Medicine:Labyrinthitis

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Labyrinthitis and vestibular neuritis
Other namesOtitis interna, vestibular neuronitis, vestibular neuritis
Gray920.png
Diagram of the inner ear
SpecialtyOtorhinolaryngology
Frequency35 million per year[1][dubious – discuss]

Labyrinthitis is inflammation of the labyrinth, a maze of fluid-filled channels in the inner ear. Vestibular neuritis is inflammation of the vestibular nerve (the nerve in the inner ear that sends messages related to motion and position to the brain).[2][3][4] Both conditions involve inflammation of the inner ear.[5] Labyrinths that house the vestibular system sense changes in the head's position or the head's motion.[6] Inflammation of these inner ear parts results in a sensation of the world spinning and also possible hearing loss or ringing in the ears.[6] It can occur as a single attack, a series of attacks, or a persistent condition that diminishes over three to six weeks. It may be associated with nausea, vomiting, and eye nystagmus.

The cause is often not clear. It may be due to a virus, but it can also arise from bacterial infection, head injury, extreme stress, an allergy, or as a reaction to medication. 30% of affected people had a common cold prior to developing the disease.[1] Either bacterial or viral labyrinthitis can cause a permanent hearing loss in rare cases.[7] This appears to result from an imbalance of neuronal input between the left and right inner ears.[8]

Signs and symptoms

The main symptoms are severe vertigo and nystagmus. The most common symptom for vestibular neuritis is the onset of vertigo that has formed from an ongoing infection or trauma.[9] The dizziness sensation that is associated with vertigo is thought to be from the inner ear labyrinth.[10] Rapid and undesired eye motion (nystagmus) often results from the improper indication 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 system.[11] Other common symptoms include tinnitus, ear ache, and a feeling of fullness in the ear.[12][13]

Causes

Some people will report having an upper respiratory infection (common cold) or flu prior to the onset of the symptoms of vestibular neuritis; others will have no viral symptoms prior to the vertigo attack.

Some cases of vestibular neuritis are thought to be caused by an infection of the vestibular ganglion by the herpes simplex type 1 virus.[8] However, the cause of this condition is not fully understood, and in fact, many different viruses may be capable of infecting the vestibular nerve.

Acute localized ischemia of these structures also may be an important cause. Especially in children, vestibular neuritis may be preceded by symptoms of a common cold. However, the causative mechanism remains uncertain.[14]

This can also be brought on by pressure changes such as those experienced while flying or scuba diving.[15][16][17]

Mechanism

In the vestibular system, there are three canals that are semicircular in shape that input sensory clues.[18] These canals allow the brain to sense rotational motion and linear motion changes.[19] The brain then uses the sensory input clues and the visual input clues from the vestibular system to retain balance. The vestibulo–ocular reflex retains continuous visual focus during motion which is also the vestibular systems job during activity.[19]

Treatment

The treatment for vestibular neuritis depends on the cause. However, symptoms of vertigo can be treated in the same way as other vestibular dysfunctions with vestibular rehabilitation.[20]

Physical therapy

Typical treatments include combinations of head and eye movements, postural changes, and walking exercises. Specifically, exercises that may be prescribed include keeping eyes fixated on a specific target while moving the head, moving the head right to left at two targets at a significant distance apart, walking while keeping eyes fixated on a specific target, and walking while keeping eyes fixated on a specific target while also turning the head in different directions.[21] The main function behind repeating a combination of head and eye movements, postural changes and walking is that through this repetition, compensatory changes for the dysfunctions arising from peripheral vestibular structures may be promoted in the central vestibular system (brainstem and cerebellum).[21]

Vestibular rehabilitation therapy is a highly effective way to substantially reduce or eliminate residual dizziness from labyrinthitis.[22] VRT works by causing the brain to use already existing neural mechanisms for adaptation, neuroplasticity, and compensation.[20] Vestibular neuritis rehabilitation is an effective and safe management to improve symptoms.[23] The vestibular neuritis rehabilitation can improve symptoms or resolve the symptoms which is dependent on each individual. [23]

Rehabilitation strategies most commonly used are:[20]

  • Gaze stability exercises – moving the head from side to side while fixated on a stationary object (aimed at assisting the eye to fixate during head rotation without the input from the lost canal vestibulo–ocular reflex). An advanced progression of this exercise would be walking in a straight line while looking side to side by turning the head.
  • Habituation exercises – movements designed to provoke symptoms and subsequently reduce the negative vestibular response upon repetition. Examples of these include Brandt–Daroff exercises.
  • Functional retraining – including postural control, relaxation, and balance training.

These exercises function by challenging the vestibular system. Progression occurs by increasing the amplitude of the head or focal point movements, increasing the speed of movement, and combining movements such as walking and head turning.[24]

One study found that patients who believed their illness was out of their control showed the slowest progression to full recovery, long after the initial vestibular injury had healed.[25] The study revealed that the patient who compensated well was one who, at the psychological level, was not afraid of the symptoms and had some positive control over them. Notably, a reduction in negative beliefs over time was greater in those patients treated with rehabilitation than in those untreated. "Of utmost importance, baseline beliefs were the only significant predictor of change in a handicap at 6 months follow-up."

Medication

Vestibular neuritis is generally a self-limiting disease. Treatment with drugs is neither necessary nor possible. The effect of glucocorticoids has been studied, but they have not been found to significantly affect long-term outcome.[26]

Symptomatic treatment with antihistaminics such as cinnarizine, however, can be used to suppress the symptoms of vestibular neuritis while it spontaneously regresses.[27] Prochlorperazine is another commonly prescribed medication to help alleviate the symptoms of vertigo and nausea.

Mental disorders

Because mood disorders can hamper recovery from labyrinthitis, treatment may also include any co-occurring anxiety disorder or depression. Severe anxiety episodes are usually addressed by short-term benzodiazepine therapy.[28]

Prognosis

Recovery from acute labyrinthine inflammation generally takes from one to six weeks, but it is not uncommon for residual symptoms such as dysequilibrium and dizziness to last for a couple of months.[25]

Recovery from a temporarily damaged inner ear typically follows two phases:

  1. An acute period, which may include severe vertigo and vomiting
  2. approximately two weeks of sub-acute symptoms and rapid recovery

Epidemiology

Labyrinthitis affects approximately 35 million people per year[dubious – discuss] (approximately 3.5 cases per 100,000 people).[29] It typically occurs in those between 30 and 60 years of age,[29] and there are no significant differences between male and female incidence rates.[29] In 95% of cases, sufferers experience a single attack and fully recover.[30] Vestibular rehabilitation showed a statistically significant increase in controlling symptoms over no intervention in people who have vestibular neuritis.[31]

References

  1. ↑ 1.0 1.1 Greco, A; Macri, GF; Gallo, A; Fusconi, M; De Virgilio, A; Pagliuca, G; Marinelli, C; de Vincentiis, M (2014). "Is vestibular neuritis an immune related vestibular neuropathy inducing vertigo?". Journal of Immunology Research 2014: 459048. doi:10.1155/2014/459048. PMID 24741601. 
  2. ↑ "Labyrinthitis and vestibular neuritis". 23 October 2017. https://www.nhs.uk/conditions/labyrinthitis/. 
  3. ↑ Ferri's Clinical Advisor 2016: 5 Books in 1. Elsevier Health Sciences. 2015. p. 735. ISBN 9780323378222. https://books.google.com/books?id=bbLSCQAAQBAJ&pg=PA735. 
  4. ↑ Hogue, JD (June 2015). "Office Evaluation of Dizziness". Primary Care 42 (2): 249–258. doi:10.1016/j.pop.2015.01.004. PMID 25979586. 
  5. ↑ "Labyrinthitis" (in en). https://www.ncbi.nlm.nih.gov/pubmedhealth/PMHT0027300/. 
  6. ↑ 6.0 6.1 "Clinical Methods: The History, Physical, and Laboratory Examinations". Annals of Internal Medicine 113 (7): 563. 1990-10-01. doi:10.7326/0003-4819-113-7-563_2. ISSN 0003-4819. 
  7. ↑ "NLM". https://www.nlm.nih.gov/medlineplus/ency/article/001054.htm. 
  8. ↑ 8.0 8.1 Marill, Keith (2011-01-13). "Vestibular Neuronitis: Pathology". eMedicine, Medscape Reference. http://emedicine.medscape.com/article/794489-overview#showall. 
  9. ↑ Dewyer, Nicholas A.; Kiringoda, Ruwan; McKenna, Michael J. (2018), "Inner Ear Infections (Labyrinthitis)", Infections of the Ears, Nose, Throat, and Sinuses (Springer International Publishing): pp. 79–88, doi:10.1007/978-3-319-74835-1_7, ISBN 978-3-319-74834-4 
  10. ↑ Murdin, Louisa; Hussain, Kiran; Schilder, Anne GM (2013-08-11), "Betahistine for symptoms of vertigo", in The Cochrane Collaboration (in en), Cochrane Database of Systematic Reviews, John Wiley & Sons, Ltd, pp. CD010696, doi:10.1002/14651858.cd010696 
  11. ↑ "Table 1: The Single Nucleotide Polymorphisms in cathepsin B protein mined from literature (PMID: 16492714).". PeerJ BIOINFORMATICS AND GENOMICS. doi:10.7717/peerj.7425/table-1. 
  12. ↑ "Infections of the Inner Ear". https://vestibular.org/article/diagnosis-treatment/types-of-vestibular-disorders/labyrinthitis-and-vestibular-neuritis/. 
  13. ↑ "Inner Ear Infection (Labyrinthitis) Symptoms, Causes, Contagious, Treatment Cure" (in en). https://www.medicinenet.com/labyrinthitis_inner_ear_inflammation/article.htm. 
  14. ↑ Keith A Marill. "Vestibular Neuronitis". http://www.emedicine.com/emerg/TOPIC637.HTM. 
  15. ↑ "Clinical aspects of inflight incapacitations in commercial aviation". Aviation, Space, and Environmental Medicine 61 (3): 256–60. March 1990. PMID 2317181. 
  16. ↑ Farmer, Jr JC, ed (1973). "Labyrinthine Dysfunction During Diving". 1st Undersea and Hyperbaric Medical Society Workshop.. UHMS Publication Number WS6-15-74.. Undersea and Hyperbaric Medical Society. pp. 11. http://archive.rubicon-foundation.org/4291. Retrieved 2009-03-11. 
  17. ↑ Kennedy RS (March 1974). "General history of vestibular disorders in diving". Undersea Biomedical Research 1 (1): 73–81. PMID 4619861. http://archive.rubicon-foundation.org/2663. Retrieved 2009-03-11. 
  18. ↑ "Labyrinthitis". http://www.audiologicaldiagnostics.com/labyrinthitis. 
  19. ↑ 19.0 19.1 "Germany". International Journal of Health Care Quality Assurance 19 (4). 2017. doi:10.1108/ijhcqa.2006.06219dab.003. ISSN 0952-6862. 
  20. ↑ 20.0 20.1 20.2 Burton M. J.; Monsell E. M.; Rosenfeld R. M. (2008). "Extracts from the cochrane library: Vestibular rehabilitation for unilateral peripheral vestibular dysfunction (review)". Otolaryngology–Head and Neck Surgery 138 (4): 415–417. doi:10.1016/j.otohns.2008.02.004. PMID 18359346. 
  21. ↑ 21.0 21.1 Walker, MF (January 2009). "Treatment of vestibular neuritis.". Current Treatment Options in Neurology 11 (1): 41–5. doi:10.1007/s11940-009-0006-8. PMID 19094835. 
  22. ↑ "Vestibular Rehabilitation Therapy (VRT)" (in en). Vestibular Disorders Association. 2011-12-27. https://vestibular.org/understanding-vestibular-disorder/treatment/treatment-detail-page#. 
  23. ↑ 23.0 23.1 Fishman, Jonathan M; Burgess, Chris; Waddell, Angus (2010-07-07), "Corticosteroids for the treatment of idiopathic acute vestibular dysfunction (vestibular neuritis)", in The Cochrane Collaboration (in en), Cochrane Database of Systematic Reviews, John Wiley & Sons, Ltd, pp. CD008607, doi:10.1002/14651858.cd008607 
  24. ↑ "Physical Therapy Rehabilitation" (in en). https://www.fisioterapialabirintica40.com.br/publicacoes. 
  25. ↑ 25.0 25.1 Bronstein, Adolfo (February 2002). "Visual and psychological aspects of vestibular disease". Current Opinion in Neurology 15 (1): 1–3. doi:10.1097/00019052-200202000-00001. PMID 11796943. 
  26. ↑ Fishman, JM; Burgess C; Waddell A (May 2011). "Corticosteroids for the treatment of idiopathic acute vestibular dysfunction (vestibular neuritis)". Cochrane Database Syst Rev (5): CD008607. doi:10.1002/14651858.CD008607.pub2. PMID 21563170. 
  27. ↑ Scholtz, AW; Steindl R; Burchardi N; Bognar-Steinberg I; Baumann W (June 2012). "Comparison of the therapeutic efficacy of a fixed low-dose combination of cinnarizine and dimenhydrinate with betahistine in vestibular neuritis: a randomized, double-blind, non-inferiority study". Clin Drug Investig 32 (6): 387–399. doi:10.2165/11632410-000000000-00000. PMID 22506537. 
  28. ↑ Solomon, D; Shepard, NT (July 2002). "Chronic Dizziness.". Current Treatment Options in Neurology 4 (4): 281–288. doi:10.1007/s11940-002-0028-y. PMID 12036501. 
  29. ↑ 29.0 29.1 29.2 Greco, A.; Macri, G. F.; Gallo, A.; Fusconi, M.; De Virgilio, A.; Pagliuca, G.; Marinelli, C.; de Vincentiis, M. (2014). "Is vestibular neuritis an immune related vestibular neuropathy inducing vertigo?". Journal of Immunology Research 2014: 459048. doi:10.1155/2014/459048. ISSN 2314-7156. PMID 24741601. 
  30. ↑ "Vestibular Neuritis" (in en). https://my.clevelandclinic.org/health/diseases/15227-vestibular-neuritis. 
  31. ↑ McDonnell, Michelle N; Hillier, Susan L (2015-01-13). Cochrane ENT Group. ed. "Vestibular rehabilitation for unilateral peripheral vestibular dysfunction" (in en). Cochrane Database of Systematic Reviews 1: CD005397. doi:10.1002/14651858.CD005397.pub4. PMID 25581507. 

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