What are the main types of inner ear infections. How do labyrinthitis and vestibular neuritis differ in symptoms. What treatments are available for inner ear infections. How do inner ear infections affect children differently than adults.

Understanding Inner Ear Infections: Labyrinthitis and Vestibular Neuritis

Inner ear infections can significantly impact a person’s hearing and balance, often occurring as a result of a cold, flu, or the spread of a middle ear infection. These infections primarily affect the deepest part of the human ear, which is responsible for converting sound waves into nerve impulses and maintaining balance.

There are two main types of inner ear infections:

• Labyrinthitis
• Vestibular neuritis

Labyrinthitis: Inflammation of the Inner Ear Maze

Labyrinthitis is characterized by inflammation of the labyrinth, a complex network of fluid-filled channels in the inner ear. This condition can be caused by either viral or bacterial infections, with viral infections being more common. Labyrinthitis primarily affects adults between 30 and 60 years of age and is twice as prevalent in females as in males.

Vestibular Neuritis: Infection of the Balance Nerve

Vestibular neuritis involves the inflammation of the vestibular nerve, which plays a crucial role in detecting balance by transmitting signals from the inner ear to the brain. This condition is often preceded by or accompanies a viral infection, with the reactivation of the herpes simplex virus being a likely cause.

Recognizing the Symptoms of Inner Ear Infections

While both labyrinthitis and vestibular neuritis share some common symptoms, there are key differences that can help distinguish between the two conditions.

Symptoms of Labyrinthitis

Labyrinthitis symptoms typically appear suddenly and without warning. They may include:

• Vertigo
• Nausea
• Vomiting
• Tinnitus
• Hearing loss or impairment

These symptoms can be severe and may persist for several days, often resolving on their own within 1-2 weeks. However, in some cases, treatment may be necessary if symptoms persist for an extended period.

Symptoms of Vestibular Neuritis

Vestibular neuritis symptoms typically develop within hours and reach their peak intensity within the first 1-2 days. Common symptoms include:

• Vertigo
• Nausea
• Vomiting
• Balance problems

Unlike labyrinthitis, vestibular neuritis does not typically cause hearing loss. Symptoms are often constant and tend to worsen with head movements. While the condition usually resolves within several days, in rare cases, it may take weeks or months for symptoms to disappear entirely.

Diagnosing Inner Ear Infections: A Comprehensive Approach

Diagnosing inner ear infections requires a thorough evaluation by a healthcare professional. The diagnostic process may involve several steps to accurately identify the type and severity of the infection.

Medical History and Physical Examination

The first step in diagnosing an inner ear infection is a comprehensive review of the patient’s medical history and a physical examination. The healthcare provider will inquire about the onset and duration of symptoms, any recent illnesses, and other relevant factors that may contribute to the condition.

Balance and Hearing Tests

To assess the extent of balance and hearing impairment, the healthcare provider may conduct various tests, including:

• Electronystagmography (ENG) or videonystagmography (VNG) to evaluate eye movements and vestibular function
• Audiometry to assess hearing ability
• Posturography to evaluate balance and postural control

Imaging Studies

In some cases, imaging studies may be necessary to rule out other conditions or complications. These may include:

• Magnetic Resonance Imaging (MRI) to visualize the inner ear structures and surrounding tissues
• Computed Tomography (CT) scan to assess the bony structures of the inner ear

Treatment Options for Inner Ear Infections

The treatment approach for inner ear infections depends on the underlying cause, severity of symptoms, and individual patient factors. While many cases resolve on their own, medical intervention may be necessary in some instances.

Medications for Symptom Relief

Several medications can help alleviate the symptoms associated with inner ear infections:

• Antivertigo medications (e.g., meclizine) to reduce dizziness and vertigo
• Antiemetics to control nausea and vomiting
• Corticosteroids to reduce inflammation
• Antiviral medications for suspected viral infections
• Antibiotics for confirmed bacterial infections (rare in inner ear infections)

Vestibular Rehabilitation Therapy

Vestibular rehabilitation therapy is a specialized form of physical therapy that can help patients improve balance and reduce dizziness. This therapy involves exercises designed to:

• Strengthen the vestibular system
• Improve gaze stability
• Enhance balance and coordination
• Reduce fall risk

Home Remedies and Lifestyle Modifications

In addition to medical treatments, several home remedies and lifestyle changes can support recovery from inner ear infections:

• Rest and avoiding sudden movements
• Staying hydrated
• Avoiding alcohol and caffeine
• Using a cold or warm compress to alleviate discomfort
• Practicing relaxation techniques to manage stress and anxiety

Inner Ear Infections in Children: Special Considerations

While inner ear infections are less common in children compared to middle ear infections, they can still occur and may present unique challenges.

Bacterial Meningitis and Inner Ear Infections

Children who have had bacterial meningitis are at risk of developing inner ear infections. Approximately 20% of children with bacterial meningitis experience hearing problems or issues with balance and dizziness.

Cochlear Ossification: A Potential Complication

Cochlear ossification is a condition where bone begins to replace the lymph fluids in the cochlea of the inner ear following an infection or surgery. This can lead to significant hearing impairment. Recent research suggests that cochlear implantation surgery may be a successful treatment option for children who have experienced cochlear ossification.

Hearing Tests and Monitoring

Due to the risk of hearing loss, doctors often perform hearing tests on young children who have recovered from bacterial labyrinthitis. In cases of severe hearing loss, cochlear implants may be considered as a treatment option.

Risk Factors and Prevention of Inner Ear Infections

Understanding the risk factors associated with inner ear infections can help in developing preventive strategies and early intervention.

Common Risk Factors

Several factors may increase the likelihood of developing an inner ear infection:

• Recent upper respiratory infections
• History of allergies
• Smoking or exposure to secondhand smoke
• Stress and fatigue
• Certain autoimmune disorders

Preventive Measures

While not all inner ear infections can be prevented, certain steps can help reduce the risk:

• Practicing good hand hygiene to prevent viral infections
• Managing allergies effectively
• Quitting smoking and avoiding exposure to secondhand smoke
• Maintaining a healthy diet and exercise routine to support overall immune function
• Managing stress through relaxation techniques and adequate sleep

Long-term Outlook and Potential Complications

The prognosis for most inner ear infections is generally favorable, with many cases resolving without long-term consequences. However, it’s important to be aware of potential complications and long-term effects.

Recovery Timeline

The recovery period for inner ear infections can vary:

• Acute symptoms typically improve within 1-2 weeks
• Some patients may experience residual dizziness or balance issues for several weeks or months
• In rare cases, symptoms may persist or recur, requiring ongoing management

Potential Complications

While uncommon, some patients may experience complications from inner ear infections:

• Permanent hearing loss
• Chronic balance problems
• Benign paroxysmal positional vertigo (BPPV)
• Anxiety or depression related to chronic symptoms

Long-term Management

For patients with persistent or recurrent symptoms, long-term management strategies may include:

• Ongoing vestibular rehabilitation therapy
• Regular hearing and balance assessments
• Lifestyle modifications to minimize symptom triggers
• Psychological support for coping with chronic symptoms

Understanding the intricacies of inner ear infections, from their causes and symptoms to treatment options and long-term outlook, is crucial for effective management and improved quality of life. By recognizing the signs early and seeking appropriate medical care, patients can minimize the impact of these conditions and achieve optimal outcomes. As research in this field continues to advance, new treatment modalities and preventive strategies may emerge, offering hope for those affected by inner ear infections.

Definition, symptoms, treatment, and more

Inner ear infections can cause certain parts of the inner ear to become inflamed. These infections can affect a person’s hearing and balance. They often occur when a person has a cold or the flu or if a middle ear infection spreads into the inner ear.

The inner ear is the deepest part of the human ear. It sits at the end of the ear tubes. It is the part of the ear that turns sound waves into nerve impulses. It also plays an important role in helping a person balance.

Inner ear infections can cause the structures of the inner ear to become inflamed, which can lead to a number of symptoms. These include nausea, dizziness, a sensation of imbalance, and hearing impairments.

This article explores types of inner ear infections, looking at their symptoms, causes, diagnosis, treatment options, and home remedies. It also looks at risk factors, complications, and inner ear infections in children.

There are two main types of inner ear infections: labyrinthitis and vestibular neuritis. The following sections will look at these in more detail.

Labyrinthitis

Labyrinthitis is a viral or bacterial infection of the inner ear. It causes inflammation of the labyrinth, which is the maze of fluid-filled channels in the inner ear.

This inflammation can disrupt the transmission of sensory information from the inner ear to the brain. It is this disruption that can cause some of the symptoms of labyrinthitis.

Viral infections are the most common causes of labyrinthitis. Viral labyrinthitis is most common in adults aged 30–60 years. It is also twice as common in females as in males.

Labyrinthitis often follows more common illnesses, such as a common cold or the flu. In some instances, a bacterial infection can cause labyrinthitis.

Vestibular neuritis

Vestibular neuritis is an infection of the vestibular nerve. This nerve sits in the inner ear and plays a role in detecting balance by sending signals from the inner ear to the brain.

Vestibular neuritis causes this nerve to become inflamed, which can cause symptoms such as vertigo and nausea.

This infection often comes before or alongside a viral infection. According to an older article from 2009, the reactivation of a herpes simplex virus is a likely cause of vestibular neuritis.

Doctors consider vestibular neuritis to be a benign condition that tends to last for a short period of time before going away without treatment. It can also be a sequela, which is a condition that arises as the consequence of a previous disease or injury.

The different types of inner ear infections often have similar symptoms. The main difference between the symptoms is that hearing loss occurs with labyrinthitis but not with vestibular neuritis. Learn more about symptoms in the sections below.

Labyrinthitis

Labyrinthitis symptoms can appear suddenly and without warning. Common symptoms of labyrinthitis include:

• vertigo
• nausea
• vomiting
• tinnitus
• hearing loss or impairment

These symptoms may last for several days and be quite severe. They often disappear on their own after 1–2 weeks. However, if the problem lasts for a longer period of time, the person may require treatment for their symptoms.

Vestibular neuritis

A person who has vestibular neuritis may experience some of the following symptoms:

• vertigo
• nausea
• vomiting
• problems with balance

Vestibular neuritis symptoms often develop within hours and peak within the first 1–2 days. They are often constant and tend to worsen with head movements.

This condition usually lasts for several days. After this period, the symptoms often disappear with no intervention necessary. However, on some rare occasions, it can take weeks or months for the symptoms to disappear entirely.

Inner ear infections are most common among people aged 30–60 years. They are much less common in children when compared with middle ear infections.

Children may develop an inner ear infection as a result of having bacterial meningitis. Around 20% of children with bacterial meningitis develop hearing problems or issues with balance and dizziness.

Cochlear ossification can also be an issue in children after meningitis. This occurs when bone begins to replace the lymph fluids filling the cochlea of the inner ear after a surgery or infection.

Recent research suggests that cochlear implantation surgery can be a successful treatment option for those who have experienced cochlear ossification.

Because of the risk of deafness, a doctor will often carry out a hearing test in young children who have recovered from bacterial labyrinthitis. They may choose to treat severe hearing loss with a cochlear implant.

A cochlear implant is a small electrical device that does not cure deafness but helps deaf people have a useful representation of sounds to help them better understand speech.

There are multiple reasons that someone may or may not be a suitable candidate for cochlear implantation. Timing also plays an important role. Since labyrinthitis ossificans can begin soon after meningitis and worsen over time, early implementation is the best approach to prevent further complications.

In some rare instances, a doctor may use antiviral medications or antibiotics to treat the virus or bacteria, respectively, that caused the inner ear infection. However, they will often only treat the symptoms of inner ear infections, not the infection itself.

A person may take antihistamines or benzodiazepines to treat vertigo. Antihistamines can also help ease nausea and dizziness.

Over-the-counter (OTC) antihistamines include fexofenadine (Allegra), diphenhydramine (Benadryl), and loratadine (Claritin).

A doctor may also recommend antiemetics, such as prochlorperazine, to help control nausea and vomiting, or a vestibular suppressant such as Meclizine. It is also common for doctors to prescribe steroids to treat inflammation.

Anyone can develop an inner ear infection. However, there are some factors that can increase a person’s risk of developing one. These include:

• contracting an upper respiratory infection, such as a common cold or the flu
• having a middle ear infection
• contracting meningitis
• sustaining a head injury
• having a respiratory illness, such as bronchitis
• having a viral infection, such as herpes or measles
• having an autoimmune condition

A person’s risk of permanent inner ear damage is low. However, severe inner ear infections can cause permanent damage to different parts of the inner ear.

Permanent damage to parts of the inner ear can cause varying degrees of hearing loss as well as balance problems.

Another possible complication of severe inner ear infections is BPPV. This is a type of vertigo that results from sudden head movements.

BPPV is not a life threatening condition, but it can increase a person’s risk of falling over, which may lead to other injuries. BPPV can also cause serious discomfort and limit physical activity.

A doctor may be able to diagnose an inner ear infection with a balance examination. They may also carry out a complete examination that includes a neurological assessment.

Both the balance examination and the neurological assessment are key, as it is not possible to detect an inner ear infection just by looking inside the ear with an otoscope.

Both labyrinthitis and vestibular neuritis share symptoms with a number of other conditions. A doctor may carry out tests to rule out these other conditions, which include:

• Meniere’s disease
• migraine
• stroke
• a brain hemorrhage
• damaged neck arteries
• BPPV
• a brain tumor

In order to check for these conditions, a doctor may carry out one of the following tests:

• hearing tests
• blood tests
• a CT scan
• an MRI scan
• an electroencephalogram
• electronystagmography

A person should contact a doctor as soon as symptoms of an inner ear infection appear.

Despite these infections often resolving without treatment, it is still important that a doctor determines the cause of the condition. Early diagnosis can help prevent complications and lasting hearing damage.

Inner ear infections cause certain parts of the inner ear to become inflamed. They commonly occur when a person has a cold or the flu or if a middle ear infection spreads into the inner ear.

The main two types of inner ear infections are labyrinthitis and vestibular neuritis. Both of these inner ear infections can cause a number of symptoms, including vertigo, dizziness, and nausea. A person with labyrinthitis may also experience hearing issues.

Inner ear infections often go away without treatment after a period of time. However, a doctor may prescribe medication to treat the symptoms of the infection.

A person should contact a doctor as soon as symptoms of an inner ear infection appear. This is because early diagnosis can rule out more serious conditions and prevent lasting ear damage.

Inner Ear Infection (Labyrinthitis / Vestibular Neuritis)

Written by: Jade Poole

Reviewed by: Dr Tamlyn Maree

• Inner Ear Infection (Labyrinthitis)
• What are the types of labyrinthitis?
• What are the symptoms of labyrinthitis?
• What causes labyrinthitis?
• How is labyrinthitis diagnosed?
• What is the treatment for labyrinthitis?
• Outlook for labyrinthitis
• Answers to inner ear infection (Labyrinthitis) FAQs

What is labyrinthitis?

If you’ve recently been diagnosed with an inner ear infection (medically termed labyrinthitis), the first thought going through your mind may have been that you didn’t even know you had an inner ear. And if you did, you may not have known that the inner ear, when infected, causes a medical condition that can you leave you feeling quite ill. 

Your inner ear is the section between the oval window and the round window (membranes covering the entrance to the middle ear) and the eardrum. Your middle ear is responsible for transmitting sounds from your outer ear to your inner ear. Your inner ear plays a vital part in hearing as it converts nerve impulses from the fluid inside of it and sends these to the brain.

So, now that you know that you have an inner ear and exactly where it is, let’s look at what it means to have an infection of the inner ear (labyrinthitis). 

The labyrinth is the spiral-like cavity of the inner ear that is made up of two sections, the vestibular system which is responsible for balance and movement, and the cochlea which facilitates hearing. When this part of the ear develops an infection, it will become inflamed and swollen and your hearing and balance can be affected.

The result of this inflammation is often a sudden surge of vertigo, one of the primary symptoms of an inner ear infection. When you experience vertigo, you may feel dizzy, disorientated, hear a ringing noise in your ears or experience difficulty in hearing or even a temporary loss of hearing. It is also not uncommon to feel as though you are on a boat that is rocking to and fro on the ocean and experience nausea and vomiting associated with this, even though in reality, you are not moving.

Vertigo associated with an inner ear infection can last from a few days to a few weeks, and in more severe cases it can take months to resolve. The inflammation that causes this symptom tends to disappear on its own. The typical treatment for vertigo is to rest until you can either teach your body to deal with it a little better or until it resolves completely. Sedatives and antihistamines are normally given as a treatment for vertigo.

When all of this happens, your doctor may refer to the condition as either labyrinthitis or vestibular neuronitis, depending on the particular symptoms you are exhibiting. The two infections generally have similar symptoms and treatment as they both involve inflammation of the vestibular nerve, however, labyrinthitis includes a loss of hearing which vestibular neuronitis doesn’t. 

When the labyrinth is inflamed, it can often be painful as the build-up of fluid in the inner ear creates pressure and pain. However, it is not yet known how labyrinthitis can be prevented.

Vestibular neuronitis and labyrinthitis are often triggered by a cold, flu or upper respiratory infection and as such, are viral in nature. Other infections such as mumps, measles or glandular fever are less common causes of viral labyrinthitis.

The condition can, however, sometimes be linked to a bacterial cause, although this is not as common. When this does occur, these cases are more frequently found in children and are often serious. Bacteria can gain access to the ear if the thin membranes that separate the middle and inner are broken, causing a bacterial infection. This often happens when suffering from a middle ear infection or due to meningitis which infects the lining of the brain.

**My Med Memo – Vestibular neuronitis refers to the inflammation of a nerve, whereas vestibular neuritis refers to the inflammation of more than one nerve. The two terms are often used interchangeably, however, neuronitis is the correct term in the case of an inner ear infection.  

Symptoms and signs of labyrinthitis, myths about the disease

Labyrinthitis is an inflammation of the inner ear, in which the labyrinth is located, consisting of channels filled with fluid.

This organ is responsible for the reception of sounds and their transformation into nerve impulses. When pathogenic microflora gets inside the ear, an infection develops. The disease causes hearing impairment and can be complicated by meningitis, therefore, at the first suspicion of infection of the inner ear, it is necessary to go to an ENT doctor.

Symptoms and signs

Symptoms of inflammation of the inner ear :

• dizziness, gag reflex, nausea;
• impaired coordination of movements;
• headaches, tinnitus, hearing loss;
• nystagmus.

Relapse may occur, so the patient must be careful while driving or working at height.

Causes of disease

Often, the causes of an emerging illness remain unclear. Experts believe that labyrinthitis is caused by pathogenic microorganisms that cause influenza, or viruses that provoke SARS. The disease may occur for other reasons:

• head trauma;
• allergies;
• frequent drinking;
• benign tumor;
• taking drugs in unlimited dosage.

Pathogenic microbes damage the labyrinth of the inner ear and its septum. Blood production rises and edema appears, provoking a serous infection. Pathogenic flora destroys the bone walls inside the ear, which can infect the tissues of the brain and blood vessels. When infected, there is a restriction to the bone shaft, then the disease is called limited labyrinthitis.

Types of disease and possible routes of infection

According to structural changes, several types of disease are distinguished.

1. Serous labyrinthitis. The channels of the labyrinth are intensively filled with liquid, intra-labyrinth pressure increases.
2. Purulent inflammation. The disease is caused by microbes, due to which the channels of the labyrinth are filled with pus. Labyrinthitis is severe and prone to chronic development.
3. Necrotic lesion. In connection with such an infection, the bone tissue of the inner ear breaks down, which affects hearing and the vestibular apparatus. Usually the disease develops during scarlet fever.

Depending on the cause, the following variants of infection of the inner ear are distinguished:

The most common type of labyrinthitis is viral. This disease begins to develop in people over 30 years of age. In childhood, inflammation of the inner ear is rare.

Infants under 2 years of age may develop purulent infections caused by meningitis. If the disease in children is not caused by meningococci, then its course is favorable.

Risk factors for inflammatory processes in the ears

Serous inflammation without complications does not pose a threat to human health and life, it ends in recovery. Diffuse purulent inflammation with necrotic complication has a negative effect on auditory perception and the vestibular apparatus. Inflammation of the middle ear, if left untreated, can be aggravated by infection of the inside of the hearing organ.

In case of ENT infection of the inner ear, the following risk factors are manifested:

• dizziness, nausea, vomiting;
• meningitis;
• relapses – hearing loss;
• sepsis;
• Meniere’s disease.

In severe cases, the disease can be fatal, so if you have labyrinthitis, you need to quickly consult a doctor.

When should I see a doctor?

Patients should make an appointment with an otolaryngologist if symptoms of the disease appear:

• severe vomiting;
• earache, fever, hearing loss;
• headache and spinning for more than 2 hours;
• impaired speech, bifurcation, dysfunction of the muscles of the face and skeleton;
• damage to the head or ear.

Diagnosis of labyrinthitis in patients

Timely diagnosis of labyrinthitis makes it possible to get rid of the disease. At the appointment, the ENT collects an anamnesis of the disease, is interested in how long ago its first signs appeared. The doctor asks about past infections and medications that the patient has taken. The ENT together with the neurologist examine the patient, do an otoscopy and evaluate the hearing. If necessary, the specialist prescribes additional methods – CT or MRI of the skull. When performing a diagnosis, it is important to rule out stroke or coronary heart disease.

Myths and dangerous misconceptions

A dangerous misconception is the belief that the pain will go away on its own or after taking drugs that stop the pain syndrome. The disease has serious consequences. If the purulent inflammation that affects the labyrinth of the ear progresses, then the person can become completely deaf.

The disease is treated at home – a myth that leads to disastrous consequences.

Disease prevention

Prevention of labyrinthitis by applying precautions:

• protect ears and head from injury;
• timely treat acute, otitis media and other diseases;
• to go to the ENT on time when the first symptoms appear.

In case of pathological changes in the ear and imbalance, it is recommended to consult an otolaryngologist.

MC Nevro-Med. Dizziness.

D. Labyrinthitis

1. Bacterial labyrinthitis. In a bacterial infection of the middle ear or mastoid process (eg, chronic otitis media), bacterial toxins can cause inflammation of the inner ear structures (serous labyrinthitis). Initially, symptoms may be minimal, but without treatment, they gradually increase. Direct infection of the labyrinth (purulent labyrinthitis) is possible with bacterial meningitis or a violation of the integrity of the membranes that separate the inner ear from the middle ear. Patients present with severe vestibular vertigo, nausea, hearing loss, fever, headache, and earache. Purulent labyrinthitis is a dangerous disease that requires early diagnosis and antibiotic therapy.

2. Viral labyrinthitis. The defeat of the auditory and vestibular organs is observed in various viral infections, including influenza, herpes, rubella, mumps, viral hepatitis, measles, Epstein-Barr virus infection. Most patients recover on their own.

E. Functional vertigo occurs as a result of a violation of the interaction between the vestibular, visual and somatosensory systems, which normally together provide spatial orientation. Dizziness can also be caused by physiological stimulation of normally functioning sensory systems.

1. Motion sickness is caused by an unusual acceleration of the body or a mismatch between the afferent input to the brain from the vestibular and visual systems. In a person who is in a closed cabin of a ship or in the back seat of a moving car, vestibular afferentation creates a feeling of acceleration, while visual afferentation indicates the relative immobility of surrounding objects. The intensity of nausea and dizziness is directly proportional to the degree of sensory mismatch. Motion sickness is reduced with a sufficient panoramic view to verify the reality of movement.

2. Visual dizziness occurs when watching moving objects – due to a mismatch of visual afferentation with vestibular or somatosensory (for example, when a person watches a movie with car chases).

3. Altitude dizziness is a common phenomenon that occurs when the distance between a person and the stationary objects he observes exceeds a certain critical value. The often observed fear of heights prevents adaptation to the physiological mismatch of vestibular and visual afferentation.

G. Transient ischemia of the brainstem

Clinical picture

1) Vestibular vertigo and imbalance are the two most common symptoms of transient ischemia of the brain stem resulting from damage to the arteries of the vertebrobasilar basin. At the same time, only in rare cases they are the only manifestations of this disease. If repeated attacks of vertigo are not accompanied by other signs of ischemia of the trunk (diplopia, dysarthria, impaired sensitivity of the face or limbs, ataxia, hemiparesis, Horner’s syndrome or hemianopsia), then they are usually caused not by vertebrobasilar insufficiency, but by peripheral vestibulopathy.

2) Disbalance and blurred vision occur both in vestibular neuronitis and in lesions of the trunk, and therefore do not allow clarifying the localization of the focus. Acute hearing loss is not typical for ischemic damage to the trunk; a rare exception is occlusion of the anterior inferior cerebellar artery, from which the internal auditory artery branches to the inner ear.

b. Differential Diagnosis

1) Since transient brain stem ischemia requires active therapy to prevent stem stroke, it is important to differentiate it from more benign disorders (particularly vestibular neuronitis).

2) In the interictal period with transient trunk ischemia, there are no signs of focal brain damage. However, during an attack, a thorough examination can reveal such disorders as Horner’s syndrome, slight strabismus, internuclear ophthalmoplegia, central alternating or vertical nystagmus, etc., characteristic of a lesion of the trunk, but not the vestibular apparatus. With ischemia of the trunk, it is often possible to cause positional nystagmus. The Nilen-Barani test helps to distinguish the central lesion from the peripheral one. Vestibular vertigo and imbalance can also occur with brainstem lesions of other etiologies, such as multiple sclerosis or tumors.

Z. Cerebellar stroke

1. Clinical picture. Damage to the cerebellum due to ischemia or hemorrhage in the basin of the posterior inferior cerebellar artery may present with severe vestibular vertigo and imbalance, which are easily mistaken for symptoms of acute vestibular neuronitis. Sometimes the lesion is limited to the cerebellar hemisphere, and in this case there are no signs of damage to the lateral part of the medulla oblongata (dysarthria, numbness and paresis of the muscles of the face, Horner’s syndrome, etc.). Infarction in the basin of the superior cerebellar artery causes abasia and ataxia, which are usually not accompanied by severe dizziness.

2. Diagnosis. An imbalance with a tendency to fall towards the lesion is observed when both the vestibular system and the cerebellar hemispheres are damaged and does not help in differential diagnosis. Central alternating nystagmus, the fast phase of which is directed towards the gaze, and hemiataxia testify in favor of damage to the cerebellar hemisphere. CT can diagnose cerebellar hemorrhage, but may not detect a heart attack (especially if the study is done immediately after the onset of symptoms). A more reliable method for diagnosing cerebellar infarction is MRI.

3. Flow. Cerebellar infarcts and hemorrhages are often limited in size, and the outcome is favorable. As a rule, there is a gradual recovery, and the residual defect is minimal. Larger foci, accompanied by cerebellar edema, can cause compression of the trunk and the fourth ventricle. This serious complication requires surgical decompression, but it can be prevented with timely dehydration, so early diagnosis and close monitoring in the acute phase are extremely important in cerebellar strokes.

I. Oscillopsia is the illusion of motionless objects vibrating. Oscillopsia in combination with vertical nystagmus, instability and vestibular vertigo is observed in craniovertebral anomalies (for example, Arnold-Chiari syndrome) and degenerative lesions of the cerebellum (including olivopontocerebellar atrophy and multiple sclerosis).

K. Vestibular epilepsy. Dizziness can be the leading manifestation of simple and complex partial seizures if they occur in the vestibular cortex (superior temporal gyrus and association areas of the parietal lobe). Dizziness in this case is often accompanied by tinnitus, nystagmus, paresthesias in the contralateral limbs. Attacks are usually short-lived and can easily be confused with other disorders that cause vestibular vertigo. In most cases, these seizures are combined with typical manifestations of temporal lobe epilepsy. The diagnosis is confirmed by EEG changes. Treatment: anticonvulsants or resection of the affected area of ​​the brain.

L. Migraine

1. Clinical picture. Dizziness may be the leading symptom of basilar migraine. During the attack, there are also visual and sensory disturbances, impaired consciousness, intense headache.

2. Diagnosis. Recurrent attacks of vestibular vertigo (in the absence of other symptoms) may be a manifestation of dissociated migraine. The diagnosis of migraine in this case is possible only with the exclusion of all other causes; it is more likely if there are other manifestations of this disease.

M. Chronic vestibular dysfunction

1. General information. The brain is able to correct the broken communication between vestibular, visual and proprioceptive signals. Due to central adaptation processes, acute dizziness, regardless of its cause, usually resolves within a few days. However, sometimes vestibular disorders are not compensated due to damage to the brain structures responsible for vestibulo-ocular or vestibulospinal reflexes. In other cases, adaptation does not occur due to concomitant visual or proprioceptive impairments.

2. Treatment. Constant dizziness, imbalance and coordination of movements can cause disability of the patient. Drug therapy in such cases is usually ineffective. Patients with persistent vestibular dysfunction are shown a set of special exercises (vestibular gymnastics).

a. Exercise goals

1) Reduce dizziness.

2) Improve balance.

3) Restore self-confidence.

b. Standard complex of vestibular gymnastics

1) Exercises for the development of vestibular adaptation are based on the repetition of certain movements or postures that cause dizziness or imbalance. It is believed that this should contribute to the adaptation of the vestibular structures of the brain and inhibition of vestibular reactions.

2) Balance exercises are structured in such a way as to improve coordination of movements and use information from various senses to improve balance.

IV. Diagnosis and treatment of diseases accompanied by imbalance

A. Multiple sensory deficiency

1. General information. In violation of the proprioception of the legs, pronounced instability, uncertainty and unsteadiness when walking (“drunk” gait) develop. This feeling of unsteadiness is often referred to as “dizziness” by patients. The cause of impaired proprioception is often polyneuropathy or myelopathy (due to vitamin B12 deficiency, cervical spondylosis, dorsal tabes). Since vision plays an important role in spatial orientation and balance, dizziness and unsteadiness often increase in the dark.

With concomitant visual impairments (cataracts or macular degeneration), extrapyramidal disorders, orthostatic hypotension or vestibular dysfunction, even mild disturbances in proprioception lead to marked imbalances (multiple sensory deficiency syndrome).

2. Treatment should be directed to the underlying disease whenever possible. Consultation with a physiotherapist is required. To avoid falls, you should use a stick or other devices while walking. At night, it is recommended to leave a night light, in the light of which it is easier for the patient to get to the toilet room. Vestibular gymnastics is also carried out.

B. Diseases of the cerebellum (alcoholic cerebellar degeneration and other degenerative lesions, tumors, infarcts) and extrapyramidal disorders (parkinsonism, progressive supranuclear palsy) often lead to imbalance, which patients often refer to as “dizziness”.

B. Schwannomas and other tumors of the cerebellopontine angle

Schwannomas (Schwann cell tumors), also called neuromas, usually grow from the vestibulocochlear nerve in the region of the internal auditory canal. As the tumor gradually grows into the cerebellopontine angle, new symptoms appear in succession:

1) Hearing loss, tinnitus and mild imbalance.

2) Headache.

3) Severe disturbance of balance and coordination.

4) Damage to neighboring cranial nerves (numbness and paresthesia of the face, weakness of mimic muscles).

5) Symptoms of increased ICP. The first symptom of the disease is usually unilateral hearing loss, sometimes accompanied by tinnitus, but patients often do not attach any importance to this and seek help only when headaches, balance disorders or dizziness appear.

b. Meningiomas, epidermoid tumors and other neoplasms can also be localized in the region of the cerebellopontine angle, manifesting similar symptoms.

2. Diagnosis. Running inoperable schwannomas of the vestibulocochlear nerve cause severe disability. Therefore, early diagnosis of the tumor is important – at the stage when its removal is safe and does not leave a gross defect. Therefore, in all patients with sensorineural hearing loss (especially if it is combined with vestibular disorders), it is necessary to exclude a tumor of the cerebellopontine angle.

a. Neurological examination often reveals only hearing loss. Of the other symptoms, the weakening of the corneal reflex, nystagmus, and hypoesthesia of the face are most often detected.

b. Audiologic examination distinguishes cochlear involvement from retrocochlear disorders. The latter are characterized by a violation of speech intelligibility in combination with an increase in the thresholds for perceiving tones, the absence of the phenomenon of an accelerated increase in sound volume, fading of the tone and a decrease in the acoustic reflex.

c. The best method for diagnosing tumors of the posterior cranial fossa is MRI with gadolinium, which makes it possible to detect even small intracanalicular tumors.

High-resolution thin-section CT (with or without IV contrast) also detects posterior fossa tumors but does not detect relatively small intracanalicular neoplasms.

3. Treatment. For most tumors of the cerebellopontine angle, resection is indicated. Schwannomas of the vestibulocochlear nerve in a significant proportion of cases can be removed, while maintaining the function of the facial nerve. With small tumors (less than 2 cm in diameter), it is sometimes possible to save hearing as well. Since the tumor grows slowly, in the elderly it is sometimes possible not to rush into surgery, but to observe the condition (using CT or MRI).

D. Drug-induced balance disorders. Balance disorders, dizziness and other symptoms of labyrinth damage may be the result of the toxic effects of various drugs. Drug intoxications usually cause symmetrical vasoparetic nystagmus. When looking sideways, the eyes slowly return to the midline, followed by a quick reverse movement in the direction of gaze.

1. Anticonvulsants. Most commonly used anticonvulsants (phenobarbital, phenytoin, ethosuximide, primidone, carbamazepine) cause vestibular symptoms (nystagmus, dizziness) and ataxia if their concentration in the blood reaches toxic levels. Symptoms usually disappear when the drug is discontinued and its concentration in the blood decreases.

2. Alcohol intoxication is usually accompanied by unsteady gait and dysarthria, which is probably due to cerebellar dysfunction. Equally common are positional nystagmus and positional vertigo. Apparently, positional vertigo is due to the difference in the rate of penetration of ethanol into the cupula and endolymph, which causes transient changes in sensitivity to gravity.

3. Salicylates. The first symptoms of poisoning are tinnitus and vestibular dizziness. Hearing loss is also possible, closely correlated with the level of salicylate in the blood. When these symptoms appear in patients receiving high doses of salicylate for a long time, the drug is canceled or its dose is reduced. Vestibular disturbances and hearing loss disappear within 2-3 days after withdrawal.

4. Aminoglycosides have a pronounced ototoxicity, causing both auditory and vestibular disorders. Streptomycin, gentamicin, and tobramycin commonly cause vestibular disturbances, while amikacin, kanamycin, and neomycin cause auditory disturbances. Aminoglycosides damage the hair cells of the inner ear. Ototoxicity directly depends on the concentration of the drug in the blood and the duration of treatment.

a. Patients rarely complain of dizziness, more often they are disturbed by an imbalance that worsens in the dark, when visual control is impossible. Another common symptom is oscillopsia, which occurs as a result of impaired vestibulo-ocular reflexes and manifests itself mainly with head movements. Reactions to the cold test gradually decrease on both sides.

b. Hearing loss (initially to high-frequency sounds) sometimes appears later than vestibular disorders.

There is no cure for maze damage. After discontinuation of the antibiotic, improvement usually occurs within a few days, but recovery may take a year or more, and in some patients, especially the elderly, it may not occur at all.

Prophylactic measures prevent the ototoxic effect of aminoglycosides. It is necessary to carefully monitor the daily dose, duration of therapy and the concentration of the drug in the blood. This is especially important in renal failure, when the excretion of aminoglycosides is impaired. During treatment, vestibular and auditory functions are regularly examined. At the first symptoms of ototoxicity, the drug is canceled.

V. Hyperventilation syndrome and psychogenic dizziness

A. Hyperventilation syndrome is a common cause of dizziness. Attacks of hyperventilation are caused by anxiety or other affective disorders.

1. General information. Hyperventilation leads to hypocapnia, alkalosis, vasoconstriction and reduced cerebral blood flow. Patients complain of a vague feeling of lightheadedness, often accompanied by paresthesia of the lips and fingers, feeling short of breath, sweating, chills, palpitations, and fear. A provocative test with a three-minute hyperventilation has not only diagnostic, but also important psychotherapeutic value, since the patient becomes clear about the origin of the symptoms.

2. Treatment. First of all, it is necessary to convince the patient that his disease is not dangerous. In severe cases, psychiatric consultation and psychotherapy are indicated. Attacks of hyperventilation can be stopped by inviting the patient to breathe into a bag (in this case, he will inhale the carbon dioxide exhaled by him, which prevents hypocapnia and alkalosis).

B. Psychogenic dizziness

1. General information. In some neuroses and psychoses, dizziness occurs, unlike any of the known conditions (vestibular dizziness, fainting or imbalance) and not reproduced in any of the provocative tests described above. Dizziness is noted in approximately 70% of patients with hypochondriacal neurosis and more than 80% with hysterical neurosis. Dizziness in such patients often lasts for years and is constant rather than episodic. Many of them call “dizziness” general weakness, impaired attention, a feeling of ambiguity in the head.

2. Anxiety or depression do not necessarily indicate psychogenic dizziness, as they are often not the cause but the consequence of acute and chronic vestibular disorders. During severe attacks of vestibular vertigo, there may be a feeling of impending death.

3. Treatment

a. The patient must be convinced of the absence of a dangerous disease, which is possible only with a trusting relationship with the doctor. However, patients are often not satisfied with the conclusion about the psychogenic nature of their disease, and when they hear that they have “nothing serious”, they persistently continue to look for a serious illness in themselves, turning to one doctor after another. It is necessary to tactfully and clearly explain the nature of the violation, show maximum participation and ensure constant monitoring.

b. Benzodiazepines (diazepam, lorazepam, or oxazepam) are especially effective for acute anxiety. In patients with hypochondriacal or hysterical neurosis, the intake of these drugs must be carefully monitored. If depression predominates, then tricyclic antidepressants are indicated.

VI. Noise in the ears

A. Definition. Noise in the ears is called unpleasant auditory sensations that occur in the absence of an external sound source.

B. General information. Tinnitus in diseases of the middle ear, cochlea and cochlear part of the vestibulocochlear nerve is usually described as ringing, roaring, buzzing, or as “the noise of the sea surf.” The nature of the noise does not indicate the localization of the lesion. Possible causes of tinnitus include acoustic trauma, presbycusia, Meniere’s syndrome, tympanosclerosis, vestibulocochlear schwannoma. All these disorders are usually accompanied by hearing loss. With the appearance of noise in the ear, first of all, the schwannoma of the vestibulocochlear nerve is excluded. In more than half of patients with “ringing” in the ears, hearing is not reduced; in this case, it is rarely possible to establish the cause of the noise.

Q. Medicines (including salicylates, quinidine, aminophylline, indomethacin, and caffeine) can cause tinnitus without hearing loss. With such complaints, these funds are canceled if possible.

D. Pulsatile tinnitus, synchronous with the pulse, often associated with turbulent blood flow. Patients may hear a murmur in a stenotic or tortuous carotid or vertebral artery. Pulsatile murmurs can also be caused by vascular malformations and vascular tumors (eg, jugular glomus paraganglioma). Correction of the vascular anomaly usually eliminates such noise.

E. Treatment. Tinnitus can be extremely annoying and sometimes makes life unbearable. The noise is usually more pronounced at night and often causes insomnia. Chronic anxiety and depression often develop with incessant noise. Treating emotional disorders can improve the condition.

1. Medicines for chronic tinnitus are usually ineffective. Sometimes temporary improvement is achieved by intravenous administration of lidocaine, but it is not suitable for long-term therapy.

2. Noise masking. Many patients drown out tinnitus with external sounds. You can leave the radio turned on at night or wear special headphones with “background” noise. Unfortunately, these methods do not always help.

VII. Fainting. Many patients describe the feeling of an approaching loss of consciousness as dizziness, others as a feeling of emptiness in the head, slight intoxication, and lightheadedness. The same sensations occur with vestibular vertigo. Pre-fainting may be accompanied by other symptoms characteristic of vestibular vertigo: nausea, pallor, sweating, a feeling of fear, a veil before the eyes. Therefore, complaints of dizziness can sometimes be difficult to interpret. In such cases, provocative tests are especially useful. Although falls due to a sudden loss of balance are possible with vestibular vertigo, transient loss of consciousness is not characteristic of this condition.

A. Reflex syncope occurs as a result of reflex vegetative reactions, causing mainly vasodilation. As a result, there is a decrease in peripheral vascular resistance, insufficient filling of the right heart and a drop in cardiac output. The attack usually occurs in a standing position, less often in a sitting position. Loss of consciousness is often preceded by nausea, pallor, sweating, lightheadedness, or dizziness.

1. Vasovagal syncope is usually triggered by fear, stress, or pain. This is the most common type of syncope in healthy young people.

2. Situational syncope (vagal or visceral reflex syncope)

a. Fainting during urination and defecation.

b. Fainting on coughing.

Fainting when swallowing.

Arterial hypotension after eating (one of the common causes of syncope in the elderly, in whom impaired baroreflexes are not able to compensate for the increase in celiac blood flow after eating).

3. Carotid sinus syndrome. Dizziness and fainting in this condition may be due to bradycardia, vasodilation, or a combination of both.

4. Orthostatic hypotension is caused by insufficiency of reflex sympathetic mechanisms that ensure the maintenance of blood pressure during the transition to a standing position.

a. Primary autonomic insufficiency is observed in Shy-Drager syndrome and idiopathic orthostatic hypotension.

b. Secondary orthostatic hypotension develops as a result of:

1) Vegetative polyneuropathy (diabetes mellitus, alcoholism, amyloidosis).

2) Drug treatment (hypotensive and vasodilators, nitrates, tranquilizers, antidepressants, phenothiazines, etc.).

3) Hypovolemia (with blood loss, vomiting, increased diuresis, dehydration).

4) Prolonged bed rest detraining the cardiovascular system.

B. Cardiogenic syncope is caused by a decrease in left ventricular output. In cardiogenic syncope, unlike reflex syncope, loss of consciousness often occurs suddenly, without previous symptoms.

1. Obstructive cardiogenic syncope is caused by narrowing of the outflow tract of the left ventricle (with aortic stenosis, hypertrophic cardiomyopathy, pulmonary hypertension, cardiac tamponade, atrial myxoma, etc.).

2. Arrhythmic cardiogenic syncope occurs with ventricular tachycardia, AV block, sick sinus syndrome, long QT interval syndrome, etc.

3. Since cardiogenic syncope is life threatening, recurrent syncope of unknown origin should be ruled out as a first step in cardiac disease. In most cases, this can be done on the basis of anamnesis, examination and conventional instrumental research methods. However, sometimes an electrophysiological study, tests on an orthostatic table, Holter ECG monitoring may be required to determine the cause of fainting.

C. For stenosing lesions of the cerebral arteries, syncope is not characteristic, and therefore it is erroneous to explain these conditions as transient cerebral ischemia. Rarely, however, syncope can occur with widespread stenosis or occlusion of extracranial arteries. This happens with the following diseases:

1. Atherosclerotic bilateral occlusion of several extracranial arteries: in this case, primary orthostatic cerebral ischemia (isolated cerebral orthostatic hypotension) is possible.

2. Aortoarteritis (Takayasu’s disease).

3. Subclavian steal syndrome.

Literature

1. Baloh, R. W., Honrubia, V., and Jacobson, K. Benign positional vertigo. Neurology 37:371, 1987.

2. Brandt, T. Vertigo: Its Multisensory Syndromes. London: Springer-Verlag, 1991.

3. Brandt, T., and Daroff, R. B. The multisensory physiological and pathological vertigo syndromes. Ann. Neurol. 7:195, 1980.

4. Drachman, D. A., and Hart, C. W. An approach to the dizzy patient. Neurology 2:323, 1972.

5. Kroenke, K., et al. Causes of persistent dizziness: A prospective study of 100 patients in ambulatory care.