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Labyrinthitis
Introduction
Labyrinthitis is an inflammation of the membranous labyrinth of the inner ear, presenting with symptoms such as vertigo, nausea, vomiting, tinnitus, and/or hearing loss.[1] Epidemiological data on labyrinthitis are limited, but the incidence increases with age.[2] Notably, labyrinthitis can mimic other conditions, such as a cerebrovascular accident (CVA), necessitating a thorough evaluation before a final diagnosis. Bacterial or viral infections of the ear usually cause labyrinthitis, but it can be a manifestation of systemic disease due to autoimmunity, medication toxicity, or infection such as human immunodeficiency virus (HIV) or syphilis.[3][4][5][6] The etiology determines the appropriate treatment and symptom control. Although some patients recover completely, others experience residual balance or hearing deficits.
Etiology
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Etiology
Labyrinthitis is an inflammation of the membranous labyrinth caused by viruses, bacteria, or systemic diseases.[3] In rare cases, it can cause labyrinthitis ossificans, a disease in which pathological new bone formation occurs within the membranous labyrinth.[7] Vestibular neuritis (also referred to as vestibular neuronitis) is often used interchangeably with labyrinthitis, as the symptoms and clinical picture are similar. However, true vestibular neuritis is characterized by inflammation confined to the vestibular nerve without the involvement of the membranous labyrinth.[8] For the remainder of this article, we will focus exclusively on labyrinthitis.
Viral Labyrinthitis
The most common cause of labyrinthitis is a viral infection of the upper respiratory tract. Local inflammatory mediators are produced in response to the viral infection and enter the cochlea through either the round or oval window, leading to inflammation. Less commonly, viruses can directly enter and infect the cochlea, possibly causing hearing impairment.[9] For instance, labyrinthitis secondary to maternal rubella or cytomegalovirus (CMV) infections is one of the most common causes of congenital deafness. In the post-natal period, mumps and measles are the leading causes of viral hearing loss.[10][11][12][13] Ramsay-Hunt syndrome, also known as herpes zoster oticus, is due to a latent varicella-zoster virus infection reactivating, often years after the primary viral infection.[14] This syndrome typically produces a vesicular rash, usually on the oral mucosa or ear, accompanied by peripheral facial nerve paralysis. Additionally, the virus can infect the vestibular and cochlear nerves in 25% of cases.[15] Moreover, CMV-mediated inflammation can be a cause of sudden sensorineural hearing loss, although the cause is usually unknown.[16][17]
Bacterial Labyrinthitis
Bacterial labyrinthitis typically arises from either bacterial meningitis or bacterial acute otitis media. Similarly, 20% of children with bacterial meningitis will develop auditory or vestibular symptoms.[18][19] Inflammation occurs through 2 different mechanisms in serous and suppurative labyrinthitis. In serous labyrinthitis, the inflammation is secondary to bacterial toxins and/or host cytokines and inflammatory mediators passing into the membranous labyrinth via the round or oval window.[18] Suppurative labyrinthitis is inflammation caused directly by a bacterial infection. Bacteria enter the inner ear from the middle ear via the round window (most common) or the oval window. They can also enter the central nervous system via the cochlear aqueduct or auditory canal. Congenital or acquired defects in the bony labyrinth can predispose to further bacterial infection.[19]
Autoimmune Labyrinthitis
Both polyarteritis nodosa and granulomatosis with polyangiitis are rare autoimmune conditions that are associated with labyrinthitis.[20][21]
HIV/ Syphilis
Both syphilis and HIV infections are associated with labyrinthitis. However, it is unclear whether the inflammation is due to opportunistic infections or if HIV causes the inflammation.[22]
Epidemiology
There is limited research on the incidence and prevalence of labyrinthitis, as most epidemiologic studies focus on broader categories of vestibular dysfunction or vertigo rather than labyrinthitis alone. In a prospective study of 200 patients presenting with sudden sensorineural hearing loss, labyrinthitis was identified in 3% of cases based on MRI findings.[23]While vestibular dysfunction and balance abnormalities increase with age, the precise prevalence of labyrinthitis is difficult to determine, although it is considered rare.[24]
Otogenic suppurative labyrinthitis can occur at any age and is usually associated with a cholesteatoma or secondary to untreated, longstanding otitis media. Suppurative bacterial labyrinthitis, a complication of bacterial meningitis, is the most common cause of deafness in children under age 2. Fortunately, it is exceedingly rare in the post-antibiotic era.[18][25]
Pathophysiology
Anatomy
The inner ear consists of 2 structures: the bony labyrinth and the membranous labyrinth. The bony labyrinth is a collection of bony cavities situated within the temporal bone of the skull, comprising three main parts: the vestibule, the cochlea, and the 3 semicircular canals.[19] All three of these structures contain a substance called perilymph, also known as Cotunnius' liquid. Perilymph is similar in composition to cerebrospinal fluid, with sodium as the primary cation and a lower concentration of potassium than intracellular fluid.[26][27]
The membranous labyrinth is situated within the bony labyrinth and comprises four structures: the saccule, utricle, semicircular ducts, and cochlear duct. Endolymph fills the membranous labyrinth. It has a principal cation of potassium and a lower concentration of sodium, similar to intracellular fluid. The gradient across Reissner's membrane, created by the opposing concentrations of endolymph and perilymph, is responsible for generating the electrical impulses of the hair cells, known as the endocochlear potential.[28]
The inner ear has 2 connections with the middle ear and 2 connections with the central nervous system. The oval window connects the vestibule to the middle ear, and the round window connects the cochlear duct to the middle ear. The internal auditory canal and cochlear aqueduct connect the inner ear and central nervous system (CNS).[26]
History and Physical
Labyrinthitis is a diagnosis of exclusion. When evaluating a patient with suggested labyrinthitis, it is important to screen for risk factors. Helpful clues in the history include recent viral upper respiratory tract infections, cholesteatoma, a history of ear surgery, a history of temporal bone fracture, meningitis, or acute or chronic otitis media.
Nausea, vomiting, and severe ‘room spinning’ vertigo are the most commonly reported symptoms of labyrinthitis.[1] It is also essential to clarify the number of episodes of actual ‘room spinning' or 'whirling' vertigo, as opposed to more generalized sensations of imbalance or lightheadedness, which would not be indicative of labyrinthitis.[29] The peak of vertigo rarely lasts longer than 72 hours, but ataxia and occasional brief episodes may persist for several weeks. The clinical course can be more prolonged if the patient has comorbid anxiety or depression. [30]
The differential diagnosis of labyrinthitis includes vestibular neuritis, stroke, and Meniere disease. Vestibular neuritis is distinguished by the presence of hearing loss or tinnitus, symptoms that are absent in labyrinthitis. [18] The presence of vertigo with cranial nerve deficits, crossed or uncrossed cortical tract findings, and numbness could indicate a CVA affecting the brain stem.[4] Meniere disease is characterized by fluctuating aural fullness, tinnitus, and hearing loss, often accompanied by vertiginous episodes.[31][32]
On physical examination, nystagmus is often present, and the fast phase typically moves away from the affected ear.[33] Patients can also experience gait and balance abnormalities. Therefore, Romberg sign, tandem gait, cerebellar, and meningeal testing are essential components of the neurologic examination.[34] Notably, Rinne and Weber hearing tests will likely demonstrate sensorineural hearing loss in the affected ear; therefore, a formal audiological evaluation is required. Otoscopy may provide clues to the etiology of the disease, such as otitis media or cholesteatoma. Finally, if bacterial meningitis is a consideration, skin examination may reveal a non-blanching rash.[35]
Evaluation
Audiometry is useful to assess the presence or extent of sensorineural hearing loss. Specific investigations into the vestibular system (eg, evoked myogenic potentials, electronystagmography, and rotary chair tests) are not indicated in the acute phase of the disease. However, they can be useful in assessing long-term compensation and residual deficits, as well as in differentiating inner ear pathology from other etiologies.[36][37]
The laboratory tests are tailored to the patient's symptoms and differential diagnoses. Severe vomiting should prompt a basal metabolic panel to assess electrolyte abnormalities and hydration status. Cerebrospinal fluid analysis is performed if bacterial meningitis is suggested. Subsequently, HIV and syphilis serology are helpful in high-risk individuals or atypical presentations. Finally, testing for autoimmune disease is considered in patients with systemic findings or atypical presentations, even if serological titers are negative.[38][39]
Imaging studies, such as magnetic resonance imaging (MRI) and computed tomography (CT) scans, can be useful for identifying alternative pathologies. Furthermore, expert consensus recommends imaging of the cerebello-pontine angle if the difference between the ears exceeds 15 dB, because 13% of acoustic neuromas present with sudden hearing loss.[40][41] Gadolinium-enhanced magnetic resonance imaging (Gd-MRI) predicts the development of hearing loss following bacterial meningitis, a complication that occurs in approximately 14% of cases.[42][43][44]
Treatment / Management
Treatment is primarily supportive and is tailored to the etiology and symptoms.
Viral labyrinthitis treatment typically involves hydration and bed rest in an outpatient setting. However, patients must be counseled to seek further medical intervention if their condition worsens or they develop neurological symptoms (e.g., weakness/numbness, diplopia, slurred speech, and gait disturbance).[45] Notably, antiviral medications and steroids are not supported by current evidence.[46][47](A1)
The treatment of bacterial labyrinthitis depends on the source of infection. Oral antibiotics are the first-line treatment for acute otitis media with an intact tympanic membrane. Intravenous antibiotics are recommended for recalcitrant infections. If findings are suggestive of bacterial meningitis, intravenous antibiotics are commenced immediately, while confirmatory CSF and imaging testing are performed concurrently.
Autoimmune labyrinthitis is treated initially with corticosteroids. If the disease is refractory to corticosteroid therapy, other immunomodulators are considered, such as azathioprine, etanercept, or cyclophosphamide. Compared with corticosteroids, these medications are preferable for chronic cases due to their favorable safety profile and fewer adverse effects. Treatment with immunosuppressants requires specialist referral.[48] (B3)
If serology testing is consistent with syphilis or HIV infection, appropriate treatment and referral to specialist care are warranted.[5]
During the initial phase of vertigo, patients often lie motionless with their eyes closed due to dizziness and nausea. However, early mobilization can promote vestibular compensation and improve prognosis.[49]
Benzodiazepines and antihistamines are useful initially. However, treatment with these medications should not last more than 72 hours because they can inhibit vestibular compensation. Some experts advise against these vestibular suppressant medications for all but intractable symptoms.[50][51] Antiemetics, such as prochlorperazine or ondansetron, may help control nausea and vomiting. Patients with sudden hearing loss should receive high-dose corticosteroids and specialist referral.[52](A1)
A small minority of patients may have residual tinnitus following sensorineural hearing loss. Reactive depression may coexist with prolonged tinnitus, and early intervention with tinnitus re-training, tinnitus maskers, hearing aids, and/or biofeedback can aid recovery.[53][54](B2)
Surgical intervention is required in a minority of cases. For example, mastoidectomy is required in patients with cholesteatoma or severe mastoiditis. Occasionally, patients may require drainage of effusions or myringotomy if labyrinthitis is secondary to otitis media.
Once the acute labyrinthitis has resolved, patients with persistent vestibular symptoms should be referred for vestibular rehabilitation. [55][56](A1)
Differential Diagnosis
Vestibular neuritis presents similarly to labyrinthitis but without accompanying hearing loss.[57]
Meniere disease causes hearing loss and vertigo, but the episodes are usually intermittent.[58]
Benign positional vertigo causes dizziness but not hearing loss, and patients typically exhibit an abnormal Dix-Hallpike test.[59]
Posterior fossa CVA typically presents with an abnormal neurological examination, including ataxia, hoarseness, dysarthria, or dysphagia. A CT or MRI of the head can aid in diagnosis.[60]
Acoustic neuromas/ vestibular schwannomas are diagnosed with a GdMRI.[61]
Inner ear malformations typically present with progressive or congenital hearing loss and can be diagnosed with CT or MRI imaging.[62]
Temporal bone fracture is suggested with a recent history of head trauma, and is diagnosed with CT imaging.[63]
Inner ear hemorrhage is commonly associated with trauma and is visible on MRI.[64]
Temporal bone neoplasm usually presents with cranial nerve deficits or facial paralysis and is apparent on MRI and/or CT.[65]
Multiple sclerosis often presents with additional systemic findings, such as spasticity, optic neuritis, or other cranial nerve deficits.[66]
Pertinent Studies and Ongoing Trials
Several trials are studying the effects of novel treatments for labyrinthitis. Superoxide dismutase limits hearing loss and prevents labyrinthitis ossificans in gerbils with bacterial meningitis. Additionally, TNF-alpha inhibitors reduce postmeningitic cochlear injury and hearing loss.[67][68] Some evidence suggests corticosteroid therapy for pneumococcal meningitis may prevent labyrinthitis ossificans. Furthermore, research into intra-tympanic corticosteroids as a superior therapeutic administration route shows promising results.[69] Finally, cochlear microperfusion and antioxidant therapy have potential as adjuvant therapies.[70][71][72]
Prognosis
The acute vertigo of labyrinthitis usually resolves after 48 to 72 hours. However, mild symptoms may persist for several weeks. The prognosis is generally favorable if there are no serious neurological sequelae. Conversely, neurological complications may require further interventions and portend a more guarded prognosis. For example, ventriculoperitoneal shunts are necessary in patients with hydrocephalus from bacterial meningitis.[73] Furthermore, a prolonged course of benzodiazepines and/or antihistamines for vertigo can delay vestibular recovery. Additionally, suppurative labyrinthitis can cause permanent hearing impairment.
Complications
After a severe case of labyrinthitis, some patients may develop persistent hearing loss or tinnitus, which may require the use of hearing aids or tinnitus-specific therapies.[53]
Bilateral vestibular hypofunction is a debilitating complication associated with bilateral labyrinthitis, typically resulting from bacterial meningitis. It can cause visual impairment (oscillopsia) and impaired spatial awareness.[74]
Complete deafness is a rare complication of bilateral labyrinthitis associated with bacterial meningitis. In addition, labyrinthitis ossificans is a complication of suppurative labyrinthitis.[75] Moreover, undertreated bacterial labyrinthitis can result in mastoiditis. This condition typically responds to intravenous antibiotics but can require mastoidectomy with tympanoplasty in severe cases.[76] Rarely, a labyrinthectomy may be necessary to treat labyrinthitis caused by cholesteatoma.[76]
Deterrence and Patient Education
Labyrinthitis is often a complication of infection, such as otitis media or meningitis. Therefore, early diagnosis and effective management of infections can minimize the risk of labyrinthitis or long-term complications. Furthermore, vaccinations against measles, mumps, and rubella can protect against labyrinthitis in vulnerable populations.
Patients with vertigo should be encouraged to mobilize as soon as possible to improve vestibular compensation and prognosis.[49] Patients who receive a prolonged course of benzodiazepines and/or antihistamines for vertigo may have delayed vestibular recovery.
Enhancing Healthcare Team Outcomes
The interprofessional team is crucial in delivering optimal care to patients with labyrinthitis. First, primary care clinicians should be familiar with the signs, symptoms, and differential diagnosis of labyrinthitis. These clinicians are the first line of defense and can administer prompt and effective management, thereby reducing potentially life-threatening conditions and complications of labyrinthitis.
Both nurses and pharmacists are invaluable in the initial management of a patient with labyrinthitis and must be familiar with the disease. For example, nursing staff can assist patients at high risk of falls due to vertigo. Pharmacists can recommend the most appropriate medications for nausea and vertigo. For example, pharmacists' knowledge of the role of benzodiazepines and antihistamines in short-term management can enable them to collaborate with physicians. They also know medications that may cause symptoms similar to labyrinthitis, and identify adverse effects or interactions.
Patients sometimes experience residual vestibular symptoms, which can significantly impact their quality of life. Both occupational and physical therapists can treat persistent vertigo and ataxia. Occupational therapists can also conduct assessments of the home environment and implement changes to enhance patient safety. Audiologists perform ongoing monitoring of hearing impairments to ensure optimal patient care. In summary, an interprofessional team approach can improve patient outcomes and quality of life.
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