ENT · Vestibular Disorders
The facts most likely to be tested
Labyrinthitis presents with the classic triad of acute onset continuous vertigo, sensorineural hearing loss, and tinnitus.
The presence of sensorineural hearing loss distinguishes labyrinthitis from vestibular neuritis, which presents with vertigo alone.
Physical examination typically reveals horizontal nystagmus with the fast phase directed toward the unaffected ear.
Labyrinthitis is frequently preceded by a viral upper respiratory infection or otitis media.
The head impulse test is typically abnormal on the side of the affected labyrinth.
First-line symptomatic management includes corticosteroids to reduce inflammation and antihistamines or antiemetics for vertigo suppression.
Patients with fever, meningeal signs, or focal neurologic deficits require urgent imaging to rule out meningitis or cerebellar stroke.
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A 34-year-old male presents to the urgent care clinic complaining of a 2-day history of severe spinning sensation and nausea. He reports a recent viral upper respiratory infection one week ago. On physical exam, he has horizontal nystagmus and demonstrates decreased hearing in the left ear. The head impulse test is positive for a corrective saccade when the head is turned to the left. He has no focal neurologic deficits and his gait is unsteady.
What is the most likely diagnosis?
Labyrinthitis
The patient's presentation of vertigo combined with sensorineural hearing loss following a viral infection is pathognomonic for labyrinthitis, distinguishing it from vestibular neuritis.
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Etiology / Epidemiology
Commonly follows viral URI; affects ages 30-60. Involves inflammation of the vestibular labyrinth.
Clinical Manifestations
Triad of continuous vertigo, sensorineural hearing loss, and tinnitus. Horizontal nystagmus is classic.
Diagnosis
Primarily clinical diagnosis. Audiometry is the gold standard to confirm sensorineural hearing loss.
Treatment
First-line: Meclizine for vertigo; corticosteroids for inflammation. Avoid long-term vestibular suppressants.
Prognosis
Symptoms typically resolve in weeks. Persistent deficits require vestibular rehabilitation.
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Epidemiology & Etiology
Most cases are post-viral, occurring after a URI or otitis media. It represents inflammation of the inner ear structures. It is more common in adults than children, typically presenting as a sudden, isolated episode.
Pertinent Anatomy
The condition involves the vestibular labyrinth and the cochlea. Inflammation disrupts the endolymphatic system, leading to both vestibular and auditory dysfunction.
Pathophysiology
Viral or bacterial toxins induce inflammation of the vestibular nerve (CN VIII). This creates an imbalance in neural input to the brainstem, mimicking unilateral vestibular hypofunction. The resulting sensory mismatch causes the classic vertigo and nystagmus.
Clinical Manifestations
Patients present with sudden onset of continuous vertigo lasting days. Sensorineural hearing loss and tinnitus distinguish this from vestibular neuritis. Look for horizontal nystagmus beating away from the affected side. Red flags include focal neurologic deficits, which suggest a central etiology like Wallenberg syndrome.
Diagnosis
Diagnosis is clinical. Audiometry is the gold standard to document the degree of sensorineural hearing loss. MRI is indicated if symptoms persist beyond weeks or if central pathology is suspected to rule out acoustic neuroma.
Treatment
Acute management includes Meclizine or benzodiazepines for vertigo control. Corticosteroids are used to reduce inflammation and improve hearing recovery. Do not use vestibular suppressants for >3 days as they delay central compensation. Antibiotics are reserved for cases with concurrent bacterial otitis media.
Prognosis
Most patients recover within weeks. If symptoms persist, vestibular rehabilitation is the gold standard for long-term compensation. Failure to improve warrants investigation for cholesteatoma or other structural pathology.
Differential Diagnosis
Vestibular Neuritis: No hearing loss or tinnitus
Meniere's Disease: Episodic, not continuous, vertigo
BPPV: Brief, positional vertigo lasting seconds
Acoustic Neuroma: Progressive, not acute, hearing loss
Stroke: Presence of focal neurologic deficits