🌀 Vestibular Neuritis & Peripheral Vertigo: PLAB 2 High-Yield Revision

Ann Augustin
Jul 2
3 min read

Updated: Jul 6

⭐ What is Vestibular Neuritis?

Vestibular neuritis is an inflammation of the vestibular nerve (part of the balance nerve in the inner ear) causing sudden, severe vertigo without hearing loss.

Layman explanation:"It's when a balance nerve in your ear gets inflamed, making you feel like the room is spinning, but your hearing stays normal."

🔬 Causes and Risk Factors

✅ Main risk factor: Viral infection (often after a cold or flu)

✅ Other risks:

Recent respiratory or GI infections
Stress
Rarely immune-mediated causes

🚨 Exacerbating Factors

Symptoms worsen with:

Head movements
Body movements (turning in bed, walking)
Visual stimuli (e.g. supermarket aisles)
Lack of vestibular rehabilitation
Anxiety

🧠 Clinical Features

Feature	Vestibular Neuritis
Vertigo	Sudden onset, severe, continuous for days
Hearing	Normal
Tinnitus	Absent
Nystagmus	Unidirectional, horizontal-torsional, beats away from affected side
Head Impulse Test (HIT)	Positive ➔ corrective saccade when head turned to affected side
Skew Test	Negative
Romberg	Positive (sways towards lesion side)
Gait	Veers towards affected side, wide-based gait

💡 How to Elicit Nystagmus

Observe at rest – often visible
Remove fixation (Frenzel goggles) – enhances nystagmus
Gaze-evoked testing – increases when looking towards fast phase
Head-shaking test – transient nystagmus towards healthy side

🔬 Skew Test (Alternate Cover Test)

Tests for vertical ocular misalignment.
Positive (vertical correction) ➔ Central cause (e.g. stroke)
Negative ➔ Suggests peripheral cause like vestibular neuritis.

❓ Is there ear fullness in vestibular neuritis?

❌ No.Ear fullness is seen in Meniere’s disease, not in vestibular neuritis.

🔍 Blood Investigations

✅ No specific blood tests required.Done only to rule out other causes (e.g. infection, vascular risk factors) if clinically indicated.

🏃‍♂️ Cawthorne-Cooksey Exercises

These are vestibular rehabilitation exercises to improve balance and reduce dizziness by helping the brain adapt.Includes:

Eye and head movements
Sitting to standing exercises
Walking with head turns

🔎 Differentiation from Other Peripheral Causes and Treatment

Condition	Vertigo Duration	Hearing Loss	Tinnitus	Ear Fullness	HIT	Main Treatment	Medications Used
Vestibular neuritis	Days (continuous)	❌	❌	❌	Positive	Vestibular rehab	✅ Short-term corticosteroids (some guidelines) ✅ Vestibular suppressants (prochlorperazine) only for severe nausea (≤3 days)
Labyrinthitis	Days (continuous)	✅	✅	Possible	Positive	Treat underlying cause, vestibular rehab	✅ If bacterial – antibiotics ✅ Corticosteroids sometimes ✅ Short-term vestibular suppressants
Meniere’s disease	Minutes-hours (episodic)	✅ (fluctuating)	✅	✅	May be positive during attack	Lifestyle modifications (low salt diet)	✅ Betahistine (first line) ✅ Diuretics (e.g. bendroflumethiazide) ✅ Vestibular suppressants during acute attacks only
Acoustic neuroma	Rare vertigo, chronic imbalance	✅ (progressive)	✅	Rare	Often normal	Surgical removal or stereotactic radiosurgery	❌ No medications for tumour itself ✅ Vestibular rehab for imbalance
BPPV	Seconds (positional)	❌	❌	❌	Positive if affected canal stimulated	Epley manoeuvre (canalith repositioning)	❌ No routine meds

💡 Is Acoustic Neuroma Central or Peripheral?

✅ It is a peripheral lesion (vestibular nerve sheath tumour) but large tumours can cause central signs by compressing the brainstem/cerebellum.

🔑 Key Takeaways for PLAB 2

✔ Vestibular neuritis ➔ Acute severe vertigo without hearing symptoms, positive HIT.

✔ Labyrinthitis ➔ Same as vestibular neuritis plus hearing loss.

✔ Meniere’s ➔ Episodic vertigo with fluctuating hearing loss, tinnitus, and fullness.

✔ Acoustic neuroma ➔ Chronic imbalance and progressive hearing loss, minimal vertigo.

📝 Practice Tip

Always perform HINTS exam (Head Impulse, Nystagmus, Skew test) in acute vertigo presentations to differentiate central vs peripheral causes.

📚 References: