Vestibular neuronitis, right ear
ICD-10 H81.21 is a billable code used to indicate a diagnosis of vestibular neuronitis, right ear.
Vestibular neuronitis is an acute condition characterized by inflammation of the vestibular nerve, which is responsible for transmitting balance information from the inner ear to the brain. This condition typically presents with sudden onset vertigo, which may be accompanied by nausea, vomiting, and imbalance. Patients often report a spinning sensation that can last for days, with symptoms exacerbated by head movements. The right ear is specifically affected in this code, indicating the need for precise documentation of the affected side. Diagnosis is primarily clinical, supported by a thorough history and physical examination, including tests to rule out other causes of vertigo such as benign paroxysmal positional vertigo (BPPV) or central nervous system disorders. Imaging studies are generally not required unless there are atypical features. Management focuses on symptomatic relief, often utilizing vestibular suppressants and antiemetics, while vestibular rehabilitation may be recommended for persistent symptoms. Understanding the nuances of this condition is crucial for accurate coding and appropriate treatment pathways.
Detailed history of symptoms, physical examination findings, and any diagnostic tests performed.
Patients presenting with acute vertigo, history of viral infections, or post-viral syndromes.
Ensure clear documentation of the onset, duration, and severity of symptoms, as well as any differential diagnoses considered.
Comprehensive neurological examination and any relevant imaging studies to rule out central causes of vertigo.
Patients with vertigo and neurological symptoms, such as headache or visual disturbances.
Document any neurological findings that may suggest a central cause, which would necessitate different coding.
Used to assess vestibular function in patients with vertigo.
Document the specific tests performed and the rationale for testing.
Otolaryngologists and neurologists should ensure that the tests correlate with the diagnosis.
Common symptoms include sudden onset of severe vertigo, nausea, vomiting, and imbalance, often without hearing loss.
Diagnosis is primarily clinical, based on history and physical examination, with tests to rule out other causes of vertigo.
