May 06, 2020
The First Attack of Vertigo – Is it a Stroke or is it Inner Ear Disease?
As suggested by its name it is thought to be a viral inflammation of the labyrinth (either the combined hearing and balance organs or vestibulocochlear nerve). The herpes simplex virus type 1 (the virus of colds sores) has been implicated but so has cold and flu viruses. Viral labyrinthitis very rarely recurs.
The symptoms are of sudden rotatory vertigo lasting one to several days with sweating, nausea, vomiting, hearing loss and tinnitus.
Patients stagger towards the affected ear and want to lie still.
The patient has severe horizontal spontaneous nystagmus (with a rotational component) toward the unaffected ear. There is a pathologic head-impulse test toward the affected ear.
The tuning fork tests and audiogram are consistent with a high tone sensorineural hearing loss.
Other possible causes must be considered: typically, the patients’ symptoms and physical examination and hearing test does not fit with the presentation and recurrent pattern of Méniere’s disease. It also does not fit with in herpes zoster oticus or Ramsey Hunt syndrome as there are no rashes, no ear pain, no mouth ulcers and no facial weakness. Of importance the patient should have no evidence of a stroke.
Treatment consists of:-
1. Medication to alleviate the symptoms of acute vertigo and nausea.
2. Reduce the inflammation of the labyrinth/vestibulo-cochlear nerve using prednisolone 60 mg for 5 days (with a proton pump inhibitor and no contra-indications). Salvage intratympanic steroids at 1-2 weeks if there is no hearing recovery.
3. A antiviral such as Acyclovir 800mg 5 x day for 7 days is used on immediate onset of symptoms.
4. An antibiotic such as amoxicillin if there is evidence for a middle ear infection (otitis media), such as ear pain and an abnormal ear examination suggesting fluid, redness or pus behind the ear drum.