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Labyrinthitis, Emergency Medicine

Basics

Description

- 3 most common causes of peripheral vertigo include, benign paroxysmal positional vertigo (BPPV), Meni â Ęre disease, and labyrinthitis - Labyrinthitis: - Serous: Viral or bacterial - Suppurative: Bacterial - Autoimmune: Wegener or polyarteritis nodosa - Vascular ischemia - Head injury or ear trauma - Medications: - Aminoglycosides, loop diuretics, antiepileptics (phenytoin)

- BPPV: - Onset 1 " ô5 yr of age - Symptoms: Abrupt onset of crying, nystagmus, diaphoresis, emesis, ataxia - Recurrences for up to 3 yr - Migraine " ôBPPV complex is the most common etiology of pediatric vertigo

- Vertigo: - Peripheral vertigo - Sudden onset - Associated with movement, head position - Sensation of room spinning or off balance

- Nausea and vomiting - Episodes of hearing impairment: - Unilateral or bilateral - Mild or profound - Tinnitus (consider Meni â Ęre disease)

- Complete head and neck exam - Inspect external ear (erythema, swelling, evidence of surgery), ear canal (otorrhea, vesicles), and TM and middle ear (perforation, cholesteatoma, middle ear effusion, or otitis media) - Mastoid tenderness (mastoiditis) - Ocular exam, including range of movements, pupillary response, and fundoscopy, to assess for papilledema - Nystagmus: - Augmented by head movement or rapid head shaking - Positional - Horizontal, frequently with rotational component - Direction is constant - Attenuates with fixation - Fatigable

- Complete neurologic and cardiac exams: - Assess for other causes of symptoms - Cranial nerves, Romberg test, tandem gait, cerebellar function - Orthostatic vitals, carotid and vertebral bruits

- Indications: - Findings suggestive of central vertigo: - Acute or gradual onset - Not positional but may be exacerbated by head movements - Pure direction " övertical, horizontal, or torsional - Direction may change - Nonfatigable

- High cardiovascular risk factors - Focal neurologic findings

- Peripheral vertigo: - Otitis media - Vestibular neuritis - Acoustic neuroma - Autoimmune inner ear disease - BPPV - Cholesteatoma - Meni â Ęre disease (associated tinnitus, "fullness, " Ł or hearing loss) - Otosyphilis - Ototoxic drugs (loop diuretics, aminoglycosides, streptomycin, salicylates, ethanol) - Herpes zoster (Ramsey Hunt syndrome) - Perforated TM - Perilymphatic fistula (symptoms accentuated with Valsalva) - Post-traumatic vestibular concussion - Suppurative labyrinthitis (toxic appearance) - Temporal bone fracture

- Central vertigo " öoften presents with symptoms indistinguishable from peripheral vertigo because the labyrinth has a monosynaptic connection to the brainstem: - Brainstem ischemia - Cerebellar hemorrhage - Inferior cerebellar ischemia - CNS lesions (tumors) - Chiari malformation - Multiple sclerosis (paresthesia, optic neuritis) - Partial seizures of temporal lobe - Vestibular " ômasseter syndrome (associated masseter muscle weakness) - Vestibular migraine (30% have vertigo independent of headaches) - Wallenberg syndrome (associated Horners syndrome, crossed sensory signs)

  • Inflammatory disorder of the inner ear
  • Inflammation decreases afferent firing from the labyrinthCNS interprets the decreased signal as head rotation away from the diseased labyrinthThe imbalance in firing from the labyrinth results in spontaneous nystagmus with fast phase away from the pathologic side
  • Form of unilateral vestibular dysfunction that typically cause balance disorders and vertigo, and may be associated with hearing loss and tinnitus
  • Peak onset 30 " ô60 yr old
  • Associated with upper respiratory tract infection in 50% of patients
  • Symptoms predominantly with head movement but can persist at rest
  • Recovery phase gradual over weeks to months

Etiology

  • 3 most common causes of peripheral vertigo include, benign paroxysmal positional vertigo (BPPV), Meni â Ęre disease, and labyrinthitis
  • Labyrinthitis:Serous: Viral or bacterialSuppurative: BacterialAutoimmune: Wegener or polyarteritis nodosaVascular ischemiaHead injury or ear traumaMedications:Aminoglycosides, loop diuretics, antiepileptics (phenytoin)AllergiesChronic
  • BPPV:Dislodgement of otoconia debris:Idiopathic: 49%Post-traumatic: 18%Sequela of labyrinthitis: 15%Sequela of ischemic insult
  • Suppurative and serous labyrinthitis:Usually secondary to acute otitis media, mastoiditis, or meningitis
  • BPPV:Onset 1 " ô5 yr of ageSymptoms: Abrupt onset of crying, nystagmus, diaphoresis, emesis, ataxiaRecurrences for up to 3 yrMigraine " ôBPPV complex is the most common etiology of pediatric vertigo
  • Meni â Ęre disease:

Diagnosis

Signs and Symptoms

History

  • Vertigo:Peripheral vertigoSudden onsetAssociated with movement, head positionSensation of room spinning or off balance
  • Nausea and vomiting
  • Episodes of hearing impairment:Unilateral or bilateralMild or profoundTinnitus (consider Meni â Ęre disease)
  • Otorrhea (consider otitis media, tympanic membrane [TM] perforation)
  • Otalgia (consider otitis media, mastoiditis, cholesteatoma)
  • Associated with recent infections or sick contacts
  • Predisposing factors include ear surgery, diabetes mellitus, stroke, migraine, and trauma
  • Head/cervical spine trauma is a direct causal agent, as it dislodges inner ear particles
  • Associated with family history of hearing loss or ear diseases

Physical Exam

  • Complete head and neck exam
  • Inspect external ear (erythema, swelling, evidence of surgery), ear canal (otorrhea, vesicles), and TM and middle ear (perforation, cholesteatoma, middle ear effusion, or otitis media)
  • Mastoid tenderness (mastoiditis)
  • Ocular exam, including range of movements, pupillary response, and fundoscopy, to assess for papilledema
  • Nystagmus:Augmented by head movement or rapid head shakingPositionalHorizontal, frequently with rotational componentDirection is constantAttenuates with fixationFatigable
  • Complete neurologic and cardiac exams:Assess for other causes of symptomsCranial nerves, Romberg test, tandem gait, cerebellar functionOrthostatic vitals, carotid and vertebral bruits
  • May be associated with facial weakness or asymmetry (consider stroke or Ramsay Hunt syndrome), neck pain or stiffness (consider meningitis), and visual changes (consider central cause of vertigo)
  • Caloric testing:Irrigate external ear canal with cold water for 20 sec (1st inspect to confirm absence of TM perforation).Normal response causes horizontal nystagmus with the fast phase away from the irrigated earLabyrinthitis produces partial or complete loss of response
  • Dix " ôHallpike maneuver:Tests for evidence of BPPV

Essential Workup

  • Careful neurologic exam to exclude central cause of vertigo
  • Exclude underlying infections:Acute otitis media, meningitis, mastoiditis, Ramsay Hunt syndrome (herpetic lesions on the TM)
  • Orthostatics
  • Auditory evaluation

Diagnosis Tests & Interpretation

  • Indicated only if evaluating patients for central vertigo or more unusual etiologies of peripheral vertigo
  • Chemistry panel and electrolytes if significant or refractory nausea and vomiting
  • Lumbar puncture if clinical suspicion for meningitis or subarachnoid hemorrhage

Lab

  • Finger-stick glucose
  • Syphilis screening
  • Rheumatoid factor
  • Chemistry panel and electrolytes

Imaging

  • Indications:Findings suggestive of central vertigo:Acute or gradual onsetNot positional but may be exacerbated by head movementsPure direction " övertical, horizontal, or torsionalDirection may changeNonfatigableHigh cardiovascular risk factorsFocal neurologic findings
  • Head CT:Fine cuts through the cerebellum
  • MRI and MRA:Evaluate the posterior fossa, the 8th cranial nerve, and the vertebrobasilar circulationImaging study of choice in patients suspected of central vertigo

Consider brain imaging in patients >45 yr, children, and patients with cardiovascular risk factors. é á

Diagnostic Procedures/Surgery

  • Electronystagmography: May help in diagnosing difficult cases
  • Infrared nystagmography: Torsional eye movement can be demonstrated directly

Differential Diagnosis

  • Peripheral vertigo:Otitis mediaVestibular neuritisAcoustic neuromaAutoimmune inner ear diseaseBPPVCholesteatomaMeni â Ęre disease (associated tinnitus, "fullness, " Ł or hearing loss)OtosyphilisOtotoxic drugs (loop diuretics, aminoglycosides, streptomycin, salicylates, ethanol)Herpes zoster (Ramsey Hunt syndrome)Perforated TMPerilymphatic fistula (symptoms accentuated with Valsalva)Post-traumatic vestibular concussionSuppurative labyrinthitis (toxic appearance)Temporal bone fracture
  • Central vertigo " öoften presents with symptoms indistinguishable from peripheral vertigo because the labyrinth has a monosynaptic connection to the brainstem:Brainstem ischemiaCerebellar hemorrhageInferior cerebellar ischemiaCNS lesions (tumors)Chiari malformationMultiple sclerosis (paresthesia, optic neuritis)Partial seizures of temporal lobeVestibular " ômasseter syndrome (associated masseter muscle weakness)Vestibular migraine (30% have vertigo independent of headaches)Wallenberg syndrome (associated Horners syndrome, crossed sensory signs)
  • Cardiac arrhythmia (presyncopal symptoms)
  • Hypoglycemia (gradual onset, not positional)
  • Hypotension (exacerbated with standing)
  • Cervicogenic disease (onset with rotational neck movement)
  • Hypothyroidism
  • Alcohol or drug induced

Treatment

Pre-Hospital

  • Cardiac monitor for arrhythmia
  • Finger-stick glucose to exclude hypoglycemia
  • Acute stroke assessment
  • Antiemetics for nausea and vomiting
  • IV fluids for dehydration
  • Fall precautions

Initial Stabilization/Therapy

  • Bed rest and hydration
  • Fall precautions

Ed Treatment/Procedures

  • Medications are minimally beneficial for BPPV
  • Avoid chronic use (up to 48 hr) to encourage development of vestibular compensation
  • Medications for symptomatic relief:Vestibular suppressants: Diazepam, meclizine, scopolamineAntiemetics: Ondansetron, prochlorperazine, promethazineCorticosteroids: Poor evidence for efficacy
  • Debris repositioning is primary therapy for BPPV. Effective relief in 50 " ô80% of patients:
  • Vestibular enhancement exercises
  • Surgery for failed medical and physical therapy:Posterior canal plugging to occlude canalNerve section

Medication

  • Diazepam (benzodiazepine): 2 " ô10 mg IV; 5 " ô10 mg (0.1 " ô0.3 mg/kg/24 h) PO q6 " ô12h
  • Dimenhydrinate: 5 mg/kg/24 h PO, IM, IV, or PR
  • Meclizine (antihistamine): 25 mg (50 mg/24 h for patient >12 yr) PO q6h
  • Lorazepam: 0.5 " ô2 mg IV, IM, or PO q6h (peds: 0.05 mg/kg IV/PO q4 " ô8h)
  • Ondansetron: 4 " ô8 mg IV, IM, or PO q8h (peds: 1 mo " ô12 yr and <40 kg: 0.1 mg/kg IV; >12 yr and >40 kg: 4 mg IV)
  • Prochlorperazine: 5 " ô10 mg (peds: 0.3 mg/kg/24 h IM or PO for patient >2 yr old) IV, IM, or PO q6 " ô8h
  • Promethazine: 12.5 " ô25 mg (peds: 1.5 " ô2 mg/kg/24 h) IV or PO q4 " ô6h
  • Scopolamine (anticholinergic, not approved in pediatrics): 0.4 mg PO q4 " ô6h; 1.5-mg transdermal patch q3d

Bacterial labyrinthitis: é á

  • Antibiotics IV
  • Surgical debridement
  • Class D medication: Diazepam, lorazepam
  • Class C medication: Prochlorperazine
  • Class B medication: Famciclovir
  • Class B medication: Corticosteroids

First Line

  • Meclizine
  • Ondansetron for nausea/vomiting

Second Line

  • Diazepam or lorazepam
  • Prochlorperazine or promethazine (beware dystonic or dysphoric reactions)

Follow-Up

Disposition

Admission Criteria

  • Symptoms concerning for an acute stroke or central etiology of vertigo
  • Intractable nausea and vomiting
  • Severe dehydration
  • Unsteady gait

Discharge Criteria

  • Tolerate oral fluids
  • Steady gait
  • Normal neurologic exam
  • Avoid driving, heights, and operating dangerous equipment
  • Fall precautions
  • Arrange neurology or otolaryngology follow-up

Issues for Referral

  • Recurrent symptoms
  • Concern for cholesteatoma
  • Possible severe underlying conditions such as vertebrobasilar ischemia or brainstem tumor will need consultation from neurologist or neurosurgeon

Follow-Up Recommendations

  • Vestibular rehabilitation for patients with persistent vestibular symptoms and chronic vertigo due to peripheral vestibular etiology
  • Auditory brainstem response test is indicated in younger children.
  • Surgical therapy in the form of labyrinthectomy/posterior canal occlusion/vestibular nerve section, etc., can be considered in cases of refractory vertigo and unsuccessful canalith repositioning procedure.

Pearls and Pitfalls

  • Counsel patients regarding occupation, fall risk, and driving
  • Failure to diagnose life-threatening conditions like meningitis, cerebrovascular ischemia, or brain tumors
  • Take caution while performing physical maneuvers for BPPV, as violent hyperextension at cervical spine can cause vertebral artery dissection

Additional Reading

  • Boston é áME. Labyrinthitis. Emedicine. Updated Feb 22, 2012. Available at: http://emedicine.medscape.com/article/856215-overview.
  • Charles é áJ, Fahridin é áS, Britt é áH. Vertiginous syndrome. Aust Fam Physician. 2008;37:299.
  • Kerber é áKA. Vertigo and dizziness in the emergency department. Emerg Med Clin North Am. 2009;27:39 " ô50, viii.
  • Korres é áSG, Balatsouras é áDG. Diagnostic, pathophysiologic, and therapeutic aspects of benign paroxysmal positional vertigo. Otolaryngol Head Neck Surg. 2004;131:438 " ô444.
  • Kulstad é áC, Hannafin é áB. Dizzy and confused: A step-by-step evaluation of the clinicians favorite chief complaint. Emerg Med Clin North Am. 2010;28:453 " ô469.
  • Newman-Toker é áDE, Camargo é áCA Jr, Hsieh é áYH, et al. Disconnect between charted vestibular diagnoses and emergency department management decisions: A cross-sectional analysis from a nationally representative sample. Acad Emerg Med. 2009;16:970 " ô977.
  • Schneider é áJI, Olshaker é áJS. Vertigo, vertebrobasilar disease, and posterior circulation ischemic stroke. Emerg Med Clin North Am. 2012;30:681 " ô693.

See Also (Topic, Algorithm, Electronic Media Element)

  • Dizziness
  • Vertigo
  • Meni â Ęre Disease
  • Otitis Media
  • Mastoiditis

Codes

ICD9

  • 386.30 Labyrinthitis, unspecified
  • 386.31 Serous labyrinthitis
  • 386.35 Viral labyrinthitis
  • 386.33 Suppurative labyrinthitis
  • 386.34 Toxic labyrinthitis

ICD10

  • H83.01 Labyrinthitis, right ear
  • H83.02 Labyrinthitis, left ear
  • H83.09 Labyrinthitis, unspecified ear
  • H83.03 Labyrinthitis, bilateral
  • H83.0 Labyrinthitis

SNOMED

  • 23919004 Labyrinthitis (disorder)
  • 41674001 Serous labyrinthitis
  • 409711008 Viral labyrinthitis