Labyrinthitis

What labyrinthitis is

The inner ear, or labyrinth, sits deep in the skull bone. It has two parts:

• the cochlea, which turns sound into nerve signals
• the vestibular system (three semicircular canals plus the utricle and saccule), which senses head movement and position

Inflammation of the labyrinth disrupts both. The brain receives balance signals from one ear that no longer match the other, so it feels as if the room is spinning. Hearing in that ear is muffled or lost, and ringing often starts.

Labyrinthitis vs vestibular neuritis

These two conditions are closely related and often confused.

Symptoms of labyrinthitis

• Vertigo: a sudden, intense, constant spinning sensation that peaks within hours and lasts for days, worse with head movement
• Hearing loss in one ear, from mild muffling to complete loss
• Tinnitus: ringing, hissing or buzzing in the affected ear
• Nausea and vomiting, sometimes severe
• Unsteadiness: a tendency to veer or fall toward the affected side
• Nystagmus: jerking eye movements that make vision jump
• a feeling of fullness or pressure in the ear

After the first few days, spinning usually gives way to a lighter dizziness or imbalance, especially when moving quickly, turning in bed or walking in busy places.

Causes

Viral labyrinthitis

The most common type. It often follows a cold, flu or other respiratory infection by a week or two, and may be due to the virus itself or the immune reaction to it. Measles, mumps, herpes viruses (including shingles affecting the ear, called Ramsay Hunt syndrome) and cytomegalovirus in newborns are other causes.

Bacterial labyrinthitis

Rare but serious. Bacteria spread into the inner ear from:

• an untreated middle ear infection (otitis media) or cholesteatoma
• meningitis, which can cause permanent deafness, especially in children

It causes severe symptoms, often with fever and ear discharge, and needs hospital treatment with antibiotics. Hearing loss is more likely to be permanent.

Other causes

Autoimmune inner ear disease, syphilis, Lyme disease and head injury can also inflame the labyrinth.

How it is diagnosed

Labyrinthitis is diagnosed mainly from the story and examination. The doctor's most important job is to make sure the vertigo is not a stroke affecting the brainstem or cerebellum, which can look similar.

• Ear exam with an otoscope to look for middle ear infection.
• HINTS exam: three bedside eye-movement tests (head impulse, nystagmus pattern and test of skew) that, in trained hands, separate inner ear causes from stroke better than an early CT scan.
• Walking and balance tests: most people with labyrinthitis can walk with help; inability to stand at all is a warning sign of stroke.
• Hearing test (audiogram): confirms the type of hearing loss and gives a baseline.
• MRI scan: if there are stroke features, unusual findings, or one-sided hearing loss that does not recover, to rule out a stroke or an acoustic neuroma.

Treatment

First few days

• Rest lying still in a quiet, dim room while vertigo is severe. Get up slowly and have someone help you walk.
• Anti-sickness medicines such as prochlorperazine, meclizine, promethazine or dimenhydrinate. Use them for no more than about 3 days, because longer use slows the brain's adaptation.
• Fluids: small, frequent sips. Intravenous fluids are occasionally needed.

Steroids for hearing loss

If hearing has dropped suddenly, an ear specialist may prescribe a course of oral steroids, or steroid injections through the eardrum. Guidelines advise starting within 2 weeks, and the earlier the better. Steroids may also modestly speed up recovery of balance, though evidence is mixed.

Antibiotics

Only for bacterial labyrinthitis or a related middle ear infection. Antivirals are sometimes used when shingles is the cause.

Vestibular rehabilitation

Once the vomiting has stopped, getting moving speeds recovery. The brain learns to compensate for the damaged inner ear, a process called vestibular compensation. Exercises include:

• moving the eyes and head while focusing on a fixed target
• standing and walking with feet closer together, then with eyes closed, with support nearby
• turning, bending and walking in busier environments

A vestibular physical therapist can design a program, which is especially useful if dizziness lasts beyond a few weeks.

How long labyrinthitis lasts

Hearing often recovers partly or fully, but some people are left with permanent hearing loss or tinnitus in that ear. A minority develop persistent dizziness, including persistent postural-perceptual dizziness (PPPD), which responds to vestibular therapy, and sometimes medication. Labyrinthitis rarely comes back.

Living with labyrinthitis

• Do not drive until vertigo has settled and you can turn your head quickly without dizziness.
• Avoid ladders, heights and operating machinery during recovery.
• Limit alcohol, which worsens imbalance.
• Return to work gradually; many people need 1 to 2 weeks off.

Frequently asked questions

How long does labyrinthitis last?

The severe spinning usually lasts 1 to 3 days. Milder dizziness and unsteadiness typically improve over 1 to 3 weeks, and most people have recovered within 3 to 6 weeks. Balance problems can occasionally last several months, especially without balance exercises.

What is the difference between labyrinthitis and vestibular neuritis?

Both cause sudden, severe vertigo from inflammation in the inner ear. Labyrinthitis also affects hearing, causing hearing loss or tinnitus, because it involves the cochlea. Vestibular neuritis affects only the balance nerve, so hearing is normal. Treatment is largely the same.

Is labyrinthitis an ear infection?

It is often called an inner ear infection, but most cases are caused by a virus or the body's reaction to one, not by bacteria. Antibiotics do not help viral labyrinthitis. Bacterial labyrinthitis, spreading from a middle ear infection or meningitis, is rare and needs urgent antibiotics.

Can labyrinthitis be caused by stress?

Stress does not cause labyrinthitis, which is due to inflammation, usually from a virus. Stress and anxiety can, however, make dizziness feel worse and can prolong recovery. Persistent dizziness after labyrinthitis sometimes becomes a separate condition that responds well to vestibular rehabilitation.

How can I speed up recovery from labyrinthitis?

Stop anti-sickness medicine after a few days, start moving as soon as you can, and do balance and head-movement exercises daily, ideally guided by a vestibular physical therapist. See a doctor quickly if your hearing has dropped, because early steroid treatment gives the best chance of recovery.