Labyrinthitis, Emergency Medicine

Basics

Description

Inflammatory disorder of the inner ear
Inflammation decreases afferent firing from the labyrinth
- CNS interprets the decreased signal as head rotation away from the diseased labyrinth
- The 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 bacterial
- Suppurative: Bacterial
- Autoimmune: Wegener or polyarteritis nodosa
- Vascular ischemia
- Head injury or ear trauma
- Medications:
  - Aminoglycosides, loop diuretics, antiepileptics (phenytoin)
- Allergies
- Chronic
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 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
Meni â Ęre disease:
- Rare before 10 yr of age

Diagnosis

Signs and Symptoms

History

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)
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 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
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 ear
- Labyrinthitis 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 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
Head CT:
- Fine cuts through the cerebellum
MRI and MRA:
- Evaluate the posterior fossa, the 8th cranial nerve, and the vertebrobasilar circulation
- Imaging 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 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)
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, scopolamine
- Antiemetics: Ondansetron, prochlorperazine, promethazine
- Corticosteroids: Poor evidence for efficacy
Debris repositioning is primary therapy for BPPV. Effective relief in 50 " ô80% of patients:
- Epley maneuver
Vestibular enhancement exercises
Surgery for failed medical and physical therapy:
- Posterior canal plugging to occlude canal
- Nerve 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.

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

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