Staying Balanced: Management of Labyrinthitis Symptoms

[Dr. Sujana Chandrashekhar]
Luckily for you and luckily for the vast majority of people who get labyrinthitis, it's a viral phenomenon and not a bacterial phenomenon because bacterial labyrinthitis, which we should just talk about and put to a side is horrendous. It can take out your inner ear.

People who get bacterial labyrinthitis, often post-meningitic cases or chronic otitis media, cholesteatoma cases. Those are the people that we rush to put in a cochlear implant within a few months so that we don't end up trying to drill out an ossified cochlea. Those are the people that are going to lose their ear for hearing and for balance.

That timeline becomes very rapid in terms of imaging and intervention in order to end up with an ear that can hear something. Often very well. If you get that cochlear implant into those patients in a time when there is still a membranous labyrinth to introduce, they do much better than if you're drilling out bony channels.

Luckily the vast majority, well over 90% of labyrinthitis, which is interchangeably used with vestibular neuritis or vestibular neuronitis, there's like, as you and I talked about in the past, it seems like everything in otology has at least three names, if not more. These are often interchangeable because we don't really, we cannot tell you the site of lesion is in the labyrinth or along the vestibular nerve or even along the superior or inferior vestibular nerve. We just know that it's a peripheral vestibular itis.

The vast majority are viral, which means that they don't demolish the ear and they are recoverable. We start to see recovery, initial recovery in about three weeks. Most people have a full recovery by three months, like the outside limit. If you're older, if you have some underlying balance disorder, if you have peripheral neuropathy, if you have cataracts, if you have glaucoma, if you have something else that's going to affect your balance system, it may take you longer to recover. In general, even though it's absolutely horrific, and you remember every minute of that episode, as if it happened yesterday, the full recovery happens pretty well in these patients.

The bottom line is to identify that it is in fact a peripheral vestibular lesion, to give supportive care, and then to institute physical therapy, vestibular therapy, so that you can get back to normal. For you, Ashley, vestibular therapy was being a doctor, being a mom, running around, doing your things, which is fine. For people who maybe are a little bit older, maybe on blood thinners, somebody that you really don't want to fall down, a great exercise vestibular therapy for them is to take a shopping cart, go to the grocery store, push the cart up and down the aisles as their walker, and then look up and down.

[Dr. Sujana Chandreshekar]
Yes. Supportive measures are the most important thing. The Ondansetron or Zofran is really beneficial, because what you don't want is now to compound this with some dehydration, malnutrition acute picture, because it is not at all unreasonable to stick an IV in somebody who's not able to keep anything down and just get them hydrated up because that really does help. I think Ondansetron, and I like the orally disintegrating tablets, because it's really impossible to vomit those up, right? You just stick them on your tongue and just lie there. Within about five, 10 minutes, it's absorbed into your body. It's working no matter what happens afterwards.

…

I'm a big steroid girl, like if you had nothing going on, in terms of your ear exam, or your audiogram, I probably still would have given you around a milligram per kilogram per day of prednisone. I would have given you between 40 and 60 milligrams of prednisone, at least for the first three days, four days, the sudden hearing loss dose, as we talked about is like seven days, and then you taper, some people give it for 10 days. Often you just need that acute jolt of anti-inflammatory to get people down. Then you can start tapering that off.

I think again, a Medrol dose pack doesn't do it for this degree of inner ear dysfunction. I would stick with the higher dose, but I probably tapered off more quickly than I would for a sudden hearing loss patient. Ondansetron, we talked about vestibular suppressants, and the Ondansetron is amazing. You could give it three times a day for the nausea. You could actually give it as often as you feel like. Some people take eight, most people are fine on four milligrams of the orally disintegrating tablets.

There are some old fashioned remedies that your grandmother knew, like ginger candy, ginger teas, things like that that settle your stomach. I often will tell people take the Ondansetron, take the Valium, and then eat something and drink something because that's the ideal time when you can keep things down and then just be. I tell them, this is not the time to really watch TV. This is the time to watch a blank TV. You don't want to stimulate your vestibular system in any possible way.