Vestibular neuritis and labyrinthitis: why the dizziness lingers and how vestibular rehab helps

Vestibular neuritis is a sudden loss of balance signals from one inner ear, usually because the balance nerve becomes inflamed, possibly from a virus [4]. It causes intense spinning or unsteadiness that lasts at least 24 hours, without new hearing problems or other neurological symptoms [1]. Labyrinthitis is very similar, but it also affects hearing: if your hearing is affected, labyrinthitis is the cause [2].

This is a different problem from positional vertigo (BPPV), where short bursts of spinning come with head movements. And because a stroke can look very similar, sudden severe vertigo always deserves a medical evaluation. The warning signs are at the end of this article.

How common is it?

In a population study in Croatia, there were about 12 to 16 new cases per 100,000 people a year, with men and women affected about equally and an average age of 52 [5].

How long does it take to recover?

• The worst symptoms usually ease within a few days [2], and severe symptoms usually go away within a week [3].
• Balance usually comes back over 2 to 6 weeks, although it can take longer [2], and most people are completely better within 2 to 3 months [3].
• Lingering problems are more likely in older adults [3], and some people have balance problems for many months or even years [2].

Interestingly, feeling better does not depend on the inner ear healing completely. In a Japanese study of 60 people, about half still had a weak inner ear on testing 5 to 10 years later, yet 57% were completely free of symptoms [6]. The brain learns to compensate for the weaker side, and that is exactly what vestibular rehab trains.

When dizziness does not go away

Some people develop persistent postural-perceptual dizziness (PPPD): dizziness or unsteadiness on most days for 3 months or more, made worse by standing, by moving and by busy or moving visual scenes [7]. It is a recognized functional condition, not a psychiatric one, and it can follow vestibular neuritis [7]. In studies of people with acute or episodic vestibular problems, about 25% had this kind of chronic dizziness 3 to 12 months later [7].

What predicts a slower recovery is often not the inner ear itself. In one study, people who relied more on vision for balance and had more anxiety and physical arousal early on had more dizziness 10 weeks later, while inner ear test results did not predict recovery [8].

How vestibular rehabilitation helps

Vestibular rehab uses specific exercises to help your brain recalibrate: keeping your eyes focused on a target while moving your head (gaze stabilization), balance training, and gradual exposure to movement and busy environments.

The evidence is strong. A Cochrane review of 39 trials with 2,441 people with inner ear balance problems found moderate to strong evidence that vestibular rehab is safe and effective, with about 2.7 times higher odds of improvement in dizziness compared with no treatment [9]. The physical therapy guideline strongly recommends it for people with sudden or long-lasting loss of inner ear function, and suggests considering starting within the first 2 weeks after vestibular neuritis [10]. In a trial of 65 people after vestibular neuritis, adding supervised and home vestibular rehab to standard care led to less dizziness at 3 and 12 months [11].

The guideline recommends supervised therapy plus a home program, with these minimum doses for gaze stabilization exercises [10]:

Stage	Gaze stabilization exercises	Balance exercises
First 3 months	3 times a day, at least 12 minutes a day in total	May be considered; no set dose
After 3 months	3 to 5 times a day, at least 20 minutes a day, for 4 to 6 weeks	At least 20 minutes a day for 4 to 6 weeks

Source: Hall et al., physical therapy clinical practice guideline, 2022 [10]. These doses are rated as weak recommendations.

Expect the exercises to stir up some dizziness or nausea at first. That is a known, temporary effect, and your therapist will pace the program so you can keep going [10]. The guideline also advises against eye-movement exercises done on their own without moving the head [10].

Medicines

• Anti-sickness and antihistamine tablets can help in the first days, but the NHS advises taking them for no more than 3 days, because longer use can slow recovery [2]. The physical therapy guideline agrees that long-term use of these medicines may hold back recovery [10].
• Steroids are a decision for your doctor. In one trial of 141 people, steroids led to better recovery of inner ear function on testing at 12 months:

• Steroid (methylprednisolone)62.4 points
• Steroid plus antiviral59.2 points
• Placebo39.6 points
• Antiviral (valacyclovir)36.0 points

Source: Strupp et al., New England Journal of Medicine, 2004 [12]. Percentage points of improvement on a lab test of inner ear function, not symptoms.

A Cochrane review, however, found insufficient evidence that steroids improve symptoms or long-term recovery [13]. An emergency medicine guideline suggests considering a short course of steroids [14]. The antiviral did not help [12].

What you can do now

The NHS suggests [2]:

• Lie still in a quiet, dark room when the dizziness is severe, and drink little and often if you are vomiting
• Start going for walks outside as soon as you can, with someone to steady you at first
• Avoid driving, cycling or using machinery while you are dizzy, and avoid alcohol

MedlinePlus adds avoiding driving, heavy machinery and climbing for a week after symptoms disappear [3]. Get urgent medical help for sudden hearing loss in one ear [2].

Warning signs: when vertigo is a stroke emergency

A stroke in the back of the brain can closely mimic an inner ear problem, and in more than half of such cases there are no obvious signs such as weakness [17]. Early brain scans can also miss these strokes in the first day or two [15] [16] [17]. That is why the emergency guideline recommends a specialized bedside eye exam called HINTS, done by clinicians trained in it, rather than relying on a CT scan [14]. One study found that checking for new hearing loss helped identify strokes, so hearing loss with vertigo is not automatically a harmless inner ear problem [16]. In another review, headache or neck pain was more common when the cause was in the brain [17].

Call 911 right away if sudden vertigo or loss of balance comes with any of these [3] [18]:

• Numbness or weakness in the face, arm or leg, especially on one side
• Trouble speaking or understanding, or slurred speech
• Double vision or trouble seeing
• Trouble walking or loss of coordination
• A sudden severe headache with no known cause
• Fainting, seizures, a lot of vomiting, or vertigo with a fever above 101°F (38.3°C)

Remember B.E. F.A.S.T.: Balance loss, Eyes (vision changes), Face drooping, Arm weakness, Speech difficulty, Time to call 911 [18].

The takeaway

• Vestibular neuritis causes days of severe vertigo without hearing loss. Labyrinthitis also affects hearing.
• Most people recover over weeks to a few months, because the brain learns to compensate.
• Vestibular rehab is safe and effective, and starting early may help.
• Use anti-dizziness tablets only for a few days. Steroids are a decision for your doctor.
• Sudden vertigo with weakness, speech or vision problems, or a severe headache is a stroke emergency: call 911.

This article is not a substitute for medical care. Our team offers balance, dizziness and vestibular therapy, and you can start physical therapy in Utah without a referral. If we see signs of something other than an inner ear problem, we will refer you to the right specialist.