Labyrinthitis

Labyrinthitis
ICD-10	H83.0
ICD-9	386.3
DiseasesDB	29290
MeSH	C09.218.568.315

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List of terms related to Labyrinthitis

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Aditya Ganti M.B.B.S. [2]

Synonyms and keywords: Otitis interna, vestibular neuronitis, vestibular neuritis

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 .

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.

• Bacterial labyrinthitis: This is second most common after viral infections, often, occurring as a complication of infection in the middle ear,(otitis media). 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 less common than others.

• Conditions causing damage to the cochlea inside your inner ear like meningitis, circulatory problems, or Ménière’s disease.

Differential diagnosis

Conditions which mimic Labyrinthitis are:

• Meniere's disease
• Migraine headache
• Stroke
• Intracranial hemorrage
• Damage to the vascular structures in the neck
• Benign paroxysmal positional vertigo
• Brain tumor

Epidemiology and Demographics

• Most cases occur in adults aged 30 to 60 years old. This incidence is about 3.5 cases per 100,000
• Viral labyrinthitis is relatively common in adults. Other types of ear infections are usually more widespread in children.
• Bacterial labyrinthitis is much less common.
• Younger children under two years old are more vulnerable to developing bacterial labyrinthitis.

Risk Factors

Certain conditions can increase the risk of labyrinthitis:

• Upper respiratory infections
• Middle ear infections
• Meningitis
• Head injuries
• Respiratory illnesses, such as bronchitis
• Viral infections, including herpes and measles
• Autoimmune conditions

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 often ease after a few days.
• People usually get their balance back over 2 to 6 weeks, although it can take longer.
• In very rare cases, hearing loss is permanent.

Certain factors that worsen the symptoms include:

• Colds or illness
• Tiredness
• Menstruation

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.

Recovery from a permanently damaged inner ear typically follows three phases:

1. An acute period, which may include severe vertigo and vomiting
2. approximately two weeks of ssubacute symptoms and rapid recovery
3. finally a period of chronic compensation which may last for months or years.

Diagnosis

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:

• EEG (measures the electrical activity of the brain)
• Electronystagmography, and warming and cooling the inner ear with air or water to test eye reflexes (caloric stimulation)
• Head CT scan
• Hearing test
• MRI of the head

History and Symptoms

Labyrinthitis is characterized by following symptoms and signs including :

• Dizziness
• Vertigo
• Loss of balance/gait instability
• Nausea and vomiting
• Tinnitus
• Loss of hearing in the high-frequency range
• Difficulty focusing your eyes

Physical Examination

• Hearing tests
• Eye test
• Blood pressure
• Assessment of balance

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

Diagnostic Studies and Imaging Findings

• A CT scan can help rule out mastoiditis.

• 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

• Perform culture and sensitivity testing of middle ear effusions if present

• Vestibular function testing like Caloric testing and an electronystagmogram may be used

• 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
• Weakness
• Paralysis
• Double vision

Medical Therapy

Symptomatic patients need treatment with the following:

• Antihistamines, like desloratadine and loratadine
• Drugs that can reduce dizziness and nausea, such as meclizine
• Sedatives, such as diazepam
• Corticosteroids, such as prednisone
• Over-the-counter antihistamines, such as fexofenadine, diphenhydramine, or loratadine

Prochlorperazine is commonly prescribed to help alleviate the symptoms of vertigo and nausea.

Because anxiety interferes with the balance compensation process, it is important to treat an anxiety disorder and/or 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).

Evidence suggests that 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 techniques to relieve vertigo associated with labyrinthitis:

• Avoid quick or sudden movements or brisk changes in position
• 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

• Rest in a dark room if feeling dizzy
• Plenty of fluids, drink little quantities and often
• Avoid loud noise and bright lights
• Get adequate sleep

Secondary Prevention

• Physical and occupational therapy to help improve balance.
• 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.

See also

• Balance disorder
• Dizziness
• Vestibular system
• Vertigo

References

• 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.

External links

• My personal battle with Labyrinthitis How Ryan Roper overcame the condition.
• DizzyTimes.com
• Dr. Rauch's Online Otology Clinic — video clips
• Labyrinthitis.co.uk
• Labyrinthitis.org.uk
• Vestibular neuritis and labyrinthitis
• neuro/686 at eMedicine - "Labyrinthitis and related conditions"
• ent/666 at eMedicine - "Vestibular rehabilitation therapy"
• Inner ear healthboard
• The Dizzy Lounge
• Labyrinthitis Support Forums
• Labyrinthitis and vestibular neuritis