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__NOTOC__
{{Infobox_Disease |
 
  Name          = Labyrinthitis |
  Image          = |
  Caption        = |
  DiseasesDB    = 29290 |
  ICD10          = {{ICD10|H|83|0|h|80}} |
  ICD9          = {{ICD9|386.3}} |
  ICDO          = |
  OMIM          = |
  MedlinePlus    = |
  eMedicineSubj  = |
  eMedicineTopic = |
  MeshName      = Labyrinthitis |
  MeshNumber    = C09.218.568.315 |
}}
{{SI}}
{{SI}}
{{CMG}} {{ADG}}  
{{CMG}}{{AE}} {{F.Z}}


{{SK}} Otitis interna, vestibular neuronitis, vestibular neuritis


<br />
 
{{SK}} Otitis interna
==Overview==
==Overview==
'''Labyrinthitis''' is a disorder that affects the balance in the body. It is basically an inflammatory process of the Labyrinth, which is the inner ear, and contains the vestibular system. Thus, it is responsible for sensing the position of the head and body on the whole. It contains fluid-filled channels, which in turn control the balance of the body and hearing. With any movement, the fluid moves in the channels and transmits electrical signals to the brain, thus helping the body to balance. Due to the difference in the transmitted signals from the inflamed and noninflamed ear, derangements can occur, which ultimately makes the person feel dizzy <ref name="pmid6606097">{{cite journal |vauthors=Karmody CS |title=Viral labyrinthitis: early pathology in the human |journal=Laryngoscope |volume=93 |issue=12 |pages=1527–33 |date=December 1983 |pmid=6606097 |doi=10.1288/00005537-198312000-00001 |url=}}</ref>.
Labyrinthitis is self-limiting [[inner ear]] disorder, often secondary to [[viral infection]]. The infection of vestibular neuron and labyrinth primary affects balance and hearing. The condition is commonly called as vestibular neuritis/ [[vestibular neuronitis.]] It is basically an inflammatory process of the [[labyrinth]], which is the [[inner ear]], and contains the [[vestibular system]]. Thus, it is responsible for sensing the position of the [[head]] and [[body]] on the whole. It contains fluid-filled channels, which in turn control the [[Balance disorder|balance of the body]] and [[hearing]]. With any movement, the fluid moves in the channels and transmits electrical signals to the [[brain]], thus helping the body to balance. Due to the difference in the transmitted signals from the [[inflamed]] and noninflamed [[ear]], derangements can occur, which ultimately makes the person feel dizzy .Along with balance problems, patients often experience [[hearing loss]] and [[tinnitus]]. Usually caused by a [[virus]], or from [[bacteria|bacterial]] infection,[[upper respiratory tract infection]], labyrinthitis can also occur due to [[head injury]], an [[allergy]] or as adverse drug reaction to any [[medicine]]. Although rare, all these can cause permanent hearing loss. Labyrinthitis is also known as Vestibular neuritis or acute peripheral vestibulopathy . Mostly, it is a self-limited disorder, with acute short term symptoms like [[vertigo]], [[nausea]], vomiting, and [[Gait abnormality|gait impairment]], with complete recovery in most patients. Another common condition associated with [[labyrinthitis]] is anxiety, which produces tremors, palpitations, panic attacks, and depression. in many cases, panic attacks and anxiety are the first symptoms to be associated with labyrinthitis.


Along with balance problems, patients often experience [[hearing loss]] and [[tinnitus]]. Usually caused by a [[virus]], or from [[bacteria|bacterial]] infection,[[upper respiratory tract infection]], labyrinthitis can also occur due to [[head injury]], an [[allergy]] or as adverse drug reaction to any [[medicine]]. Although rare, all these can cause permanent hearing loss. 
==Classification==


Labyrinthitis is also known as Vestibular neuritis or acute peripheral vestibulopathy <ref name="pmid12637613">{{cite journal |vauthors=Baloh RW |title=Clinical practice. Vestibular neuritis |journal=N. Engl. J. Med. |volume=348 |issue=11 |pages=1027–32 |date=March 2003 |pmid=12637613 |doi=10.1056/NEJMcp021154 |url=}}</ref>. Usually, it follows a short term course associated with vertigo, nausea, vomiting, and gait impairment. Mostly, it is a self-limited disorder, with acute short term symptoms with complete recovery in most patients.
*Viral labyrinthitis: This is caused by an viral upper respiratory tract infection, which includes cold or flu. Apart from this, many other viruses like the varicella-zoster virus, and the mumps, measles, and rubella viruses can also cause labyrinthitis . This type of disease is the most prevalent.<ref name="pmid6606097">{{cite journal |vauthors=Karmody CS |title=Viral labyrinthitis: early pathology in the human |journal=Laryngoscope |volume=93 |issue=12 |pages=1527–33 |date=December 1983 |pmid=6606097 |doi=10.1288/00005537-198312000-00001 |url=}}</ref><ref name="pmid7086745">{{cite journal |vauthors=Brill GC |title=Acute labyrinthitis: a possible association with influenza |journal=J R Coll Gen Pract |volume=32 |issue=234 |pages=47–50 |date=January 1982 |pmid=7086745 |pmc=1970972 |doi= |url=}}</ref>


Another common condition associated with labyrinthitis is anxiety, which produces tremors, palpitations, panic attacks, and depression. in many cases, panic attacks and anxiety are the first symptoms to be associated with labyrinthitis. While dizziness can occur from extreme anxiety, labyrinthitis itself can precipitate a panic disorder.  
*Bacterial labyrinthitis: This is second most common after viral infections, often, occurring as a complication of infection in the middle ear,(otitis media)<ref name="pmid15744821">{{cite journal |vauthors=Jang CH, Park SY, Wang PC |title=A case of tympanogenic labyrinthitis complicated by acute otitis media |journal=Yonsei Med. J. |volume=46 |issue=1 |pages=161–5 |date=February 2005 |pmid=15744821 |pmc=2823044 |doi=10.3349/ymj.2005.46.1.161 |url=}}</ref>. Often, there is sudden unilateral hearing loss, dizziness, and vertigo. These are more prevalent in children than in adults. The best treatment approach is with antibiotics, which successfully manages the bacterial labyrinthitis and causes full recovery.


==Classification ==
*Autoimmune labyrinthitis: This type of labyrinthitis is rare and lesser prevalent than others.<ref name="pmid12637613">{{cite journal |vauthors=Baloh RW |title=Clinical practice. Vestibular neuritis |journal=N. Engl. J. Med. |volume=348 |issue=11 |pages=1027–32 |date=March 2003 |pmid=12637613 |doi=10.1056/NEJMcp021154 |url=}}</ref


*Viral labyrinthitis: This type of labyrinthitis is usually caused by an upper respiratory tract infection, of viral etiology, which includes cold or flu. Apart from this, many other viruses like the varicella-zoster virus, and the mumps, measles, and rubella viruses can also cause labyrinthitis <ref name="pmid7086745">{{cite journal |vauthors=Brill GC |title=Acute labyrinthitis: a possible association with influenza |journal=J R Coll Gen Pract |volume=32 |issue=234 |pages=47–50 |date=January 1982 |pmid=7086745 |pmc=1970972 |doi= |url=}}</ref>. This type of disease is the most prevalent.
*Labyrinthitis ossificans: It is due to chronic infection or destructive process. <ref name="pmid27221575">{{cite journal| author=Kaya S, Paparella MM, Cureoglu S| title=Pathologic Findings of the Cochlea in Labyrinthitis Ossificans Associated with the Round Window Membrane. | journal=Otolaryngol Head Neck Surg | year= 2016 | volume= 155 | issue= 4 | pages= 635-40 | pmid=27221575 | doi=10.1177/0194599816651245 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27221575  }} </ref>


*Bacterial labyrinthitis: This is second most common after viral infections, often, occurring as a complication of infection in the middle ear,(otitis media)<ref name="pmid15744821">{{cite journal |vauthors=Jang CH, Park SY, Wang PC |title=A case of tympanogenic labyrinthitis complicated by acute otitis media |journal=Yonsei Med. J. |volume=46 |issue=1 |pages=161–5 |date=February 2005 |pmid=15744821 |pmc=2823044 |doi=10.3349/ymj.2005.46.1.161 |url=}}</ref>. Often, there is sudden unilateral hearing loss, dizziness, and vertigo. These are more prevalent in children than in adults. Treatment with antibiotics is usually successful in managing bacterial labyrinthitis and most recover fully.
*Conditions causing damage to the cochlea inside your inner ear like meningitis, circulatory problems, or Ménière’s disease.
 
*Autoimmune labyrinthitis: This type of labyrinthitis is less common than others.  


*Conditions causing damage to the cochlea inside your inner ear like meningitis, circulatory problems, or Ménière’s disease.
*Tympanogenic labyrinthitis: It is secondary to middle ear disease (rare intratemporal complication of otitis media). It is rare due to early diagnosis and treatment of  otitis media with antibiotics now a days.<ref name="pmid15744821">{{cite journal| author=Jang CH, Park SY, Wang PC| title=A case of tympanogenic labyrinthitis complicated by acute otitis media. | journal=Yonsei Med J | year= 2005 | volume= 46 | issue= 1 | pages= 161-5 | pmid=15744821 | doi=10.3349/ymj.2005.46.1.161 | pmc=2823044 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15744821  }} </ref>


== Differential diagnosis==
==Differential diagnosis==
   
   
Conditions which mimic Labyrinthitis are<ref name="pmid21603405">{{cite journal |vauthors=Thompson TL, Amedee R |title=Vertigo: a review of common peripheral and central vestibular disorders |journal=Ochsner J |volume=9 |issue=1 |pages=20–6 |date=2009 |pmid=21603405 |pmc=3096243 |doi= |url=}}</ref>:
Conditions which mimic Labyrinthitis are<ref name="pmid21603405">{{cite journal |vauthors=Thompson TL, Amedee R |title=Vertigo: a review of common peripheral and central vestibular disorders |journal=Ochsner J |volume=9 |issue=1 |pages=20–6 |date=2009 |pmid=21603405 |pmc=3096243 |doi= |url=}}</ref>:
*Meniere's disease
*Meniere's disease
*Migraine
*Migraine headache
*Small stroke
*Stroke
*Brain hemorrhage
*Intracranial hemorrhage (intralabyrinthine hemorrhage)<ref name="pmid20862477">{{cite journal| author=Dubrulle F, Kohler R, Vincent C, Puech P, Ernst O| title=Differential diagnosis and prognosis of T1-weighted post-gadolinium intralabyrinthine hyperintensities. | journal=Eur Radiol | year= 2010 | volume= 20 | issue= 11 | pages= 2628-36 | pmid=20862477 | doi=10.1007/s00330-010-1835-2 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20862477  }} </ref>
*Damage to the neck arteries
*Damage to the vascular structures in the neck
*Benign paroxysmal positional vertigo
*Benign paroxysmal positional vertigo
*Brain tumor
*Brain tumor(schwannoma)<ref name="pmid20862477">{{cite journal| author=Dubrulle F, Kohler R, Vincent C, Puech P, Ernst O| title=Differential diagnosis and prognosis of T1-weighted post-gadolinium intralabyrinthine hyperintensities. | journal=Eur Radiol | year= 2010 | volume= 20 | issue= 11 | pages= 2628-36 | pmid=20862477 | doi=10.1007/s00330-010-1835-2 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20862477  }} </ref>


== Epidemiology and Demographics==
<br />
{|
|- style="background: #4479BA; color: #FFFFFF; text-align: center;"
! rowspan="4" style="background: #4479BA; color: #FFFFFF; text-align: center;" |Diseases
| colspan="5" rowspan="1" style="background: #4479BA; color: #FFFFFF; text-align: center;" |'''Clinical manifestations'''
! colspan="2" rowspan="2" style="background: #4479BA; color: #FFFFFF; text-align: center;" |Para-clinical findings
| colspan="1" rowspan="4" style="background: #4479BA; color: #FFFFFF; text-align: center;" |'''Gold standard'''
! rowspan="4" style="background: #4479BA; color: #FFFFFF; text-align: center;" |Additional findings
|-
| colspan="4" rowspan="2" style="background: #4479BA; color: #FFFFFF; text-align: center;" |'''Symptoms'''
! rowspan="3" style="background: #4479BA; color: #FFFFFF; text-align: center;" |Physical examination
|-
! rowspan="2" style="background: #4479BA; color: #FFFFFF; text-align: center;" |Lab Findings
! rowspan="2" style="background: #4479BA; color: #FFFFFF; text-align: center;" |Imaging
|-
! style="background: #4479BA; color: #FFFFFF; text-align: center;" |Acute onset
! style="background: #4479BA; color: #FFFFFF; text-align: center;" |Recurrency
! colspan="1" rowspan="1" style="background: #4479BA; color: #FFFFFF; text-align: center;" |Nystagmus
! style="background: #4479BA; color: #FFFFFF; text-align: center;" |Hearing problems
|-
| colspan="10" style="background: #7d7d7d; color: #FFFFFF; text-align: center;" |'''Peripheral'''
|-
| style="background: #DCDCDC; padding: 5px; text-align: center;" |[https://www.wikidoc.org/index.php/Benign_paroxysmal_positional_vertigo BPPV]<ref name="pmid20607044">{{cite journal |vauthors=Lee SH, Kim JS |title=Benign paroxysmal positional vertigo |journal=J Clin Neurol |volume=6 |issue=2 |pages=51–63 |date=June 2010 |pmid=20607044 |pmc=2895225 |doi=10.3988/jcn.2010.6.2.51 |url=}}</ref><ref name="pmid11771020">{{cite journal |vauthors=Chang MB, Bath AP, Rutka JA |title=Are all atypical positional nystagmus patterns reflective of central pathology? |journal=J Otolaryngol |volume=30 |issue=5 |pages=280–2 |date=October 2001 |pmid=11771020 |doi= |url=}}</ref><ref name="pmid24642523">{{cite journal |vauthors=Dorresteijn PM, Ipenburg NA, Murphy KJ, Smit M, van Vulpen JK, Wegner I, Stegeman I, Grolman W |title=Rapid Systematic Review of Normal Audiometry Results as a Predictor for Benign Paroxysmal Positional Vertigo |journal=Otolaryngol Head Neck Surg |volume=150 |issue=6 |pages=919–24 |date=June 2014 |pmid=24642523 |doi=10.1177/0194599814527233 |url=}}</ref>
| style="background: #F5F5F5; padding: 5px; text-align: center;" | +
| style="background: #F5F5F5; padding: 5px; text-align: center;" | +
| style="background: #F5F5F5; padding: 5px; text-align: center;" | +/−
| style="background: #F5F5F5; padding: 5px; text-align: center;" |−
| style="background: #F5F5F5; padding: 5px;" |
*+ [https://www.wikidoc.org/index.php/Dix-Hallpike_test Dix-Hallpike maneuver]
| style="background: #F5F5F5; padding: 5px; text-align: center;" |−
| style="background: #F5F5F5; padding: 5px; text-align: center;" |−
| style="background: #F5F5F5; padding: 5px;" |
*[https://www.wikidoc.org/index.php/Dix-Hallpike_test Dix-Hallpike maneuver]
| style="background: #F5F5F5; padding: 5px;" |
*May be associated with [https://www.wikidoc.org/index.php/Nausea nausea], [https://www.wikidoc.org/index.php/Vomiting vomiting], and [https://www.wikidoc.org/index.php/Gait_abnormality gait instability]
|-
| style="background: #DCDCDC; padding: 5px; text-align: center;" |[https://www.wikidoc.org/index.php/Vestibular_neuronitis Vestibular neuritis]<ref name="pmid18283159">{{cite journal |vauthors=Mandalà M, Nuti D, Broman AT, Zee DS |title=Effectiveness of careful bedside examination in assessment, diagnosis, and prognosis of vestibular neuritis |journal=Arch. Otolaryngol. Head Neck Surg. |volume=134 |issue=2 |pages=164–9 |date=February 2008 |pmid=18283159 |doi=10.1001/archoto.2007.35 |url=}}</ref>
| style="background: #F5F5F5; padding: 5px; text-align: center;" | +
| style="background: #F5F5F5; padding: 5px; text-align: center;" | +/−
| style="background: #F5F5F5; padding: 5px; text-align: center;" | + /−
(unilateral)
| style="background: #F5F5F5; padding: 5px; text-align: center;" |−
| style="background: #F5F5F5; padding: 5px;" |
*+ Head thrust test
| style="background: #F5F5F5; padding: 5px; text-align: center;" |−
| style="background: #F5F5F5; padding: 5px; text-align: center;" |−
| style="background: #F5F5F5; padding: 5px;" |
*[https://www.wikidoc.org/index.php/History_and_Physical_examination History/ Physical exam]
| style="background: #F5F5F5; padding: 5px;" |
*May be associated with [https://www.wikidoc.org/index.php/Nausea nausea], [https://www.wikidoc.org/index.php/Vomiting vomiting], [https://www.wikidoc.org/index.php/Gait_abnormality gait instability] and previous [https://www.wikidoc.org/index.php/Upper_respiratory_infection upper respiratory infection]
|-
| style="background: #DCDCDC; padding: 5px; text-align: center;" |[https://www.wikidoc.org/index.php/M%C3%A9ni%C3%A8re's_disease Meniere disease]<ref name="Watanabe1980">{{cite journal|last1=Watanabe|first1=Isamu|title=Ménière’s Disease|journal=ORL|volume=42|issue=1-2|year=1980|pages=20–45|issn=1423-0275|doi=10.1159/000275477}}</ref><ref name="pmid9487176">{{cite journal |vauthors=Saeed SR |title=Fortnightly review. Diagnosis and treatment of Ménière's disease |journal=BMJ |volume=316 |issue=7128 |pages=368–72 |date=January 1998 |pmid=9487176 |pmc=2665527 |doi= |url=}}</ref>
| style="background: #F5F5F5; padding: 5px; text-align: center;" | +/−
| style="background: #F5F5F5; padding: 5px; text-align: center;" | +
| style="background: #F5F5F5; padding: 5px; text-align: center;" | +/−
| style="background: #F5F5F5; padding: 5px; text-align: center;" | + (Progressive)
| style="background: #F5F5F5; padding: 5px;" |
*[https://www.wikidoc.org/index.php/Sensorineural_hearing_loss Sensorineural hearing loss]
| style="background: #F5F5F5; padding: 5px; text-align: center;" |−
| style="background: #F5F5F5; padding: 5px;" |
*In [https://www.wikidoc.org/index.php/CT_scan CT scan] we may see small or invisible [https://www.wikidoc.org/index.php/Vestibular_aqueduct vestibular aqueduct]
| style="background: #F5F5F5; padding: 5px;" |
*[https://www.wikidoc.org/index.php/History_and_Physical_examination History/ Physical exam]/ Rulling out other diagnoses
| style="background: #F5F5F5; padding: 5px;" |
*May be associated with [https://www.wikidoc.org/index.php/Nausea_and_vomiting nausea], [https://www.wikidoc.org/index.php/Nausea_and_vomiting vomiting], and [https://www.wikidoc.org/index.php/Tinnitus tinnitus]
|-
| style="background: #DCDCDC; padding: 5px; text-align: center;" |Labyrinthine concussion
<ref name="DürrerPoláčková1971">{{cite journal|last1=Dürrer|first1=J.|last2=Poláčková|first2=J.|title=Labyrinthine Concussion|journal=ORL|volume=33|issue=3|year=1971|pages=185–190|issn=1423-0275|doi=10.1159/000274994}}</ref><ref name="pmid24653897">{{cite journal |vauthors=Choi MS, Shin SO, Yeon JY, Choi YS, Kim J, Park SK |title=Clinical characteristics of labyrinthine concussion |journal=Korean J Audiol |volume=17 |issue=1 |pages=13–7 |date=April 2013 |pmid=24653897 |pmc=3936518 |doi=10.7874/kja.2013.17.1.13 |url=}}</ref>
| style="background: #F5F5F5; padding: 5px; text-align: center;" | +
| style="background: #F5F5F5; padding: 5px; text-align: center;" |−
| style="background: #F5F5F5; padding: 5px; text-align: center;" |−
| style="background: #F5F5F5; padding: 5px; text-align: center;" | +
| style="background: #F5F5F5; padding: 5px;" |
*[https://www.wikidoc.org/index.php/High_frequency_hearing_loss high frequency hearing loss]
| style="background: #F5F5F5; padding: 5px; text-align: center;" |−
| style="background: #F5F5F5; padding: 5px;" |
*We may see other evidences of [https://www.wikidoc.org/index.php/Head_trauma head trauma] or [https://www.wikidoc.org/index.php/Temporal_bone temporal bone] [https://www.wikidoc.org/index.php/Fracture fracture]
| style="background: #F5F5F5; padding: 5px;" |
*[https://www.wikidoc.org/index.php/History_and_Physical_examination History/ Physical exam]
| style="background: #F5F5F5; padding: 5px;" |
*It happens following blunt [https://www.wikidoc.org/index.php/Head_trauma head trauma]
*May be associated with [https://www.wikidoc.org/index.php/Dizziness dizziness] or [https://www.wikidoc.org/index.php/Tinnitus tinnitus]
|-
| style="background: #DCDCDC; padding: 5px; text-align: center;" |Semicircular canal
dehiscence syndrome


*Most cases occur in adults aged 30 to 60 years old. This incidence is about 3.5 cases per 100,000
<ref name="pmid15655395">{{cite journal |vauthors=Lempert T, von Brevern M |title=Episodic vertigo |journal=Curr. Opin. Neurol. |volume=18 |issue=1 |pages=5–9 |date=February 2005 |pmid=15655395 |doi= |url=}}</ref><ref name="pmid10680810">{{cite journal |vauthors=Watson SR, Halmagyi GM, Colebatch JG |title=Vestibular hypersensitivity to sound (Tullio phenomenon): structural and functional assessment |journal=Neurology |volume=54 |issue=3 |pages=722–8 |date=February 2000 |pmid=10680810 |doi= |url=}}</ref>
*Viral labyrinthitis is relatively common in adults. Other types of ear infections are usually more widespread in children.  
| style="background: #F5F5F5; padding: 5px; text-align: center;" | +/−
*Bacterial labyrinthitis is much less common.  
| style="background: #F5F5F5; padding: 5px; text-align: center;" | +
*Younger children under two years old are more vulnerable to developing bacterial labyrinthitis.
| style="background: #F5F5F5; padding: 5px; text-align: center;" |−
| style="background: #F5F5F5; padding: 5px; text-align: center;" | +
(air-bone gaps on audiometry)
| style="background: #F5F5F5; padding: 5px;" |
*[https://www.wikidoc.org/index.php/Tullio_phenomenon Tullio phenomenon]
| style="background: #F5F5F5; padding: 5px; text-align: center;" |−
| style="background: #F5F5F5; padding: 5px;" |
*[https://www.wikidoc.org/index.php/CT_scan CT scan] may show defect in the arcuate eminence of the [https://www.wikidoc.org/index.php/Superior_semicircular_canal superior semicircular canal]
| style="background: #F5F5F5; padding: 5px;" |
*[https://www.wikidoc.org/index.php/History_and_Physical_examination History/ Physical exam]/[https://www.wikidoc.org/index.php/Imaging Imaging]
| style="background: #F5F5F5; padding: 5px;" |
*It may be provoked by [https://www.wikidoc.org/index.php/Valsalva_maneuver Valsalva maneuver], [https://www.wikidoc.org/index.php/Cough coughing], and [https://www.wikidoc.org/index.php/Sneeze sneezing]
|-
| style="background: #DCDCDC; padding: 5px; text-align: center;" |Vestibular paroxysmia
<ref name="HufnerBarresi2008">{{cite journal|last1=Hufner|first1=K.|last2=Barresi|first2=D.|last3=Glaser|first3=M.|last4=Linn|first4=J.|last5=Adrion|first5=C.|last6=Mansmann|first6=U.|last7=Brandt|first7=T.|last8=Strupp|first8=M.|title=Vestibular paroxysmia: Diagnostic features and medical treatment|journal=Neurology|volume=71|issue=13|year=2008|pages=1006–1014|issn=0028-3878|doi=10.1212/01.wnl.0000326594.91291.f8}}</ref><ref name="pmid23400324">{{cite journal |vauthors=Strupp M, von Stuckrad-Barre S, Brandt T, Tonn JC |title=Teaching neuroimages: Compression of the eighth cranial nerve causes vestibular paroxysmia |journal=Neurology |volume=80 |issue=7 |pages=e77 |date=February 2013 |pmid=23400324 |doi=10.1212/WNL.0b013e318281cc2c |url=}}</ref><ref name="pmid18809837">{{cite journal |vauthors=Hüfner K, Barresi D, Glaser M, Linn J, Adrion C, Mansmann U, Brandt T, Strupp M |title=Vestibular paroxysmia: diagnostic features and medical treatment |journal=Neurology |volume=71 |issue=13 |pages=1006–14 |date=September 2008 |pmid=18809837 |doi=10.1212/01.wnl.0000326594.91291.f8 |url=}}</ref>
| style="background: #F5F5F5; padding: 5px; text-align: center;" | +
| style="background: #F5F5F5; padding: 5px; text-align: center;" | +
| style="background: #F5F5F5; padding: 5px; text-align: center;" | +/−
(Induced by [https://www.wikidoc.org/index.php/Hyperventilation hyperventilation])
| style="background: #F5F5F5; padding: 5px; text-align: center;" |−
| style="background: #F5F5F5; padding: 5px;" |
*Impaired [https://www.wikidoc.org/index.php/Caloric_reflex_test caloric testing]
| style="background: #F5F5F5; padding: 5px; text-align: center;" |−
| style="background: #F5F5F5; padding: 5px;" |
*We may see evidence of [https://www.wikidoc.org/index.php/Vestibulocochlear_nerve vestibulocochlear nerve] compression on [https://www.wikidoc.org/index.php/MRI MRI]
| style="background: #F5F5F5; padding: 5px;" |
*[https://www.wikidoc.org/index.php/History_and_Physical_examination History/ Physical exam]/Imaging
| style="background: #F5F5F5; padding: 5px;" |
*It may be provoked by head turn or other action
*They respond well to treatment with [https://www.wikidoc.org/index.php/Carbamazepine carbamazepine] or [https://www.wikidoc.org/index.php/Oxcarbazepine oxcarbazepine]
|-
| style="background: #DCDCDC; padding: 5px; text-align: center;" |[https://www.wikidoc.org/index.php/Vestibular_schwannoma Vestibular schwannoma]<ref>{{Cite journal
| author = [[Robert W. Foley]], [[Shahram Shirazi]], [[Robert M. Maweni]], [[Kay Walsh]], [[Rory McConn Walsh]], [[Mohsen Javadpour]] & [[Daniel Rawluk]]
| title = Signs and Symptoms of Acoustic Neuroma at Initial Presentation: An Exploratory Analysis
| journal = [[Cureus]]
| volume = 9
| issue = 11
| pages = e1846
| year = 2017
| month = November
| doi = 10.7759/cureus.1846
| pmid = 29348989
}}</ref><ref>{{Cite journal
| author = [[E. P. Lin]] & [[B. T. Crane]]
| title = The Management and Imaging of Vestibular Schwannomas
| journal = [[AJNR. American journal of neuroradiology]]
| volume = 38
| issue = 11
| pages = 2034–2043
| year = 2017
| month = November
| doi = 10.3174/ajnr.A5213
| pmid = 28546250
}}</ref>
| style="background: #F5F5F5; padding: 5px; text-align: center;" |−
| style="background: #F5F5F5; padding: 5px; text-align: center;" | +
| style="background: #F5F5F5; padding: 5px; text-align: center;" | +/−
| style="background: #F5F5F5; padding: 5px; text-align: center;" | +
| style="background: #F5F5F5; padding: 5px;" |
*[https://www.wikidoc.org/index.php/Sensorineural_hearing_loss Sensorineural hearing loss]
*+ [https://www.wikidoc.org/index.php/Rinne_test Rinne test]
*Lateralization of [https://www.wikidoc.org/index.php/Weber_test Weber test] to the normal [https://www.wikidoc.org/index.php/Ear ear]
| style="background: #F5F5F5; padding: 5px; text-align: center;" |−
| style="background: #F5F5F5; padding: 5px;" |
*In [https://www.wikidoc.org/index.php/CT_scan CT scan] we may see erosion, and widening of the [https://www.wikidoc.org/index.php/Internal_auditory_meatus internal acoustic meatus]
*Hypointense [https://www.wikidoc.org/index.php/Mass mass] on T1-weighted [https://www.wikidoc.org/index.php/MRI MRI], and hyperintense [https://www.wikidoc.org/index.php/Mass mass] on T2-weighted [https://www.wikidoc.org/index.php/MRI MRI]
| style="background: #F5F5F5; padding: 5px;" |
*[https://www.wikidoc.org/index.php/Imaging Imaging]
| style="background: #F5F5F5; padding: 5px;" |
*[https://www.wikidoc.org/index.php/Gadolinium Gadolinium]-enhanced [https://www.wikidoc.org/index.php/MRI MRI] scan is definitive diagnostic test of [https://www.wikidoc.org/index.php/Vestibular_schwannoma acoutic neuroma]
|-
| style="background: #DCDCDC; padding: 5px; text-align: center;" |[https://www.wikidoc.org/index.php/Otitis_media Otitis media]<ref name="urlEar infection - acute: MedlinePlus Medical Encyclopedia">{{cite web |url=https://www.nlm.nih.gov/medlineplus/ency/article/000638.htm |title=Ear infection - acute: MedlinePlus Medical Encyclopedia |format= |work= |accessdate=}}</ref><ref name="pmid25213276">{{cite journal |vauthors=Rettig E, Tunkel DE |title=Contemporary concepts in management of acute otitis media in children |journal=Otolaryngol. Clin. North Am. |volume=47 |issue=5 |pages=651–72 |year=2014 |pmid=25213276 |pmc=4393005 |doi=10.1016/j.otc.2014.06.006 |url=}}</ref>
| style="background: #F5F5F5; padding: 5px; text-align: center;" | +
| style="background: #F5F5F5; padding: 5px; text-align: center;" |−
| style="background: #F5F5F5; padding: 5px; text-align: center;" |−
| style="background: #F5F5F5; padding: 5px; text-align: center;" | +/−
| style="background: #F5F5F5; padding: 5px;" |
*Fever
*Presence of effusion in the [https://www.wikidoc.org/index.php/Middle_ear middle ear]
| style="background: #F5F5F5; padding: 5px; text-align: center;" |Increased [https://www.wikidoc.org/index.php/Acute_phase_reactant acute phase reactants]
| style="background: #F5F5F5; padding: 5px;" |
*Opacification of the [https://www.wikidoc.org/index.php/Middle_ear middle ear]
| style="background: #F5F5F5; padding: 5px;" |
*[https://www.wikidoc.org/index.php/History_and_Physical_examination History/ Physical exam]
| style="background: #F5F5F5; padding: 5px;" |
*Patient may show other [https://www.wikidoc.org/index.php/Signs signs] and [https://www.wikidoc.org/index.php/Symptoms symptoms] of [https://www.wikidoc.org/index.php/Upper_respiratory_infection upper respiratory infection] such az [https://www.wikidoc.org/index.php/Cough cough], [https://www.wikidoc.org/index.php/Nasal_discharge nasal discharge], and [https://www.wikidoc.org/index.php/Fever fever]
|-
| style="background: #DCDCDC; padding: 5px; text-align: center;" |Aminoglycoside toxicity
<ref name="pmid8597959">{{cite journal |vauthors=Ernfors P, Duan ML, ElShamy WM, Canlon B |title=Protection of auditory neurons from aminoglycoside toxicity by neurotrophin-3 |journal=Nat. Med. |volume=2 |issue=4 |pages=463–7 |date=April 1996 |pmid=8597959 |doi= |url=}}</ref>
| style="background: #F5F5F5; padding: 5px; text-align: center;" | +
| style="background: #F5F5F5; padding: 5px; text-align: center;" |−
| style="background: #F5F5F5; padding: 5px; text-align: center;" |−
| style="background: #F5F5F5; padding: 5px; text-align: center;" | +
| style="background: #F5F5F5; padding: 5px;" |
*[https://www.wikidoc.org/index.php/Oscillopsia Oscillopsia]
| style="background: #F5F5F5; padding: 5px; text-align: center;" |−
| style="background: #F5F5F5; padding: 5px; text-align: center;" |−
| style="background: #F5F5F5; padding: 5px;" |
*[https://www.wikidoc.org/index.php/History_and_Physical_examination History/ Physical exam]
| style="background: #F5F5F5; padding: 5px;" |
*May be associated with [https://www.wikidoc.org/index.php/Nausea nausea], [https://www.wikidoc.org/index.php/Vomiting vomiting], and [https://www.wikidoc.org/index.php/Ataxia ataxia]
*It may be irreversible
*[https://www.wikidoc.org/index.php/Gentamicin Gentamicin] is the most common one
|- style="background: #4479BA; color: #FFFFFF; text-align: center;"
! colspan="10" style="background: #7d7d7d; color: #FFFFFF; text-align: center;" |Central
|-
| style="background: #DCDCDC; padding: 5px; text-align: center;" |[https://www.wikidoc.org/index.php/Brain_tumor Brain tumors]<ref name="DunniwayWelling2016">{{cite journal|last1=Dunniway|first1=Heidi M.|last2=Welling|first2=D. Bradley|title=Intracranial Tumors Mimicking Benign Paroxysmal Positional Vertigo|journal=Otolaryngology–Head and Neck Surgery|volume=118|issue=4|year=2016|pages=429–436|issn=0194-5998|doi=10.1177/019459989811800401}}</ref>
| style="background: #F5F5F5; padding: 5px; text-align: center;" | +/−
| style="background: #F5F5F5; padding: 5px; text-align: center;" | +
| style="background: #F5F5F5; padding: 5px; text-align: center;" | +
| style="background: #F5F5F5; padding: 5px; text-align: center;" | +
| style="background: #F5F5F5; padding: 5px;" |
*[https://www.wikidoc.org/index.php/Papilledema Papilledema]
*[https://www.wikidoc.org/index.php/Focal_neurological_deficits Focal neurological deficits]
| style="background: #F5F5F5; padding: 5px; text-align: center;" |Cerebral spinal fluid ([https://www.wikidoc.org/index.php/CSF CSF]) may show cancerous cells
| style="background: #F5F5F5; padding: 5px;" |
*On [https://www.wikidoc.org/index.php/CT_scan CT scan] most of the [https://www.wikidoc.org/index.php/Brain_tumors brain tumors] appears as a hypodense mass lesions
*On [https://www.wikidoc.org/index.php/MRI_scan MRI] most of the [https://www.wikidoc.org/index.php/Brain_tumors brain tumors] appears as a hypointense or isointense on T1-weighted scans, or hyperintense on T2-weighted [https://www.wikidoc.org/index.php/MRI_contrast_agent MRI].
| style="background: #F5F5F5; padding: 5px;" |
*[https://www.wikidoc.org/index.php/Imaging Imaging]


== Risk Factors==
*[https://www.wikidoc.org/index.php/Biopsy_forceps Biopsy]
| style="background: #F5F5F5; padding: 5px;" |
*Patieny may experience  [https://www.wikidoc.org/index.php/Headache headache], [https://www.wikidoc.org/index.php/Seizures seizures], [https://www.wikidoc.org/index.php/Visual_disturbance visual changes] and changes in [https://www.wikidoc.org/index.php/Personality personality], [https://www.wikidoc.org/index.php/Mood mood] and [https://www.wikidoc.org/index.php/Concentration concentration]
|-
| style="background: #DCDCDC; padding: 5px; text-align: center;" |[https://www.wikidoc.org/index.php/Cerebellar_infarction Cerebellar infarction]/hemorrhage
| style="background: #F5F5F5; padding: 5px; text-align: center;" | +
| style="background: #F5F5F5; padding: 5px; text-align: center;" |−
| style="background: #F5F5F5; padding: 5px; text-align: center;" | ++/−
| style="background: #F5F5F5; padding: 5px; text-align: center;" |−
| style="background: #F5F5F5; padding: 5px;" |
*[https://www.wikidoc.org/index.php/Limb Limb] [https://www.wikidoc.org/index.php/Ataxia ataxia]
*[https://www.wikidoc.org/index.php/Gait_abnormality Gait disturbance]
*[https://www.wikidoc.org/index.php/Dysarthria Dysarthria]
| style="background: #F5F5F5; padding: 5px; text-align: center;" |−
| style="background: #F5F5F5; padding: 5px;" |
*Based on the time interval between [https://www.wikidoc.org/index.php/Stroke stroke] and [https://www.wikidoc.org/index.php/Imaging imaging] we may have different presentations
| style="background: #F5F5F5; padding: 5px;" |
*[https://www.wikidoc.org/index.php/Imaging Imaging]
| style="background: #F5F5F5; padding: 5px;" |
*[https://www.wikidoc.org/index.php/Posterior_inferior_cerebellar_artery Posterior inferior cerebellar artery] is the most common artery that causes [https://www.wikidoc.org/index.php/Vertigo vertigo]
|-
| style="background: #DCDCDC; padding: 5px; text-align: center;" |Brain stem ischemia
| style="background: #F5F5F5; padding: 5px; text-align: center;" | +
| style="background: #F5F5F5; padding: 5px; text-align: center;" |−
| style="background: #F5F5F5; padding: 5px; text-align: center;" | +/−
| style="background: #F5F5F5; padding: 5px; text-align: center;" |−
| style="background: #F5F5F5; padding: 5px;" |
*Contralateral body [https://www.wikidoc.org/index.php/Muscle_weakness weakness]
*[https://www.wikidoc.org/index.php/Visual_field Visual field] deficits
*[https://www.wikidoc.org/index.php/Oculomotor_nerve Oculomotor] abnormalities
*[https://www.wikidoc.org/index.php/Bulbar Bulbar] findings
| style="background: #F5F5F5; padding: 5px; text-align: center;" |−
| style="background: #F5F5F5; padding: 5px;" |
*Based on the time interval between [https://www.wikidoc.org/index.php/Stroke stroke] and [https://www.wikidoc.org/index.php/Imaging imaging] we may have different presentations
*For more information [https://www.wikidoc.org/index.php/Ischemic_stroke_CT click here]
| style="background: #F5F5F5; padding: 5px;" |
*[https://www.wikidoc.org/index.php/Imaging Imaging]
| style="background: #F5F5F5; padding: 5px;" |
*It may be associated with [https://www.wikidoc.org/index.php/Subclavian_steal_syndrome subclavian steal syndrome]
|}<br />
 
==Epidemiology and Demographics==
 
*Adults in the age group of 30 to 60 years are most commonly affected. The incidence of labyrinthitis is around 3.5 cases per 100,000.
*Viral labyrinthitis, the most common type, is more prevalent in adults, whereas the other types of infections affect the children on a larger scale. This can be assessed by the fact that children under the age of two are more predisposed to develop bacterial labyrinthitis.
*Bacterial labyrinthitis is overall, less prevalent than other causes.
 
==Risk Factors==


Certain conditions can increase the risk of labyrinthitis:
Certain conditions can increase the risk of labyrinthitis:
*Upper respiratory infections
 
*Middle ear infections
*Upper respiratory tract infections
*Infections of the middle ear
*Meningitis
*Meningitis
*Head injuries
*Head injuries
*Respiratory illnesses, such as bronchitis
*Respiratory illnesses like bronchitis
*Viral infections, including herpes and measles
*Viral infections, like herpes and measles
*Autoimmune conditions
*Autoimmune diseases


== Natural History, Complications, and Prognosis==
==Natural History, Complications, and Prognosis==


*Symptoms can start suddenly. They may be there when you wake up and get worse as the day goes on.
*The symptoms of labyrinthitis usually start suddenly. Occasionally the patient wakes up with these symptoms and they are progressive.
*The symptoms often ease after a few days.
*There is usually a relief in the symptoms after a few days. Often, the loss of balance is restored in a couple of weeks, but in some cases, it can take longer.
*People usually get their balance back over 2 to 6 weeks, although it can take longer.
*In some severe and rare cases, there can be a permanent loss of hearing.
*In very rare cases, hearing loss is permanent.
*Certain factors like cold, previous illnesses, fatigue, menstruation, and respiratory infections can worsen the symptoms.
 
*Complications following labyrinthitis includes: labyrinthine fistula, meningitis, cerebellar abscess, mastoiditis etc <ref name="pmid26718959">{{cite journal| author=Maranhão AS, Godofredo VR, Penido Nde O| title=Suppurative labyrinthitis associated with otitis media: 26 years' experience. | journal=Braz J Otorhinolaryngol | year= 2016 | volume= 82 | issue= 1 | pages= 82-7 | pmid=26718959 | doi=10.1016/j.bjorl.2014.12.012 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26718959  }} </ref>
Certain factors that worsen the symptoms include:
 
*Colds or illness
*Tiredness
*Menstruation


===Recovery===
===Recovery===
Recovery from acute labyrinthine inflammation generally takes from one to six weeks; however, it is not uncommon for residual symptoms (dysequilibrium and/or dizziness) to last for many months or even years (Bronstein, 2002) if permanent damage occurs.
The recovery from an attack of labyrinthitis follows the following phases:


Recovery from a permanently damaged inner ear typically follows three phases:
#'''An acute period''', which includes symptoms like vertigo, nausea, and vomiting.
# '''An acute period''', which may include severe vertigo and vomiting
#'''subacute symptoms, which last for a couple of weeks, followed by a rapid recovery'''
# approximately two weeks of '''ssubacute symptoms and rapid recovery'''
#'''chronic compensation''', which extends over a period of a couple of months or even years.
# finally a period of '''chronic compensation''' which may last for months or years.


==Diagnosis ==
==Diagnosis==
===Diagnostic Study of Choice===
===Diagnostic Study of Choice===


Viral labyrinthitis is a clinical diagnosis. But a number of a diagnostic tests are performed to rule out other diseases. Tests that can rule out other causes of your symptoms include:
Viral labyrinthitis could be a clinical diagnosis. But a variety of diagnostic tests are performed to rule out other diseases. Tests that may rule out other causes of your symptoms include:


*EEG (measures the electrical activity of the brain)
*EEG
*Electronystagmography, and warming and cooling the inner ear with air or water to test eye reflexes (caloric stimulation)
*Electronystagmography, also known as caloric stimulation.
*Head CT scan
*CT Scan of the head: to rule out mastoiditis.
*Hearing test
*Temporal bone CT scan: diagnostic techniques in patients with cholesteatoma.
*MRI of the head
*Rinne and Weber hearing tests
*Head MRI
*Eye test
*Blood pressure
*Assessment of balance
*Culture and sensitivity of the middle ear effusions.
*Vestibular-evoked myogenic potentials to assess vestibular activity
*Gadolinium-nuclear magnetic resonance (NMR) imaging<ref name="pmid26718959">{{cite journal| author=Maranhão AS, Godofredo VR, Penido Nde O| title=Suppurative labyrinthitis associated with otitis media: 26 years' experience. | journal=Braz J Otorhinolaryngol | year= 2016 | volume= 82 | issue= 1 | pages= 82-7 | pmid=26718959 | doi=10.1016/j.bjorl.2014.12.012 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26718959  }} </ref>


===History and Symptoms===
===History and Symptoms===
Labyrinthitis is characterized by following symptoms and signs including :
Labyrinthitis can be suspected when bone conduction loss co-exists with otitis media<ref name="pmid15744821">{{cite journal| author=Jang CH, Park SY, Wang PC| title=A case of tympanogenic labyrinthitis complicated by acute otitis media. | journal=Yonsei Med J | year= 2005 | volume= 46 | issue= 1 | pages= 161-5 | pmid=15744821 | doi=10.3349/ymj.2005.46.1.161 | pmc=2823044 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15744821  }} </ref>
Labyrinthitis is characterized by the following symptoms and signs including :
 
*Dizziness
*Dizziness
*Vertigo
*Vertigo
*Loss of balance/gait instability
*Instability of gait
*Nausea and vomiting
*Nausea or vomiting
*Tinnitus
*Tinnitus or ringing in the ears
*Loss of hearing in the high-frequency range  
*Hearing loss particularly of the high-frequency range
*Difficulty focusing your eyes
*Nystagmus<ref name="pmid26718959">{{cite journal| author=Maranhão AS, Godofredo VR, Penido Nde O| title=Suppurative labyrinthitis associated with otitis media: 26 years' experience. | journal=Braz J Otorhinolaryngol | year= 2016 | volume= 82 | issue= 1 | pages= 82-7 | pmid=26718959 | doi=10.1016/j.bjorl.2014.12.012 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26718959  }} </ref>
===Physical Examination===
 
*Hearing tests
*Eye test
*Blood pressure
*Assessment of balance


===Laboratory Findings===
===Laboratory Findings===


Labyrinthitis is a clinical diagnosis. As a result, routine blood tests are not helpful in making any diagnosis. However, if systemic infection is suspected, FBC and blood cultures are indicated
Labyrinthitis could be a clinical diagnosis. As a result, routine blood tests don't seem to be helpful in making any diagnosis. However, if systemic infection is suspected, FBC and blood cultures are indicated.


=== Diagnostic Studies and Imaging Findings===
==Treatment==


*A CT scan can help rule out mastoiditis.
Viral labyrinthitis causes a sudden onset of vertigo, nausea, vomiting, and sudden hearing impairment. As we know that the antibiotics are not effective against viruses, we must adopt the symptomatic treatment techniques, including medications for vertigo, antihistaminics, and complete rest. With all these measures, the patient usually feels better in  a week or two. Nevertheless, acute episodes can sometimes last for up to months. Apart from that, most people will have a full recovery after an episode of viral labyrinthitis if proper and timely vestibular rehabilitation exercises are adopted.  


*A temporal bone CT scan may help in patients with cholesteatoma and labyrinthitis, although gadolinium MRI is more useful in the early stages of suppurative labyrinthitis
Bacterial labyrinthitis can be effectively treated with antibiotics preventing long term complications
<ref name="pmid15744821">{{cite journal| author=Jang CH, Park SY, Wang PC| title=A case of tympanogenic labyrinthitis complicated by acute otitis media. | journal=Yonsei Med J | year= 2005 | volume= 46 | issue= 1 | pages= 161-5 | pmid=15744821 | doi=10.3349/ymj.2005.46.1.161 | pmc=2823044 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15744821  }} </ref>
===Certain emergency conditions which warrant immediate medical attention are===


*Perform culture and sensitivity testing of middle ear effusions if present
*loss of consciousness
 
*Convulsions or seizures
*Vestibular function testing like Caloric testing and an electronystagmogram may be used
*Speech abnormalities
 
*Vestibular-evoked myogenic potentials to assess vestibular activity
 
==Treatment==
 
Viral labyrinthitis causes a sudden onset of vertigo, nausea, vomiting, and sudden hearing loss. Due to the inefficacy of antibiotics against viruses, symptomatic treatment is preferred which includes antivertigo medications, antihistamines, and rest. Usually, the patient feels better within a week and after two weeks will begin to compensate for the dizziness/vertigo. Acute episodes can sometimes last up to one to two months. Most people recover fully from viral labyrinthitis and the vestibular rehabilitation exercises are highly recommended. 
 
===Certain emergency conditions which warrant immediate medical attention are ===
*Fainting
*Convulsions
*Slurred speech
*Fever
*Fever
*Weakness
*Weakness
*Paralysis
*Stroke
*Double vision
*Vision disorders like diplopia
===Medical Therapy ===
 
===Medical Therapy===
Symptomatic patients need treatment with the following:
Symptomatic patients need treatment with the following:


*Antihistamines, like desloratadine and loratadine
*Antihistamines, whic include drugs like desloratadine and loratadine
*Drugs that can reduce dizziness and nausea, such as meclizine  
*Antivertigo medications, such as meclizine
*Sedatives, such as diazepam  
*Sometimes we need to give sedatives to the patienst to ensure rest and recovery, such as diazepam
*Corticosteroids, such as prednisone
*Corticosteroids, like prednisone
*Over-the-counter antihistamines, such as fexofenadine, diphenhydramine, or loratadine
*[[Prochlorperazine]] is also commonly prescribed, which helps to alleviate symptoms of vertigo and nausea.


[[Prochlorperazine]] is commonly prescribed to help alleviate the symptoms of vertigo and nausea.  
As we know that, sometimes an attack or anxiety or panic attack can aggravate the symptoms of labyrnthitis, it becomes imperative to treat an [[anxiety disorder]] and/or [[clinical depression|depression]], simultaneously with the medication for otehr symptoms, to treat any vestibular damage. This can be achieved with [[benzodiazepines]] like [[diazepam]] ([[Valium]]); but caution should be taken to avoid long term usage of these drugs due to associated addiction with this class of drugs and their interference with the vestibular system (Solomon and Shepard, 2002). Likewise the efficacy of corticosteroids such as [[prednisone]], to treat early stages of labyrnthitis has been advocated and they are very frequently used for proper recovery, along with some antiviral medication. It should be understood that the treatment should be started as soon as possible to prevent any permanent damage to the inner ear.


Because anxiety interferes with the balance compensation process, it is important to treat an [[anxiety disorder]] and/or [[clinical depression|depression]] as soon as possible to allow the brain to compensate for any vestibular damage. Acute anxiety can be treated in the short term with [[benzodiazepines]] such as [[diazepam]] ([[Valium]]); however, long-term use is not recommended because of the addictive nature of benzodiazepines and the interference they may cause with vestibular compensation and adaptive plasticity (Solomon and Shepard, 2002).
===Interventions===
 
Evidence suggests that [[Selective serotonin reuptake inhibitor|selective serotonin-reuptake inhibitors]] may be more effective in treating labyrinthitis. They act by relieving anxiety symptoms and may stimulate new neural growth within the inner ear, allowing more rapid vestibular compensation to occur. Trials have shown that SSRIs do in fact affect the vestibular system in a direct manner and can decrease dizziness (Staab and Ruckenstein, 2005). 
 
Some evidence suggests that viral labyrinthitis should be treated in its early stages with corticosteroids such as [[prednisone]], and possibly antiviral medication such as [[Valtrex]] and that this treatment should be undertaken as soon as possible to prevent permanent damage to the inner ear.


===Interventions===
Apart from medical therapy, we can use several lifestyle techniques to relieve vertigo associated with labyrinthitis:


Apart from medical therapy, we can use several techniques to relieve vertigo associated with labyrinthitis:
*Avoiding sudden or jerky movements or any sudden changes in body position
*Rest during the attack and avoid any movements
*Smooth and slow movements when trying to get up from lying
*Avoiding prolonged exposure to screens, and abstain from bright lights in lieu of an attack
*Keeping the head still, while sitting in a chair
*Stress management techniques, to mitigate and factors which can aggravate the anxiety or stressors
*Warm compresses can be used to bring relief from the pain
*Avoiding smoking and limiting the intake of alcohol


*Avoid quick or sudden movements or brisk changes in position
===Primary Prevention===
*Try and sit still during a vertigo attack
*Slow and smooth movements while getting up from lying down position
*Avoid prolonged watching of screens, and bright or flashing lights during an attack
*Sitting up in a chair and keeping the head still, if experience vertigo in sitting position also
*Stress management techniques to control emotional and psychological stress
*Using warm compresses over the ear helps in relieving the pain
*Avoid smoking and limit alcohol intake


===Primary Prevention ===
*Resting in a cool dark place, if experiencing any symptoms like dizziness or vertigo
*Rest in a dark room if feeling dizzy
*Drinking plenty of fluids and adequate hydration
*Plenty of fluids, drink little quantities and often
*Avoiding loud noises and exposure to bright lights which can aggravate the symptoms
*Avoid loud noise and bright lights
*Adequate sleep, as lack of sleep can bring on an attack
*Get adequate sleep


===Secondary Prevention ===
===Secondary Prevention===


*Physical and occupational therapy to help improve balance.
*Implementation of therapies to allow rehabilitation and improve balance, like physical and occupational therapy
*Vestibular rehabilitation: exercises under the supervision of a physiotherapist, that can help to restore balance. Vestibular rehabilitation therapy (VRT) is a highly effective way to substantially reduce or eliminate residual dizziness from labyrinthitis. VRT works by causing the brain to use already existing neural mechanisms for adaptation, plasticity, and compensation. Vestibular rehabilitation therapy can help with your balance and walking and make everyday activities easier. The direction, duration, frequency, and magnitude of the directed exercises are closely correlated with adaptation and recovery. Symmetry is more rapidly restored when VRT exercises are specifically tailored for the patient.
*Vestibular rehabilitation: This includes various exercises performed under the supervision of a trained physiotherapist, which helps to improve the gait, movements, and functionality. It substantially reduces any residual symptoms from the attack of labyrinthitis. It helps with balancing and makes everyday activities easier.


<br />
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==References==
==References==
{{Reflist|2}}


* Bronstein A ([[2002]]), Visual and psychological aspects of vestibular disease, ''Current Opinion in Neurology'' 2002, '''15''':1–3.
*Bronstein A ([[2002]]), Visual and psychological aspects of vestibular disease, ''Current Opinion in Neurology'' 2002, '''15''':1–3.
* Simon NM, Pollack MH, Tuby KS ''et al'' ([[1998]]), Dizziness and panic disorder: a review of the association between vestibular dysfunction and anxiety, ''Ann Clin Psychiatry'', '''10'''(2):75–80.
*Simon NM, Pollack MH, Tuby KS ''et al'' ([[1998]]), Dizziness and panic disorder: a review of the association between vestibular dysfunction and anxiety, ''Ann Clin Psychiatry'', '''10'''(2):75–80.
* Solomon D and Shepard NT ([[2002]]), Chronic Dizziness, ''Current Treatment Options in Neurology'', '''4''':281–288.
*Solomon D and Shepard NT ([[2002]]), Chronic Dizziness, ''Current Treatment Options in Neurology'', '''4''':281–288.
* Staab J and Ruckenstein M ([[2005]]), Chronic Dizziness and Anxiety, ''Arch Otolaryngol Head Neck Surg'', '''131''':675-679.
*Staab J and Ruckenstein M ([[2005]]), Chronic Dizziness and Anxiety, ''Arch Otolaryngol Head Neck Surg'', '''131''':675-679.


==External links==
==External links==


* [http://www.sledgehammercomputers.com/wiki/index.php/Labyrinthitis My personal battle with Labyrinthitis] How Ryan Roper overcame the condition.
*[http://www.sledgehammercomputers.com/wiki/index.php/Labyrinthitis My personal battle with Labyrinthitis] How Ryan Roper overcame the condition.
* [http://www.dizzytimes.com DizzyTimes.com]
*[http://www.dizzytimes.com DizzyTimes.com]
* [http://www.meei.harvard.edu/patient/rauch.php Dr. Rauch's Online Otology Clinic — video clips]
*[http://www.meei.harvard.edu/patient/rauch.php Dr. Rauch's Online Otology Clinic — video clips]
* [http://www.labyrinthitis.co.uk/ Labyrinthitis.co.uk]
*[http://www.labyrinthitis.co.uk/ Labyrinthitis.co.uk]
* [http://www.labyrinthitis.org.uk/ Labyrinthitis.org.uk]
*[http://www.labyrinthitis.org.uk/ Labyrinthitis.org.uk]
* [http://www.dizziness-and-balance.com/disorders/unilat/vneurit.html Vestibular neuritis and labyrinthitis]
*[http://www.dizziness-and-balance.com/disorders/unilat/vneurit.html Vestibular neuritis and labyrinthitis]
* {{eMedicine|neuro|686}} - "Labyrinthitis and related conditions"
*{{eMedicine|neuro|686}} - "Labyrinthitis and related conditions"
* {{eMedicine|ent|666}} - "Vestibular rehabilitation therapy"
*{{eMedicine|ent|666}} - "Vestibular rehabilitation therapy"
* [http://www.healthboards.com/boards/forumdisplay.php?f=76 Inner ear healthboard]
*[http://www.healthboards.com/boards/forumdisplay.php?f=76 Inner ear healthboard]
* [http://p084.ezboard.com/bdizzylounge The Dizzy Lounge]
*[http://p084.ezboard.com/bdizzylounge The Dizzy Lounge]
* [http://www.labyrinthitissupport.org.uk/ Labyrinthitis Support Forums]
*[http://www.labyrinthitissupport.org.uk/ Labyrinthitis Support Forums]
* [http://betterhealth.vic.gov.au/bhcv2/bhcarticles.nsf/pages/Labyrinthitis_and_vestibular_neuritis?OpenDocument Labyrinthitis and vestibular neuritis]
*[http://betterhealth.vic.gov.au/bhcv2/bhcarticles.nsf/pages/Labyrinthitis_and_vestibular_neuritis?OpenDocument Labyrinthitis and vestibular neuritis]


<br>
<br>

Latest revision as of 12:02, 27 May 2021


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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]Associate Editor(s)-in-Chief: Fizza Zulfiqar, MD[2]


Synonyms and keywords: Otitis interna

Overview

Labyrinthitis is self-limiting inner ear disorder, often secondary to viral infection. The infection of vestibular neuron and labyrinth primary affects balance and hearing. The condition is commonly called as vestibular neuritis/ vestibular neuronitis. It is basically an inflammatory process of the labyrinth, which is the inner ear, and contains the vestibular system. Thus, it is responsible for sensing the position of the head and body on the whole. It contains fluid-filled channels, which in turn control the balance of the body and hearing. With any movement, the fluid moves in the channels and transmits electrical signals to the brain, thus helping the body to balance. Due to the difference in the transmitted signals from the inflamed and noninflamed ear, derangements can occur, which ultimately makes the person feel dizzy .Along with balance problems, patients often experience hearing loss and tinnitus. Usually caused by a virus, or from bacterial infection,upper respiratory tract infection, labyrinthitis can also occur due to head injury, an allergy or as adverse drug reaction to any medicine. Although rare, all these can cause permanent hearing loss. Labyrinthitis is also known as Vestibular neuritis or acute peripheral vestibulopathy . Mostly, it is a self-limited disorder, with acute short term symptoms like vertigo, nausea, vomiting, and gait impairment, with complete recovery in most patients. Another common condition associated with labyrinthitis is anxiety, which produces tremors, palpitations, panic attacks, and depression. in many cases, panic attacks and anxiety are the first symptoms to be associated with labyrinthitis.

Classification

  • Viral labyrinthitis: This is caused by an viral upper respiratory tract infection, which includes cold or flu. Apart from this, many other viruses like the varicella-zoster virus, and the mumps, measles, and rubella viruses can also cause labyrinthitis . This type of disease is the most prevalent.[1][2]
  • Bacterial labyrinthitis: This is second most common after viral infections, often, occurring as a complication of infection in the middle ear,(otitis media)[3]. Often, there is sudden unilateral hearing loss, dizziness, and vertigo. These are more prevalent in children than in adults. The best treatment approach is with antibiotics, which successfully manages the bacterial labyrinthitis and causes full recovery.
  • Autoimmune labyrinthitis: This type of labyrinthitis is rare and lesser prevalent than others.
  • Conditions causing damage to the cochlea inside your inner ear like meningitis, circulatory problems, or Ménière’s disease.
  • Tympanogenic labyrinthitis: It is secondary to middle ear disease (rare intratemporal complication of otitis media). It is rare due to early diagnosis and treatment of otitis media with antibiotics now a days.[3]

Differential diagnosis

Conditions which mimic Labyrinthitis are[4]:

  • Meniere's disease
  • Migraine headache
  • Stroke
  • Intracranial hemorrhage (intralabyrinthine hemorrhage)[5]
  • Damage to the vascular structures in the neck
  • Benign paroxysmal positional vertigo
  • Brain tumor(schwannoma)[5]


Diseases Clinical manifestations Para-clinical findings Gold standard Additional findings
Symptoms Physical examination
Lab Findings Imaging
Acute onset Recurrency Nystagmus Hearing problems
Peripheral
BPPV[6][7][8] + + +/− − − −
Vestibular neuritis[9] + +/− + /−

(unilateral)

−
  • + Head thrust test
 − −
Meniere disease[10][11] +/− + +/− + (Progressive) −
Labyrinthine concussion

[12][13]

+ − − + −
Semicircular canal

dehiscence syndrome

[14][15]

+/− + − +

(air-bone gaps on audiometry)

−
Vestibular paroxysmia

[16][17][18]

+ + +/−

(Induced by hyperventilation)

− −
Vestibular schwannoma[19][20] − + +/− + −
Otitis media[21][22] + − − +/− Increased acute phase reactants
Aminoglycoside toxicity

[23]

+ − − + − −
Central
Brain tumors[24] +/− + + + Cerebral spinal fluid (CSF) may show cancerous cells
  • On CT scan most of the brain tumors appears as a hypodense mass lesions
  • On MRI most of the brain tumors appears as a hypointense or isointense on T1-weighted scans, or hyperintense on T2-weighted MRI.
Cerebellar infarction/hemorrhage + − ++/− − −
  • Based on the time interval between stroke and imaging we may have different presentations
Brain stem ischemia + − +/− − −
  • Based on the time interval between stroke and imaging we may have different presentations
  • For more information click here


Epidemiology and Demographics

  • Adults in the age group of 30 to 60 years are most commonly affected. The incidence of labyrinthitis is around 3.5 cases per 100,000.
  • Viral labyrinthitis, the most common type, is more prevalent in adults, whereas the other types of infections affect the children on a larger scale. This can be assessed by the fact that children under the age of two are more predisposed to develop bacterial labyrinthitis.
  • Bacterial labyrinthitis is overall, less prevalent than other causes.

Risk Factors

Certain conditions can increase the risk of labyrinthitis:

  • Upper respiratory tract infections
  • Infections of the middle ear
  • Meningitis
  • Head injuries
  • Respiratory illnesses like bronchitis
  • Viral infections, like herpes and measles
  • Autoimmune diseases

Natural History, Complications, and Prognosis

  • The symptoms of labyrinthitis usually start suddenly. Occasionally the patient wakes up with these symptoms and they are progressive.
  • There is usually a relief in the symptoms after a few days. Often, the loss of balance is restored in a couple of weeks, but in some cases, it can take longer.
  • In some severe and rare cases, there can be a permanent loss of hearing.
  • Certain factors like cold, previous illnesses, fatigue, menstruation, and respiratory infections can worsen the symptoms.
  • Complications following labyrinthitis includes: labyrinthine fistula, meningitis, cerebellar abscess, mastoiditis etc [25]


Recovery

The recovery from an attack of labyrinthitis follows the following phases:

  1. An acute period, which includes symptoms like vertigo, nausea, and vomiting.
  2. subacute symptoms, which last for a couple of weeks, followed by a rapid recovery
  3. chronic compensation, which extends over a period of a couple of months or even years.

Diagnosis

Diagnostic Study of Choice

Viral labyrinthitis could be a clinical diagnosis. But a variety of diagnostic tests are performed to rule out other diseases. Tests that may rule out other causes of your symptoms include:

  • EEG
  • Electronystagmography, also known as caloric stimulation.
  • CT Scan of the head: to rule out mastoiditis.
  • Temporal bone CT scan: diagnostic techniques in patients with cholesteatoma.
  • Rinne and Weber hearing tests
  • Head MRI
  • Eye test
  • Blood pressure
  • Assessment of balance
  • Culture and sensitivity of the middle ear effusions.
  • Vestibular-evoked myogenic potentials to assess vestibular activity
  • Gadolinium-nuclear magnetic resonance (NMR) imaging[25]

History and Symptoms

Labyrinthitis can be suspected when bone conduction loss co-exists with otitis media[3] Labyrinthitis is characterized by the following symptoms and signs including :

  • Dizziness
  • Vertigo
  • Instability of gait
  • Nausea or vomiting
  • Tinnitus or ringing in the ears
  • Hearing loss particularly of the high-frequency range
  • Nystagmus[25]

Laboratory Findings

Labyrinthitis could be a clinical diagnosis. As a result, routine blood tests don't seem to be helpful in making any diagnosis. However, if systemic infection is suspected, FBC and blood cultures are indicated.

Treatment

Viral labyrinthitis causes a sudden onset of vertigo, nausea, vomiting, and sudden hearing impairment. As we know that the antibiotics are not effective against viruses, we must adopt the symptomatic treatment techniques, including medications for vertigo, antihistaminics, and complete rest. With all these measures, the patient usually feels better in a week or two. Nevertheless, acute episodes can sometimes last for up to months. Apart from that, most people will have a full recovery after an episode of viral labyrinthitis if proper and timely vestibular rehabilitation exercises are adopted.

Bacterial labyrinthitis can be effectively treated with antibiotics preventing long term complications [3]

Certain emergency conditions which warrant immediate medical attention are

  • loss of consciousness
  • Convulsions or seizures
  • Speech abnormalities
  • Fever
  • Weakness
  • Stroke
  • Vision disorders like diplopia

Medical Therapy

Symptomatic patients need treatment with the following:

  • Antihistamines, whic include drugs like desloratadine and loratadine
  • Antivertigo medications, such as meclizine
  • Sometimes we need to give sedatives to the patienst to ensure rest and recovery, such as diazepam
  • Corticosteroids, like prednisone
  • Prochlorperazine is also commonly prescribed, which helps to alleviate symptoms of vertigo and nausea.

As we know that, sometimes an attack or anxiety or panic attack can aggravate the symptoms of labyrnthitis, it becomes imperative to treat an anxiety disorder and/or depression, simultaneously with the medication for otehr symptoms, to treat any vestibular damage. This can be achieved with benzodiazepines like diazepam (Valium); but caution should be taken to avoid long term usage of these drugs due to associated addiction with this class of drugs and their interference with the vestibular system (Solomon and Shepard, 2002). Likewise the efficacy of corticosteroids such as prednisone, to treat early stages of labyrnthitis has been advocated and they are very frequently used for proper recovery, along with some antiviral medication. It should be understood that the treatment should be started as soon as possible to prevent any permanent damage to the inner ear.

Interventions

Apart from medical therapy, we can use several lifestyle techniques to relieve vertigo associated with labyrinthitis:

  • Avoiding sudden or jerky movements or any sudden changes in body position
  • Rest during the attack and avoid any movements
  • Smooth and slow movements when trying to get up from lying
  • Avoiding prolonged exposure to screens, and abstain from bright lights in lieu of an attack
  • Keeping the head still, while sitting in a chair
  • Stress management techniques, to mitigate and factors which can aggravate the anxiety or stressors
  • Warm compresses can be used to bring relief from the pain
  • Avoiding smoking and limiting the intake of alcohol

Primary Prevention

  • Resting in a cool dark place, if experiencing any symptoms like dizziness or vertigo
  • Drinking plenty of fluids and adequate hydration
  • Avoiding loud noises and exposure to bright lights which can aggravate the symptoms
  • Adequate sleep, as lack of sleep can bring on an attack

Secondary Prevention

  • Implementation of therapies to allow rehabilitation and improve balance, like physical and occupational therapy
  • Vestibular rehabilitation: This includes various exercises performed under the supervision of a trained physiotherapist, which helps to improve the gait, movements, and functionality. It substantially reduces any residual symptoms from the attack of labyrinthitis. It helps with balancing and makes everyday activities easier.


See also

References

  1. ↑ Karmody CS (December 1983). "Viral labyrinthitis: early pathology in the human". Laryngoscope. 93 (12): 1527–33. doi:10.1288/00005537-198312000-00001. PMID 6606097.
  2. ↑ Brill GC (January 1982). "Acute labyrinthitis: a possible association with influenza". J R Coll Gen Pract. 32 (234): 47–50. PMC 1970972. PMID 7086745.
  3. ↑ 3.0 3.1 3.2 3.3 Jang CH, Park SY, Wang PC (February 2005). "A case of tympanogenic labyrinthitis complicated by acute otitis media". Yonsei Med. J. 46 (1): 161–5. doi:10.3349/ymj.2005.46.1.161. PMC 2823044. PMID 15744821.
  4. ↑ Thompson TL, Amedee R (2009). "Vertigo: a review of common peripheral and central vestibular disorders". Ochsner J. 9 (1): 20–6. PMC 3096243. PMID 21603405.
  5. ↑ 5.0 5.1 Dubrulle F, Kohler R, Vincent C, Puech P, Ernst O (2010). "Differential diagnosis and prognosis of T1-weighted post-gadolinium intralabyrinthine hyperintensities". Eur Radiol. 20 (11): 2628–36. doi:10.1007/s00330-010-1835-2. PMID 20862477.
  6. ↑ Lee SH, Kim JS (June 2010). "Benign paroxysmal positional vertigo". J Clin Neurol. 6 (2): 51–63. doi:10.3988/jcn.2010.6.2.51. PMC 2895225. PMID 20607044.
  7. ↑ Chang MB, Bath AP, Rutka JA (October 2001). "Are all atypical positional nystagmus patterns reflective of central pathology?". J Otolaryngol. 30 (5): 280–2. PMID 11771020.
  8. ↑ Dorresteijn PM, Ipenburg NA, Murphy KJ, Smit M, van Vulpen JK, Wegner I, Stegeman I, Grolman W (June 2014). "Rapid Systematic Review of Normal Audiometry Results as a Predictor for Benign Paroxysmal Positional Vertigo". Otolaryngol Head Neck Surg. 150 (6): 919–24. doi:10.1177/0194599814527233. PMID 24642523.
  9. ↑ Mandalà M, Nuti D, Broman AT, Zee DS (February 2008). "Effectiveness of careful bedside examination in assessment, diagnosis, and prognosis of vestibular neuritis". Arch. Otolaryngol. Head Neck Surg. 134 (2): 164–9. doi:10.1001/archoto.2007.35. PMID 18283159.
  10. ↑ Watanabe, Isamu (1980). "Ménière's Disease". ORL. 42 (1–2): 20–45. doi:10.1159/000275477. ISSN 1423-0275.
  11. ↑ Saeed SR (January 1998). "Fortnightly review. Diagnosis and treatment of Ménière's disease". BMJ. 316 (7128): 368–72. PMC 2665527. PMID 9487176.
  12. ↑ Dürrer, J.; Poláčková, J. (1971). "Labyrinthine Concussion". ORL. 33 (3): 185–190. doi:10.1159/000274994. ISSN 1423-0275.
  13. ↑ Choi MS, Shin SO, Yeon JY, Choi YS, Kim J, Park SK (April 2013). "Clinical characteristics of labyrinthine concussion". Korean J Audiol. 17 (1): 13–7. doi:10.7874/kja.2013.17.1.13. PMC 3936518. PMID 24653897.
  14. ↑ Lempert T, von Brevern M (February 2005). "Episodic vertigo". Curr. Opin. Neurol. 18 (1): 5–9. PMID 15655395.
  15. ↑ Watson SR, Halmagyi GM, Colebatch JG (February 2000). "Vestibular hypersensitivity to sound (Tullio phenomenon): structural and functional assessment". Neurology. 54 (3): 722–8. PMID 10680810.
  16. ↑ Hufner, K.; Barresi, D.; Glaser, M.; Linn, J.; Adrion, C.; Mansmann, U.; Brandt, T.; Strupp, M. (2008). "Vestibular paroxysmia: Diagnostic features and medical treatment". Neurology. 71 (13): 1006–1014. doi:10.1212/01.wnl.0000326594.91291.f8. ISSN 0028-3878.
  17. ↑ Strupp M, von Stuckrad-Barre S, Brandt T, Tonn JC (February 2013). "Teaching neuroimages: Compression of the eighth cranial nerve causes vestibular paroxysmia". Neurology. 80 (7): e77. doi:10.1212/WNL.0b013e318281cc2c. PMID 23400324.
  18. ↑ Hüfner K, Barresi D, Glaser M, Linn J, Adrion C, Mansmann U, Brandt T, Strupp M (September 2008). "Vestibular paroxysmia: diagnostic features and medical treatment". Neurology. 71 (13): 1006–14. doi:10.1212/01.wnl.0000326594.91291.f8. PMID 18809837.
  19. ↑ Robert W. Foley, Shahram Shirazi, Robert M. Maweni, Kay Walsh, Rory McConn Walsh, Mohsen Javadpour & Daniel Rawluk (2017). "Signs and Symptoms of Acoustic Neuroma at Initial Presentation: An Exploratory Analysis". Cureus. 9 (11): e1846. doi:10.7759/cureus.1846. PMID 29348989. Unknown parameter |month= ignored (help)
  20. ↑ E. P. Lin & B. T. Crane (2017). "The Management and Imaging of Vestibular Schwannomas". AJNR. American journal of neuroradiology. 38 (11): 2034–2043. doi:10.3174/ajnr.A5213. PMID 28546250. Unknown parameter |month= ignored (help)
  21. ↑ "Ear infection - acute: MedlinePlus Medical Encyclopedia".
  22. ↑ Rettig E, Tunkel DE (2014). "Contemporary concepts in management of acute otitis media in children". Otolaryngol. Clin. North Am. 47 (5): 651–72. doi:10.1016/j.otc.2014.06.006. PMC 4393005. PMID 25213276.
  23. ↑ Ernfors P, Duan ML, ElShamy WM, Canlon B (April 1996). "Protection of auditory neurons from aminoglycoside toxicity by neurotrophin-3". Nat. Med. 2 (4): 463–7. PMID 8597959.
  24. ↑ Dunniway, Heidi M.; Welling, D. Bradley (2016). "Intracranial Tumors Mimicking Benign Paroxysmal Positional Vertigo". Otolaryngology–Head and Neck Surgery. 118 (4): 429–436. doi:10.1177/019459989811800401. ISSN 0194-5998.
  25. ↑ 25.0 25.1 25.2 Maranhão AS, Godofredo VR, Penido Nde O (2016). "Suppurative labyrinthitis associated with otitis media: 26 years' experience". Braz J Otorhinolaryngol. 82 (1): 82–7. doi:10.1016/j.bjorl.2014.12.012. PMID 26718959.
  • Bronstein A (2002), Visual and psychological aspects of vestibular disease, Current Opinion in Neurology 2002, 15:1–3.
  • Simon NM, Pollack MH, Tuby KS et al (1998), Dizziness and panic disorder: a review of the association between vestibular dysfunction and anxiety, Ann Clin Psychiatry, 10(2):75–80.
  • Solomon D and Shepard NT (2002), Chronic Dizziness, Current Treatment Options in Neurology, 4:281–288.
  • Staab J and Ruckenstein M (2005), Chronic Dizziness and Anxiety, Arch Otolaryngol Head Neck Surg, 131:675-679.

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