By Marcello Cherchi, MD PhD
§1: What are these diseases, and how are they related?
Discussions in the medical literature use the terms “vestibular neuritis,” “labyrinthitis” and “sudden sensorineural hearing loss” under the apparent assumption that these are three discrete diagnoses that are easily distinguishable from one another. While it is true that exemplar cases of each may seem clinically distinct, in real-world clinical practice one encounters many cases that appear to blur the putative boundaries between these diseases. Consequently, the author would argue that these diseases more likely represent a gradation of clinical manifestations that reflect a similar gradation of underlying pathology. We have discussed this in some detail elsewhere (Cherchi and Yacovino 2021).
§1.1: What is vestibular neuritis?
Vestibular neuritis, also called vestibular neuronitis, was originally described by Margaret Ruth Dix and Charles Skinner Hallpike in 1952 (Dix and Hallpike 1952). It is currently suspected to be an inflammatory-mediated insult (damage) to the balance-related nerve (vestibular nerve) between the ear and the brain that manifests with abrupt-onset, severe dizziness that lasts days to weeks, and occasionally recurs.
Although vestibular neuritis is usually regarded as a process affecting the vestibular nerve itself, damage restricted to the vestibule (balance components of the inner ear) would manifest clinically in a similar way, and might be termed “vestibulitis,” although that term is seldom applied (Izraeli, Rachmel et al. 1989). Thus, distinguishing between “vestibular neuritis” (inflammation of the vestibular nerve) and “vestibulitis” (inflammation of the balance-related components of the inner ear) would be difficult.
§1.2: What is labyrinthitis?
Labyrinthitis is currently suspected to be due to an inflammatory-mediated insult (damage) to both the “hearing component” (the cochlea) and the “balance component” (the semicircular canals and otolith organs) of the inner ear (labyrinth) itself. Labyrinthitis is sometimes also termed “vertigo with sudden hearing loss” (Pogson, Taylor et al. 2016, Kim, Choi et al. 2018) – and we will discuss sudden hearing loss further in a moment.
Labyrinthitis usually manifests with severe dizziness (similar to vestibular neuritis) accompanied by ear symptoms on one side (typically hearing loss and tinnitus). It is less clear whether labyrinthitis recurs, because frequent recurrence is usually clinically more suggestive of Ménière’s disease.
Although labyrinthitis is usually regarded as a process affecting the labyrinth (inner ear) itself, damage to the vestibulocochlear nerve (which transmits hearing and balance signals from the inner ear to the brain) would manifest in a similar fashion clinically; this would be termed “vestibulocochlear neuritis.” Thus, distinguishing “labyrinthitis” (inflammation of the entire inner ear) from “vestibulocochlear neuritis” (inflammation of the entire vestibulocochlear nerve) would be difficult.
§1.3: What is sudden sensorineural hearing loss?
Idiopathic sudden sensorineural hearing loss (SSNHL) is currently suspected to be due to an inflammatory-mediated insult (damage) to the “hearing component” (cochlea) of the inner ear, which technically should be termed “cochleitis,” though that term is seldom used (Sataloff and Vassallo 1968, Fitzgerald and Mark 1999, Luigetti, Cianfoni et al. 2011). However, damage to the auditory component of the vestibulocochlear nerve could manifest in a similar fashion clinically; this would be termed “cochlear neuritis.” Thus, distinguishing between sudden sensorineural hearing loss from “cochleitis” (inflammatory damage of the hearing-related components of the inner ear) and “cochlear neuritis” (inflammation of the hearing-related nerve) would be difficult (Goodale, Golub et al. 2016).
§2: What is the relationship between vestibular neuritis, labyrinthitis and sudden sensorineural hearing loss?
Most textbooks depict vestibular neuritis, labyrinthitis and sudden sensorineural hearing loss as distinct clinical entities, which may be didactically useful, but is probably an oversimplification. The reality is likely more complex since damage can occur to varying proportions of the vestibulocochlear nerve, varying proportions of the labyrinth, and varying combinations thereof; in other words, the underlying pathobiology probably spans a continuum, with a corresponding range of clinical presentations – with different combinations/degrees of vestibular symptoms (dizziness/imbalance) and ear symptoms (hearing loss, tinnitus).
This “continuum” of disease is likely underappreciated because it is under-studied for practical reasons. Specifically, if a patient complains exclusively of hearing symptoms, then she will probably not undergo any balance testing; conversely if a patient complains exclusively of imbalance, then he will probably not undergo any hearing testing. However, if these patients do undergo more comprehensive evaluation, then some surprising results may emerge. Some examples follow.
The literature usually describes vestibular neuritis as presenting purely with vestibular symptoms (dizziness/imbalance), and no auditory symptoms. However, when such patients are studied carefully, it turns out that some of them have detectable hearing deficits on the affected side (Yao, Xu et al. 2018), or abnormalities in other auditory functions such as an elevated stapedius reflex threshold (Bergenius and Borg 1983, Bagger-Sjoback, Perols et al. 1993). In other words, “pure” vestibular neuritis may not actually be so pure.
The literature usually describes sudden sensorineural hearing loss as presenting purely with auditory symptoms (hearing loss and sometimes tinnitus), and no vestibular (dizziness/imbalance) symptoms. However, when such patients are studied carefully, it turns out that some of them have detectable vestibular deficits (Hong, Byun et al. 2008, Korres, Stamatiou et al. 2011, Zhang, Hu et al. 2013, Fujimoto, Egami et al. 2015) on the same side as the hearing loss. In other words, the “pure” sudden sensorineural hearing loss may not actually be so pure. Emerging literature suggests that even some patients with the isolated symptom of tinnitus, with normal audiometry and no vestibular complaints, may still have detectable vestibular deficits on instrumented testing (Nagarajan and Sinha 2025).
Thus, these terms (“vestibular neuritis”/“vestibulitis”, versus “sudden sensorineural hearing loss”/“cochleitis”, versus “labyrinthitis”/“vestibulocochlear neuritis”) assume distinct clinical presentations (purely vestibular symptoms, purely auditory symptoms, or a combination thereof, respectively), while other terms (“vestibular neuritis” versus “vestibulitis”; “sudden sensorineural hearing loss” versus “cochleitis”; “cochleovestibular neuritis” versus “labyrinthitis”) assume that the underlying disease process is restricted to a discrete anatomical area (the neural pathways versus the inner ear, respectively). But these distinctions, while perhaps terminologically convenient, are flawed, missing what is likely a pathobiological continuum with a corresponding spectrum of clinical presentations. This is illustrated in the Table below.
| Exclusively vestibular function affected | Both vestibular and auditory function affected | Exclusively auditory function affected | |
| Exclusively neural structure involved | “Vestibular neuritis” | “Vestibulocochlear neuritis” | “Cochlear neuritis” |
| Both neural structure and inner ear structure involved | “Vestibular neuritis” + “vestibulitis” | “Vestibulocochlear neuritis” + “labyrinthitis” | “Cochlear neuritis” + “cochleitis” |
| Exclusively inner ear structure involved | “Vestibulitis” | “Labyrinthitis” | “Cochleitis” |
References
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Bergenius J, Borg E (1983) Audio-vestibular findings in patients with vestibular neuritis. Acta Otolaryngol 96: 389-95. doi: 10.3109/00016488309132724
Cherchi M, Yacovino DA (2021) Dysfunction along the continuum of vestibulocochlear anatomy, and the corresponding spectrum of clinical presentation: how little we know, and what else we need to learn. Hearing, Balance and Communication: 1-12. doi: 10.1080/21695717.2021.1975984
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