Pathophysiology and Inflammatory Pathway in Vestibular Neuritis
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Abstract
Introduction: Vestibular neuritis (VN) causes acute vertigo from sudden unilateral vestibular dysfunction, mainly in adults aged 30–60. Previous reviews have focused on clinical and therapeutic aspects, but the inflammatory and immune mechanisms are less well understood. This review summarizes recent evidence on viral, immune, and vascular pathways in VN.
Method: A narrative review was conducted using PubMed, Scopus, and Web of Science databases. Forty articles published between 2001 and 2025 were included, focusing on pathophysiology, immune pathways, and therapeutic approaches implications.
Results: VN is primarily caused by HSV-1 reactivation, leading to vestibular nerve inflammation. Other viruses, such as SARS-CoV-2 and Epstein–Barr, are also involved. Immune dysregulation, characterized by alterations in leukocytes and cytokines, drives neuroinflammation. Vascular issues, especially blood-labyrinth barrier disruption, worsen swelling. Corticosteroids reduce inflammation; vestibular rehab aids recovery. Combining treatments improves early outcomes.
Conclusion: VN is a complex disorder caused by viral reactivation, immune inflammation, and vascular issues. Recovery primarily depends on central compensation, rather than peripheral nerve regeneration. Combining anti-inflammatory treatment with early rehab yields the best results. Future research should investigate the molecular connections between viral infection, immune response, and vestibular damage to develop targeted therapies.
1. Adamec I, Krbot Skorić M, Handžić J, Habek M. Incidence, seasonality and comorbidity in vestibular neuritis. Neurological Sciences. 2015 Jan 2;36(1):91–5.
2. Strupp M, Brandt T. Vestibular Neuritis. Semin Neurol. 2009 Nov 15;29(05):509–19.
3. Bae CH, Na HG, Choi YS. Current diagnosis and treatment of vestibular neuritis: a narrative review. Journal of Yeungnam Medical Science. 2022 Apr 30;39(2):81–8.
4. Strupp M, Brandt T. Vestibular Neuritis. Semin Neurol. 2009 Nov 15;29(05):509–19.
5. Greco A, Macri GF, Gallo A, Fusconi M, De Virgilio A, Pagliuca G, et al. Is Vestibular Neuritis an Immune Related Vestibular Neuropathy Inducing Vertigo? J Immunol Res. 2014;2014:1–8.
6. Bronstein AM, Dieterich M. Long-term clinical outcome in vestibular neuritis. Curr Opin Neurol. 2019 Feb;32(1):174–80.
7. Kim JS, Kim HJ. Inferior vestibular neuritis. J Neurol. 2012 Aug 4;259(8):1553–60.
8. Lee JY, Park JS, Kim MB. Clinical Characteristics of Acute Vestibular Neuritis According to Involvement Site. Otology & Neurotology. 2020 Jan;41(1):143.
9. Vlastarakos P V, Sideris G, Vasileiou E, Michailidou E, Papadimitriou N, Palantzas D, et al. Developing a Diagnostic Algorithm for Identifying Vestibular Neuronitis in Acute Dizziness: An Overview of Epidemiology, Pathogenesis, and Evidence-Based Guidelines for Diagnostic Approaches. Cureus. 2025 Jan 28;
10. Ahmadi SA, Vivar G, Navab N, Möhwald K, Maier A, Hadzhikolev H, et al. Modern machine-learning can support diagnostic differentiation of central and peripheral acute vestibular disorders. J Neurol. 2020 Dec 11;267(S1):143–52.
11. Zhao Z, Liu X, Zong Y, Shi X, Sun Y. Cellular Processes Induced by HSV-1 Infections in Vestibular Neuritis. Viruses. 2023 Dec 20;16(1):12.
12. Arbusow V, Theil D, Strupp M, Mascolo A, Brandt T. HSV-1 Not Only in Human Vestibular Ganglia but Also in the Vestibular Labyrinth. Audiology and Neurotology. 2001;6(5):259–62.
13. Himmelein S, Lindemann A, Sinicina I, Horn AKE, Brandt T, Strupp M, et al. Differential Involvement during Latent Herpes Simplex Virus 1 Infection of the Superior and Inferior Divisions of the Vestibular Ganglia: Implications for Vestibular Neuritis. J Virol. 2017 Jul 15;91(14).
14. Richard C, Linthicum FH. Vestibular Neuritis. Otology & Neurotology. 2012 Sep;33(7):e59–60.
15. Rujescu D, Hartmann AM, Giegling I, Konte B, Herrling M, Himmelein S, et al. Genome-Wide Association Study in Vestibular Neuritis: Involvement of the Host Factor for HSV-1 Replication. Front Neurol. 2018 Jul 20;9.
16. Haeussler SM, Zabaneh SI, Stegemann M, Olze H, Böttcher A, Stölzel K. Is Vestibular Neuropathy Rather a Neuritis? Cureus. 2022 Oct 5;
17. Fancello V, Hatzopoulos S, Corazzi V, Bianchini C, Skarżyńska MB, Pelucchi S, et al. SARS-CoV-2 (COVID-19) and audio-vestibular disorders. Int J Immunopathol Pharmacol. 2021 Jan 18;35.
18. Malayala S V, Raza A. A Case of COVID-19-Induced Vestibular Neuritis. Cureus. 2020 Jun 30;
19. Mat Q, Noël A, Loiselet L, Tainmont S, Chiesa-Estomba CM, Lechien JR, et al. Vestibular Neuritis as Clinical Presentation of COVID-19. Ear Nose Throat J. 2023 Mar 11;102(3):NP129–32.
20. Jeong J. Vestibular neuritis after COVID-19 vaccination. Hum Vaccin Immunother. 2021 Dec 2;17(12):5126–8.
21. Shahali H, Hamidi Farahani R, Hazrati P, Hazrati E. Acute vestibular neuritis: A rare complication after the adenoviral vector-based COVID-19 vaccine. J Neurovirol. 2022 Dec 25;28(4–6):609–15.
22. Ergul Y, Ekici B, Tastan Y, Sezer T, Uysal S. Vestibular Neuritis Caused by Enteroviral Infection. Pediatr Neurol. 2006 Jan;34(1):45–6.
23. He Y, Guo T, Dai T, Zhou B, Xie H. Inflammatory proteins and vestibular neuronitis: A Mendelian randomization study. Medicine. 2024 Dec 20;103(51):e41081.
24. Zhang DG, Yu WQ, Liu JH, Kong LG, Zhang N, Song YD, et al. Serum/glucocorticoid-inducible kinase 1 deficiency induces NLRP3 inflammasome activation and autoinflammation of macrophages in a murine endolymphatic hydrops model. Nat Commun. 2023 Mar 6;14(1):1249.
25. Hegemann SCA, Wenzel A. Diagnosis and Treatment of Vestibular Neuritis/Neuronitis or Peripheral Vestibulopathy (PVP)? Open Questions and Possible Answers. Otology & Neurotology. 2017 Jun;38(5):626–31.
26. Udit S, Blake K, Chiu IM. Somatosensory and autonomic neuronal regulation of the immune response. Nat Rev Neurosci. 2022 Mar 7;23(3):157–71.
27. Şahin Mİ, Kökoğlu K, Gülmez E. Mean platelet volume, neutrophil- and platelet to lymphocyte ratios are elevated in vestibular neuritis. Journal of Clinical Neuroscience. 2019 Sep;67:134–8.
28. Quaranta NAA, Salzo AE, Pontillo V, Scarano E, Sergi B, Picciotti PM. Neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR) in Ménière’s disease and vestibular neuritis. Hearing Balance Commun. 2021 Sep;19(4):235–9.
29. Ishiyama G, Lopez IA, Ishiyama P, Vinters H V., Ishiyama A. The blood labyrinthine barrier in the human normal and Meniere’s disease macula utricle. Sci Rep. 2017 Mar 21;7(1):253.
30. Maniaci A, Briglia M, Allia F, Montalbano G, Romano GL, Zaouali MA, et al. The Role of Pericytes in Inner Ear Disorders: A Comprehensive Review. Biology (Basel). 2024 Oct 8;13(10):802.
31. Eliezer M, Hautefort C, Van Nechel C, Duquesne U, Guichard JP, Herman P, et al. Electrophysiological and inner ear MRI findings in patients with bilateral vestibulopathy. European Archives of Oto-Rhino-Laryngology. 2020 May 8;277(5):1305–14.
32. Büki B, Mair A, Pogson JM, Andresen NS, Ward BK. Three-Dimensional High-Resolution Temporal Bone Histopathology Identifies Areas of Vascular Vulnerability in the Inner Ear. Audiology and Neurotology. 2022;27(3):249–59.
33. Yi Z, Wang X, Yin G, Sun Y. The Blood-Labyrinth Barrier: Non-Invasive Delivery Strategies for Inner Ear Drug Delivery. Pharmaceutics. 2025 Apr 7;17(4):482.
34. Leong K, Lau T, Stewart V, Canetti EFD. Systematic Review and Meta‐analysis: Effectiveness of Corticosteroids in Treating Adults With Acute Vestibular Neuritis. Otolaryngology–Head and Neck Surgery. 2021 Aug 2;165(2):255–66.
35. Oliveira J. e Silva L, Khoujah D, Naples JG, Edlow JA, Gerberi DJ, Carpenter CR, et al. Corticosteroids for patients with vestibular neuritis: An evidence synthesis for guidelines for reasonable and appropriate care in the emergency department. Academic Emergency Medicine. 2023 May 4;30(5):531–40.
36. Ismail EI, Morgan AE, Abdel Rahman AM. Corticosteroids versus vestibular rehabilitation in long-term outcomes in vestibular neuritis. Journal of Vestibular Research. 2019 Apr 16;28(5–6):417–24.
37. Bogdanova A, Dlugaiczyk J, Heckmann JG, Schwab S. Corticosteroids in patients with vestibular neuritis: An updated meta‐analysis. Acta Neurol Scand. 2022 Nov 27;146(5):429–39.
38. Tokle G, Mørkved S, Bråthen G, Goplen FK, Salvesen Ø, Arnesen H, et al. Efficacy of Vestibular Rehabilitation Following Acute Vestibular Neuritis: A Randomized Controlled Trial. Otology & Neurotology. 2020 Jan;41(1):78–85.
39. Jafarzadeh S. Vestibular Assessment and Rehabilitation in Three Patients with Covid-19 Induced Vestibular Neuritis. Journal of Rehabilitation Sciences and Research [Internet]. 2022 Jun 1 [cited 2025 Dec 22];9(2):89–92. Available from: https://www.researchgate.net/publication/362057533_Vestibular_Assessment_and_Rehabilitation_in_Three_Patients_with_Covid-19_Induced_Vestibular_Neuritis_Original_Article
40. Huang HH, Chen CC, Lee HH, Chen HC, Lee TY, Tam KW, et al. Efficacy of Vestibular Rehabilitation in Vestibular Neuritis. Am J Phys Med Rehabil. 2024 Jan;103(1):38–46.
2. Strupp M, Brandt T. Vestibular Neuritis. Semin Neurol. 2009 Nov 15;29(05):509–19.
3. Bae CH, Na HG, Choi YS. Current diagnosis and treatment of vestibular neuritis: a narrative review. Journal of Yeungnam Medical Science. 2022 Apr 30;39(2):81–8.
4. Strupp M, Brandt T. Vestibular Neuritis. Semin Neurol. 2009 Nov 15;29(05):509–19.
5. Greco A, Macri GF, Gallo A, Fusconi M, De Virgilio A, Pagliuca G, et al. Is Vestibular Neuritis an Immune Related Vestibular Neuropathy Inducing Vertigo? J Immunol Res. 2014;2014:1–8.
6. Bronstein AM, Dieterich M. Long-term clinical outcome in vestibular neuritis. Curr Opin Neurol. 2019 Feb;32(1):174–80.
7. Kim JS, Kim HJ. Inferior vestibular neuritis. J Neurol. 2012 Aug 4;259(8):1553–60.
8. Lee JY, Park JS, Kim MB. Clinical Characteristics of Acute Vestibular Neuritis According to Involvement Site. Otology & Neurotology. 2020 Jan;41(1):143.
9. Vlastarakos P V, Sideris G, Vasileiou E, Michailidou E, Papadimitriou N, Palantzas D, et al. Developing a Diagnostic Algorithm for Identifying Vestibular Neuronitis in Acute Dizziness: An Overview of Epidemiology, Pathogenesis, and Evidence-Based Guidelines for Diagnostic Approaches. Cureus. 2025 Jan 28;
10. Ahmadi SA, Vivar G, Navab N, Möhwald K, Maier A, Hadzhikolev H, et al. Modern machine-learning can support diagnostic differentiation of central and peripheral acute vestibular disorders. J Neurol. 2020 Dec 11;267(S1):143–52.
11. Zhao Z, Liu X, Zong Y, Shi X, Sun Y. Cellular Processes Induced by HSV-1 Infections in Vestibular Neuritis. Viruses. 2023 Dec 20;16(1):12.
12. Arbusow V, Theil D, Strupp M, Mascolo A, Brandt T. HSV-1 Not Only in Human Vestibular Ganglia but Also in the Vestibular Labyrinth. Audiology and Neurotology. 2001;6(5):259–62.
13. Himmelein S, Lindemann A, Sinicina I, Horn AKE, Brandt T, Strupp M, et al. Differential Involvement during Latent Herpes Simplex Virus 1 Infection of the Superior and Inferior Divisions of the Vestibular Ganglia: Implications for Vestibular Neuritis. J Virol. 2017 Jul 15;91(14).
14. Richard C, Linthicum FH. Vestibular Neuritis. Otology & Neurotology. 2012 Sep;33(7):e59–60.
15. Rujescu D, Hartmann AM, Giegling I, Konte B, Herrling M, Himmelein S, et al. Genome-Wide Association Study in Vestibular Neuritis: Involvement of the Host Factor for HSV-1 Replication. Front Neurol. 2018 Jul 20;9.
16. Haeussler SM, Zabaneh SI, Stegemann M, Olze H, Böttcher A, Stölzel K. Is Vestibular Neuropathy Rather a Neuritis? Cureus. 2022 Oct 5;
17. Fancello V, Hatzopoulos S, Corazzi V, Bianchini C, Skarżyńska MB, Pelucchi S, et al. SARS-CoV-2 (COVID-19) and audio-vestibular disorders. Int J Immunopathol Pharmacol. 2021 Jan 18;35.
18. Malayala S V, Raza A. A Case of COVID-19-Induced Vestibular Neuritis. Cureus. 2020 Jun 30;
19. Mat Q, Noël A, Loiselet L, Tainmont S, Chiesa-Estomba CM, Lechien JR, et al. Vestibular Neuritis as Clinical Presentation of COVID-19. Ear Nose Throat J. 2023 Mar 11;102(3):NP129–32.
20. Jeong J. Vestibular neuritis after COVID-19 vaccination. Hum Vaccin Immunother. 2021 Dec 2;17(12):5126–8.
21. Shahali H, Hamidi Farahani R, Hazrati P, Hazrati E. Acute vestibular neuritis: A rare complication after the adenoviral vector-based COVID-19 vaccine. J Neurovirol. 2022 Dec 25;28(4–6):609–15.
22. Ergul Y, Ekici B, Tastan Y, Sezer T, Uysal S. Vestibular Neuritis Caused by Enteroviral Infection. Pediatr Neurol. 2006 Jan;34(1):45–6.
23. He Y, Guo T, Dai T, Zhou B, Xie H. Inflammatory proteins and vestibular neuronitis: A Mendelian randomization study. Medicine. 2024 Dec 20;103(51):e41081.
24. Zhang DG, Yu WQ, Liu JH, Kong LG, Zhang N, Song YD, et al. Serum/glucocorticoid-inducible kinase 1 deficiency induces NLRP3 inflammasome activation and autoinflammation of macrophages in a murine endolymphatic hydrops model. Nat Commun. 2023 Mar 6;14(1):1249.
25. Hegemann SCA, Wenzel A. Diagnosis and Treatment of Vestibular Neuritis/Neuronitis or Peripheral Vestibulopathy (PVP)? Open Questions and Possible Answers. Otology & Neurotology. 2017 Jun;38(5):626–31.
26. Udit S, Blake K, Chiu IM. Somatosensory and autonomic neuronal regulation of the immune response. Nat Rev Neurosci. 2022 Mar 7;23(3):157–71.
27. Şahin Mİ, Kökoğlu K, Gülmez E. Mean platelet volume, neutrophil- and platelet to lymphocyte ratios are elevated in vestibular neuritis. Journal of Clinical Neuroscience. 2019 Sep;67:134–8.
28. Quaranta NAA, Salzo AE, Pontillo V, Scarano E, Sergi B, Picciotti PM. Neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR) in Ménière’s disease and vestibular neuritis. Hearing Balance Commun. 2021 Sep;19(4):235–9.
29. Ishiyama G, Lopez IA, Ishiyama P, Vinters H V., Ishiyama A. The blood labyrinthine barrier in the human normal and Meniere’s disease macula utricle. Sci Rep. 2017 Mar 21;7(1):253.
30. Maniaci A, Briglia M, Allia F, Montalbano G, Romano GL, Zaouali MA, et al. The Role of Pericytes in Inner Ear Disorders: A Comprehensive Review. Biology (Basel). 2024 Oct 8;13(10):802.
31. Eliezer M, Hautefort C, Van Nechel C, Duquesne U, Guichard JP, Herman P, et al. Electrophysiological and inner ear MRI findings in patients with bilateral vestibulopathy. European Archives of Oto-Rhino-Laryngology. 2020 May 8;277(5):1305–14.
32. Büki B, Mair A, Pogson JM, Andresen NS, Ward BK. Three-Dimensional High-Resolution Temporal Bone Histopathology Identifies Areas of Vascular Vulnerability in the Inner Ear. Audiology and Neurotology. 2022;27(3):249–59.
33. Yi Z, Wang X, Yin G, Sun Y. The Blood-Labyrinth Barrier: Non-Invasive Delivery Strategies for Inner Ear Drug Delivery. Pharmaceutics. 2025 Apr 7;17(4):482.
34. Leong K, Lau T, Stewart V, Canetti EFD. Systematic Review and Meta‐analysis: Effectiveness of Corticosteroids in Treating Adults With Acute Vestibular Neuritis. Otolaryngology–Head and Neck Surgery. 2021 Aug 2;165(2):255–66.
35. Oliveira J. e Silva L, Khoujah D, Naples JG, Edlow JA, Gerberi DJ, Carpenter CR, et al. Corticosteroids for patients with vestibular neuritis: An evidence synthesis for guidelines for reasonable and appropriate care in the emergency department. Academic Emergency Medicine. 2023 May 4;30(5):531–40.
36. Ismail EI, Morgan AE, Abdel Rahman AM. Corticosteroids versus vestibular rehabilitation in long-term outcomes in vestibular neuritis. Journal of Vestibular Research. 2019 Apr 16;28(5–6):417–24.
37. Bogdanova A, Dlugaiczyk J, Heckmann JG, Schwab S. Corticosteroids in patients with vestibular neuritis: An updated meta‐analysis. Acta Neurol Scand. 2022 Nov 27;146(5):429–39.
38. Tokle G, Mørkved S, Bråthen G, Goplen FK, Salvesen Ø, Arnesen H, et al. Efficacy of Vestibular Rehabilitation Following Acute Vestibular Neuritis: A Randomized Controlled Trial. Otology & Neurotology. 2020 Jan;41(1):78–85.
39. Jafarzadeh S. Vestibular Assessment and Rehabilitation in Three Patients with Covid-19 Induced Vestibular Neuritis. Journal of Rehabilitation Sciences and Research [Internet]. 2022 Jun 1 [cited 2025 Dec 22];9(2):89–92. Available from: https://www.researchgate.net/publication/362057533_Vestibular_Assessment_and_Rehabilitation_in_Three_Patients_with_Covid-19_Induced_Vestibular_Neuritis_Original_Article
40. Huang HH, Chen CC, Lee HH, Chen HC, Lee TY, Tam KW, et al. Efficacy of Vestibular Rehabilitation in Vestibular Neuritis. Am J Phys Med Rehabil. 2024 Jan;103(1):38–46.
| Issue | Articles in Press | |
| Section | Review Article(s) | |
| Keywords | ||
| Vestibular neuritis; Vertigo; Inflammation; Pathophysiology | ||
| Rights and permissions | |
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This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License. |
How to Cite
1.
Fayaz M, Alsaad S, Rasouli A. Pathophysiology and Inflammatory Pathway in Vestibular Neuritis. jmr. 2026;(-).
