Methylprednisolone, Valacyclovir, or the Combination for Vestibular Neuritis

TLDR

Vestibular neuritis, the second most common cause of peripheral vestibular vertigo, is thought to result from reactivation of herpes simplex virus type 1. The study aimed to determine whether corticosteroids, antiviral agents, or their combination improve recovery in patients with vestibular neuritis. A prospective, randomized, double‑blind, two‑by‑two factorial trial enrolled 141 patients who were assigned to placebo, methylprednisolone, valacyclovir, or methylprednisolone plus valacyclovir, and vestibular function was assessed by caloric irrigation and a paresis formula at 3 days and 12 months. Methylprednisolone significantly accelerated recovery of peripheral vestibular function (average 62.4 ± 16.9 pp) compared with placebo (39.6 ± 28.1 pp), whereas valacyclovir had no effect and the combination was not superior to corticosteroid monotherapy.

Abstract

Vestibular neuritis is the second most common cause of peripheral vestibular vertigo. Its assumed cause is a reactivation of herpes simplex virus type 1 infection. Therefore, corticosteroids, antiviral agents, or a combination of the two might improve the outcome in patients with vestibular neuritis.We performed a prospective, randomized, double-blind, two-by-two factorial trial in which patients with acute vestibular neuritis were randomly assigned to treatment with placebo, methylprednisolone, valacyclovir, or methylprednisolone plus valacyclovir. Vestibular function was determined by caloric irrigation, with the use of the vestibular paresis formula (to measure the extent of unilateral caloric paresis) within 3 days after the onset of symptoms and 12 months afterward.Of a total of 141 patients who underwent randomization, 38 received placebo, 35 methylprednisolone, 33 valacyclovir, and 35 methylprednisolone plus valacyclovir. At the onset of symptoms there was no difference among the groups in the severity of vestibular paresis. The mean (+/-SD) improvement in peripheral vestibular function at the 12-month follow-up was 39.6+/-28.1 percentage points in the placebo group, 62.4+/-16.9 percentage points in the methylprednisolone group, 36.0+/-26.7 percentage points in the valacyclovir group, and 59.2+/-24.1 percentage points in the methylprednisolone-plus-valacyclovir group. Analysis of variance showed a significant effect of methylprednisolone (P<0.001) but not of valacyclovir (P=0.43). The combination of methylprednisolone and valacyclovir was not superior to corticosteroid monotherapy.Methylprednisolone significantly improves the recovery of peripheral vestibular function in patients with vestibular neuritis, whereas valacyclovir does not.