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This is a clinician-written, evidence-based summary aligned to the 2026 MLA Content Map. It is intended for medical students and junior doctors preparing for the UKMLA. Always cross-reference with NICE guidance, local protocols, and clinical judgement.
Key points
- Vestibular neuritis: acute vestibular nerve inflammation — vertigo WITHOUT hearing loss
- Labyrinthitis: labyrinth inflammation — vertigo WITH hearing loss
- Usually viral post-URTI, severe constant vertigo 2–3 days then gradual improvement
- HINTS exam: positive HIT + unidirectional nystagmus + no skew = peripheral (reassuring)
- HINTS: negative HIT + direction-changing nystagmus + positive skew = central (stroke) — more sensitive than early MRI
- Short-term vestibular suppressants then EARLY rehabilitation exercises
Overview
Vestibular neuritis is acute inflammation of the vestibular nerve (likely viral/HSV-1 reactivation), causing sudden severe rotational vertigo lasting days, WITHOUT hearing loss. Labyrinthitis involves both vestibular and cochlear components — vertigo AND hearing loss. Both are self-limiting but recovery depends on central compensation facilitated by early mobilisation.
Epidemiology
Third most common peripheral vertigo cause. Incidence ~3.5 per 100,000/year. Peak 30–60 years. Often follows URTI. Critical to distinguish from posterior circulation stroke.
Clinical Features
Symptoms
Acute severe constant rotational vertigo — days (2–3 days intense, then weeks improving)
Severe nausea and vomiting
Falls towards affected side
Hearing loss/tinnitus: present in labyrinthitis, ABSENT in vestibular neuritis
Vertigo with headache, diplopia, dysarthria, limb weakness → suspect stroke
Signs
Spontaneous unidirectional horizontal nystagmus — fast phase AWAY from affected ear
Positive HIT: corrective saccade towards affected side = peripheral
Negative test of skew = peripheral
NEGATIVE HIT (no saccade) = concerning for central cause
Direction-changing or vertical nystagmus = central
Investigations
First-line
HINTS examHead Impulse, Nystagmus, Test of Skew — more sensitive than early MRI for posterior circulation stroke
Second-line
AudiometryNormal in neuritis, SNHL in labyrinthitis
Specialist
MRI brain (DWI)If central cause suspected — may be falsely negative in first 48 h
Caloric testingCanal paresis on affected side
Management
NICE CKS1
Acute (48–72 h)
- Prochlorperazine 5–10 mg TDS — max 3 days
- Anti-emetics for vomiting
- IV fluids if unable to drink
2
Recovery — EARLY vestibular rehab
- STOP suppressants after 72 h — they delay compensation
- Start Cawthorne-Cooksey exercises ASAP
- Encourage early mobilisation
- Physio referral for vestibular rehab
3
Bacterial labyrinthitis
- Secondary to AOM/meningitis → IV ceftriaxone + ENT input
- Higher risk of permanent hearing loss
4
Follow-up
- Review 1 week and 6 weeks
- Not improving by 6 weeks → audiovestibular/neurology referral
- DVLA: do not drive during acute vertigo
Complications
- BPPV: Develops in 10–15% after vestibular neuritis
- Chronic vestibular hypofunction
- Permanent SNHL: In labyrinthitis (especially bacterial)
- Missed stroke: Most dangerous — HINTS exam is critical
UKMLA Exam Tips
- 1Vertigo SECONDS = BPPV. HOURS = Ménière's. DAYS = vestibular neuritis/labyrinthitis or stroke
- 2Vestibular neuritis = NO hearing loss. Labyrinthitis = hearing loss
- 3HINTS more sensitive than early MRI. Peripheral: +HIT, unidirectional nystagmus, no skew. Central: -HIT, direction-changing, +skew
- 4Stop prochlorperazine after 72 h — delays compensation
- 5Vestibular rehab exercises ARE the treatment
- 6AICA stroke can mimic labyrinthitis (vertigo + hearing loss)
practicetest your knowledge on Vestibular Neuritis and LabyrinthitisApply what you've learnt with UKMLA-style questions from the iatroX Q-Bank — ENT and beyond.
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