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This is a clinician-written, evidence-based summary aligned to the USMLE Step 2 CK Content Outline. It is intended for medical students preparing for USMLE Step 2 CK. Management reflects current ACC/AHA, USPSTF, and APA guidelines. Always cross-reference with UpToDate, institutional protocols, and clinical judgment.
The Bottom Line
- Vestibular neuritis = acute continuous vertigo for days without hearing loss; labyrinthitis = vertigo with hearing loss/tinnitus
- Typical peripheral pattern: unidirectional horizontal-torsional nystagmus, abnormal head impulse, no skew deviation, and no focal neurologic deficits
- HINTS can outperform early MRI only when performed by trained clinicians in continuous acute vestibular syndrome
- Treat acutely with antiemetics and short-course vestibular suppressants; start vestibular rehabilitation early
- New hearing loss, neurologic deficits, severe gait ataxia, direction-changing nystagmus, or skew deviation raises concern for stroke or alternative pathology
Overview
Vestibular neuritis is inflammation or dysfunction of the vestibular portion of cranial nerve VIII, usually post-viral, causing acute sustained vertigo, nausea, vomiting, and gait instability without hearing loss. Labyrinthitis involves the labyrinth and produces similar vertigo plus auditory symptoms such as hearing loss or tinnitus. These disorders fall under acute vestibular syndrome, a high-yield Step 2 CK differential because posterior circulation stroke can mimic peripheral vestibular disease.
Epidemiology
Vestibular neuritis and labyrinthitis are less common than BPPV but are important causes of acute continuous vertigo. They often follow viral upper respiratory infection. Vascular risk factors, older age, headache/neck pain, inability to walk, or neurologic symptoms shift concern toward cerebellar or brainstem stroke. Bacterial labyrinthitis may occur as a complication of otitis media or meningitis and is more severe.
Clinical Features
Symptoms
Abrupt severe continuous vertigo lasting days, worsened by head movement but present at rest
Nausea, vomiting, oscillopsia, and gait unsteadiness
Recent viral illness may precede vestibular neuritis
Hearing loss or tinnitus suggests labyrinthitis rather than vestibular neuritis
Diplopia, dysarthria, limb weakness/numbness, severe headache, or neck pain suggests central cause
Inability to sit or walk unaided is concerning for cerebellar stroke
Signs
Unidirectional horizontal-torsional nystagmus that suppresses with fixation supports peripheral vestibulopathy
Positive abnormal head impulse test supports peripheral vestibular hypofunction
No vertical skew deviation and no focal neurologic deficits in typical vestibular neuritis
Direction-changing gaze-evoked or vertical nystagmus suggests central lesion
Otitis media or meningismus with vertigo/hearing loss suggests bacterial labyrinthitis
Investigations
First-line
Focused neurologic and otologic examAssess gait, cranial nerves, cerebellar signs, otoscopy, hearing, and nystagmus pattern
HINTS exam in continuous acute vestibular syndromePeripheral pattern: abnormal head impulse, unidirectional nystagmus, no skew. Central pattern: normal head impulse, direction-changing nystagmus, or skew
Bedside hearing assessmentNew unilateral hearing loss makes labyrinthitis, AICA stroke, or sudden SNHL more likely
Second-line
AudiometryIf hearing loss, tinnitus, or labyrinthitis suspected
Basic labsOnly as clinically indicated for dehydration, infection, or stroke risk; labs do not diagnose vestibular neuritis
Specialist
MRI brain with diffusion-weighted imagingIf central signs, high stroke risk, atypical HINTS, severe gait ataxia, new headache/neck pain, or new hearing loss concerning for AICA stroke
ENT/neurology referralDiagnostic uncertainty, persistent symptoms, hearing loss, recurrent episodes, or suspected central cause
Lumbar punctureIf meningitis suspected after imaging/clinical stabilization
1
Acute symptomatic treatment
- Short-course vestibular suppressants such as meclizine or benzodiazepine for severe nausea/vertigo during first 24-72 h only
- Antiemetics such as ondansetron or prochlorperazine and hydration
- Avoid prolonged vestibular suppressants because they delay central compensation
2
Vestibular neuritis
- Vestibular rehabilitation and early mobilization are central to recovery
- Oral corticosteroids may be considered early in selected patients, but benefit is modest/variable and should not delay stroke evaluation when indicated
- Antivirals are not routinely recommended for typical vestibular neuritis
3
Labyrinthitis
- If viral: supportive care, audiology follow-up, and consider steroid discussion especially with sudden SNHL pattern
- If bacterial or associated with otitis media/meningitis: urgent IV antibiotics and ENT/infectious disease involvement
- Manage hearing loss urgently under sudden sensorineural hearing loss pathway when appropriate
4
Rule out central causes
- Posterior circulation stroke is the dangerous mimic; image/admit if red flags, central HINTS pattern, or vascular risk with atypical features
Complications
- Persistent imbalance: Incomplete vestibular compensation, especially with prolonged bed rest or suppressants
- Falls: Acute vertigo and gait instability increase injury risk
- Permanent hearing loss: More likely with labyrinthitis, sudden SNHL, or bacterial disease
- Missed posterior circulation stroke: The most dangerous diagnostic error in acute vestibular syndrome
- Dehydration: From severe vomiting
USMLE Step 2 CK Exam Tips
- 1Vestibular neuritis = continuous vertigo for days with NO hearing loss
- 2Labyrinthitis = vertigo plus hearing loss or tinnitus
- 3BPPV lasts seconds and is positional; vestibular neuritis is continuous for days
- 4HINTS central signs: normal head impulse, direction-changing nystagmus, or skew deviation
- 5Meclizine is short-term only; prolonged use delays vestibular compensation
- 6Severe truncal ataxia or inability to walk is a stroke red flag
- 7New hearing loss in acute vestibular syndrome can be AICA stroke — do not dismiss it
practicetest your knowledge on vestibular neuritis & labyrinthitisApply what you've learnt with USMLE Step 2 CK-style questions from the iatroX Q-Bank — ent and beyond.
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