plane to the left and right
      • If reflex is intact their eyes will stay fixed on your nose
      • If reflex is abnormal eyes will move w/ their head and won't stay fixed on your nose
    • It is reassuring if the reflex is abnormal!(due to dysfunction of the nerve)
  • 2. Nystagmus
    • Benign nystagmus only beats in one direction no matter which direction their eyes look
    • Bad nystagums beats in every direction their eyes look
      • If pt looks left, get left nystagmus, if looks right, get right-beating nystagmus
  • 3. Test of Skew
    • Vertical dysconjugate gaze is bad
    • Alternating cover test
      • Have pt look at your nose w/ their eyes and then cover one eye
      • When rapidly uncover the eye look to see if the eye quickly moves to re-align
  • If any of the above 3 tests are consistent w/ CVA obtain full work-up (including MRI)

DDX

• Cerebellum lesion
  • Nystagmus
    • Not suppressed with visual fixation
    • May be other than horizontal or horizontal-torsional
    • May change direction with gaze
  • Ataxia
  • Pt may have limb dysmetria, dysarthria, or HA
  • Head impulse test usually normal
• Brainstem infarction
  • Usually associated with other symptoms of Wallenberg syndrome (lateral medulla infarct)
    • Ipsilateral Horner's, sensory loss, loss of corneal reflex, dysphagia, limb ataxia

Treatment

• Treat associated vertigo symptomatically

Source

UpToDate