Management of Patient With Vestibular Neuronitis (VN)

Stephen Chiang (21209166) Rural GP Case 2GP CLINIC

Presenting complaint

TW is a 22 year old woman who was presented with a 3 day history of dizziness and light-headedness.

History of presenting complaint

• Patient first experienced dizziness and light-headedness after returning from her holiday in Sydney.
• History of viral URTI 4 weeks ago which has been resolved.
• Describes the dizziness as “walking on air” and feeling unstable on her feet.
• Patient denies any sensation of vertigo – “head spinning” or “everything spinning”.
• Associated with a right- sided headache that worsens the day after. Also associated with nausea, malaise and myalgia. Denies any vomiting. Symptoms are exacerbated by changing position – getting out from bed and standing up from sitting position. Relieved by resting in a dark, quiet room.
• Patient denies any visual symptoms (flashes), tinnitus or deafness.
• No recent head injury or ingestion of any drugs – alcohol & marijuana
• Pt went to see a physiotherapist ?vertigo but no abnormalities was detected by the physiotherapist. No nystagmus. Patient admits dizziness improved slightly with the hall-pike manoeuvre.

Past Medical History

– Nil

Medications

– Estelle-35 ED tablets2mg/35mcgdaily

No known drug allergies

Family History

– Nil remarkable

Social History

– TW works as a hair stylist.

– Lives with her parents and siblings.

– Non-smoker and occasional ETOH consumption 2-3 standard drinks a week.

– Diet consists of take outs and fast food. Moderate physical activities.

Examinations

– Pleasant looking young woman.

– Not in any obvious pain or distress.

Vitals – BP 118/80, HR 80, RR 18, afebrile, no signs of anaemia.

ENT – NAD on otoscope examination, no redness, swelling or discharge. Weber and Rinne test grossly intact.

Optic – visual acuity 6/6 on L and R eye. No evidence of nystagmus on examination.

Cardiovascular – Dual heart sound noted, nil added. No postural drop of blood pressure.

Cranial nerves – olfactory sensation intact. Visual field and pupillary light reflex normal. Nil ptosis, diplopia and good accommodation. Light touch on the cheeks and forehead grossly intact. Power of muscle of mastication 5/5. Facial nerve intact and NAD. No deviations and fasciculation of tongue and uvula. Accessory muscles 5/5.

Cerebellum – Normal gait, good coordination, negative dysdiadochokinesia and negative rhomberg test. Normal reflexes and no past pointing.

Negative Hallpike manoeuvre.

Investigations Ordered

– Nil

Murtagh’s Diagnostic Model

Management Plan

1. Viral vestibular neuronitis

– Reassurance and careful explanation to patient about nature of disease.

– Symptomatic treatment of nausea, prochlorperazine prescribed.

– Supportive treatment at home, bed rest and special vestibular exercises – explained by GP.

– Avoid movement or position that exacerbates symptoms.

– Return to GP if no resolution of symptoms.

Follow up – Patient did not represent to GP practice during my placement.

Preventative Health Activities

1. Nutrition – education and advice on healthy diet plan

2. Alcohol – education on appropriate alcohol intake, early recognition or drinking problem

3. Sexual health – education for prevention of sexually transmitted infection and contraception.

4. Physical activity – encourage importance of physical activities.

Clinical Evidence Base

In the management of patient with vestibular neuronitis (VN), is the usage of pharmacological treatment (glucocorticoid) more effective in terms of recovery compared to supportive treatment alone.

Vestibular neuronitis is defined as the dysfunction of the peripheral vestibular system with associated vertigo, nausea and vomiting.⁵ Hearing symptoms such as deafness and tinnitus are rarely associated with vestibular neuronitis.³ Up to today, the cause of vestibular neuronitis remains unknown hence, the main treatment options remain unclear limiting it to corticosteroids, antiviral therapy and vestibular exercises.^1,4

The OneSearch UWA library database was searched and keywords used were “acute”, “vestibular neuronitis”, “corticosteroid”, “conservative treatment” and “head manoeuvre”. Other related terms were also included in the search.

One study was identified, “Corticosteroid and vestibular exercises in vestibular neuronitis” by John K. Goudakos, MSc; Konstantinos D. Markou, George Psillas, Victor Vital, Miltiadis Tsaligopoulos.¹

The study is single-blind randomised clinical trial measuring the recovery of 40 patients with vestibular neuronitis by using vestibular exercises vs corticosteroid at 1, 6 and 12 months.¹ The 40 patients were randomised into 2 groups where one received corticosteroid therapy and the other underwent vestibular exercises for 3 weeks.¹ Recovery was measured by monitoring the scores on the European Evaluation of Vertigo scale (EEV), Dizziness Handicap Inventory (DHI) and vestibular evoked myogenic potentials (VEMPs).¹

Patient included in the study were:

Aged 18-80 presenting with history of acute onset associated with vertigo, nausea, vomiting, postural imbalance, no hearing loss, no central lesion on neurological examination, horizontal nystagmus with rotational component, ipsilateral deficit on the head thrust test and unilateral reduced calorie response on the electronystagmography(ENG).¹

Patient excluded from the study were:

glaucoma, recent infection, signs of central vestibular dysfunction, history of chronic vestibular dysfunction, hearing loss and patients that are contraindicated for steroid use.¹

Results:

At 1 month, the EEV in both group showed an improvement with a score of 3.75 in the vestibular exercise group and 4.17 in the corticosteroid group. However (P>0.05) hence there is not significant difference between the two groups.¹

At the 6 months follow up, 35% of the patient in the corticosteroid group had a complete disease resolution compared to 5% in the vestibular exercise group, (P<0.05) hence there is a significant difference.¹

At the 12 months follow up for disease resolution, 50% of patient in the corticosteroid group showed complete disease resolution and 45% of the patient in the vestibular exercise group showed disease resolution however (P>0.05) hence there was no significant difference.¹

Strength and Weaknesses

This study is level II based on the NHMRC. Methods of measuring outcome were clearly explained. Inclusion and exclusion criteria were well defined. Single-blinded study. No statistically significant difference in age, sex and disease onset between both groups.

Small sample size of 40 patients. Method of randomisation was not defined, may include bias. Measurement of recovery did not include other factors. Tools of measurement such as VEMPs are good for diagnostic clarification but not measurement of disease. Measurement did not include clinical improvement.

Application – This study showed that there is a quicker resolution of vestibular neuronitis in the short term within 6 months of corticosteroid therapy. However in the long term follow up, (12 months) the efficacy of corticosteroid therapy is similar to vestibular exercises. Further studies should be performed combining vestibular exercises with corticosteroid therapy with a larger sample size to measure efficacy. In this case, my GP did not offer corticosteroid therapy to the patient but educated the patient on vestibular exercises which corresponds to the finding above because corticosteroid therapy does not offer additional long term benefits.

References

1. John K. Goudakos, MD, MSc; Konstantinos D. Markou, MD, PhD; George Psillas, MD, PhD; Victor Vital, MD, PhD; Miltiadis Tsaligopoulos, MD, PhD. Corticosteroids and Vestibular Exercises in Vestibular Neuritis Single-blind Randomized Clinical Trial.JAMA Otolaryngol Head Neck SurgeryPublished online March 6, 2014.; 140(5) pages 434-440

2. Mikael L.-Å. Karlberg and Måns Magnusson. Treatment of Acute Vestibular Neuronitis With Glucocorticoids.Otology & Neurotology2011; 32 pages 1140-1143

3. Keith A Marill, MD.Vestibular Neuronitis. http://emedicine.medscape.com/article/794489-overview#a5 (accessed 18 June 2015)

4. John Murtagh AM.Murtagh’s General Practise, Fifth edition ed. Published in Australia: McGraw-Hill Australia Pty Ltd; This fifth edition published 2011

5. John C. Goddard MD and Jose N. Fayad MD. Vestibular Neuritis.Otolaryngologic Clinics of North America2011; 44(2)pages 361-365