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Vestibular neuronitis - Management
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What should I advise a person with vestibular neuronitis?
- Reassure the person that symptoms will usually settle over several weeks, even if no treatment is given. Advise that factors such as alcohol, tiredness, or intercurrent illness may have a greater than usual effect on their balance. Explain that there may be periods during their recovery when their symptoms appear to be worsening again.
- Advise that bed rest may be necessary if symptoms are particularly severe during the acute phase, but that activity should be resumed as soon as possible (even if vertigo becomes more prominent during movement).
- Advise on safety issues.
- Advise the person not to drive when they are dizzy, or if they are likely to experience an episode of vertigo while driving.
- The Driver and Vehicle Licensing Agency state that people liable to 'sudden attacks of unprovoked or unprecipitated disabling giddiness' should stop driving.
- Workplace — the person should inform their employer if their vertigo poses a risk in the workplace (for example people using ladders, operating heavy machinery, or driving).
- Falls in the home — discuss the risk of falling in the home during an episode of vertigo and suggest measures to reduce this.
Basis for recommendation
Reassurance
- The recommendation to reassure people that symptoms will settle is based on expert opinion in review articles that central vestibular compensation will eventually ameliorate symptoms [Baloh, 2003; Macleod and McAuley, 2008]. The advice on the fluctuant nature of the recovery process and factors which may affect balance more than usual is based on expert opinion from reviewers of this CKS topic.
Self-care advice
- This recommendation has been extrapolated from expert opinion in a US guideline on the management of benign paroxysmal positional vertigo [Bhattacharyya et al, 2008], guidelines from the Driver and Vehicle Licensing Agency [DVLA, 2010], expert opinion in a review article [Parnes et al, 2003], and CKS expert reviewers.
- For detailed guidance on driving, see At a glance guide to the current medical standards of fitness to drive, available to download from www.dft.gov.uk/dvla.
Rest and activity
- The recommendation to rest if necessary during the acute phase, but to encourage activity, is based on expert opinion in review articles [Hain and Uddin, 2003; Kuo et al, 2008a]. It is thought that vestibular compensation can develop more quickly and more effectively if the person is active as soon as possible [Baloh, 2003].
How should I treat the symptom of vertigo?
- If symptoms are severe, offer short-term symptomatic drug treatment.
- To rapidly relieve severe nausea or vomiting associated with vertigo, consider giving buccal prochlorperazine, or a deep intramuscular injection of prochlorperazine.
- To alleviate less severe nausea, vomiting, and vertigo, consider prescribing a short course of:
- Prochlorperazine (the buccal preparation has a faster onset of action than standard-release oral tablets), or antihistamines (cinnarizine, cyclizine, or promethazine teoclate). Prochlorperazine is less sedating than the recommended antihistamines but may cause a dystonic reaction (particularly in young women).
- Advise the person to take medication regularly for 3 days then, if possible, on an as-required basis. Explain that medication should be taken for the minimum time possible (ideally no longer than 1 week), as it may delay recovery by affecting the body's compensatory mechanisms.
- For more information, see Prescribing information.
- Treatment with antiviral drugs, corticosteroids, or benzodiazepines is not recommended.
- Advise the person to return if their symptoms deteriorate or have not fully resolved after 1 week of treatment.
Basis for recommendation
Choice of drug treatment
- The recommendation that symptomatic treatment can be useful in the short term is based on expert opinion in review articles and the opinion of CKS expert reviewers [Nadol, 1995; Hanley et al, 2001; Macleod and McAuley, 2008].
- CKS found no good-quality evidence of benefit for the different symptomatic treatment options. However, the recommended drugs are all licensed for use in people with nausea, vomiting, and vertigo [ABPI Medicines Compendium, 2010a; ABPI Medicines Compendium, 2010c; ABPI Medicines Compendium, 2010d; ABPI Medicines Compendium, 2010e; ABPI Medicines Compendium, 2010f].
Duration of drug treatment
- Expert opinion from review articles suggests that symptomatic drug treatment should only be used in the short term, because prolonged use may delay central vestibular compensation [Nadol, 1995; Hanley et al, 2001; Macleod and McAuley, 2008]. The opinion of CKS expert reviewers was consistent with this.
Corticosteroids
- Some experts consider that the use of corticosteroids in people with vestibular neuronitis may improve vestibular function in the long term; however, this is uncertain, and high doses are used [Kuo et al, 2008a; Seemungal and Bronstein, 2008].
- Evidence from a systematic review and meta-analysis suggests that, compared with placebo, corticosteroids for vestibular neuronitis cause improvement on caloric testing, but do not affect clinical symptoms [Goudakos et al, 2010].
Antiviral drugs
- Evidence from a prospective study with some methodological limitations found that methylprednisolone improved the vestibular recovery of people with vestibular neuronitis, but valaciclovir did not [Strupp et al, 2004].
Benzodiazepines
- Benzodiazepines are not recommended because although some experts advocate their use, CKS found no evidence to support this, and they are not licensed for this purpose [BNF 60, 2010].
When should I admit or refer a person with vestibular neuronitis?
- Admit the person to hospital if they have severe nausea and vomiting and cannot tolerate oral fluids or symptomatic drug treatment.
- Refer the person to a balance specialist (audiovestibular physician or neurologist — depending on local protocol) for further assessment or consideration of vestibular rehabilitation, (involving exercises to promote central nervous system compensation) if:
- Symptoms are not typical of vestibular neuronitis (for example additional neurological symptoms).
- Symptoms persist without improvement for more than 1 week despite treatment (urgently refer).
- Symptoms persist for longer than 6 weeks — investigation to exclude other causes, or vestibular rehabilitation may be required.
Basis for recommendation
Referral recommendations are based on expert opinion from:
- A review article on the diagnosis of vertigo in general practice [Barraclough and Bronstein, 2009].
- A study reporting referral patterns for dizziness in primary care [Bird et al, 1998]. Referral criteria were formulated from expert opinion for this study.
- CKS expert reviewers, who suggest that it is appropriate to refer after 1 week to exclude more serious diagnoses if symptoms persist despite treatment.
Vestibular rehabilitation
- There is evidence from a Cochrane systematic review that vestibular rehabilitation is effective and has a well-established safety profile for unilateral peripheral vestibular dysfunction, and that it helps symptoms in the medium term [Hillier and Holohan, 2007].
- CKS expert reviewers suggest that the quality and availability of vestibular rehabilitation varies depending on locality.
Prescriptions
For information on contraindications, cautions, drug interactions, and adverse effects, see the electronic Medicines Compendium (eMC) (http://emc.medicines.org.uk), or the British National Formulary (BNF) (www.bnf.org).
Rapid relief of severe nausea and vomiting
Age from 18 years onwards
Prochlorperazine 12.5mg IM injection
Prochlorperazine 12.5mg/1ml solution for injection ampoules
Give 12.5mg by deep intramuscular injection.
Supply 1 1ml ampoules.
Prochlorperazine buccal tablets: 6mg stat
Prochlorperazine 3mg buccal tablets
Place two tablets high up between the upper lip and gum and leave to dissolve.
Supply 2 tablets.
Short-course antihistamine
Age from 18 years onwards
7-day supply: cyclizine 50mg up to three times a day
Cyclizine 50mg tablets
Take one tablet up to three times a day when required for the relief of sickness.
Supply 21 tablets.
7-day supply: promethazine teoclate 25mg up to 3 x/day
Promethazine teoclate 25mg tablets
Take one tablet up to three times a day when required for the relief of sickness.
Supply 21 tablets.
7-day supply: cinnarizine 30mg three times a day
Cinnarizine 15mg tablets
Take two tablets up to three times a day when required for the relief of sickness.
Supply 42 tablets.
Short-course prochlorperazine
Age from 18 years onwards
7-day supply: prochlorperazine 5mg three times a day
Prochlorperazine 5mg tablets
Take one tablet up to three times a day when required for the relief of sickness. Increase to a maximum of two tablets three times a day if necessary.
Supply 42 tablets.
7-day supply: prochlorperazine buccal 3mg twice a day
Prochlorperazine 3mg buccal tablets
Use one to two tablets up to twice a day when required for the relief of sickness. Place high up between the upper lip and gum and leave to dissolve.
Supply 30 tablets.
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