PANCE Blueprint EENT (7%)

Labyrinthitis (Lecture)

Patient will present as → a 23-year-old female PA student with unilateral hearing loss and tinnitus that began yesterday. She describes a sensation of the room "spinning" around her. She feels extremely nauseous and has vomited already one time this morning. On physical exam, horizontal nystagmus is observed. You excuse her from her histology exam later that afternoon.

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Labyrinthitis presents with acute onset, continuous vertigo, hearing loss, and tinnitus of several days to a week.

  • Often preceded by a viral respiratory illness
  • There is an absence of neurologic deficits
  • Vertigo associated with labyrinthitis progressively improves over a few weeks, but the hearing loss may or may not resolve
"Sometimes vestibular neuritis is used synonymously with viral labyrinthitis. However, vestibular neuronitis only presents with vertigo, while viral labyrinthitis is also accompanied by tinnitus, unilateral hearing loss, or both.

Labyrinthitis is associated with CONTINUOUS vertigo along with unilateral hearing loss +/- tinnitus and is usually associated with an upper respiratory infection. This differentiates it from Meniere’s syndrome, which is EPISODIC and not typically associated with a viral infection."

Labyrinthitis involves the inflammation of both branches of the vestibulocochlear nerve (the vestibular portion and the cochlear portion) that affects balance and hearing. It is related to viral URIs and presents with acute onset, continuous vertigo, unilateral hearing loss, and tinnitus of several days to a week. The symptoms of labyrinthitis are the same as vestibular neuritis plus the additional symptoms of tinnitus and/or hearing loss.

Vestibular neuritis is an inflammation of the vestibular nerve. Vestibular neuritis presents with continuous vertigo, nausea and vomiting, but NOT hearing loss or tinnitus. It is related to viral URIs and develops over several hours, with symptoms worse on the first day, with gradual recovery over several days. The symptoms of vestibular neuritis are the same as labyrinthitis minus tinnitus and/or hearing loss.

  • “Auditory function is preserved; when the symptoms and signs of vestibular neuritis are combined with unilateral hearing loss, the condition is called labyrinthitis.” – (UpToDate)

Ménière syndrome is a disorder of the endolymphatic compartment with the classic triad of episodic vertigo, unilateral low-frequency sensorineural hearing loss, and tinnitus. Labyrinthitis is similar to Meniere’s disease except that labyrinthitis causes continuous symptoms (vs. the episodic symptoms of Meniere’s disease).

Benign paroxysmal positional vertigo (BPPV) is generally thought to be due to debris that has collected within a part of the inner ear. BPPV occurs with changes in position, especially rapid movements of the head. Nausea may occur, but vomiting is not significant. It causes episodic vertigo without hearing loss.

Acoustic neuroma is a benign tumor of the Schwann cells (the cells which produce myelin sheath). Patient will present with an insidious unilateral hearing loss, tinnitus, headache, facial numbness, continuous disequilibrium (unsteadiness), +/- vertigo.

Labyrinthitis is a clinical diagnosis in the absence of neurologic deficits

  • May have a positive Romberg test - fall to the side of the affected ear
  • Rule out other etiologies with imaging, audiograms, TSH levels
    • MRI is required for patients with acute sustained vertigo whose examination is not entirely consistent with labyrinthitis, or in patients who are older (>60 years), or have a headache, any focal neurologic signs, or vascular risk factors

Vestibular suppressants (meclizine) and antiemetics (ondansetron) to limit symptoms in the first 24 to 48 hours

  • A 10-day course of prednisone; 60 mg daily on days 1 through 5, 40 mg on day 6, 30 mg on day 7, 20 mg on day 8, 10 mg on day 9, and 5 mg on day 10
  • Antibiotics are indicated with associated fever or signs of bacterial infection

Question 1
A 26-year-old woman comes to your office with a 6-day history of severe dizziness associated with ataxia and right-sided hearing loss. She had an upper respiratory tract infection 1 week ago. At that time, her right ear felt plugged. On examination, there is fluid behind the right eardrum. There is horizontal nystagmus present, with the slow component to the right and the quick component to the left. Ataxia is present. What is the most likely diagnosis in this patient?
A
vestibular neuronitis
Hint:
See B for explanation
B
acute labyrinthitis
C
positional vertigo
Hint:
See B for explanation
D
orthostatic hypotension
Hint:
See B for explanation
E
Meniere disease
Hint:
See B for explanation
Question 1 Explanation: 
This patient has acute labyrinthitis. Acute labyrinthitis usually follows otitis media or an upper respiratory tract infection. The disorder probably represents a chemical irritation of the canals of the inner ear. The features of acute labyrinthitis are similar to those of vestibular neuronitis, except it includes significant sensorineural hearing loss (with a conductive component if a middle ear effusion is present) and severe vertigo that lasts several days. Fever may accompany the illness.
Question 2
What is the treatment of choice for this patient?
A
avoidance of caffeine and alcohol
Hint:
See D for explanation
B
a thiazide diuretic
Hint:
See D for explanation
C
endolymphatic surgery
Hint:
See D for explanation
D
rest and antiemetics
E
none of the above
Hint:
See D for explanation
Question 2 Explanation: 
The treatment of choice for acute labyrinthitis includes rest, antiemetics, and, if the etiology is bacterial, antibiotics. Bacterial labyrinthitis may complicate serous labyrinthitis if antibiotics are not administered. Amoxicillin would be a good first-line agent for antibiotic prophylaxis. If symptoms do not improve, the addition of clavulanic acid to amoxicillin would be a reasonable second choice. If a patient appears very ill from presumed acute bacterial labyrinthitis, hospitalization and intravenous antibiotics are required. On occasion, surgical drainage may be necessary.
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References: Merck Manual · UpToDate

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