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Vestibular Neuronitis: The Ultimate High-Yield MSRA Revision Guide

Updated: Jul 3

Definition

Acute inflammation of the vestibular nerve (often viral-induced), causing sudden severe vertigo without hearing loss.


🔬 Pathophysiology & Recovery

  • Cause: Often post-viral inflammation (e.g. HSV-1 reactivation in Scarpa's ganglion)

  • Recovery: Through central compensation (brain adapts to loss of input)


⚡ Clinical Presentation – Key Triggers & Clues

Feature

Clue

Onset

Acute, sudden severe rotational vertigo, often upon waking

Course

Constant at rest, worsened by head movement  Severe for 2–3 days  Gradual recovery over 2–6 weeks

Associated symptoms

Nausea, vomiting, autonomic symptoms (malaise, pallor, sweating) Unsteadiness veering towards affected side

Auditory/Neurological

No hearing loss No tinnitus No focal neurological signs (e.g. diplopia, dysarthria)

Precipitating factors

Recent viral illness (blocked nose, sore throat) or contact with similar illness

👁️ Examination Findings

  • Nystagmus:

    • Fine horizontal ± torsional

    • Fast phase away from affected ear

    • Unidirectional, suppressed by visual fixation

  • Head-Impulse Test (HIT):

    • Positive (abnormal) towards affected side (corrective saccade towards target)

  • Hearing & Otoscopy: Strictly normal


🔍 Head-Impulse Test Summary

Finding

Interpretation

Eyes remain fixed on target

Normal VOR (central cause likely if vertigo present)

Corrective saccade towards target

Peripheral vestibular hypofunction (e.g. neuronitis)

🔬 Mechanism of Unsteadiness – Veering to Affected Side

Due to loss of vestibular input from the affected side, brain interprets imbalance as if turning to the healthy side, leading to veering towards the lesion side.



🔎 Vertigo Duration by Cause – Rapid Differential Table

Condition

Vertigo Duration

Notes

Vestibular neuronitis

Continuous for 2–3 days, improves over weeks

No hearing loss

Labyrinthitis

Continuous for days

+ hearing loss/tinnitus

BPPV

Seconds (<1 min)

Triggered by position changes, resolves when still

Meniere’s disease

Episodic attacks lasting 20 min – few hours

Vertigo + fluctuating hearing loss + tinnitus

Stroke (PICA/AICA)

Continuous hours–days

With neurological signs

Cerebellar tumour

Gradual persistent imbalance

Progressive + headache, raised ICP

Multiple sclerosis

Minutes–days, recurrent

Other CNS symptoms

Vestibular migraine

Minutes–hours (up to 72h)

± headache, aura, photophobia


🩺 Management Summary

Severity

Intervention

Mild–Moderate

Oral prochlorperazine or antihistamines (cinnarizine, cyclizine, promethazine) for ≤3 days, then stop to avoid delayed central compensation

Severe nausea/vomiting

Buccal or IM prochlorperazine / cyclizine

All patients

Reassure + encourage early mobilisation + safety advice

Avoid

Antivirals, corticosteroids, benzodiazepines (no proven benefit + delays compensation)

Escalation

Admit if intolerant of oral intake Refer if persists >1 week, >6 weeks, or develops atypical neuro signs

🧠 Why avoid certain medications?

  • Antivirals: No proven benefit

  • Corticosteroids: No routine benefit, potential side effects

  • Benzodiazepines: Delay compensation, sedation, dependence risk


⚠️ Prognosis

✅ Peak severity 2–3 days

✅ Near-complete recovery over weeks via central compensation

✅ < 10% risk of persistent imbalance


🔬 Peripheral vs Central Vertigo Differentiation Table

Feature

Peripheral

Central

Examples

Vestibular neuronitis, BPPV, Meniere’s, Labyrinthitis

Stroke, cerebellar tumour, MS, vestibular migraine

Vertigo intensity

Severe, spinning

Often less intense, unsteadiness

Nystagmus

Unidirectional, suppressed by fixation

Vertical, bidirectional, not suppressed

Head-Impulse Test

Abnormal (positive)

Normal

Neurological signs

Absent

Present (ataxia, dysarthria, diplopia)


🔍 HINTS Exam Summary

Test

Peripheral (Neuronitis)

Central (Stroke)

Head-Impulse

Abnormal

Normal

Nystagmus

Unidirectional

Direction-changing or vertical

Test of Skew

Negative

Positive

✔️ HINTS more sensitive than early MRI for posterior circulation stroke


📝 High-Yield MSRA MCQs

Q1. A patient with sudden continuous vertigo, veering to right, no hearing loss, positive HIT to right. Diagnosis?✅ Answer: Vestibular neuronitis

Q2. Vertigo lasting seconds, positional, resolves when still. Diagnosis?✅ Answer: BPPV

Q3. Vertigo with hearing loss, tinnitus, ear vesicles, facial palsy. Diagnosis?✅ Answer: Ramsay Hunt syndrome

Q4. In vestibular neuronitis, why stop vestibular suppressants after ≤3 days?✅ Answer: To avoid delaying central compensation

Q5. Patient with normal HIT, direction-changing nystagmus, ataxia. Likely cause?✅ Answer: Central cause (stroke)

(✔️ Full MCQ sets with explanations provided in the conversation above for your flashcards.)


🧠 Extra High-Yield Pearls

✅ Alexander's Law: Nystagmus amplitude increases when gazing in the direction of the fast phase (peripheral lesions).

✅ Persistent Postural-Perceptual Dizziness (PPPD): Chronic dizziness post-neuronitis, managed with vestibular rehab and CBT.

✅ Vestibular Rehabilitation: Gaze stabilisation, balance retraining, habituation exercises aid recovery.


💡 Final Exam Clencher

✅ Vestibular neuronitis = sudden continuous severe vertigo + no hearing loss + positive HIT + normal neuro exam.

✅ Central cause (stroke) = vertical or direction-changing nystagmus + normal HIT + neuro signs.


📚 References



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