Labyrinthitis

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

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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 balance disorder. It is an inflammatory process affecting the labyrinths that house the vestibular system (which sense changes in head position) of the inner ear. The labyrinth is made up of fluid-filled channels controlling the balance and hearing. On movement of the head, the fluid in the channels move and this transmits the electrical signals to the brain. This information helps the body to balance. Hearing is controlled by the part of the labyrinth known as the cochlea. When the organs of balance in an ear are inflamed the information sent to the brain will be different from the unaffected ear. This varied information can make a person feel dizzy. The hearing may also be affected if this part of the inner ear is also inflamed .

In addition to balance control problems, a labyrinthitis patient may encounter hearing loss and tinnitus. Labyrinthitis is caused by a virus, but it can also arise from bacterial infection, head injury, an allergy or as a reaction to a particular medicine. Both bacterial and viral labyrinthitis can cause permanent hearing loss, although this is rare.

Labyrinthitis often follows an upper respiratory tract infection (URI). It is also known as Vestibular neuritis, vestibular neuronitis, neuro labyrinthitis, and acute peripheral vestibulopathy . Usually, it follows a short term course associated with vertigo, nausea, vomiting, and gait impairment. It is a self-limited disorder, with acute short term symptoms with complete recovery in most patients.

Labyrinthitis and vertigo

A prominent and debilitating symptom of labyrinthitis is chronic dizziness. The vestibular system is a sensory input consisting of three semicircular canals, sensing changes in rotational motion, and the otoliths, sensing changes in linear motion. The brain combines visual cues with sensory input from the vestibular system to determine adjustments required to retain balance. When working properly, the vestibular system also relays information on the head movement to the eye muscle, forming the vestibulo-ocular reflex, in order to retain continuous visual focus during motion. When the vestibular system is affected by labyrinthitis, rapid, undesired eye motion (nystagmus), often results from the improper indications of rotational motion. Nausea, anxiety, and a general ill feeling are common due to the distorted balance signals that the brain receives from the inner ear.

Labyrinthitis and anxiety

Chronic anxiety is a common side effect of labyrinthitis which can produce tremors, heart palpitations, panic attacks, and depression. Often a panic attack is one of the first symptoms to occur as labyrinthitis begins. While dizziness can occur from extreme anxiety, labyrinthitis itself can precipitate a panic disorder. Three models have been proposed to explain the relationship between vestibular dysfunction and panic disorder (Simon et al., 1998):

• Psychosomatic model: vestibular dysfunction which occurs as a result of anxiety.

• Somatopsychic model: panic disorder triggered by misinterpreted internal stimuli (e.g., stimuli from vestibular dysfunction), that are interpreted as signifying imminent physical danger. Heightened sensitivity to vestibular sensations leads to increased anxiety and, through conditioning, drives the development of the panic disorder.

• Network alarm theory: panic which involves noradrenergic, serotonergic, and other connected neuronal systems. According to this theory, panic can be triggered by stimuli that set off a false alarm via afferents to the locus ceruleus, which then triggers the neuronal network. This network is thought to mediate anxiety and includes limbic, midbrain, and prefrontal areas. Vestibular dysfunction in the setting of increased locus ceruleus sensitivity may be a potential trigger.

Classification

• Viral labyrinthitis: These are usually linked to an upper respiratory tract viral infection, such as a cold or flu. But many other viruses including the varicella-zoster virus (that causes shingles), and the mumps, measles, and rubella viruses may cause them.

• Bacterial labyrinthitis: This occurs as a complication of a middle ear infection (otitis media) or meningitis caused by bacteria. These are more common in children than in adults.

• 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.

Causes

Viral Labyrinthitis This form of infection is more common than bacterial. Viruses causing this include measles, mumps,influenza, hepatitis, and certain types of herpes viruses that cause cold sores, chickenpox, or shingles .

Bacteria can cause the inflammation of the inner ear, after entering through the oval or round windows, after any middle ear infection, causing sudden unilateral hearing loss, nystagmus, and vertigo. Treatment with antibiotics is usually successful in managing bacterial labyrinthitis and most recover fully.

Differential diagnosis

Conditions which mimic Labyrinthitis are:

• Meniere's disease
• Migraine
• Small stroke
• Brain hemorrhage
• Damage to the neck arteries
• 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