Summary

Labyrinthitis is acute inflammation of the membranous labyrinth (inner ear), affecting both vestibular and cochlear function. It is typically viral (post-URI) and presents with sudden-onset sustained vertigo, nausea, vomiting, and unilateral hearing loss/tinnitus. The key differentiator from vestibular neuritis is the presence of hearing loss (labyrinthitis = vertigo + hearing loss). The main diagnostic challenge is distinguishing peripheral labyrinthitis from central causes (posterior circulation stroke). The HINTS examination is more sensitive than early MRI for detecting stroke. Management involves short-term vestibular suppressants (48-72 hours only) and early vestibular rehabilitation.

Key Facts

• Definition: Inflammation of inner ear affecting vestibular AND cochlear portions
• Difference from Vestibular Neuritis: Labyrinthitis = vertigo + HEARING LOSS
• Cause: Usually viral (30% post-viral URI)
• Duration: Acute phase 3-7 days; weeks to months for full compensation
• Key Test: HINTS exam (distinguishes peripheral from central)
• Management: Short-term suppressants + early mobilisation/vestibular rehab

Clinical Pearls

"Hearing Loss = Labyrinthitis": If there's vertigo WITH hearing loss → Labyrinthitis. If vertigo WITHOUT hearing loss → Vestibular neuritis. Both are treated similarly.

"HINTS Beats MRI Early": In acute vertigo, the HINTS exam is more sensitive than MRI in the first 48 hours for detecting posterior circulation stroke.

"Limit Suppressants to 72 Hours": Vestibular suppressants (prochlorperazine, cinnarizine) delay central compensation. Use only for severe symptoms in first 3 days.

"Positive Head Impulse = Peripheral = Safe": If the head impulse test is positive (corrective saccade), the lesion is peripheral. Negative HIT in acute vertigo = think STROKE.

Vestibular Examination

Head Impulse Test (HIT)

• Rapidly rotate head and observe for corrective saccade
• POSITIVE (corrective saccade) = Peripheral lesion (reassuring)
• NEGATIVE = Central lesion or normal (if negative in acute vertigo = WORRY)

Nystagmus Assessment

• Peripheral: Unidirectional, horizontal-torsional, suppressed by fixation
• Central: Any direction, vertical, direction-changing, not suppressed

Test of Skew

• Cover-uncover test looking for vertical correction
• Positive = Central lesion

HINTS Examination (Head Impulse, Nystagmus, Test of Skew)

┌──────────────────────────────────────────────────────────┐
│   HINTS: INFARCT = CENTRAL (DANGEROUS)                   │
├──────────────────────────────────────────────────────────┤
│                                                          │
│  Impulse Negative (no corrective saccade)              │
│  +                                                      │
│  Fast phase Alternating (direction-changing nystagmus)  │
│  +                                                      │
│  Refixation on Cover Test (skew deviation)             │
│                                                          │
│  ANY of these = Central cause until proven otherwise     │
│  → Urgent neurology/stroke team                         │
│                                                          │
└──────────────────────────────────────────────────────────┘

Hearing Assessment

• Weber test: Lateralises to UNAFFECTED ear (sensorineural loss)
• Rinne test: Air > Bone (but reduced on affected side)
• Audiometry: Documents hearing loss

Vestibular Recovery

• 50-60% recover fully
• 40% have some residual imbalance
• Most improve significantly with vestibular rehabilitation

Hearing Recovery

• Variable
• Some recovery common if viral
• Complete recovery less common than vestibular improvement
• Bacterial labyrinthitis: Often permanent hearing loss

Factors Affecting Prognosis

Key Guidelines

1. NICE CKS: Vestibular Neuronitis/Labyrinthitis
2. AAO-HNS Guidelines
3. Bárány Society Diagnostic Criteria

Key Evidence

HINTS Exam

• Kattah et al (2009): HINTS more sensitive than MRI in first 48h for stroke
• Sensitivity 100%, Specificity 96% for central cause

Corticosteroids

• Cochrane Review: Moderate evidence steroids improve vestibular recovery
• NNT ~4 for significant improvement with steroids

Vestibular Rehabilitation

• Cochrane Review: Strong evidence for benefit
• Improves symptoms and function more than no treatment

What is Labyrinthitis?

Labyrinthitis is an inflammation of the inner ear, usually caused by a viral infection. The inner ear contains the balance organs and the hearing part, so labyrinthitis causes both dizziness and hearing problems.

What Are the Symptoms?

• Severe spinning sensation (vertigo) that lasts days, not seconds
• Feeling sick and vomiting
• Hearing loss in one ear
• Ringing in the ear (tinnitus)
• Difficulty balancing

How is it Different from Other Ear Problems?

Unlike a middle ear infection (which causes ear pain and fever), labyrinthitis affects the inner ear and causes balance problems. If you have vertigo WITHOUT hearing loss, it's likely "vestibular neuritis" - a similar condition treated the same way.

How is it Treated?

• Anti-sickness tablets for the first few days
• Rest during the acute phase
• EARLY movement is important - staying in bed too long actually slows recovery
• Balance exercises (vestibular rehabilitation) help your brain adapt

When to Seek Urgent Help

Go to A&E if you have:

• New sudden hearing loss
• Difficulty walking or standing
• Weakness, numbness, or speech problems (could suggest stroke)
• Symptoms getting worse after a few days

Recovery

Most people feel much better within 1-2 weeks, though full recovery can take several weeks to months. Some hearing loss may be permanent, but often some recovery occurs.