Approach
Treatment is in response to symptoms and primarily involves the use of vestibular suppressants, such as antihistamines with anticholinergic properties (e.g., promethazine, dimenhydrinate) and anti-emetics (e.g., prochlorperazine, metoclopramide, ondansetron). Tinnitus can be managed with masking, tinnitus retraining, amplification with hearing aids, anxiolytics and/or antidepressants in the setting of active anxiety and depression, respectively.[32] Long-term therapy typically involves the use of vestibular rehabilitation and stopping vestibular suppressants. Most acute episodes of labyrinthitis are short-lived and self-limited, and patients can be treated on an outpatient basis. Advise patients to seek further medical care if the symptoms do not improve or if they develop neurological symptoms (e.g., diplopia, slurred speech, gait disturbances, or localised weakness or numbness).
Viral labyrinthitis
Viral infections are the most common cause of labyrinthitis and the main aim of management is the symptomatic control of vertigo, nausea, and vomiting.
Acute vertigo episodes can be treated with vestibular suppressants and anti-emetics. Much of the effect is from the sedating action of these drugs, therefore warn patients about driving and operating equipment while being treated. Only one agent should be used at a time.
Suppressants include antihistamines with anticholinergic properties (e.g., promethazine, cyclizine, dimenhydrinate) and anti-emetics (e.g., prochlorperazine, metoclopramide, ondansetron).[33] Metoclopramide should be used for up to 5 days only to minimise the risk of neurological and other adverse effects. It is not recommended for this indication in children.[34]
Benzodiazepines have been used historically, but dependency and delayed vestibular compensation are significant concerns with these agents. Meclozine, an antihistamine with anticholinergic properties, has also been used historically, but is less effective than benzodiazepines.
Acute vertigo symptoms typically resolve over 72 hours.
Consider fluid and electrolyte imbalances, particularly if the patient has had prolonged nausea and vomiting. Obtaining a basic metabolic panel before and after treatment, and initiating intravenous hydration, may be necessary in these patients.
Sudden hearing loss
For patients with sudden sensorineural hearing loss, a short course of oral corticosteroids is considered the standard of care.[35]
HIV-associated labyrinthitis
A variety of auditory and vestibular complaints including labyrinthitis have been reported in patients with AIDS. The relative importance of the HIV infection itself as opposed to its associated opportunistic infections requires further study.
Bacterial labyrinthitis
This may follow otitis media (middle ear infection) or bacterial meningitis. In addition to treatments for vertigo and possible nausea and vomiting, these patients require antibiotics.
Acute and chronic otitis media
If the history and examination are consistent with otitis media, such as otalgia (ear pain) and an abnormal ear examination suggesting fluid, redness, or pus behind the ear drum, without systemic signs of infection (i.e., fever, chills), then topical antibiotics should be prescribed. Ear drops deliver antibiotic concentrations several orders of magnitude above minimum inhibitory concentrations that are obtained with culture and sensitivity testing.[36] For those with tympanic membrane perforation and purulent otorrhoea, the ear should be cleaned before topical therapy. Oral antibiotics are not typically indicated unless the patient has systemic signs of infection (i.e., fever, chills). Following a series of acute otitis media infections, the patient may require myringotomy (surgical incision of the ear drum) with pressure equalisation tube placement.
Bacterial meningitis
If intracranial infection (e.g., meningitis) is suspected, prompt treatment with intravenous antibiotics is indicated with topical antibiotic therapy if otorrhoea is present.
The use of oral corticosteroids can reduce the severity and incidence of hearing loss in patients with pneumococcal meningitis.[37] Corticosteroids decreased the rate of hearing loss in children with meningitis due to Haemophilus influenzae (4% vs. 12%), but not in children with meningitis due to other bacteria. However, Cochrane recommends the use of corticosteroids (e.g., dexamethasone) before, or with, the first dose of antibiotics in adults and children with acute bacterial meningitis in high‐income countries.[37] Practice guidelines for the management of bacterial meningitis indicate that the use of adjunctive dexamethasone in infants and children with bacterial meningitis demonstrated clinical benefit for hearing outcomes. For example, in patients with meningitis caused by H influenzae type b, dexamethasone reduced hearing impairment overall, whereas in patients with pneumococcal meningitis, dexamethasone only suggested protection for severe hearing loss if given early.[38]
Autoimmune-associated labyrinthitis
Patients with autoimmune-associated labyrinthitis (e.g., Cogan's syndrome or Behcet's disease) may respond to oral corticosteroids. In cases of corticosteroid non-responsiveness, the use of alternative immunomodulators (e.g., azathioprine) may stabilise or improve hearing and balance while avoiding the adverse effects of taking long-term corticosteroids.[39]
Syphilitic labyrinthitis
Patients with positive syphilis serology should be treated with an appropriate course of antibiotics and may warrant a thorough evaluation by an infectious disease specialist.[6]
Persistent vestibular symptoms
Patients with persistent vestibular symptoms after treatment may require vestibular rehabilitation.[40][41] This uses physiotherapy and occupational therapy techniques to treat vertigo and balance disorders.
One Cochrane review found moderate-to-strong evidence that vestibular rehabilitation (i.e., physical [repositioning] manoeuvres, exercise-based movements) is safe and effective in unilateral peripheral vestibular dysfunction. This was based on a number of high‐quality randomised controlled trials, although a quarter of the studies may have had some risk of bias due to non-blinding of outcome assessors and selective reporting.[41]
In addition, a non-blinded, randomised controlled trial found that a vestibular rehabilitation programme started early (after a confirmed vestibular neuritis diagnosis) when combined with standard care (including a corticosteroid, general information, and counselling) reduced the perception of dizziness and improved functions of daily life more effectively than standard care alone.[42]
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