Acute Unilateral Vestibulopathy (AUVP)

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What is Acute Unilateral Vestibulopathy?

AUVP is also known as acute unilateral vestibular hypofunction or vestibular neuritis.  It is described as “an acute peripheral vestibular syndrome defined by an acute unilateral loss of peripheral vestibular function without evidence for acute central neurological or acute audiological symptoms or signs” (Strupp et al., 2022).  In other words, it’s a sudden disruption of one inner ear’s balance system, leading to dizziness/vertigo and imbalance while the hearing and brain are typically unaffected.  

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History

Acute vestibular dysfunction has been recognized for over a century. Early 1900s reports described sudden vertigo and unilateral caloric weakness—later called “Neuritis vestibularis.” Around the same time, Robert Bárány’s work on caloric testing (Nobel Prize, 1914) established the basis for diagnosing unilateral vestibular loss.

Terminology evolved from an inflammatory view (neuritis / neuronitis) to a functional concept (vestibulopathy), leading to formal diagnostic criteria by the Bárány Society in 2022 (Strupp et al.).

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Dr. Robert Bárány

Etiology  

  • Viral or Post-Viral Inflammation
    The leading hypothesis is reactivation of latent HSV-1 in the vestibular ganglion, producing focal inflammation of the vestibular nerve. Some patients report preceding viral illness or show inflammatory markers consistent with a post-infectious process (Strupp et al., 2022; Jeong et al., 2013; Haeussler et al., 2022). 

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  • Vascular Ischemia
    A vestibular artery infarction can cause an identical clinical presentation, and patients with acute unilateral inner-ear hypofunction demonstrate higher cardiovascular risk factors including hypertension, diabetes, dyslipidemia and CVD, supporting a possible vascular contribution (Strupp et al., 2022; Simões et al., 2022).

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  • Idiopathic or Multifactorial
    In a proportion of cases, no single etiology is confirmed; viral, vascular, and inflammatory mechanisms are all considered possible (Strupp et al., 2022).
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  • Age-Related Degeneration
    Progressive loss of vestibular hair cells, nerve fibers, and central integration occurs with aging, leading to mild bilateral hypofunction and increased fall risk (Agrawal et al., 2019; Zalewski, 2015).
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Prevalence 

Acute unilateral vestibulopathy has an annual incidence of approximately 3.5 per 100,000 persons (Strupp et al., 2022). It accounts for about 7% of patients presenting to vertigo or dizziness clinics and is the second most common peripheral cause of acute prolonged vertigo after benign paroxysmal positional vertigo (BPPV) (Strupp & Magnusson, 2015; Lee et al., 2025). Among individuals who develop chronic unilateral vestibular hypofunction, it is identified as the most frequent precipitating cause (Karabulut et al., 2024).

Diagnostic Criteria for AUVP – Bárány Society

Each of the following criteria have to be fulfilled:

A) Acute or subacute onset of sustained spinning or non-spinning vertigo  (i.e., an acute vestibular syndrome) of moderate to severe intensity  with symptoms lasting for at least 24 hours

B) Spontaneous peripheral vestibular nystagmus i.e., a nystagmus with a trajectory appropriate to the semicircular canal afferents involved, generally horizontal-torsional, direction-fixed, and enhanced by removal of visual fixation

C) Unambiguous evidence of reduced VOR function on the side opposite the direction of the fast phase of the spontaneous nystagmus

D) No evidence for acute central neurological symptoms or acute audiological symptoms such as hearing loss or tinnitus or other otologic symptoms such as otalgia

E) No acute central neurological signs, namely no central ocular motor or central vestibular signs, in particular, no skew deviation, no gaze-evoked nystagmus, and no acute audiological signs

F) Not better accounted for by another disease or disorder

There is also diagnostic criteria on AUVP in evolution, probably AUVP and history of AUVP.  See Strupp et al., 2022 full paper for all diagnostic criteria sources. 

How to Diagnose AUVP (2)

Patient Reported Symptoms

Patients often describe sudden, continuous vertigo lasting ≥ 24 hours, with nausea, vomiting, and imbalance toward one side, no auditory symptoms, and subsequent motion-induced dizziness or unsteadiness (especially in the dark or with head turns) during recovery.

AUVP Symptoms (1)

Clinical Findings

Bedside Vestibular-Ocular Testing

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Vestibular Function Testing

  • Head Impulse (HIT/vHIT): Corrective saccades toward the affected side indicate reduced VOR gain (Strupp et al., 2022; von Bernstorff et al., 2024).

  • Caloric Irrigation: Canal paresis ≥25 % signifies unilateral horizontal canal weakness (Strupp & Magnusson, 2015).

  • Rotational Chair: Reduced gain and possible phase lead indicate unilateral or bilateral hypofunction (Hall et al., 2022).

  • Dynamic Visual Acuity: Greater then 2 line difference compared to when head is still and when the head is in motion reflects impaired gaze stabilization (Hall et al., 2022).

Balance and Gait Findings

  • Romberg / CTSIB: Increased sway or falls with eyes closed or on foam indicate vestibular dependence (Hall et al., 2022).

  • Gait Observation: Veering or unsteadiness, often worse in darkness or on uneven surfaces (Jeong et al., 2013).

  • Head Turns During Gait: Instability or oscillopsia during head motion reflects poor VOR compensation (Hall et al., 2022).

  • Functional Measures: FGA < 22 or DGI < 19 indicates fall risk (Hall et al., 2022).

Treatment

1. Vestibular Rehabilitation Therapy (Primary Treatment)

  • Guideline: Strong recommendation (Level I evidence) for unilateral vestibular hypofunction, including AUVP (Hall et al., 2022).

  • Mechanism: Facilitates central compensation via repeated gaze and balance challenges

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2. Corticosteroid Therapy?

  • Evidence: Mixed; one 2025 RCT (Sjögren et al.) found improved vestibular function recovery but no significant difference in dizziness or quality-of-life scores vs placebo.

  • Recommendation: May be considered in the acute phase (< 72 h) if no contraindications; not standard of care for all patients.

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3. Avoidance of Prolonged Vestibular Suppressants

  • Guideline: Suppressants delay central compensation. Limit to ≤ 3 days for severe vertigo/nausea (Jeong et al., 2013; Strupp & Magnusson, 2015)

Factors That May Affect Recovery

  • Anxiety/Depression
  • Abnormal Binocular Vision
  • Migraine
  • Peripheral Neuropathy
  • Long Term Use of Vestibular Suppressants 

To Learn More — Check Out These AUVP Resources

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References

  • Agrawal Y, Van de Berg R, Wuyts F, Walther L, Magnusson M, Oh E, Sharpe M, Strupp M. Presbyvestibulopathy: Diagnostic criteria Consensus document of the classification committee of the Bárány Society. J Vestib Res. 2019;29(4):161-170. doi: 10.3233/VES-190672. PMID: 31306146; PMCID: PMC9249286. https://pubmed.ncbi.nlm.nih.gov/31306146/
  • Girasoli L, Cazzador D, Padoan R, Nardello E, Felicetti M, Zanoletti E, Schiavon F, Bovo R. Update on Vertigo in Autoimmune Disorders, from Diagnosis to Treatment. J Immunol Res. 2018 Sep 26;2018:5072582. doi: 10.1155/2018/5072582. PMID: 30356417; PMCID: PMC6178164. https://pubmed.ncbi.nlm.nih.gov/30356417/
  • Hall CD, Herdman SJ, Whitney SL, Anson ER, Carender WJ, Hoppes CW, Cass SP, Christy JB, Cohen HS, Fife TD, Furman JM, Shepard NT, Clendaniel RA, Dishman JD, Goebel JA, Meldrum D, Ryan C, Wallace RL, Woodward NJ. Vestibular Rehabilitation for Peripheral Vestibular Hypofunction: An Updated Clinical Practice Guideline From the Academy of Neurologic Physical Therapy of the American Physical Therapy Association. J Neurol Phys Ther. 2022 Apr 1;46(2):118-177. doi: 10.1097/NPT.0000000000000382. PMID: 34864777; PMCID: PMC8920012. https://pubmed.ncbi.nlm.nih.gov/34864777/
  • Haeussler SM, Zabaneh SI, Stegemann M, Olze H, Böttcher A, Stölzel K. Is Vestibular Neuropathy Rather a Neuritis? Cureus. 2022 Oct 5;14(10):e29959. doi: 10.7759/cureus.29959. PMID: 36381739; PMCID: PMC9635860. https://pubmed.ncbi.nlm.nih.gov/36381739/
  • Herdman SJ. Vestibular rehabilitation. Curr Opin Neurol. 2013 Feb;26(1):96-101. doi: 10.1097/WCO.0b013e32835c5ec4. PMID: 23241567. https://pubmed.ncbi.nlm.nih.gov/23241567/
  • Huang, Hsiao-Han MD; Chen, Chih-Chung MD, PhD; Lee, Hsun-Hua MD; Chen, Hung-Chou MD; Lee, Ting-Yi MD; Tam, Ka-Wai MD, PhD; Kuan, Yi-Chun MD. Efficacy of Vestibular Rehabilitation in Vestibular Neuritis: A Systematic Review and Meta-analysis. American Journal of Physical Medicine & Rehabilitation 103(1):p 38-46, January 2024. | https://journals.lww.com/ajpmr/abstract/2024/01000/efficacy_of_vestibular_rehabilitation_in.7.aspx
  • Jeong SH, Kim HJ, Kim JS. Vestibular neuritis. Semin Neurol. 2013 Jul;33(3):185-94. doi: 10.1055/s-0033-1354598. Epub 2013 Sep 21. PMID: 24057821. https://pubmed.ncbi.nlm.nih.gov/24057821/
  • Karabulut M, Viechtbauer W, Van Laer L, Mohamad A, Van Rompaey V, Guinand N, Perez Fornos A, Gerards MC, van de Berg R. Chronic Unilateral Vestibular Hypofunction: Insights into Etiologies, Clinical Subtypes, Diagnostics and Quality of Life. J Clin Med. 2024 Sep 11;13(18):5381. doi: 10.3390/jcm13185381. PMID: 39336868; PMCID: PMC11432443. https://pubmed.ncbi.nlm.nih.gov/39336868/
  • Lee S-U, Edlow JA, Tarnutzer AA. Acute Vertigo, Dizziness and Imbalance in the Emergency Department—Beyond Stroke and Acute Unilateral Vestibulopathy—A Narrative Review. Brain Sciences. 2025; 15(9):995. https://doi.org/10.3390/brainsci15090995 https://www.mdpi.com/2076-3425/15/9/995
  • Sjögren J, Fransson P-A, Magnusson M, Karlberg M, Tjernström F. Acute unilateral vestibulopathy and corticosteroid treatment – A randomized placebo-controlled double-blind trial. Journal of Vestibular Research. 2025;35(2):91-101. doi:10.1177/09574271241307649
  • Simões, João & Vlaminck, Stephan & Seiça, Raquel & Acke, Frederic & Miguéis, António. (2022). Cardiovascular risk factors among patients with acute unilateral inner ear hypofunction: A case–control study. Laryngoscope Investigative Otolaryngology. 8. 1-8. 10.1002/lio2.992. https://www.researchgate.net/publication/366204739_Cardiovascular_risk_factors_among_patients_with_acute_unilateral_inner_ear_hypofunction_A_case-control_study
  • Strupp M, Bisdorff A, Furman J, Hornibrook J, Jahn K, Maire R, Newman-Toker D, Magnusson M. Acute unilateral vestibulopathy/vestibular neuritis: Diagnostic criteria. J Vestib Res. 2022;32(5):389-406. doi: 10.3233/VES-220201. PMID: 35723133; PMCID: PMC9661346. https://pmc.ncbi.nlm.nih.gov/articles/PMC9661346/
  • Strupp M, Magnusson M. Acute Unilateral Vestibulopathy. Neurol Clin. 2015 Aug;33(3):669-85, x. doi: 10.1016/j.ncl.2015.04.012. PMID: 26231279. https://pubmed.ncbi.nlm.nih.gov/26231279/
  • Tsuzuki N, Wasano K. Idiopathic sudden sensorineural hearing loss: A review focused on the contribution of vascular pathologies. Auris Nasus Larynx. 2024 Aug;51(4):747-754. doi: 10.1016/j.anl.2024.05.009. Epub 2024 Jun 7. PMID: 38850720. https://pubmed.ncbi.nlm.nih.gov/38850720/
  • von Bernstorff, Maximilian MD; Obermueller, Theresa MD; Blum, Julia MD; Hoxhallari, Erdi MD; Hofmann, Veit M. MD; Pudszuhn, Annett MD. Accuracy of the Bedside Examination in Patients With Suspected Acute Unilateral Peripheral Vestibulopathy. The Neurologist 29(4):p 238-242, July 2024. | https://journals.lww.com/theneurologist/abstract/2024/07000/accuracy_of_the_bedside_examination_in_patients.6.aspx
  • Zalewski CK. Aging of the Human Vestibular System. Semin Hear. 2015 Aug;36(3):175-96. doi: 10.1055/s-0035-1555120. PMID: 27516717; PMCID: PMC4906308. https://pmc.ncbi.nlm.nih.gov/articles/PMC4906308/