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This was the term applied originally by Dix and Hallpike to a distinctive disturbance of vestibular function, characterized clinically by a paroxysmal and usually a prolonged single attack of vertigo and by a conspicuous absence of tinnitus and deafness The entity is, however, more nebulous than most discussions indicate This disorder occurs mainly in young to middle-aged adults (children and older individuals may be affected), without preference for either sex The patient frequently gives a history of an antecedent upper respiratory infection of nonspeci c type, but it is not clear whether this is requisite for the diagnosis Usually the onset of vertigo is fairly abrupt, although some patients describe a prodromal period of several hours or days in which they felt topheavy or off balance Persistence of the symptoms for a day or more differentiates the process from Meniere disease The vertigo ` is severe as a rule and is associated with nausea, vomiting, and the need to remain immobile Nystagmus (quick component) and a sense of body motion are to the opposite side, whereas falling and past pointing are to the side of the lesion In some patients the caloric responses are abnormal bilaterally, and in some the vertigo may recur, affecting the same or the other ear Auditory function is normal Examination discloses vestibular paresis on one side, ie, an absent or diminished response to caloric stimulation of the horizontal semicircular canal If the patient will tolerate the small head movements, the previously described rapid-head-impulse test of Halmagyi and Cremer is one of the best means of demonstrating absent function of one lateral semicircular canal Although the symptoms can be quite disabling for a short period, vestibular neuronitis is a benign disorder The severe vertigo and associated symptoms subside in a matter of several days,

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but lesser degrees of these symptoms, made worse by rapid movements of the head, may persist for several weeks or months The caloric responses are gradually restored to normal as well In some patients there has been a recurrence months or years later The portion of the vestibular pathway that is primarily affected in this disease is thought to be the superior part of the vestibular nerve trunk, which was observed to show degenerative changes by Schuknecht and Kitamura Earlier, Dix and Hallpike had reasoned that the lesion was located central to the labyrinth, since hearing is spared and vestibular function usually returns to normal They used the term vestibular neuronitis because of the uncertainty of more precise localization within the peripheral vestibular pathway The cause is uncertain, but most authorities have attributed it to a viral infection of the vestibular nerve, analogous to Bell s palsy, and from time to time, enhancement of the eighth nerve or the membranous labyrinth is seen after gadolinium administration on MRI For want of more speci c etiologic or pathologic data, many neurologists prefer the term vestibular neuropathy or neuritis or acute unilateral peripheral vestibulopathy It is likely that many of the conditions described under the terms epidemic vertigo, epidemic labyrinthitis, and acute labyrinthitis or neurolabyrinthitis refer to the same process These many names attest to the fact that the distinction between vestibular neuronitis and labyrinthitis has never been clari ed; some otolaryngologists use the term labyrinthitis for a vestibular neuronitis with mild or moderate hearing loss Certainly herpes zoster oticus causes this syndrome (as well as affecting the seventh nerve); this characterizes the Ramsay Hunt syndrome (pages 642 and 1183) During the acute stage, antihistamine drugs, phenergan, clonazepam, and scopolamine may be helpful in reducing the symptoms Vestibular exercises are recommended by Baloh in his review of the subject (2003) One study has demonstrated a more rapid recovery with the use of methylprednisolone, 100 mg orally, tapered over 3 weeks; valcyclovir did not have this effect (Strupp et al).

Class 1 Line chart Profile chart Column chart Bar chart Doughnut chart Radar chart Area chart Profile area chart Pie chart Polar chart Speedometer Split pie chart TABLE 6-2

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Vertigo may occur with diseases that involve the eighth nerve in the petrous bone or at the cerebellopontine angle Aside from vestibular neuronitis, discussed above, the two most common causes of vertigo of eighth nerve origin are probably an acoustic neuroma and vascular irritation or compression by a small branch of the basilar artery The frequency of the vascular compression syndrome (see earlier) as a cause of otherwise undifferentiated vertigo is not known Regarding acoustic neuroma, vertigo is rarely the initial symptom; the usual sequence is deafness affecting the high-frequency tones initially, followed some months or years later by mild chronic imbalance rather than vertigo and by impaired caloric responses, and then, if untreated, by additional cranial nerve palsies (the seventh, fth, and tenth nerves), ipsilateral ataxia of limbs, and headache (see page 572) Variations in the sequence of development of symptoms are frequent, and probably many acoustic neuromas discovered in the process of an evaluation for vertigo are incidental; ie, almost 1 percent of the general population harbor small tumors In the diagnosis of acoustic neuroma, MRI and BAEP are the most important ancillary examinations Labyrinthine infarction can be a component of the stroke syndrome from occlusion of the anterior inferior cerebellar artery (AICA) In the complete syndrome there is hearing loss, cerebel-

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