Acute unilateral vestibulopathy: a practical diagnostic approach and new insight on management

Acute unilateral vestibulopathy (AUV) is the recommended term (rather than the more widely used vestibular neuritis) for all pathologies involving sudden impairment of the unilateral peripheral vestibular function regardless of the exact location of the lesion. The clinical picture of AUV is characterized by acute severe rotatory vertigo, nausea, vomiting and static and dynamic postural instability. The diagnosis is based on the presence of spontaneous nystagmus (horizontal/torsional, unidirectional), gait imbalance (falling toward the side of lesion) and a positive Head Impulse Test. Typically, no associated auditory or neurological symptoms and signs are present. AUV is thought to be caused by a viral or post-viral inflammation of the vestibular nerve (vestibular neuritis), but a vascular origin of the disease cannot be excluded, especially in presence of several vascular risk factors. A careful bedside examination and a complete battery of instrumental test (video Head Impulse Test, cervical and ocular VEMPs) could provide accurate information for a correct AUV diagnosis, both in the acute and the chronic stage of the disease, also allowing to exclude a possible central nervous system involvement (vertebrobasilar stroke syndromes may mimic peripheral disorders). After a short course of symptomatic treatment with vestibular suppressants to alleviate the patient’s neuro-vegetative symptoms and intense rotatory vertigo, vestibular rehabilitation is the treatment of choice, although recent reports suggest that an early steroidal treatment may improve long-term outcome. In this article, the diagnostic considerations, exam findings, and management of AVS are reviewed.