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.
• The cause is most often viral, frequently after an upper respiratory tract infection (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.
• Symptoms last days and settle 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.
Before you make the diagnosis, 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 or tinnitus • Abnormal head impulse test |
| Labyrinthitis | As vestibular neuronitis but with hearing loss ± tinnitus (cochlea also involved). |
| Benign paroxysmal positional vertigo (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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