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7/23/2013
Mark Howell, MD, FAC S Ear,Nose andThroat Associates Johnson City ,Tn. Michelle Tanner, MS4 Quillen College of Medicine Disclosures
 I declare that I do not have any relevant financial interest or other relationship with a commercial entity regarding the topic of vertigo in children
 I do not have any financial arrangements or affiliations with a commercial entity
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Learning Objectives
 Basic understanding of vestibular system
 Review of pertinent anatomy and function of the vestibular system
 Pediatric approach to diagnosis of vertigo
 Understand various pediatric etiologies and presentations of vertigo
 Be aware of physical exam maneuvers used  Overview of more formal vertigo testing
Clinical Scenario
 HPI: 8 yo F with 7 days of vertigo
 Described as “room spinning around her” or “riding a roller coaster”
 Lasted 30 minutes, during which she laid down
 Occurred three times over last week
 Sudden onset with nausea and balance difficulty
 Teacher reported “her eyes moved funny”
 No auras, tinnitis, hearing loss, visual field changes, diplopia or loss of consciousness
http://www.pediatriceducation.org/
Clinical Scenario
 PMHx: healthy, immunizations UTD
 FHx: +migraines and vertigo (mother)
 No history of hearing loss, deafness or neurological disease
 SHx: Doing well in school
 ROS: negative except for URI 3 weeks ago
 No fevers, chills, or cold sores
http://www.pediatriceducation.org/
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Clinical Scenario
 Pertinent PE:
 General: well appearing, growth parameters 25‐50%
 HEENT: left ear +serous fluid, PERRLA
 Neuro: EOMs intact, DTRs 2+/2+, negative Babinski, normal rapid alternating movements, finger to nose testing, tandem gait and Romberg testing; no nystagmus could be elicited
 Diagnosis???
http://www.pediatriceducation.org/
Definitions
 Dizziness: altered perception of position in the environment; can represent vertigo, presyncope or dysequilibrium
 Vertigo
 illusion of movement, most often sensation of rotation; less frequently, linear displacement or tilt
 key symptom of vestibular pathology
 often accompanied by nausea, vomiting, pallor and perspiration
 Vertigo differs in children:
 Often ignored
 Communication difficulties
 Compared to adult disease processes, frequency differs
 Prevalence:  Estimated 15% of school age children with at least one attack of vertigo over the last 12 months
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Relative Frequencies of Vertigo Syndromes in Children and Adults
Jahn K. Vertigo and balance in children – diagnostic approach and insights from imaging. Eur J Paediatr
Neurol. 2011 Jul;15(4):289‐294
Anatomy and Function
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Vestibular System
 Provides orientation of the body with respect to gravity
 Enables balanced movement  Ensures gaze stabilization
 Alters homeostatic milieu after body reorientation
Vestibular System
 Structurely fully developed sensory systems at birth
 Balance function matures with sequential acquisitions of motor milestones in infancy(head control;sitting;standing;walking)
 Experiential learning and adaptation into adolescence
 Reflexes:Moro;Tonic neck;head
righting;parachute;Doll’s eyes
 Most mature 5‐6 months
Vestibular System
 Responsible for sensing and controling motion
 3 semicircular canals
 2 otolith organs(utricle and saccule)
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Semicircular Canals
 3 matched canals
 90 degree angle relationship to each canal
 Superior,Posterior,Lateral
 Respond to angular acceleration
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Semicircular Canals
 3 matched canals
 90 degree angle relationship to each canal
 Superior,Posterior,Lateral
 Respond to angular acceleration
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Otolith Sensitivity
 Saccule
 Utricle
 Linear acceleration and head tilt to gravity
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Balance System
 Vestibular
 Visual
 Sensory/Proprioceptive
CNS
 Afferents all systems vestibular,visual and sensory/proprioceptive integrate
 Output from brainstem control motor responses to maintain balance compensate for head motion and position
CNS
 Vestibular‐occular control
 Vestibulo‐spinal tract
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Maintenance of balance
Higher centers :
* Extra pyramidal system
* Cerebellum
* Reticular formation
( Effector pathways )
(Sensory systems)
Vision
Proprioception
Brain stem
integrating center
(Vestibular nuclei)
Vestibular
labyrinths
Perception of orientation
(in Vestibular cortex)
Oculomotor system
(Vestibulo‐ocular reflex)
Antigravity muscles controlling posture & gait (Vestibulo spinal reflex)
Pathophysiology
 Balance requires –
 Normal functioning vestibular system
 Input from visual system (vestibulo‐ocular)
 Input from proprioceptive system (vestibulo‐spinal)
 Central causes compromise central circuits that mediate vestibular influences on posture, gaze control, autonomic fx
 Disruption of balance between inputs results in vertigo
 Goal of treatment: restore balance between different inputs
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Pathophysiology
 Vestibular system influences autonomic system
 Intimate linkage in brainstem pathways between vestibular and visceral inputs
 Alteration of vestibular inputs results in:
 nausea, vomiting
 Pallor
 Respiratory/circulatory changes
Components of History and Physical Exam
History
 “playground synonyms”‐true vertigo?
 Hearing loss or change (intolerance noise)
 Loss of Consciousness, mental status changes, 
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headache, neurologic (ataxia,cranial nerve changes)
Trauma –head or middle ear and neck
Infection‐fever, otitis media, viral illness
Recurrence vertigo
Use of Validated Structured Case Histories
Family history migraine
Drug ingestion
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Ravid and Colleagues. A simplified diagnostic approach to dizziness in children. Pediatr Neurol 2003;29(4):317‐20
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Vertigo
Acute
Paroxysmal
Hearing loss
Change of symptoms with head position
Headache
Fever
Vomiting
Anxiety
Depression
Change in consciousness
Head trauma
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Drugs
Family medical history
Hearing loss
Migraine
Seizures
Dizziness
Chronic
Continuous
 Age (>5, <5)
 Neuro exam: nl vs. abnl
 PE: nl vs. abnl
Ravid and Colleagues. A simplified diagnostic approach to dizziness in children. Pediatr Neurol 2003;29(4):317‐20
Specific Physical Exam Findings
 Acute otitis media findings or mastoiditis
 TM retraction pocket with middle ear mass(cholesteatoma)
 Hemotympanum,otorrhea,perforation(trauma)
 Hearing loss
 Vertigo or nystagmus from loud noise or with pneumatic otoscopy of intact TM(Tullio
phenomenon)
 Vesicles on auricle(Ramsey Hunt)
 Nystagmus
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Physical Examination
Informal
Formal
 Nystagmus
 Video‐Oculography
 Vestibulo‐Ocular Reflex
 Computerized Rotary Chair
 Head‐Thrust Testing
 Computerized Dynamic Posturography
 Dynamic Visual Acuity
 Dix‐Hallpike
 Vestibular Evoked Myogenic Potentials
 Postural Stability
Nystagmus
 Observed movement of the eye in response to stimulating the labyrinth, retro‐cochlear vestibular or central vestiulo‐ocular pathway.
 Classified by:
 Spontaneous or gaze‐evoked
 Direction (fast component)
 Fatigability *Observe for conjugate gaze
Search for spontaneous and gaze‐evoked nystagmus.
Frenzel glasses (high diopter lenses) prevent fixation and aid in identification of nystagmus.
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Nystagmus
Peripheral
Direction
Sometimes reverses Unidirectional, fast direction when patient component toward the normal ear; never reverses looks in the direction of slow component
direction
Type
Horizontal with a torsional component, never purely torsional or vertical
Central
Can be any direction
Effect of visual fixation Suppressed
Not suppressed
Other neurologic signs Absent
Often present
Postural instability
Unidirectional instability, Severe instability, patient walking preserved
often falls when walking
Deafness or tinnitus
May be present
Absent
Vestibulo‐Ocular Reflex
 Purpose is to stabilize gaze and maintain clear vision when the body or head is in motion
 Objects of interest are maintained on the fovea of the retina through inputs from the semicircular canals and otolith organs
 “head‐shake nystagmus”
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Semicircular Canal →
Vestibular Nuclei →
Oculomotor Nuclei III and VI →
Vestibulo‐Ocular Reflex
Dynamic Imbalance: Head‐Thrust Testing
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Dynamic Visual Acuity
 Modification of the typical Snellen Eye Chart
 Reads smallest line possible
 Attempts again to read during back and forth rotation of the head
 Loss of one line = insignificant
 Loss of 3 lines = VOR deficiency
Dix‐Hallpike
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Screening Postural Stability
 Romberg Maneuver
 Tandem Romberg
 Unterberger‐Fukuda Test
http://www.youtube.com/watch?feature=player_detailpage&v=atXCNq_CgHk
Video‐Oculography
 Infrared cameras embedded
 Battery of tests
 Central vs. Peripheral determination
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Computerized Rotary Chair
 Clarification of questionable VOG
 Used if caloric irrigations not tolerated
 Assessment of the VOR at multiple test frequencies
Computerized Dynamic Posturography
Dizziness Differential
 Life‐threatening conditions
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Head trauma 1
Central nervous system infection 2
Intracranial tumor or abscess
Stroke
Drug overdose and other poisons
 Other conditions
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Vestibular neuritis
Benign paroxysmal positional vertigo
Meniere disease
Perilymphatic fistula
Seizures
Ramsay Hunt syndrome
Multiple sclerosis
Congenital defects
 Common conditions
 Otitis media 1
 Migraine syndromes 2
 Benign paroxysmal vertigo of 
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childhood (BPVC) 3
Adverse effects of medications
Motion sickness
Paroxysmal torticollis of infancy
Pseudovertigo
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Cochlear‐Vestibular Integrity
 Accurate audiometric testing critical to assess integrity of VIII cranial nerve and membranous labyrinth
 Violation of cochlea or vestibular system can be anticipated with auditory dysfunction
True vertigo*
Pseudovertigo
Benign paroxysmal positional vertigo
Arrhythmia
Benign positional vertigo of childhood
Anemia
Cholesteatoma
CNS infection•
Congenital defectsΔ
Head trauma
Anxiety
Depression
Heat illness
Hyperventilation
Labyrinthitis (Vestibular neuritis)
Hypoglycemia
Mastoiditis
Orthostatic hypotension
Meniere disease
Poisoning or adverse effect of medication
Middle ear trauma
Migraine
Motion sickness
Multiple sclerosis
Otitis media
Perilymph fistula
Pregnancy
Presyncope
Visual disturbances
Poisoning or adverse effect of medication
Ramsay Hunt syndrome
Seizure
Stroke
Dizziness Differential
 Life‐threatening conditions
 Head trauma
 Central nervous system infection
 Intracranial tumor or abscess
 Stroke
 Drug overdose and other poisons
 Common conditions
 Otitis media
 Migraine syndromes
 Other conditions
 Vestibular neuritis
 Labryinthitis
 Benign paroxysmal positional vertigo
 Meniere disease
 Perilymphatic fistula
 Seizures
 Ramsay Hunt syndrome
 Multiple sclerosis
 Congenital defects
 Motor/Developmental delay
 Benign paroxysmal vertigo of childhood (BPVC)
Adverse effects of medications
Motion sickness
 Paroxysmal torticollis of infancy
 Pseudovertigo
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True Vertigo
Pseudovertigo
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Most Common Pediatric Disorders
Balatso Bower Choun D'Agos Erbek Ravid Riina et
23
3
uras et &
g et
tino, 1 et
et
al, 200
9
16
17
21
al, 200 al, 200 5
al, 200 Cotton, al, 200 997
10
7
1995 3
6
3
Weisle Wienerder &
Vacher,
24 8
Fife, 2 2008
001
%
54
34
31
>2000
Migraine n (%) 116
16.89
11
(20.4)
4 (11.8) 17
(30.9)
15 (5.4) 17 (34) 24 (39) 17
(14.3)
11
(35.5)
25%
BPVC
n (%) 133
19.36
9 (16.7) 5 (14.7) 14
(25.5)
60 (21) 6 (12)
6 (19.4) 20%
Otitis
media
n (%) 22
3.20
5 (9.2)
5 (14.7) x
Viral
n (%) 98
infection
14.26
15
(27.7)
4 (11.8) 1 (1.8)
53
(18.8)
Trauma
14.99
3 (5.5)
3 (8.8)
85
(30.3)
Summary
of studies
Total
subjects
687
n (%) 103
55
4 (7.3)
282
50
62
10 (16) 23
(19.3)
x
2 (4)
119
12
(10.1)
9 (14)
14
(11.8)
5%
2 (3)
6 (5)
10%
McCaslin DL, Jacobson GP, Gruenwald JM. The predominant forms of vertigo in children and their associated findings on balance function testing. Otolaryngol Clin North Am. 2011 Apr;44(2):291‐307
Migraine‐Associated Vertigo
 Most common diagnosis in children with vertigo and 

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
dizziness
Family History Key
50% of dizzy children also have headache
Temporal relationship is variable
20% of children with migraine suffer dizziness
Basilar Migraine variant
 3‐19% with migraine, usually < 7 years old
 Aura: audio vestibular with tinnitus, loss of hearing acute imbalance and vertigo 21
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Migraine‐Associated Vertigo
 Pathophysiology: currently unresolved
 Theories:  asymmetric activation of brainstem vestibular nuclei
 Defective calcium channels shared by brain and the inner ear, with spreading cortical depression
Migraine‐Associated Vertigo
 Balance Function Findings
 Central and Peripheral Impairment
 Vestibular manifestations varied and included spontaneous positional nystagmus, post head shaking nystagmus, BPPV, vibration induced nystagmus, absence of vestibular evoke myogenic potentials and unilateral or bilateral caloric reductions
Migraine‐Associated Vertigo
 Treatment
 Vertigo does not respond well to acute therapy with triptans or NSAIDs
 Clinical studies in children are sparse
 Magnesium‐aspartate
 Topiramate
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Benign Paroxysmal Vertigo of Childhood
 Episodic attacks of vertigo lasting from seconds to minutes with nystagmus
 Typically < 4 years old, rarely after age 8
 Migraine equivalent as recognized by International Headache society
 Sensation of spinning  Without loss of consciousness
 Complete recovery
 Unable to stand unsupported
Benign Paroxysmal Vertigo of Childhood
 Criteria for BPVC:
 3 transient episodes
 Sensation of rotation
 Interferes with normal activity
 No loss of consciousness
 No neurologic auditory abnormality
Benign Paroxysmal Vertigo of Childhood
 Pathophysiology: unknown but strong supporting evidence for migraine headache variant
 Many children develop migraine later in life
 Presumed episodic vasospasm
 Vascular disturbance of the posterior circulation with effects on the vestibular nuclei
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Benign Paroxysmal Vertigo of Childhood
 Diagnosis: depends on characteristic history, usually family history of migraine present
 Balance Function Findings: great variability
 Treatment: resolves with time
Trauma
 500,000 ED visits per year
 Vestibulopathy secondary to traumatic brain injury or labyrinthine concussion
 Incidence of dizziness, anywhere from 18‐78%
May even follow minor head injury
Trauma
 Mechanisms:  Direct trauma to eighth nerve complex and root entry zone at brainstem; Labyrinthine concussion
 Disruptions of microcirculation of the vestibule with resultant hemorrhage and inflammation
 Pressure wave may disrupt membranous labyrinth
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Trauma
 Direct injury to tympanic membrane and ossicles with disruption integrity of oval window or round window ie:perilymph fistula
Trauma
 Perilymphatic fistula:
 More frequent in children
 Caused by minor head trauma
 Sudden onset of hearing loss and vertigo
 Round or oval window rupture, creating a fistula
Trauma
 Balance Function Testing: results rarely reported
 Sustained head trauma refer for hearing evaluation
 Spontaneous and/or positional nystagmus
 Children usually recover, may develop BPPV
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Vestibular Neuritis
 Post‐viral origin  Primarily adolescents
 Symptoms: sudden onset vertigo, nausea, vomiting with postural instability
 Spontaneous nystagmus
 No hearing loss
Vestibular Neuritis
 Caloric Examination: gold standard
 Electronystagmography
 Episodes self limiting, with decreasing intensity
Labyrinthitis
 Preceding infection
 Acute, unilateral
 Rotary vertigo for days, N/V
 Falls to affected side
 Hearing loss
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Labrynthitis
 Findings:
 Rotary horizontal nystagmus
 Head Impulse Test
 Caloric Testing
 Treatment
 Vestibular suppressants Otitis Media
 “unsteadiness” and “clumsy”
 Etiology:
 Serous labyrinthitis
 Middle ear pressure changes
 Typical otoscopic appearance
 Abnormal tympanograms
 Mild to moderate hearing loss
Otitis Media
 Abnormal electronystagmography
 Treatment: antibiotic therapy
 Myringotomy with tympanostomy tube if worsening vestibular symtoms ,mastoiditis,or unresponsive to medical therapy
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Otitis Media and Retraction Pocket
ETD and Retraction Pocket
Summary  History may be difficult to obtain ; infrequent complaint
Hearing; trauma; age ;fever ;pattern; migaine Hx
Exam :nystagmus; ear findings; neuro findings
Testing: audiogram; eyes/nystagmus
Vestibular testing :difficult ; equipment adapted from adult studies(normative data limited)
 Most vestibular illnesses self limited  Must identify and differentiate the more serious causes
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Summary
 Vestibular system impairment needs to be documented
 Appropriate rehabilitative therapy prescribed
 Guides management and treatment
 Important to recognize vestibular dysfunction in children
 May lead to slowed normal locomotor development via motor incoordination and visual disturbances
Back to Clinical Scenario
 HPI: 8 yo F with 7 days of vertigo
 Described as “room spinning around her” or “riding a roller coaster”
 Lasted 30 minutes, during which she laid down
 Occurred three times over last week
 Sudden onset with nausea and balance difficulty
 Teacher reported “her eyes moved funny”
 No auras, tinnitis, hearing loss, visual field changes, diplopia or loss of consciousness
http://www.pediatriceducation.org/
29
7/23/2013
Clinical Scenario
 PMHx: healthy, immunizations UTD
 FHx: +migraines and vertigo (mother)
 No history of hearing loss, deafness or neurological disease
 SHx: Doing well in school
 ROS: negative except for URI 3 weeks ago
 No fevers, chills, or cold sores
http://www.pediatriceducation.org/
Clinical Scenario
 Pertinent PE:
 General: well appearing, growth parameters 25‐50%
 HEENT: left ear +serous fluid, PERRLA
 Neuro: EOMs intact, DTRs 2+/2+, negative Babinski, normal rapid alternating movements, finger to nose testing, tandem gait and Romberg testing; no nystagmus could be elicited
 Diagnosis???  Serous Otitis Media with probable Benign Paroxysmal Vertigo of childhood
http://www.pediatriceducation.org/
References
 McCaslin DL, Jacobson GP, Gruenwald JM. The predominant forms of vertigo in children and their associated findings on balance function testing. Otolaryngol Clin North Am. 2011 Apr;44(2):291‐307
 Jahn K. Vertigo and balance in children‐‐diagnostic approach and insights from imaging. Eur J Paediatr Neurol. 2011 Jul;15(4):289‐94. doi: 10.1016/j.ejpn.2011.04.010. Epub 2011 May 14. Review.
 O'Reilly R, Grindle C, Zwicky EF, Morlet T. Development of the vestibular system and balance function: differential diagnosis in the pediatric population. Otolaryngol Clin North Am. 2011 Apr;44(2):251‐71
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References
 O'Reilly RC, Greywoode J, Morlet T, Miller F, Henley J, Church C, Campbell J, Beaman J, Cox AM, Zwicky E, Bean C, Falcheck S. Comprehensive vestibular and balance testing in the dizzy pediatric population. Otolaryngol Head Neck Surg. 2011 Feb;144(2):142‐8.  Benun J. Balance and vertigo in children. Pediatr Rev. 2011 Feb;32(2):84‐5. doi: 10.1542/pir.32‐2‐84. Review.  Valente LM. Assessment techniques for vestibular evaluation in pediatric patients. Otolaryngol Clin North Am. 2011 Apr;44(2):273‐90,  MacGregor DL. Vertigo. Pediatr Rev. 2002 Jan;23(1):10‐6
Questions??
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