Focused Issue of This Month Vestibular Neuritis and Bilateral Vestibulopathy Kwang- Dong Choi, MD Department of Neurology, Pusan National University Medical School E - mail : choikwangdong@hanmail.net Eui-Kyung Goh, MD Department of Otolaryngology, Pusan National University Medical School E - mail : gohek@pusan.ac.kr J Korean Med Assoc 2008; 51(11): 992-1006 Abstract Vestibular neuritis is the second most common cause of peripheral vestibular vertigo. The key signs and symptoms are the acute onset of sustained rotatory vertigo without hearing loss, postural imbalance with Romberg's sign, and peripheral type nystagmus. Head thrust and caloric tests show ipsilateral hyporesponsiveness, but hearing test shows normal. Either an inflammation of the vestibular nerve or labyrinthine ischemia was proposed as a cause of vestibular neuritis. Recovery after vestibular neuritis is usually incomplete. Despite the assumed viral cause, the effects of corticosteroids, antiviral agents, or the two in combination are uncertain. Bilateral vestibulopathy is a rare disorder of the peripheral labyrinth or the eighth nerve. The most frequent etiologies include ototoxicity, autoimmune disorders, meningitis, neuropathies, sequential vestibular neuritis, cerebellar degeneration, tumors, and miscellaneous otological diseases. The two key symptoms are unsteadiness of gait and oscillopsia associated with head movements or when walking. The diagnosis is made with the simple bedside tests for defective vestibulo-ocular reflex (head thrust and dynamic visual acuity tests). Bilateral vestibulopathy is confirmed by the absence of nystagmus reaction to both caloric and rotatory chair tests. The spontaneous recovery is relatively rare and incomplete. Vestibular rehabilitation is supportive of the improvement, but the efficacy of physical therapy is limited. Keywords: Vestibular neuritis; Bilateral vestibulopathy; Peripheral vestibulopathy 992
Vestibular Neuritis and Bilateral Vestibulopathy 10 * Recording of horizontal eye movement of the left eye Recording of vertical eye movement of the left Recording of torsional eye movement of the left eye Figure 1. Spontaneous nystagmus in a patient with right vestibular neuritis. The fast phases of mixed torsional-horizontal nystagmus directs toward the intact ear. The nystagmus increases with gaze in the direction of nystagmus, and decreases with gaze in the opposite direction. Visual fixation markedly suppress the nystagmus. 993
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Vestibular Neuritis and Bilateral Vestibulopathy Figure 2. Bithermal caloric tests show a complete canal paresis in the left ear in a patient with left vestibular neuritis. 995
Choi KDGoh EK Figure 3. Rotatory chair test shows increased phase lead and the asymmetry with normal gain of the vestibulo-ocular reflex in a patient with left vestibular neuritis. Figure 4. Ocular torsion to the left side in a patient with left vestibular neuritis. 996
Vestibular Neuritis and Bilateral Vestibulopathy Figure 5. Normal vestibular-evoked myogenic potentials in a patient with right vestibular neuritis. A B Figure 6. Posturographic data in a patient with vestibular neuritis. The scores of condition 4, 5, 6 are decreased. 997
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Choi KDGoh EK Table 1. Commonly used antivertiginous and antiemetic drugs Drug Dosage Action Anticholinergics Muscarine antagonist Scopolamine (Transderm Scop) 0.6 mg po q 4~6 h or transdermal patch: 1 q 3 days Antihistamines Dimenhydrinate 50 mg po q 4~6 h or Histamine (H1) antagonist (Dramamine) im q 4~6 h or 100 mg suppository q 8~10 h Muscarine antagonist Meclizine 25 mg po q 4~6 h Histamine (H1) antagonist (Antivert, Bonine) Muscarine antagonist Promethazine 15 or 50 mg po q 4~6 h or Histamine (H1) antagonist (Phenergan) im q 4~6 h or suppository q 4~6 h Dopamine (D2) antagonist Phenothiazine Prochlorperazine 5 or 10 mg po q 4~6 h or im q 6 h or Muscarine antagonist (Compazine) 25 mg suppository q 12 h Dopamine (D2) antagonist Butyrophenone Droperidol 2.5 or 5 mg im q 12 h Muscarine antagonist (Inapsine) Dopamine (D2) antagonist Benzodiazepines Diazepam (Valium) 5 or 10 mg po bid-qid Im q 4~6 h or iv q 4~6 h GABA A agonist Clonazepam (Klonopin) 0.5 mg po tid GABA A agonist 1000
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Choi KDGoh EK Table 2. Causes of bilateral vestibulopathy Idiopathic Ototoxicity Meningitis (labyrinthine infection) Tumors Autoimmune disorders Cerebellar degeneration Neuropathies Bilateral sequential vestibular neuritis Bilateral Meniere's syndrome Congenital malformation Familial vestibulopathy Labyrinthine ischemia Gentamicin & other antibiotics, anticancer chemotherapy Antihistamines (meclizine, phenergan) Antidepressant (Amitriptyline, other TCA agents) Aspirin & NSAID Diazepam, alprazolam, lorazepam Verapamil and other CCAs Furosemide Quinine & related drugs Streptococcus aureus, N. menigitidis, S. pneumoniae, M. tuberculosis, HIV Neurofibromatosis (bilateral acoustic neuromas), NHL, Leptomeningeal metastasis Cogan's syndrome, Behcet's disease, SLE, RA, PAN Wegener's granulomatosis, Giant cell arteritis, Antiphospholipid syndrome Friedrich's ataxia, Charcot - Marie syndrome Vit. B12 deficiency, Hereditary sensory and autonomic neuropathy (HSMN IV), Nutritional (beri beri), Neurosarcoidosis Usher's syndrome 1002
Vestibular Neuritis and Bilateral Vestibulopathy Figure 7. Bithermal caloric tests show markedly decreased respones to warm and cold stimulation bilaterally in a patient with bilateral vestibulopathy. 1003
Choi KDGoh EK Figure 8. Rotatory chair test shows increased phase lead and decreased gain of the vestibulo-ocular reflex in a patient with bilateral vestibulopathy. 1004
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