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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
  • Affects the entire labyrinth, which includes the vestibulocochlear nerve - both branches - vestibular (balance) + cochlear (hearing)
  • 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 that produce myelin sheath). A patient will present with an insidious unilateral hearing loss, tinnitus, headache, facial numbness, continuous disequilibrium (unsteadiness), +/- vertigo.

Condition Characteristics Cause Treatment
Labyrinthitis Hearing loss, continuous vertigo, associated with upper respiratory infection (URI) Often viral infection, sometimes bacterial

(affects entire labyrinth and vestibulocochlear nerve)

Supportive care, antiemetics for nausea, vestibular suppressants, corticosteroids for severe cases, antibiotics if bacterial
Vestibular Neuritis No hearing loss or tinnitus, vertigo, associated with URI Viral infection affecting the vestibular nerve

(affects vestibular nerve)

Supportive care, antiemetics, vestibular rehabilitation, corticosteroids
Meniere's Disease Hearing loss, episodic vertigo, not associated with URI Unknown, but involves fluid buildup in the inner ear Low-salt diet, diuretics, betahistine, invasive therapies for severe cases (e.g., intratympanic steroid injections, endolymphatic sac surgery)
Benign Paroxysmal Positional Vertigo (BPPV) No hearing loss or tinnitus, episodic vertigo with position changes Otoconia (calcium carbonate crystals) dislodged from otolith organs, moving into semicircular canals Epley maneuver or other canalith repositioning procedures, vestibular rehabilitation
Acoustic Neuroma Unilateral hearing loss, insidious onset vertigo and ataxia, +/- facial numbness Benign tumor on the vestibulocochlear nerve (CN VIII) Observation for small, asymptomatic tumors, stereotactic radiosurgery, surgical removal for larger or symptomatic tumors

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 female patient consults you with a six-day history of intense dizziness, difficulty coordinating movements, and loss of hearing on the right side. She reports having a cold one week prior, during which she noticed her right ear feeling blocked. Upon examination, you observe fluid accumulation behind the right eardrum and detect horizontal nystagmus, characterized by a slow phase towards the right and a fast phase towards the left. Ataxia is also evident. Based on these findings, what is the most probable diagnosis?
A
Vestibular neuronitis
Hint:
This condition typically presents with severe vertigo but without auditory symptoms such as hearing loss, making it less likely in this case.
B
Acute labyrinthitis
C
Benign paroxysmal positional vertigo (BPPV)
Hint:
BPPV causes brief episodes of vertigo related to changes in head position and does not involve hearing loss or middle ear fluid.
D
Orthostatic hypotension
Hint:
This refers to a significant drop in blood pressure upon standing, leading to dizziness or lightheadedness, but it would not explain the hearing loss or the presence of middle ear fluid.
E
Ménière's disease
Hint:
Characterized by episodic vertigo, fluctuating hearing loss, tinnitus, and a feeling of fullness in the ear, Ménière's disease is a chronic condition. The acute onset following an upper respiratory infection and the presence of fluid behind the eardrum are more indicative of labyrinthitis.
Question 1 Explanation: 
Acute labyrinthitis is the most likely diagnosis given the patient's symptoms of severe dizziness, ataxia, and unilateral hearing loss following an upper respiratory tract infection. Labyrinthitis often results from an infection that spreads to the inner ear, affecting both the cochlea (leading to hearing loss) and the vestibular system (causing dizziness and ataxia). The presence of fluid behind the eardrum suggests a recent or ongoing middle ear infection that could have extended into the inner ear structures, consistent with labyrinthitis.
Question 2
A 35-year-old woman presents to the emergency department with a two-day history of severe vertigo, nausea, vomiting, and right-sided hearing loss. She reports a recent viral upper respiratory infection. Examination reveals horizontal nystagmus and positive Romberg sign. Which of the following is the most appropriate initial management for this patient?
A
Meclizine, prochlorperazine, and oral hydration
B
Intravenous ceftriaxone
Hint:
Antibiotics are only indicated if there's suspicion of a bacterial cause, which is less common than viral labyrinthitis.
C
Tympanostomy tube placement
Hint:
This procedure is indicated for recurrent or chronic middle ear effusions, not acute labyrinthitis.
D
Oral prednisone
Hint:
Treatment with glucocorticoids during the acute period of vertigo was shown in at least one clinical trial to improve the recovery of peripheral vestibular function in patients with acute labyrinthitis. However, subsequent studies, albeit with many limitations, have not found a clear benefit of glucocorticoid therapy.
E
Epley maneuver
Hint:
This maneuver is used to treat Benign Paroxysmal Positional Vertigo (BPPV), a different condition involving displacement of otoconia.
Question 2 Explanation: 
Acute labyrinthitis is a self-limiting inflammation of the inner ear, often following a viral infection. Initial management focuses on symptomatic relief. Meclizine (an antihistamine) helps reduce vertigo, prochlorperazine (an antiemetic) controls nausea and vomiting, and oral hydration is important due to fluid loss from vomiting.
Question 3
Which of the following would you NOT expect to find in a patient presenting with acute labyrinthitis?
A
Continuous vertigo
Hint:
Continuous vertigo is a hallmark symptom of labyrinthitis, resulting from the disturbance in the inner ear's balance mechanisms. Patients often describe a sensation of spinning or motion, which is consistent with labyrinthitis.
B
Sensorineural hearing loss
Hint:
Sensorineural hearing loss can occur in labyrinthitis due to inflammation affecting the cochlea. This type of hearing loss is a common finding in patients presenting with labyrinthitis.
C
Tinnitus
Hint:
Tinnitus, or ringing in the ears, is another symptom that can accompany labyrinthitis. It results from the cochlear involvement and is consistent with the disease's presentation.
D
Episodic vertigo with position changes
E
Nystagmus
Hint:
Nystagmus, involuntary eye movements, can be observed in patients with labyrinthitis as a result of the imbalance created by the inner ear's inflammation. It is a physical finding that supports the diagnosis of labyrinthitis.
Question 3 Explanation: 
Acute labyrinthitis, an inflammation of the inner ear, typically presents with continuous vertigo, sensorineural hearing loss, tinnitus, and sometimes nystagmus due to irritation of the vestibulocochlear nerve. Episodic vertigo with position changes in consistent with benign positional vertigo (BPV).
Question 4
Which of the following physical exam findings would allow you to differentiate Labyrinthitis from Meniere's syndrome?
A
Continuous vertigo lasting several days
B
Fluctuating hearing loss
Hint:
Both Labyrinthitis and Meniere's syndrome can present with hearing loss. However, fluctuating hearing loss is more characteristic of Meniere's syndrome
C
Positive Romberg test
Hint:
Fluctuating sensorineural hearing loss is characteristic of Meniere's syndrome. The buildup of endolymphatic fluid within the inner ear causes intermittent episodes of hearing changes. Although hearing loss can occasionally occur in labyrinthitis, it is not typically a fluctuating pattern.
D
Absence of nystagmus
Hint:
Nystagmus, involuntary eye movements, can occur in both Labyrinthitis and Meniere's syndrome due to the vestibular disturbance. Its absence does not reliably differentiate between the two conditions.
E
Presence of tinnitus
Hint:
Tinnitus (ringing or buzzing in the ears) is very common in both labyrinthitis and Meniere's syndrome. Its presence doesn't help differentiate the two.
Question 4 Explanation: 
Labyrinthitis is characterized by an acute onset of continuous vertigo that can last several days, often accompanied by hearing loss and tinnitus, due to inflammation of the inner ear. This continuous, prolonged vertigo helps differentiate it from Meniere's syndrome, where vertigo episodes are typically episodic, lasting from 20 minutes to several hours, but not continuously over days.
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References: Merck Manual · UpToDate

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