GPAtlas🧭 When to suspect
Vestibular neuronitis (also called vestibular neuritis, or peripheral acute vestibular syndrome) is acute, sustained vertigo caused by inflammation of the vestibular nerve – most often viral, frequently after a URTI, and probably due to reactivation of latent herpes simplex in the vestibular ganglion. The hallmark is sudden, severe, continuous spinning vertigo with nausea, vomiting and unsteadiness, lasting days and settling over weeks as the brain compensates.
The defining negative is normal hearing: there is no hearing loss and no tinnitus. If either is present, think labyrinthitis, Ménière's disease, or – crucially – a posterior circulation stroke.
The single most important task is not to make the diagnosis but to exclude its dangerous mimic. A cerebellar or brainstem stroke can present identically: in an older patient with vascular risk factors, acute continuous vertigo is a stroke until the bedside examination says otherwise.
| Pattern | Key discriminating feature |
|---|---|
| Vestibular neuronitis | Constant vertigo over days, exacerbated (not triggered) by head movement; no hearing loss / tinnitus; abnormal head impulse test. |
| Labyrinthitis | As vestibular neuronitis but with hearing loss ± tinnitus (cochlea also involved). |
| BPPV | Brief (seconds), positional vertigo triggered by head turns; well between episodes; positive Dix–Hallpike. |
| Vestibular migraine | Recurrent episodes (minutes–72 h) with migraine features (headache, photophobia); usually a migraine history. |
| Posterior circulation stroke | Central signs: direction-changing or vertical nystagmus, normal head impulse test, unable to stand unaided, other neurology; vascular risk. |
Source: NICE
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