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26.12.2014

Treatment for labyrinthitis and vestibular neuritis, hearing aids for tinnitus relief - Try Out

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Vestibular neuritis causes dizziness due to a viral infection of the vestibular nerve (see Figure 1). While there are several different definitions for vestibular neuritis in the literature, with variable amounts of vertigo and hearing symptoms, we will use the definition of Silvoniemi (1988) who stated that the syndrome is confined to the vestibular system.
Labyrinthitis is a similar syndrome to vestibular neuritis, but with the addition of hearing symptoms (sensory type hearing loss or tinnitus). The symptoms of both vestibular neuritis and labyrinthitis typically include dizziness or vertigo, disequilibrium or imbalance, and nausea. About 5% of all dizziness (and perhaps 15% of all vertigo) is due to vestibular neuritis or labyrinthitis.
Fortunately, in the great majority of cases (at least 95%) vestibular neuritis it is a one-time experience. In vestibular neuritis, the virus that causes the infection is thought to be usually a member of the herpes family, the same group that causes cold sores in the mouth as well as a variety of other disorders (Pollak et al., 2011). In labyrinthitis, it is also thought that generally viruses cause the infection, but rarely labyrinthitis can be the result of a bacterial middle ear infection. There are several possible locations for the damage to the vestibular system that manifests as vestibular neuritis. Finally, there is also some evidence for viral damage to the brainstem vestibular nucleus (Arbusow et al, 2000). Acutely, vestibular neuritis is treated symptomatically, meaning that medications are given for nausea (anti-emetics) and to reduce dizziness (vestibular suppressants).
Because the symptoms associated with labyrinthitis and vestibular neuritis are associated with acute inflammation, laboratory trials have evaluated the use of the potent anti-inflammatory agent etanercept (TNF-alpha) and found it no more helpful than steroids (Lobo, 2006). The American Hearing Research Foundation is a non-profit foundation that funds research into hearing loss and balance disorders related to the inner ear, and to educating the public about these health issues. Vestibular neuritis and labyrinthitis are disorders resulting from an infection that inflames the inner ear or the nerves connecting the inner ear to the brain. The hearing function involves the cochlea, a snail-shaped tube filled with fluid and sensitive nerve endings that transmit sound signals to the brain.
Signals travel from the labyrinth to the brain via the vestibulo-cochlear nerve (the eighth cranial nerve), which has two branches. The brain integrates balance signals sent through the vestibular nerve from the right ear and the left ear. Neuritis (inflammation of the nerve) affects the branch associated with balance, resulting in dizziness or vertigo but no change in hearing. Labyrinthitis (inflammation of the labyrinth) occurs when an infection affects both branches of the vestibulo-cochlear nerve, resulting in hearing changes as well as dizziness or vertigo.
Inner ear infections that cause vestibular neuritis or labyrinthitis are usually viral rather than bacterial.
In serous labyrinthitis, bacteria that have infected the middle ear or the bone surrounding the inner ear produce toxins that invade the inner ear via the oval or round windows and inflame the cochlea, the vestibular system, or both. Less common is suppurative labyrinthitis, in which bacterial organisms themselves invade the labyrinth. Some of the viruses that have been associated with vestibular neuritis or labyrinthitis include herpes viruses (such as the ones that cause cold sores or chicken pox and shingles), influenza, measles, rubella, mumps, polio, hepatitis, and Epstein-Barr.
Symptoms of viral neuritis can be mild or severe, ranging from subtle dizziness to a violent spinning sensation (vertigo).
Many people with chronic neuritis or labyrinthitis have difficulty describing their symptoms, and often become frustrated because although they may look healthy, they don’t feel well.
Some people find it difficult to work because of a persistent feeling of disorientation or “haziness,” as well as difficulty with concentration and thinking. When other illnesses have been ruled out and the symptoms have been attributed to vestibular neuritis or labyrinthitis, medications are often prescribed to control nausea and to suppress dizziness during the acute phase. If symptoms persist, further testing may be appropriate to help determine whether a different vestibular disorder is in fact the correct diagnosis, as well as to identify the specific location of the problem within the vestibular system. Physicians and audiologists will review test results to determine whether permanent damage to hearing has occurred and whether hearing aids may be useful.


If symptoms of dizziness or imbalance are chronic and persist for several months, vestibular rehabilitation exercises (a form of physical therapy) may be suggested in order to evaluate and retrain the brain’s ability to adjust to the vestibular imbalance.
In order to develop effective retraining exercises, a physical therapist will assess how well the legs are sensing balance (that is, providing proprioceptive information), how well the sense of vision is used for orientation, and how well the inner ear functions in maintaining balance. The exercises may provide relief immediately, but a noticeable difference may not occur for several weeks. Visit VEDA's Resource Library to get more information about your vestibular disorder and download one of VEDA's many short publications.
Please help VEDA continue to provide resources that help vestibular patients cope and find help. Movement of the head is detected by the semicircular canals, and transmitted to the brain via the vestibular nerve. There is good evidence for occasional lesions in the nerve itself, as this can be seen lighting up on MRI scan.
For example, pathologic study of a single patient documented findings compatible with an isolated viral infection of Scarpa’s ganglion (the vestibular ganglion).
Since the vestibular neurons are distinct from cochlear neurons in the brainstem, a brainstem localization as well as the vestibular ganglion makes more sense than the nerve lesions in persons with no hearing symptoms. Certain types of specialists, namely otologists, neurotologist, and otoneurologists, are especially good at making these diagnoses and seeing one of these doctors early on may make it possible to avoid unnecessary testing. Occasionally other ocular disturbances will occur such as skew deviation (Cnyrim et al., 2008) and asymmetric gaze evoked nystagmus. In this situation, nearly all patients will be asked to undergo an audiogram and an Electronystagmography (ENG). Typical medications used are Antivert (meclizine), Ativan (lorazepam) , Phenergan, Compazine, and Valium (diazepam) . Recovery happens due to a combination of the body fighting off the infection, and the brain getting used to the vestibular imbalance (compensation).
You may be left with some minor sensitivity to head motion which will persist for several years, and may reduce your ability to perform athletic activities such as racquetball or volleyball. TNFalpha blockers do not improve the hearing recovery obtained with glucocorticoid therapy in an autoimmune experimental labyrinthitis.
Fluid and hair cells in the three loop-shaped semicircular canals and the sac-shaped utricle and saccule provide the brain with information about head movement.
One branch (the cochlear nerve) transmits messages from the hearing organ, while the other (the vestibular nerve) transmits messages from the balance organs. The term neuronitis (damage to the sensory neurons of the vestibular ganglion) is also used.
Although the symptoms of bacterial and viral infections may be similar, the treatments are very different, so proper diagnosis by a physician is essential.
Serous labyrinthitis is most frequently a result of chronic, untreated middle ear infections (chronic otitis media) and is characterized by subtle or mild symptoms. An inner ear viral infection may be the result of a systemic viral illness (one affecting the rest of the body, such as infectious mononucleosis or measles); or, the infection may be confined to the labyrinth or the vestibulo-cochlear nerve. They can also include nausea, vomiting, unsteadiness and imbalance, difficulty with vision, and impaired concentration. These additional tests will usually include an audiogram (hearing test); and electronystagmography (ENG) or videonystagmography (VNG), which may include a caloric test to measure any differences between the function of the two sides.
Usually, the brain can adapt to the altered signals resulting from labyrinthitis or neuritis in a process known as compensation.
Most of these exercises can be performed independently at home, although the therapist will continue to monitor and modify the exercises. Many people find they must continue the exercises for years in order to maintain optimum inner ear function, while others can stop doing the exercises altogether without experiencing any further problems. Vestibular neuritis may affect the nerve itself or the vestibular ganglion (Scarpa’s ganglion). When one of the two vestibular nerves is infected, there is an imbalance between the two sides, and vertigo appears.


It is also thought that a similar syndrome, indistinguishable from vestibular neuritis, can be caused by loss of blood flow to the inner ear (Chuang et al., 2011.
Both vestibular neuritis and labyrinthitis are rarely painful — when there is pain it is particularly important to get treatment rapidly as there may be a treatable bacterial infection or herpes infection. There is also reasonable evidence that vestibular neuritis often spares part of the vestibular nerve, the inferior-division (Kim et al., 2012). There was loss of hair cells, epithelialization of the utricular maculae and semicircular canal cristae on the deafferented side, and reduced synaptic density in the ipsilateral vestibular nucleus (Baloh et al, 1996).
Nevertheless, if the nerve were involved after it separates from the cochlear nerve, neuritis would still be a reasonable mechanism.
In large part, the process involves ascertaining that the entire situation can be explained by a lesion in one or the other vestibular nerve. An audiogram is a hearing test needed to distinguish between vestibular neuritis and other possible diagnoses such as Meniere’s disease and Migraine.
After the acute phase is over, for a moderate deficit, falls are no more likely than in persons of your age without vestibular deficit (Ishiyama, 2009). Herpes simplex virus type 1 in saliva of patients with vestibular neuronitis: a preliminary study.
Because the symptoms of an inner ear virus often mimic other medical problems, a thorough examination is necessary to rule out other causes of dizziness, such as stroke, head injury, cardiovascular disease, allergies, side effects of prescription or nonprescription drugs (including alcohol, tobacco, caffeine, and many illegal drugs), neurological disorders, and anxiety.
Vestibular evoked myogenic potentials (VEMP) may also be suggested to detect damage in a particular portion of the vestibular nerve.
It is usually recommended that vestibular-suppressant medications be discontinued during this exercise therapy, because the drugs interfere with the ability of the brain to achieve compensation. A key component of successful adaptation is a dedicated effort to keep moving, despite the symptoms of dizziness and imbalance. It is not possible on clinical examination to be absolutely certain that the picture of vestibular neuritis is not actually caused by a brainstem or cerebellar stroke, so mistakes are possible.
After two to three months, testing (that is,an ENG, audiogram and others) is indicated to be certain that this is indeed the correct diagnosis. Positional dizziness or BPPV (Benign Paroxysmal Positional Vertigo) can also be a secondary type of dizziness that develops from neuritis or labyrinthitis and may recur on its own chronically. The various terms for the same clinical syndrome probably reflect our lack of ability to localize the site of lesion.
These include benign paroxysmal vertigo in children (Basser, 1964), benign recurrent vertigo (Slater 1979, Moretti et al, 1980), or Meniere’s disease (Rassekh and Harker, 1992).
Furthermore, it is common to have another dizziness syndrome, BPPV, follow vestibular neuritis. Labyrinthitis may also cause endolymphatic hydrops (abnormal fluctuations in the inner ear fluid called endolymph) to develop several years later.
Presumably this happens because the utricle is damaged (supplied by the superior vestibular nerve), and deposits loose otoconia into the preserved posterior canal.
Acute labyrinthitis is treated with the same medications as as vestibular neuritis, plus 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. Occasionally, especially for persons whose nausea and vomiting cannot be controlled, an admission to the hospital is made to treat dehydration with intravenous fluids. Blood tests for diabetes, thyroid disorders, Lyme disease, collagen vascular disease and syphilis are sometimes performed, looking for these treatable illnesses.
Generally, admission is brief, just long enough to rehydrate the patient and start them on an effective medication to prevent vomiting.



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