Steroids for patients with vestibular neuronitis
Date First Published:
May 14, 2009
Last Updated:
November 4, 2009
Report by:
Hao-Chang Chou, MD (National Taiwan University Hospital)
Three-Part Question:
In [an adult presenting to the emergency department with acute vestibular neuronitis] does [steroids therapy] improve the [time to recovery]?
Clinical Scenario:
A 50-year-old male patient came to the emergency department with the symptoms of acute onset of severe rotatory vertigo, nausea, and postural imbalance. Physical examination revealed right-beating nystagmus in all positions of gaze but otherwise no focal neurological findings. After physical and neurological examinations, a clinical diagnosis of acute vestibular neuronitis was made. You wondered if steroids were useful to reduce his symptoms and improve time to recovery.
Search Strategy:
Medline 1950 to April 2009 using the OVID interface
[(exp Vestibular neuronitis or vestibular neuronitis.mp) OR (exp Vertigo or vertigo.mp) ] AND (exp Steroids or steroids.mp) limited to human AND English
Cochrane Library: [vestibular neuronitis]
[(exp Vestibular neuronitis or vestibular neuronitis.mp) OR (exp Vertigo or vertigo.mp) ] AND (exp Steroids or steroids.mp) limited to human AND English
Cochrane Library: [vestibular neuronitis]
Outcome:
Altogether, 211 papers were found on Medline and 11 papers were found in the Cochrane Library. 6 of them were relevant to the topic of interest (Table 1)
Relevant Paper(s):
| Study Title | Patient Group | Study type (level of evidence) | Outcomes | Key results | Study Weaknesses |
|---|---|---|---|---|---|
| The beneficial effect of methylprednisolone in acute vestibular vertigo Ariyasu L. Byl FM. Sprague MS. et al. 1990 Japan | 20 patients (18-65 years of age), divided into study group and control group. 32 mg methylprednisolone was given orally on the first day and then decreased to 4 mg gradually over the next 7 days. | PRCT and Crossover study | Subjective relief of symptoms within first 24 hours | Methylprednisolone was beneficial,p=0.02 | Small number of patients Poor randomization and blinding procedure No prior estimation of sample size No use of intention to treat analysis Short follow-up period |
| One-month ENG | No difference,p=0.06 | ||||
| Recovery of the vestibular function after vestibular neuronitis. Ohbayashi S. Oda M. Yamamoto M. et al. 1993 Japan | 111 patients (17-73 years of age), divided into study group and control group. 500 mg intravenous hydrocortisone was given initially and then decreased gradually by 100 mg every 2 days for 10 days. Oral prednisolone was given for 10 days at a starting dose of 30-40mg and decreased gradually | Prospective Comparative study | Subjective relief of symptoms | 1 month:no difference,3 months:no difference,6 months:no difference,12 months:no difference | Small number of patients No randomization and blinding procedure |
| Disappearance of spontaneous nystagmus | 1 month:no difference,3 months:steroids were beneficial,p<0.05,6 months:no difference,12 months:no difference | ||||
| Recovery of canal paralysis | Steroids were beneficial,p<0.05 | ||||
| Steroid effects on vestibular compensation in human. Kitahara T. Kondoh K. Morihana T. et al 2003 Japan | 36 patients (18-75 years of age), divided into study group and control group. 500 mg intravenous methylprednisolone was given initially and then decreased gradually to zero in one week. | PRCT | SPEV after 2 years | No difference, p=0.07 | Small number of patients Poor randomization and blinding procedure No prior estimation of sample size |
| Canal improvement ratio after 2 years | No difference | ||||
| Subjective relief of symptoms | Methylprednisolone was beneficial,p<0.05 | ||||
| Methylprednisolone, valacyclovir, or the combination for vestibular neuritis. Strupp M. Zingler VC. Arbusow V. et al 2004 Germany | 141 patients (18-80 years of age), divided into placebo group, methylprednisolone group, valacyclovir group and methylprednisolone-plus- valacyclovir group. 100 mg methylprednisolone was given daily for 3 days, then tapered off to 10 mg over the next 19 days. 1000 mg valacyclovir was given three times daily for 7 days | PRCT | Vestibular function determined by Jongkee’s formula within 3 days after the onset of symptoms and 12 months afterward | Jongkee’s formula (extent of vestibular paresis):At baseline (%): Placebo:78.9±24.0, Methylprednisolone:78.7±15.8, Valacyclovir:78.4±20.0, Methylprednisolone-plus-Valacyclovir:78.6±21.1, At 12 months (%): Placebo: 39.0±19.9, Methylprednisolone:15.4±16.2, P<0.001, Valacyclovir:42.7±32.3, P=0.63, Methylprednisolone-plus-Valacyclovir:20.4±28.4, P=0.006 | Small number of patients Unclear blinding procedure No use of intention to treat analysis 27 patient (20%) were lost during follow up |
| Corticosteroids effect onvestibular neuritis symptom relief. Ali Akbar Rezaie, Farnaz Hashemian, Nima Rezaie. 2006 Iran | 40 patients (15-55 years of age), devided into placebo group and study group. Study group was treated by Dexamethasone 18mg plus Deminohydrinate 100mg daily, and the placebo group was treated by placebo plus Deminohydrinate 100mg daily for 3 days | PRCT | Mean time for relief of Vertigo (hours) | Study group:45.6±15.3, Control group:68.4±11.7, P<0.001 | Small number of patients Poor randomization Unclear blinding procedure No prior estimation of sample size Short follow-up period |
| Mean time for relief of nausea (hours) | Study group:28.8±15.3, Control group:54±20.4, P<0.001 | ||||
| Mean time for relief of nystagmus (hours) | Study group:28.8±9.8, Control group:63.6±16.1, P<0.001 | ||||
| Prednisone treatment for vestibular neuritis. Shupak A. Issa A. Golz A. et al. 2008 Israel | 30 patients (22-72 years of age), divided into study group and control group. Prednisolone 1mg/kg was given daily for 5 days, followed by gradually reduced doses for the next 15 days | PRCT | Presence of symptoms and signs | 1 month: no difference,3 months:no difference,6 months:no difference,12 months:no difference | Small number of patients Unclear randomization and blinding procedure No prior estimation of sample size |
| DHI score | 1 month:no difference,3 months:no difference,6 months:no difference,12 months:no difference | ||||
| Caloric lateralization on ENG | 1 month:prednisolone was beneficial,p<0.03,3 months:prednisolone was beneficial,p<0.01,6 months:no difference,12 months:no difference | ||||
| Pathologic finding on ENG | 1 month:no difference,3 months:prednisolone was beneficial,p<0.03,6 months:no difference,12 months:no difference | ||||
| Complete resolution | 1 month:no difference,3 months:prednisolone was beneficial,p<0.03,6 months:prednisolone was beneficial,p<0.03,12 months:no difference |
Author Commentary:
Vestibular neuronitis is the second most common cause of peripheral vestibular vertigo. It is characterized by acute onset of sustained rotatory vertigo, postural imbalance with Romberg’s sign, horizontal spontaneous nystagmus and nausea, all of which can last days to weeks. The best treatment for the acute episode of vestibular neuronitis is still controversial. Currently, vestibular neuronitis is thought to be a viral inflammatory condition and it makes sense that steroids are probably effective for stopping inflammation. Nevertheless, there are limited data to support such strategies for the treatment of vestibular neuronitis. Six clinical trials were found directly accessing the value of steroids in the treatment of vestibular neuronitis. Most of these studies supported the hypothesis that steroids have a beneficial effect but suffered from too many quality issues, such as unclear randomization, blinding process and small number of patients. Thus, more randomized control trials with a large number of patients are needed to clarify the effectiveness of steroids in the treatment of vestibular neuronitis.
Bottom Line:
Steroids might be an effective treatment for vestibular neuronitis. More randomized control trials with a large number of patients are needed to answer this question.
References:
- Ariyasu L. Byl FM. Sprague MS. et al.. The beneficial effect of methylprednisolone in acute vestibular vertigo
- Ohbayashi S. Oda M. Yamamoto M. et al.. Recovery of the vestibular function after vestibular neuronitis.
- Kitahara T. Kondoh K. Morihana T. et al. Steroid effects on vestibular compensation in human.
- Strupp M. Zingler VC. Arbusow V. et al . Methylprednisolone, valacyclovir, or the combination for vestibular neuritis.
- Ali Akbar Rezaie, Farnaz Hashemian, Nima Rezaie.. Corticosteroids effect onvestibular neuritis symptom relief.
- Shupak A. Issa A. Golz A. et al.. Prednisone treatment for vestibular neuritis.