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Staying Balanced: Management of Labyrinthitis Symptoms

Author Julia Casazza covers Staying Balanced: Management of Labyrinthitis Symptoms on BackTable ENT

Julia Casazza • Mar 27, 2024 • 38 hits

While the vomiting, vertigo, and hearing loss associated with labyrinthitis typically self-resolve within three weeks, patients are often debilitated during their illness. Dr. Ashley Agan, host of the BackTable ENT podcast, recently shared her labyrinthitis journey with otologist and neurologist Dr. Sujana Chandrashekar. Interested in learning more about how labyrinthitis affects patients’ lives and how best to manage symptoms? Keep reading!

This article features excerpts from the BackTable ENT Podcast. We’ve provided the highlight reel in this article, but you can listen to the full podcast below.

The BackTable ENT Brief

• Inflammation (often infectious in nature) in the labyrinth of the inner ear or the peripheral vestibular nerve causes labyrinthitis. For this reason, the condition is also called vestibular neuritis or vestibular neuronitis.

• Most labyrinthitis is viral and self-limited. Bacterial labyrinthitis is a serious condition that can destroy the inner ear.

• Vestibular physical therapy consists of balance and coordination exercises performed under the supervision of a therapist and at home that help patients restore their vestibular function.

• Labyrinthitis patients benefit from antiemetics such as ondansetron, systemic steroids, and intratympanic steroids in cases of hearing loss. Vestibular suppressants such as diazepam and meclizine alleviate vertigo but can lengthen recovery.

Staying Balanced: Management of Labyrinthitis Symptoms

Table of Contents

(1) Defining Labyrinthitis

(2) Physical Therapy to Assist Vestibular Recovery

(3) Using Medication to Alleviate Labyrinthitis Symptoms

Defining Labyrinthitis

Labyrinthitis is inflammation of the peripheral vestibular system. Since testing cannot differentiate lesions in the labyrinth from those along the vestibular nerves, the terms “vestibular neuritis” and “vestibular neuronitis” are used interchangeably with “labyrinthitis.” Inflammation can arise from infectious causes (which are most commonly viral, but include upper respiratory tract infection, otitis media, or meningitis) or cholesteatoma. Symptoms of labyrinthitis include vomiting, vertigo, and hearing loss. Most patients recover within three weeks, but those with underlying visual or balance disorders may face a longer duration of symptoms.

[Dr. Sujana Chandrashekhar]
Luckily for you and luckily for the vast majority of people who get labyrinthitis, it's a viral phenomenon and not a bacterial phenomenon because bacterial labyrinthitis, which we should just talk about and put to a side is horrendous. It can take out your inner ear.

People who get bacterial labyrinthitis, often post-meningitic cases or chronic otitis media, cholesteatoma cases. Those are the people that we rush to put in a cochlear implant within a few months so that we don't end up trying to drill out an ossified cochlea. Those are the people that are going to lose their ear for hearing and for balance.

That timeline becomes very rapid in terms of imaging and intervention in order to end up with an ear that can hear something. Often very well. If you get that cochlear implant into those patients in a time when there is still a membranous labyrinth to introduce, they do much better than if you're drilling out bony channels.

Luckily the vast majority, well over 90% of labyrinthitis, which is interchangeably used with vestibular neuritis or vestibular neuronitis, there's like, as you and I talked about in the past, it seems like everything in otology has at least three names, if not more. These are often interchangeable because we don't really, we cannot tell you the site of lesion is in the labyrinth or along the vestibular nerve or even along the superior or inferior vestibular nerve. We just know that it's a peripheral vestibular itis.

The vast majority are viral, which means that they don't demolish the ear and they are recoverable. We start to see recovery, initial recovery in about three weeks. Most people have a full recovery by three months, like the outside limit. If you're older, if you have some underlying balance disorder, if you have peripheral neuropathy, if you have cataracts, if you have glaucoma, if you have something else that's going to affect your balance system, it may take you longer to recover. In general, even though it's absolutely horrific, and you remember every minute of that episode, as if it happened yesterday, the full recovery happens pretty well in these patients.

The bottom line is to identify that it is in fact a peripheral vestibular lesion, to give supportive care, and then to institute physical therapy, vestibular therapy, so that you can get back to normal. For you, Ashley, vestibular therapy was being a doctor, being a mom, running around, doing your things, which is fine. For people who maybe are a little bit older, maybe on blood thinners, somebody that you really don't want to fall down, a great exercise vestibular therapy for them is to take a shopping cart, go to the grocery store, push the cart up and down the aisles as their walker, and then look up and down.

Listen to the Full Podcast

Labyrinthitis Unpacked: Clinical Perspectives & Management with Dr. Sujana Chandrasekhar on the BackTable ENT Podcast)
Ep 154 Labyrinthitis Unpacked: Clinical Perspectives & Management with Dr. Sujana Chandrasekhar
00:00 / 01:04

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Physical Therapy to Assist Vestibular Recovery

After an insult to the vestibular system, such as in a case of labyrinthitis, patients suffer from difficulties with balance and coordination. These difficulties are often accompanied by fatigue. Vestibular physical therapy teaches patients exercises that help them re-engage their vestibular faculties. Ideally, patients should practice their exercises daily.

[Dr. Sujana Chandrashekhar]
The more that the patient is able to do something, the better. I absolutely am so glad that you got into vestibular PT because that really, really helps that immediate compensation. Then it helps the activities in daily living compensation because the fear of falling makes you more likely to fall. If you can't cross a street in a crosswalk looking both ways as you're moving forward, you're going to be stuck just like living on your block. I think these are things where our physical therapy colleagues are just outstanding in terms of compensation and full recovery.



You have to do your home exercise program. I have dialogues about home exercise program with my patients all the time. I'm like, it's pointless to go twice a week if the other five days you're doing nothing. You really have to do it. You have to push yourself. It's like any other PT. The more you do it in a normal fashion, the better you'll be. For somebody like you who's running, whose life is full of vestibular exercise, you can almost incorporate those home exercises into your daily living. But, there are people who really do shut down and get so scared and they really have to be encouraged to do their PT.

[Dr. Ashley Agan]
Yes, it's pretty humbling where the exercise is, okay, stare at this dot and move your head back and forth side to side for a minute, three times a day. It's just so uncomfortable to do that, that I remember having to like work, I'd be like, okay, got to go do my physical therapy. Over time, now we're six months out and I don't think about it anymore. It was the increments of improvement, just teeny tiny every-- That was another nice thing about going to physical therapy is that they were able to really show me like, Look, how much you couldn't do this last week. They were great.

Using Medication to Alleviate Labyrinthitis Symptoms

While medications cannot precipitate labyrinthitis recovery, they can make it more tolerable. Ondansetron provides relief to vomiting patients. Diazepam – sometimes as little as 5 mg – suppresses the vestibular system to relieve vertigo. Exercise caution when prescribing this medication, however, as prolonged courses can lengthen the time needed for patients to recover. Systemic steroids relieve general inflammation. In cases of hearing loss, intratympanic steroid injections are warranted.

[Dr. Sujana Chandreshekar]
Yes. Supportive measures are the most important thing. The Ondansetron or Zofran is really beneficial, because what you don't want is now to compound this with some dehydration, malnutrition acute picture, because it is not at all unreasonable to stick an IV in somebody who's not able to keep anything down and just get them hydrated up because that really does help. I think Ondansetron, and I like the orally disintegrating tablets, because it's really impossible to vomit those up, right? You just stick them on your tongue and just lie there. Within about five, 10 minutes, it's absorbed into your body. It's working no matter what happens afterwards.



I'm a big steroid girl, like if you had nothing going on, in terms of your ear exam, or your audiogram, I probably still would have given you around a milligram per kilogram per day of prednisone. I would have given you between 40 and 60 milligrams of prednisone, at least for the first three days, four days, the sudden hearing loss dose, as we talked about is like seven days, and then you taper, some people give it for 10 days. Often you just need that acute jolt of anti-inflammatory to get people down. Then you can start tapering that off.

I think again, a Medrol dose pack doesn't do it for this degree of inner ear dysfunction. I would stick with the higher dose, but I probably tapered off more quickly than I would for a sudden hearing loss patient. Ondansetron, we talked about vestibular suppressants, and the Ondansetron is amazing. You could give it three times a day for the nausea. You could actually give it as often as you feel like. Some people take eight, most people are fine on four milligrams of the orally disintegrating tablets.

There are some old fashioned remedies that your grandmother knew, like ginger candy, ginger teas, things like that that settle your stomach. I often will tell people take the Ondansetron, take the Valium, and then eat something and drink something because that's the ideal time when you can keep things down and then just be. I tell them, this is not the time to really watch TV. This is the time to watch a blank TV. You don't want to stimulate your vestibular system in any possible way.

Podcast Contributors

Dr. Sujana Chandrasekhar discusses Labyrinthitis Unpacked: Clinical Perspectives & Management on the BackTable 154 Podcast

Dr. Sujana Chandrasekhar

Dr. Sujana Chandrasekhar is an otologist / neurotologist practicing at ENT and Allergy Associates in New York City.

Dr. Ashley Agan discusses Labyrinthitis Unpacked: Clinical Perspectives & Management on the BackTable 154 Podcast

Dr. Ashley Agan

Dr. Ashley Agan is a practicing ENT and assistant professor at UT Southwestern Medical Center in Dallas, TX.

Cite This Podcast

BackTable, LLC (Producer). (2024, January 16). Ep. 154 – Labyrinthitis Unpacked: Clinical Perspectives & Management [Audio podcast]. Retrieved from https://www.backtable.com

Disclaimer: The Materials available on BackTable.com are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.

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