Labyrinthitis and vestibular neuritis
These are two closely related conditions of the inner ear in which a person suddenly loses all sense of steadiness: the room starts to spin, nausea sets in…
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Medicines commonly prescribed for Labyrinthitis and vestibular neuritis
For informational purposes only. Always consult a doctor before using any medicine.
Dosage form: ORAL SOLUTION/SUSPENSION, 4 mg/mlActive substance: prednisoloneManufacturer: Laboratorio Aldo Union S.L.Prescription requiredDosage form: TABLET, 8 mgActive substance: betahistineManufacturer: Laboratorios Cinfa S.A.Prescription requiredDosage form: TABLET, 24 mgActive substance: betahistineManufacturer: Tarbis Farma S.L.Prescription required
These are two closely related conditions of the inner ear in which a person suddenly loses all sense of steadiness: the room starts to spin, nausea sets in, and standing or walking becomes impossible. The attack lasts not seconds or minutes but hours and days on end, which is what sets it apart from most other kinds of dizziness. Both nearly always settle on their own, but the first few days are hard going. The main task during that time is not to miss the uncommon cases in which the same picture is coming from the brain rather than the ear.
What the first days are like
The onset is abrupt. The vertigo may strike in the morning as the head lifts off the pillow, or build up over a few hours, often one to two weeks after a cold. The sensation is very distinctive: it is the room that spins rather than the head, and any head movement makes it worse.
Alongside the spinning there is usually:
- heavy nausea and vomiting, sometimes repeatedly;
- unsteadiness — the person veers to one side and can only walk along the walls;
- a feeling that the eyes will not hold still on an object and everything jerks;
- in labyrinthitis, hearing loss in one ear with ringing or buzzing in it.
The worst of it is the first one to three days. The acute spinning then dies down, but a wobbliness remains that grows worse in crowds, in a supermarket aisle, or when the head turns quickly. That part clears over two to six weeks, sometimes longer: the brain is relearning how to lean on signals from the intact side and to damp down the mismatch between the two ears. That relearning is what recovery consists of, rather than repair of the inflamed nerve — which is why lying still until every symptom has gone is not merely unnecessary but harmful.
How the two differ
The difference lies in which part of the inner ear is affected. The labyrinth is the system of fluid-filled semicircular canals together with the cochlea, and it serves both balance and hearing. The vestibular nerve carries only head-position signals to the brain; sound does not travel along it.
Hence a simple rule: if hearing is unchanged, this is vestibular neuritis; if deafness and noise in the ear are added to the vertigo, it is labyrinthitis. The distinction is not cosmetic. With any loss of hearing the doctor has to check that this is not one of the situations needing urgent treatment, described below.
When the trouble is not in the ear
Sudden severe vertigo can be the only sign of a stroke in the cerebellum or brainstem. There is no way of telling it apart from inner-ear inflammation by how it feels: a doctor does that on examination, largely from the eye movements. In the first twenty-four hours it is therefore better to err on the side of caution.
Call an ambulance (in Spain, Italy, Portugal, Poland and Ukraine on the single European number 112) if any of the following comes with the vertigo:
- double vision or loss of part of the visual field;
- slurred speech, difficulty swallowing, choking on food or drink;
- weakness or numbness of an arm, a leg or one side of the face;
- severe headache unlike any before, or pain in the neck and back of the head, particularly after an injury or a sharp twist of the neck;
- being unable to stand or sit without support: not swaying, but falling;
- confusion or loss of consciousness.
Stroke risk is higher in anyone with high blood pressure, diabetes or atrial fibrillation, in smokers and in people past sixty. But it happens in younger people too, and there the cause is more often a tear in the wall of a vertebral artery — the one that comes with neck pain.
Two further situations call for a doctor the same day rather than tomorrow. The first is a sudden drop in hearing in one ear. Sudden sensorineural hearing loss is treated with steroids, and the outcome depends on starting within the first few days; after two or three weeks there is little left to be done. The second is vertigo preceded by earache, discharge from the ear or a long-standing chronic ear infection. Bacterial labyrinthitis is then possible, and it can go on to meningitis and brain abscess. A high temperature, a worsening headache, dislike of bright light and a stiff neck need help immediately.
Why the inner ear becomes inflamed
The usual cause is viral. Some cases follow ordinary respiratory viruses, others come from the waking of a herpes-family virus that had sat quietly in a nerve ganglion for years. Labyrinthitis itself does not pass from person to person; what is passed on is the cold, and whether it turns into inner-ear inflammation has nothing to do with whoever passed it on.
Less often the inflammation arrives from the middle ear — with acute suppurative otitis media, a chronic ear infection, cholesteatoma or mastoiditis. This is the bacterial form, the dangerous one, and it needs treatment in its own right. In children the inner ear is sometimes damaged by meningitis, and hearing suffers as a result. Much rarer causes are autoimmune disease and injury.
It is worth naming plainly what is not on that list: draughts, washing your hair and cleaning your ears with cotton buds do not cause labyrinthitis. Tiredness, poor sleep and stress are not causes either, although they noticeably worsen vertigo that has already begun and slow recovery down.
What the doctor does
The diagnosis is made from the history and the examination, without tests. What matters to the doctor is how long a single episode of vertigo lasts, whether it began suddenly, whether hearing has changed and what happened in the preceding days. The doctor then watches the eye movements, checks coordination and walking, and uses particular manoeuvres to separate an ear cause from a brain one. If hearing has changed, a hearing test is arranged; if stroke is suspected, an MRI scan — an ordinary CT sees the cerebellum and brainstem poorly and reads as normal in the first hours even when there is an infarct.
At the same time the conditions most often mistaken for neuritis are ruled out: benign positional vertigo (short bursts of a few seconds on turning over in bed), Ménière's disease (repeated episodes with a blocked feeling in the ear and fluctuating hearing) and vestibular migraine.
Medicines are there only to get through the first days. The doctor may prescribe something to suppress nausea and vertigo — an antihistamine or an anti-sickness drug — but as a short course of around three days. They are deliberately not continued beyond that: they blunt the very signals the brain is recalibrating from, and stretch recovery out over months. Antibiotics are useless in viral inflammation and are given only for the bacterial kind. Steroids are not always used in the first days: in neuritis their benefit is debated, whereas in sudden deafness they are the main treatment.
Getting through the first days at home
- During the worst hours, lie still in a darkened, quiet room; many people find propped up easier than flat.
- Take small sips often. If vomiting is repeated and even water will not stay down, see a doctor — dehydration sets in quickly here.
- As soon as the vomiting stops, start getting up and walking, even if it means holding someone's arm. Add a little each day. Staying in bed longer than necessary is the commonest reason the illness drags on.
- Outdoors, hold your gaze on a fixed point ahead rather than looking about you.
- Get enough sleep: lack of it makes vertigo worse than you would expect.
- Do not drive, cycle or work at height or with machinery — and not until you feel a bit better, but until your balance is reliably steady.
- Leave alcohol alone for the time being.
- Older people and those living alone should clear rugs and cables off the floor, leave a night light on and keep a phone within reach: falls are a real risk in this period.
When balance does not come back
If confidence on your feet has not returned after a few weeks, vestibular rehabilitation helps: exercises for the eyes, head and gait set out by a physiotherapist or an audiologist. They are counter-intuitive in design, because the movements deliberately provoke mild dizziness and that is exactly what the habituation is built on. They need doing regularly, and it is best not to start without a professional, so as not to train a faulty compensation.
Avoidance is a trap of its own. The person stops turning their head, walks slowly and holds on to walls, and the brain is left with nothing to recalibrate from. This is how persistent postural-perceptual dizziness sets in: a swaying sensation that does not let up for months, worse in supermarkets, on escalators and in front of a screen, and almost always accompanied by anxiety. It is neither imagined nor "just nerves" but a recognised diagnosis with its own treatment — rehabilitation, and sometimes medication as well.
Repeated attacks mean the diagnosis needs revisiting: neuritis by definition happens once. Fairly often benign positional vertigo develops afterwards, with brief attacks on rolling over in bed that a particular manoeuvre by the doctor settles in a single visit. Hearing loss from labyrinthitis is sometimes permanent; a hearing aid is then discussed, and with complete deafness in one ear, other ways of helping.
Online consultation
At an online appointment the doctor goes first for what settles the question: how long an episode lasts, what came before it, whether hearing has changed and whether there are signs that call for an ambulance. From that description alone it is often clear whether this is vestibular neuritis, positional vertigo, or a situation needing an urgent face-to-face examination. You will be told which medicines can be used for the sickness and for how many days, and why they must not be continued longer; how to start moving again and how fast to build activity up; and when you can go back to driving and to work. If recovery is dragging, the doctor will point you to the right professional for vestibular rehabilitation and to the investigations worth having beforehand.
This material is for information only and does not replace medical advice.
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