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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]

Search 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)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Ariyasu L.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
Ohbayashi S.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
Kitahara 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
Michael Strupp,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
Ali Akbar Rezaie et al. 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
Avi Shupak 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

Comment(s)

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.

Clinical 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

1. Ariyasu L. Byl FM. Sprague MS. et al. The beneficial effect of methylprednisolone in acute vestibular vertigo Arch Otolaryngol Head Neck Surg 1990;116:700-703
2. Ohbayashi S. Oda M. Yamamoto M. et al. Recovery of the vestibular function after vestibular neuronitis. Acta Otolaryngol. 1993;Suppl.503:31-34
3. Kitahara T. Kondoh K. Morihana T. et al Steroid effects on vestibular compensation in human. Neurol Res 2003;25(3):287-291
4. Strupp M. Zingler VC. Arbusow V. et al Methylprednisolone, valacyclovir, or the combination for vestibular neuritis. N Engl J Med. 2004;351:354-61
5. Ali Akbar Rezaie, Farnaz Hashemian, Nima Rezaie. Corticosteroids effect onvestibular neuritis symptom relief. Pak J Med Sci 2006;22(4):409-411
6. Shupak A. Issa A. Golz A. et al. Prednisone treatment for vestibular neuritis. Otol Neurotol. 2008;29(3):368-374