Vestibular Neuritis...or a Stroke?

Vestibular neuritis (VN) is thought to be the second most common cause of dizziness affecting the peripheral vestibular system, after BPPV. "Peripheral" meaning the vestibular organ and corresponding cranial nerve eight, as opposed to "central", meaning the vestibular pathways in the brain. It tends to occur in patients 30-60 years of age, but can occur in both younger and older patients.

Breaking it down - defining vestibular neuritis

Everybody loves a good ol' vocabulary lesson, right? Okay, so bear with me anyway. What is vestibular neuritis. Well, you might have a good understanding of 'vestibular' since you've probably read every article on this site, right? But in case you are one of the few who have not...ehem, most people...let's fill you in. Our vestibular system is like a tiny gyroscope (about the size of a dime) located in the innermost part of both of our ears. It sends signals to our brain to communicate which way is up and in which direction we are moving. Got it? Good.

"Neuritis" can be broken down into "neur-" meaning neuron, and "-itis" meaning inflammation. So, vestibular neuritis basically means inflammation of the vestibular nerve. This is why it is considered a peripheral condition as it does not involve damage to central vestibular pathways in the brain. Below is an image of our vestibular system and the vestibular nerve.

Image: Kim JS. When the Room Is Spinning: Experience of Vestibular Neuritis by a Neurotologist. 2020.

What does it feel like?

So, does inflammation of my vestibular nerve feel like inflammation of any other nerve in my body...like sciatica or shingles? Not quite. People with vestibular neuritis will generally experience a sudden onset of severe vertigo (spinning sensation), lasting for at least 24 hours and possibly days. Some patients may experience nausea and vomiting, and be so imbalanced they can't even stand or walk. Pretty horrifying, right? In fact, this is similar to what certain types of strokes can feel like. This is why many will go to the emergency room (ER), and that is not a bad idea. Doctors and physical therapists working in the ER can discern whether the symptoms you are experiencing are caused by vestibular neuritis or caused by a stroke in the brainstem or cerebellum (posterior fossa). Remember, being dizzy is never normal. Here are some similarities and differences between symptoms experienced with vestibular neuritis versus a stroke in the posterior fossa.

Symptom	Vestibular Neuritis	Posterior Fossa Stroke
Dizziness/Vertigo	Severe, sudden onset	Sudden, often less severe
Nausea/Vomiting	Common	Possible
Balance Issues	Significant	Possible, but may vary
Ringing in your ears	Common	Rare
Hearing Loss	Absent	Possibly on one side
Headache	Rare	Common
Facial Weakness	Absent	Possible
Discoordination	Absent	Possible
Visual Disturbances	Absent	Possible

Common Causes of Vestibular Neuritis

Viral Infections

One of the most common culprits behind vestibular neuritis is a viral infection. Often, it follows a bout of something like the flu or a cold. The virus can end up affecting the vestibular nerve, which can lead to vestibular neuritis. The most common virus causing vestibular neuritis is the herpes simplex 1 virus, the virus that causes cold sores.

Other Infections

Sometimes, other infections can also play a role. For instance, a respiratory infection or even a gastrointestinal bug might lead to vestibular neuritis.

Autoimmune Responses

In some cases, your immune system might mistakenly attack your vestibular nerve. This autoimmune response can result in inflammation, leading to the symptoms of vestibular neuritis.

Stress and Fatigue

While not direct causes, stress and fatigue can exacerbate symptoms or make you more susceptible to getting sick. When your body is run down, it might not fight off infections as well, potentially leading to vestibular issues down the line.

Treatment for Vestibular Neuritis

After the initial onset of severe dizziness, nausea, and imbalance, symptoms will wane over the next few days. Some patients gradually return to baseline without any intervention within a couple of weeks. In the acute phase, some patients may be provided steroids to help reduce inflammation and accelerate recovery. Even so, some patients will continue to report imbalance and/or dizziness with movement or quick head turns. This is where vestibular rehabilitation therapy (VRT) can help! In fact, we have a robust amount of evidence to support the efficacy of VRT in the treatment of vestibular neuritis. VRT post vestibular neuritis typically includes:

1. Balance training to reduce fall risk and improve your balance in situations that are challenging for patients after vestibular neuritis (i.e. dark environments or uneven and sloped surfaces).

2. Gaze stability exercises to help keep your visual world stable and focused when you move or turn your head.

3. Habituation to gradually expose your system to movements, positions, or environments that provoke symptoms and allow your brain adapt to reduce sensitivity.

4. Sensory integration exercises to help your brain process sensory input from your visual, vestibular, and somatosensory systems for better balance and spatial orientation.

5. Aerobic conditioning to help the vestibular adapt to more dynamic movement and support overall health.

6. Canalith repositioning maneuvers to resolve associated Benign Paroxysmal Positional Vertigo (BPPV) that can commonly occur with vestibular neuritis.

7. Education and self-management to help manage symptoms with day to day life and know what to expect of the recovery process.

Vestibular neuritis can be quite disruptive, affecting your balance, spatial orientation, and causing dizziness with daily movement. While it seems very scary and is definitely unpleasant, it is a very treatable condition. It's also worth noting that vestibular neuritis can mimic other more serious conditions, so it's crucial not to ignore these symptoms. Seeking medical advice can lead to an accurate diagnosis and effective, timely treatment. When managed properly, many individuals are able to fully recover and return to their daily activities without ongoing dizziness or imbalance.

References

1. Hall CD, Herdman SJ, Whitney SL, et al. Vestibular rehabilitation for peripheral vestibular hypofunction: an evidence-based clinical practice guideline: from the American Physical Therapy Association Neurology Section. J Neurol Phys Ther. 2016;40(2):124-155.