Clinical Topic A-Z Clinical Speciality

Vestibular neuronitis

Vestibular neuronitis
D020338Vestibular Neuronitis
Ear, nose and throatNeurological
2011-02-07Last revised in February 2011

Vestibular neuronitis - Summary

Vestibular neuronitis (sometimes called 'vestibular neuritis') is a syndrome of acute vertigo of peripheral origin.

The terms 'vestibular neuronitis' and 'labyrinthitis' have been used interchangeably in the past, but specific terminology is now recommended by experts.

Vestibular neuronitis is thought to be due to inflammation of the vestibular nerve and often occurs after a viral infection. Labyrinthitis is a different diagnosis that involves inflammation of the labyrinth and the vestibular nerve, and is often attributed to a viral infection. Hearing loss is a feature of labyrinthitis, but hearing is not affected in vestibular neuronitis.

Vestibular neuronitis often affects previously well, young or middle-aged adults, but can affect anyone.

People with vestibular neuronitis will typically get better even if they have permanent unilateral loss of vestibular function. This may take several weeks, or even longer.

Symptoms of vestibular neuronitis include spontaneous onset of vertigo, which usually settles over a few days, and nausea and vomiting. Hearing loss and tinnitus are not present, and there are no focal neurological symptoms.

Signs include:

Presence of nystagmus - usually fine horizontal but may be mixed horizontal-torsional with the fast phase away from the affected ear. It always beats in the same direction, even if the head is rotated, and is reduced when the vision is fixed on a point.

The head impulse test may be positive (but may also be positive for other peripheral causes of vertigo).

Differential diagnosis of vertigo includes benign paroxysmal positional vertigo, labyrinthitis, Meniere’s disease, and central causes such as migraine, stroke, transient ischaemic attack, cerebellar tumour, acoustic neuroma, and multiple sclerosis.

Symptoms will usually settle over a few weeks, even if no treatment is given.

Advice should be offered regarding resuming activity as soon as possible, and safety issues such as driving, work, and prevention of falls.

If symptoms are severe, short-term symptomatic drug treatment can be offered.

Buccal or intramuscular prochlorperazine can be considered to rapidly relieve severe nausea or vomiting associated with vertigo.

A short course of oral prochlorperazine, cinnarizine, cyclizine, or promethazine teoclate can be considered to alleviate less severe nausea, vomiting and vertigo.

If nausea and vomiting is so severe that a person cannot tolerate oral fluids or symptomatic drug treatment, they should be admitted to hospital.

Referral is necessary if there are atypical symptoms (e.g. additional neurological symptoms), symptoms are not improving after a week of treatment, or symptoms persist for more than 6 weeks.

Have I got the right topic?

216months3060monthsBoth

This CKS topic covers the management of vestibular neuronitis in adults.

This CKS topic does not cover the management of other causes of vertigo (including labyrinthitis), or how to differentiate between different causes of vertigo. This is discussed in the CKS topic on Vertigo.

There are separate CKS topics on Benign paroxysmal positional vertigo and Meniere's disease.

The target audience for this CKS topic is healthcare professionals working within the NHS in the UK, and providing first contact or primary health care.

How up-to-date is this topic?

How up-to-date is this topic?

Changes

Last revised in February 2011

July 2013 — minor update. Links to the DVLA website have been updated.

November 2010 to February 2011 — this is a new CKS topic. The evidence-base has been reviewed in detail, and recommendations are clearly justified and transparently linked to the supporting evidence.

Update

New evidence

Evidence-based guidelines

No new evidence-based guidelines since 1 August 2010.

HTAs (Health Technology Assessments)

No new HTAs since 1 August 2010.

Economic appraisals

No new economic appraisals relevant to England since 1 August 2010.

Systematic reviews and meta-analyses

Systematic reviews published since the last revision of this topic:

Fishman, J.M., Burgess, C., and Waddell, A. (2011) Corticosteroids for the treatment of idiopathic acute vestibular dysfunction (vestibular neuritis) (Cochrane Review). The Cochrane Library. Issue 5. John Wiley & Sons, Ltd. www.thecochranelibrary.com [Free Full-text]

Nauta, J.J. (2013) Meta-analysis of clinical studies with betahistine in Meniere's disease and vestibular vertigo. European Archives of Oto-Rhino-Laryngology epub ahead of print. [Abstract]

Primary evidence

No new randomized controlled trials published in the major journals since 1 August 2010.

New policies

No new national policies or guidelines since 1 August 2010.

New safety alerts

No new safety alerts since 1 August 2010.

Changes in product availability

No changes in product availability since 1 August 2010.

Goals and outcome measures

Goals

To support primary healthcare professionals:

To clinically diagnose vestibular neuronitis

To offer advice on managing the symptom of vertigo

To offer short-term symptomatic drug treatment, if necessary

To advise on vestibular rehabilitation exercises

To refer appropriately to secondary care

Background information

Definition

What is it?

Vestibular neuronitis (sometimes called 'vestibular neuritis') is a syndrome of acute vertigo of peripheral origin [Baloh, 2003].

The terms 'vestibular neuronitis' and 'labyrinthitis' have been used interchangeably in the past, but specific terminology is now recommended by experts.

Vestibular neuronitis is thought to be due to inflammation of the vestibular nerve and often occurs after a viral infection [Hanley et al, 2001; Kuo et al, 2008a; Macleod and McAuley, 2008].

Labyrinthitis is a different diagnosis that involves inflammation of the labyrinth and the vestibular nerve, and is often attributed to a viral infection [Swartz and Longwell, 2005; Kuo et al, 2008a]. Hearing loss is a feature of labyrinthitis, but hearing is not affected in vestibular neuronitis. For more information on the management of labyrinthitis, see the CKS topic on Vertigo.

Prevalence

How common is it?

In a prospective study in primary care of 70 people with vertigo [Hanley and O'Dowd, 2002]: 43% had benign paroxysmal positional vertigo; 40% had vestibular neuronitis; 10% had Meniere's disease; and the remainder had stroke, transient ischaemic attack, multiple sclerosis, or psychogenic vertigo. However, these findings may be misleading as:

The study did not report people for whom the cause of vertigo remained undiagnosed. No diagnosis is made in a substantial proportion of people.

It is unclear whether they were working diagnoses before further investigation or confirmed diagnoses.

CKS expert reviewers highlighted that the study overestimated the incidence of Meniere's disease (which is rare) and omits migrainous vertigo (which may be one of the most common causes of vertigo).

Prognosis

What is the prognosis?

People with vestibular neuronitis will typically get better even if they have permanent unilateral loss of vestibular function. This may take several weeks, or even longer.

[Baloh, 2003]

Complications

What are the complications?

Benign paroxysmal positional vertigo can develop following vestibular neuronitis [Baloh, 2003]. For more information on the features of this condition, see the CKS topic on Benign paroxysmal positional vertigo.

Complications of the symptom of vertigo include:

Adverse effects on quality of life. Vertigo can be disabling, affecting such activities as driving and employment and causing loss of confidence in everyday living.

Increased risk of falls.

Increased likelihood of anxiety or depression.

[Bird et al, 1998; Minor et al, 2004]

Diagnosis

Diagnosis of vestibular neuronitis

Diagnosis

How do I know my patient has it?

Vestibular neuronitis often affects previously well, young or middle-aged adults, but can affect anyone.

Enquire about symptoms indicative of vestibular neuronitis.

Vertigo occurs spontaneously, may develop on waking, or may develop over the course of the day. Acute symptoms usually settle in a few days because vestibular compensation occurs.

Nausea and vomiting occur, and balance may be affected. Gait apraxia is not a prominent feature.

Hearing loss and tinnitus are not features of vestibular neuronitis (but may be present in labyrinthitis).

There are no focal neurological symptoms.

Look for signs of vestibular neuronitis.

Nystagmus is present and is usually fine horizontal but may be mixed horizontal-torsional with the fast phase away from the affected ear. It always beats in the same direction, even if the head is rotated, and is reduced when the vision is fixed on a point.

The head impulse test may be positive (but is less reliable than nystagmus as an examination finding, as it may also be positive for other peripheral causes of vertigo and so cannot be used to differentiate between them).

Head impulse test

Head impulse test

Use caution if the person has neck pathology, as the head impulse test involves rapid repositioning of the head [Kuo et al, 2008b]. Always start by asking the person to rotate their neck themselves to assess for any limitation of neck movement. If in doubt about the safety of the manoeuvre, seek specialist advice or refer the person to a balance specialist.

To carry out the head impulse test [Macleod and McAuley, 2008]:

Advise the person to sit upright and to fix their gaze on the examiner.

Then rapidly turn the head 20 degrees to one side and watch the eyes for corrective abnormal movements (saccades).

Repeat several times to the same or opposite side, randomly and unpredictably, until satisfied as to the consistent presence or absence of the corrective saccade.

A corrective saccade represents a positive test and implies moderate to severe loss of function of the horizontal semi-circular canal on the side to which the test is positive.

Video illustrations of performing the head impulse test and demonstrating corrective saccades are available at the Imperial College London Faculty of Medicine website.

Basis for recommendation

Basis for recommendation

This information is based on expert opinion in review articles [Hanley et al, 2001; Baloh, 2003; Hain and Uddin, 2003; Macleod and McAuley, 2008].

Differential diagnosis

What else might it be?

Other causes of vertigo include:

Benign paroxysmal positional vertigo. For more information, see the CKS topic on Benign paroxysmal positional vertigo.

Labyrinthitis (similar features to vestibular neuronitis, but also involves hearing loss).

Meniere's disease. For more information, see the CKS topic on Meniere's disease.

Central causes (for example migraine, stroke, transient ischaemic attack, cerebellar tumour, acoustic neuroma, and multiple sclerosis).

For more information on differentiating between these conditions, see the CKS topic on Vertigo.

Basis for recommendation

Basis for recommendation

This information is based on expert opinion in a review article [Nadol, 1995]. Further sources of information are discussed in the CKS topic on Vertigo.

Management

Management

Scenario: Management : covers the management of vestibular neuronitis, including symptomatic drug treatment, advice to patients, and referral.

Scenario: Management

Scenario: Management of vestibular neuronitis

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Advice

What should I advise a person with vestibular neuronitis?

Reassure the person that symptoms will usually settle over several weeks, even if no treatment is given. Advise that factors such as alcohol, tiredness, or intercurrent illness may have a greater than usual effect on their balance. Explain that there may be periods during their recovery when their symptoms appear to be worsening again.

Advise that bed rest may be necessary if symptoms are particularly severe during the acute phase, but that activity should be resumed as soon as possible (even if vertigo becomes more prominent during movement).

Advise on safety issues.

Advise the person not to drive when they are dizzy, or if they are likely to experience an episode of vertigo while driving.

The Driver and Vehicle Licensing Agency state that people liable to 'sudden attacks of unprovoked or unprecipitated disabling giddiness' should stop driving.

Workplace — the person should inform their employer if their vertigo poses a risk in the workplace (for example people using ladders, operating heavy machinery, or driving).

Falls in the home — discuss the risk of falling in the home during an episode of vertigo and suggest measures to reduce this.

Basis for recommendation

Basis for recommendation

Reassurance

The recommendation to reassure people that symptoms will settle is based on expert opinion in review articles that central vestibular compensation will eventually ameliorate symptoms [Baloh, 2003; Macleod and McAuley, 2008]. The advice on the fluctuant nature of the recovery process and factors which may affect balance more than usual is based on expert opinion from reviewers of this CKS topic.

Self-care advice

This recommendation has been extrapolated from expert opinion in a US guideline on the management of benign paroxysmal positional vertigo [Bhattacharyya et al, 2008], guidelines from the Driver and Vehicle Licensing Agency [DVLA, 2011], expert opinion in a review article [Parnes et al, 2003], and CKS expert reviewers.

For detailed guidance on driving, see At a glance guide to the current medical standards of fitness to drive, available to download from www.gov.uk.

Rest and activity

The recommendation to rest if necessary during the acute phase, but to encourage activity, is based on expert opinion in review articles [Hain and Uddin, 2003; Kuo et al, 2008a]. It is thought that vestibular compensation can develop more quickly and more effectively if the person is active as soon as possible [Baloh, 2003].

Symptomatic drug treatment

How should I treat the symptom of vertigo?

If symptoms are severe, offer short-term symptomatic drug treatment.

To rapidly relieve severe nausea or vomiting associated with vertigo, consider giving buccal prochlorperazine, or a deep intramuscular injection of prochlorperazine.

To alleviate less severe nausea, vomiting, and vertigo, consider prescribing a short course of:

Prochlorperazine (the buccal preparation has a faster onset of action than standard-release oral tablets), or antihistamines (cinnarizine, cyclizine, or promethazine teoclate). Prochlorperazine is less sedating than the recommended antihistamines but may cause a dystonic reaction (particularly in young women).

Advise the person to take medication regularly for 3 days then, if possible, on an as-required basis. Explain that medication should be taken for the minimum time possible (ideally no longer than 1 week), as it may delay recovery by affecting the body's compensatory mechanisms.

For more information, see Prescribing information.

Treatment with antiviral drugs, corticosteroids, or benzodiazepines is not recommended.

Advise the person to return if their symptoms deteriorate or have not fully resolved after 1 week of treatment.

Basis for recommendation

Basis for recommendation

Choice of drug treatment

The recommendation that symptomatic treatment can be useful in the short term is based on expert opinion in review articles and the opinion of CKS expert reviewers [Nadol, 1995; Hanley et al, 2001; Macleod and McAuley, 2008].

CKS found no good quality evidence of benefit for the different symptomatic treatment options. However, the recommended drugs are all licensed for use in people with nausea, vomiting, and vertigo [ABPI Medicines Compendium, 2010a; ABPI Medicines Compendium, 2010c; ABPI Medicines Compendium, 2010d; ABPI Medicines Compendium, 2010e; ABPI Medicines Compendium, 2010f].

Duration of drug treatment

Expert opinion from review articles suggests that symptomatic drug treatment should only be used in the short term, because prolonged use may delay central vestibular compensation [Nadol, 1995; Hanley et al, 2001; Macleod and McAuley, 2008]. The opinion of CKS expert reviewers was consistent with this.

Corticosteroids

Some experts consider that the use of corticosteroids in people with vestibular neuronitis may improve vestibular function in the long term; however, this is uncertain, and high doses are used [Kuo et al, 2008a; Seemungal and Bronstein, 2008].

Evidence from a systematic review and meta-analysis suggests that, compared with placebo, corticosteroids for vestibular neuronitis cause improvement on caloric testing, but do not affect clinical symptoms [Goudakos et al, 2010].

Antiviral drugs

Evidence from a prospective study with some methodological limitations found that methylprednisolone improved the vestibular recovery of people with vestibular neuronitis, but valaciclovir did not [Strupp et al, 2004].

Benzodiazepines

Benzodiazepines are not recommended because although some experts advocate their use, CKS found no evidence to support this, and they are not licensed for this purpose [BNF 60, 2010].

Admission or referral

When should I admit or refer a person with vestibular neuronitis?

Admit the person to hospital if they have severe nausea and vomiting and cannot tolerate oral fluids or symptomatic drug treatment.

Refer the person to a balance specialist (audiovestibular physician or neurologist — depending on local protocol) for further assessment or consideration of vestibular rehabilitation, (involving exercises to promote central nervous system compensation) if:

Symptoms are not typical of vestibular neuronitis (for example additional neurological symptoms).

Symptoms persist without improvement for more than 1 week despite treatment (urgently refer).

Symptoms persist for longer than 6 weeks — investigation to exclude other causes, or vestibular rehabilitation may be required.

Basis for recommendation

Basis for recommendation

Referral recommendations are based on expert opinion from:

A review article on the diagnosis of vertigo in general practice [Barraclough and Bronstein, 2009].

A study reporting referral patterns for dizziness in primary care [Bird et al, 1998]. Referral criteria were formulated from expert opinion for this study.

CKS expert reviewers, who suggest that it is appropriate to refer after 1 week to exclude more serious diagnoses if symptoms persist despite treatment.

Vestibular rehabilitation

There is evidence from a Cochrane systematic review that vestibular rehabilitation is effective and has a well-established safety profile for unilateral peripheral vestibular dysfunction, and that it helps symptoms in the medium term [Hillier and Holohan, 2007].

CKS expert reviewers suggest that the quality and availability of vestibular rehabilitation varies depending on locality.

Important aspects of prescribing information relevant to primary healthcare are covered in this section specifically for the drugs recommended in this CKS topic. For further information on contraindications, cautions, drug interactions, and adverse effects, see the electronic Medicines Compendium (eMC) (http://medicines.org.uk/emc), or the British National Formulary (BNF) (www.bnf.org).

Prochlorperazine

Prochlorperazine

Prescribing issues

Prescribing issues

Do not give prochlorperazine if the person has:

Parkinson's disease — prochlorperazine can cause drug-induced Parkinsonism and other extrapyramidal adverse effects.

Arrhythmias, hypokalaemia, or is taking other drugs known to prolong the QT interval — prochlorperazine has the potential to increase the QT interval. Use a sedating antihistamine instead.

Use prochlorperazine with caution (use a low dose and monitor adverse effects) if the person has:

Liver or kidney dysfunction.

Cardiovascular disease (check serum electrolytes and electrocardiogram [ECG] before starting treatment).

Prostatic hypertrophy, narrow-angle glaucoma.

Epilepsy or a history of seizures — prochlorperazine can lower the seizure threshold.

In addition:

For pregnant women, cyclizine or promethazine are preferred (off-label use). There are fewer safety data on the use of prochlorperazine in pregnancy (off-label use), but it is also considered suitable [NTIS, 1999].

For women who are breastfeeding, phenothiazines are minimally excreted in breastmilk, so occasional, short-term use of prochlorperazine is unlikely to affect the infant [LactMed, 2009].

If possible, check electrolytes and obtain an ECG before starting treatment, to rule out a predisposition towards ventricular arrhythmias.

The most commonly reported adverse effects are nervous system disorders.

Elderly people are particularly susceptible (and so lower doses are recommended), although some adverse events only occur with prolonged use (for example drug-induced Parkinsonism adverse effects such as tremor).

Acute dystonia and dyskinesia are usually transitory, are more common in children and young adults, and usually occur within the first 4 days of treatment.

Prochlorperazine may cause drowsiness; but it is less sedating than cinnarizine, cyclizine, and promethazine teoclate.

Antimuscarinic adverse effects may also occur (for example blurred vision and dry mouth). Elderly people are particularly susceptible to antimuscarinic adverse effects (but they are not common).

Prochlorperazine may cause postural hypotension (especially in elderly people, and in those requiring deep intramuscular injection of prochlorperazine).

Prochlorperazine should be discontinued in people with an unexplained fever as this may be a sign of neuroleptic malignant syndrome (NMS). NMS is rare, but life-threatening. Other signs of NMS include rigidity, autonomic instability, labile blood pressure, tachycardia, sweating, incontinence, flushing, pallor, and altered level of consciousness.

[ABPI Medicines Compendium, 2010b; ABPI Medicines Compendium, 2010e]

Advice for patients

Advice for patients

Advise the person that:

Prochlorperazine may cause drowsiness and affect their ability to drive or operate machinery. Alcohol should be avoided while taking prochlorperazine (otherwise drowsiness will be potentiated).

High doses may cause a sensitivity to sunlight. If this occurs, sun lamps and direct sunlight should be avoided.

Prochlorperazine may affect how the body responds to environmental temperatures. Elderly people (especially) should consider their body temperature in very hot or very cold weather.

People should inform their doctor immediately if they have any of the following:

Fainting or dizziness on standing or sitting up.

Inability to control certain muscles, especially within the first 4 days of treatment or after an increase in dose. This may affect the tongue, mouth, arms, and legs; it is more common in young people.

Heart palpitations (unusually rapid or irregular heart beat).

Unexpected sore throat, infection, or fever.

Very slow, shallow breathing.

Advise the person to stop taking their medicine and seek immediate medical advice if they develop:

A yellow tinge of the skin or eyes (jaundice).

A combination of high temperature, sweating, pale complexion, difficulty in passing urine, muscle stiffness, altered level of alertness (indicating neuroleptic malignant syndrome — rare, but life-threatening).

[ABPI Medicines Compendium, 2010b; ABPI Medicines Compendium, 2010e]

Sedating antihistamines

Sedating antihistamines

Prescribing issues

What issues should I consider before prescribing a sedating antihistamine?

Sedating antihistamines should be used with caution if the person has:

Liver or kidney dysfunction.

Urinary retention, prostatic hypertrophy, angle-closure glaucoma, or pyloroduodenal obstruction — if possible, avoid using sedating antihistamines because of their significant antimuscarinic activity (particularly in elderly people).

Epilepsy — avoid antihistamines if possible, as they reduce the seizure threshold.

In addition:

If the person has severe heart failure: avoid using cyclizine if possible, as it may decrease cardiac output.

If the person has Parkinson's disease: avoid using cinnarizine if possible, as there have been rare reports of cinnarizine-induced Parkinsonism [Micromedex, 2010].

Pregnant women: cyclizine or promethazine teoclate are both considered to be suitable for use during pregnancy (off-label use). No increase in birth defects after clinical use of cinnarizine have been shown but in the absence of controlled studies, cinnarizine should not be routinely used in pregnancy [NTIS, 2002; Schaefer et al, 2007].

Women who are breastfeeding: do not use sedating antihistamines. There are no data on whether cinnarizine, cyclizine, or promethazine are excreted in breastmilk. Other sedating antihistamines (such as chlorphenamine) that are known to be excreted in breastmilk cause sedation and poor feeding in the infant [Trent Drug Information Service, 2001].

The most commonly reported adverse effects are nervous system disorders.

Elderly people are particularly susceptible (and so lower doses are recommended).

Sedating antihistamines may cause drowsiness.

Antimuscarinic adverse effects may also occur (for example blurred vision and dry mouth).

Extrapyramidal symptoms are rare but have been reported with cinnarizine. At most risk are elderly people receiving prolonged treatment.

Cyclizine is a recognized substance of misuse for its euphoric or hallucinatory effects and extra vigilance is needed when prescribing it [RPSGB, 2006].

[ABPI Medicines Compendium, 2010a; ABPI Medicines Compendium, 2010d; ABPI Medicines Compendium, 2010f]

Advice for patients

What advice should I give to patients about sedating antihistamines?

Advise the person that:

Sedating antihistamines may cause drowsiness. The degree of sedation will vary between individuals and will depend on the dose given, but if affected the person should avoid driving or performing skilled tasks. Alcohol should be avoided while taking prochlorperazine otherwise drowsiness will be potentiated.

Cinnarizine may cause gastrointestinal irritation; but this is usually transient and can be minimized by taking it with or after food.

Evidence

Evidence

Supporting evidence

Symptomatic drug treatment

Evidence on symptomatic drug treatment for vestibular neuronitis

CKS found no good-quality evidence of benefit for the different symptomatic treatment options. However, the recommended drugs are all licensed for use in people with nausea, vomiting, and vertigo.

Corticosteroids

Evidence on corticosteroids for vestibular neuronitis

Evidence from a systematic review and meta-analysis suggests that compared with placebo, corticosteroids for vestibular neuronitis cause improvement in the caloric recovery of canal paresis, but do not affect clinical symptoms.

A systematic review of the role of corticosteroids in the treatment of vestibular neuronitis found four prospective randomized controlled trials which compared corticosteroids with placebo. Data from three of the studies could be combined in a meta-analysis [Goudakos et al, 2010].

When treatment with corticosteroids and placebo was compared:

Clinical recovery was not significantly different between the two groups after 1 month of treatment (odds ratio [OR] 1.45, 95% CI 0.26 to 8.01; p = 0.67), 3 months of treatment (OR 1.71, 95% CI 0.40 to 7.29; p = 0.47), or 6 months of treatment (OR 1.75; 95% CI 0.40 to 7.66; p = 0.46). Data for this outcome were taken from only one study.

Caloric complete recovery differed significantly between the corticosteroid and placebo groups at 1 month (OR 12.64, 95% CI 2.6 to 61.52; p = 0.002) and 12 months (OR 3.35, 95% CI 1.45 to 7.76; p = 0.005). Data were taken from two studies.

Antivirals

Evidence on antivirals for vestibular neuronitis

Limited evidence from a small, methodologically flawed study indicates that methylprednisolone is effective at improving peripheral vestibular function compared with placebo and valaciclovir. However, patient-orientated outcomes were not reported.

A prospective, randomized, double-blind trial included 141 people with vestibular neuronitis. Of these, 38 were given placebo, 35 methylprednisolone, 33 valaciclovir, and 35 methylprednisolone plus valaciclovir [Strupp et al, 2004].

After 12 months of follow up, the mean (+/–SD) improvement in peripheral vestibular function (measured by caloric testing and assessing nystagmus rather than symptoms relevant to patients) was:

Placebo group: 39.6 +/– 28.1 percentage points.

Methylprednisolone group: 62.4 +/– 16.9 percentage points (p < 0.001).

Valaciclovir group: 36.0 +/– 26.7 percentage points (p = 0.43).

Methylprednisolone plus valaciclovir group: 59.2 +/– 24.1 percentage points.

The effect of methylprednisolone was statistically significant, whereas the effect of valaciclovir was not. The methylprednisolone plus valaciclovir group showed no advantage over corticosteroid monotherapy.

Vestibular rehabilitation

Evidence on vestibular rehabilitation for vestibular neuronitis

Low-quality evidence suggests that vestibular rehabilitation (exercises to promote central nervous system compensation) is effective at reducing dizziness and other symptoms (such as balance and gait). However, results were mainly from single studies with significant heterogeneity.

A Cochrane systematic review (search date March 2007) identified 21 trials on the use of vestibular rehabilitation in adults for unilateral peripheral vestibular dysfunction in people with benign paroxysmal positional vertigo, vestibular neuronitis, labyrinthitis, Meniere's disease, or surgery [Hillier and Holohan, 2007].

The studies varied in terms of the vestibular rehabilitation method used, and whether vestibular rehabilitation was compared with placebo, another vestibular rehabilitation manoeuvre, or another management intervention (for example drugs, or passive manoeuvres). Different outcome measures were also used.

Data from three similar studies were pooled — vestibular rehabilitation was found to be more effective than sham interventions or control in terms of dizziness.

Single studies found that vestibular rehabilitation was effective at improving other parameters (such as balance, vision, and gait).

Studies in which people were followed up showed a positive effect for 3–12 months.

Evidence was insufficient to determine which form of vestibular rehabilitation is more effective.

Search strategy

Scope of search

A literature search was conducted for guidelines, systematic reviews and randomized controlled trials on primary care management of vestibular Neuronitis.

Search dates

Date unrestricted – August 2010

Key search terms

Various combinations of searches were carried out. The terms listed below are the core search terms that were used for Medline.

exp vestibular neuronitis/, vestibular neuronitis.tw., vestibular neuritis.tw.

Table 1 . Key to search terms.
Search commands Explanation
/ indicates a MeSh subject heading with all subheadings selected
.tw indicates a search for a term in the title or abstract
exp indicates that the MeSH subject heading was exploded to include the narrower, more specific terms beneath it in the MeSH tree
$ indicates that the search term was truncated (e.g. wart$ searches for wart and warts)
Sources of guidelines

National Institute for Health and Care Excellence (NICE)

Scottish Intercollegiate Guidelines Network (SIGN)

NICE Evidence

National Guidelines Clearinghouse

New Zealand Guidelines Group

British Columbia Medical Association

Canadian Medical Association

Institute for Clinical Systems Improvement

Guidelines International Network

National Library of Guidelines

National Health and Medical Research Council (Australia)

Alberta Medical Association

University of Michigan Medical School

Michigan Quality Improvement Consortium

Royal College of Nursing

Singapore Ministry of Health

Royal Australian College of General Practitioners

Health Protection Agency

National Resource for Infection Control

CREST

World Health Organization

NHS Scotland National Patient Pathways

Agency for Healthcare Research and Quality

TRIP database

Patient UK Guideline links

UK Ambulance Service Clinical Practice Guidelines

RefHELP NHS Lothian Referral Guidelines

Medline (with guideline filter)

Driver and Vehicle Licensing Agency

Sources of systematic reviews and meta-analyses

The Cochrane Library :

Systematic reviews

Protocols

Database of Abstracts of Reviews of Effects

Medline (with systematic review filter)

EMBASE (with systematic review filter)

Sources of health technology assessments and economic appraisals

NIHR Health Technology Assessment programme

The Cochrane Library :

NHS Economic Evaluations

Health Technology Assessments

Canadian Agency for Drugs and Technologies in Health

International Network of Agencies for Health Technology Assessment

Sources of randomized controlled trials

The Cochrane Library :

Central Register of Controlled Trials

Medline (with randomized controlled trial filter)

EMBASE (with randomized controlled trial filter)

Sources of evidence based reviews and evidence summaries

Bandolier

Drug & Therapeutics Bulletin

MeReC

NPCi

BMJ Clinical Evidence

DynaMed

TRIP database

Central Services Agency COMPASS Therapeutic Notes

Sources of national policy

Department of Health

Health Management Information Consortium (HMIC)

Sources of medicines information

The following sources are used by CKS pharmacists and are not necessarily searched by CKS information specialists for all topics. Some of these resources are not freely available and require subscriptions to access content.

British National Formulary (BNF)

electronic Medicines Compendium (eMC)

European Medicines Agency (EMEA)

LactMed

Medicines and Healthcare products Regulatory Agency (MHRA)

REPROTOX

Scottish Medicines Consortium

Stockley's Drug Interactions

TERIS

TOXBASE

Micromedex

UK Medicines Information

References

ABPI Medicines Compendium (2010a) Summary of product characteristics for Stugeron 15mg. Electronic Medicines CompendiumDatapharm Communications Ltd. www.medicines.org.uk [Free Full-text]

ABPI Medicines Compendium (2010b) Summary of product characteristics for Stemetil injection. Electronic Medicines CompendiumDatapharm Communications Ltd. www.medicines.org.uk [Free Full-text]

ABPI Medicines Compendium (2010c) Summary of product characteristics for Buccastem 3mg. Electronic Medicines CompendiumDatapharm Communications Ltd. www.medicines.org.uk [Free Full-text]

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