|Year : 2021 | Volume
| Issue : 1 | Page : 5-10
Vertigo during childhood: A disabling clinical entity
Santosh Kumar Swain1, Loknath Sahoo1, Rachita Sarangi2
1 Department of Otorhinolaryngology, IMS and SUM Hospital, Siksha “O” Anusandhan University (Deemed to be), Bhubaneswar, Odisha, India
2 Department of Pediatrics, IMS and SUM Hospital, Siksha “O” Anusandhan University (Deemed to be), Bhubaneswar, Odisha, India
|Date of Submission||23-May-2020|
|Date of Decision||08-Jul-2020|
|Date of Acceptance||30-Oct-2020|
|Date of Web Publication||2-Feb-2021|
Santosh Kumar Swain
Department of Otorhinolaryngology, IMS and SUM Hospital, Bhubaneswar, Odisha
Source of Support: None, Conflict of Interest: None
The etiology of the vertigo in pediatric age group is often multi-factorial, so clinician should approach a dizzy child with an open mind. Vertigo is not an uncommon symptom in children, though it often unrecognized in clinical practice. The vertigo in children may be acute nonrecurrent spontaneous vertigo, recurrent vertigo and nonvertiginous dizziness or disequilibrium or ataxia. The major causes for vertigo in the pediatric age group are benign paroxysmal vertigo of childhood, vestibular migraine and otitis media. Detailed patient history, routine physical examination, cochlear function tests, vestibular functions tests and imaging are helpful for getting the diagnosis in childhood vertigo. Moreover, the lack of the standard diagnostic protocol for pediatric vestibular examination represents another drawback for effective management of the pediatric vestibular impairment. This review article is a narrative discussion on prevalence, etiopathology, clinical manifestations and current management of the pediatric vertigo. This review article will make a baseline from where further prospective trials for pediatric vestibular disorders can be designed and help as a spur for further research in this clinical entity as there are not many studies in this clinical entity.
Keywords: Benign paroxysmal vertigo of children, children, vertigo, vestibular disorders
|How to cite this article:|
Swain SK, Sahoo L, Sarangi R. Vertigo during childhood: A disabling clinical entity. Int J Health Allied Sci 2021;10:5-10
|How to cite this URL:|
Swain SK, Sahoo L, Sarangi R. Vertigo during childhood: A disabling clinical entity. Int J Health Allied Sci [serial online] 2021 [cited 2021 Apr 13];10:5-10. Available from: https://www.ijhas.in/text.asp?2021/10/1/5/308579
| Introduction|| |
Vertigo is a common complaint posed to a clinician in the routine clinical practice. However, the vestibular impairment or balance problems and dizziness in the pediatric age group are thought to be rare. Patient with vestibular impairment often describes many symptoms like a spinning sensation (vertigo), disequilibrium, light headedness, dizziness and unsteadiness. These symptoms may lead to life threatening disability and burden to healthcare cost. Vertigo is an acute disabling symptom which may cause severe alteration in balance of the child and hamper the postural control. This symptom not only cause disruption of the daily work of the child but also cause inability to attend the school and even cause social withdrawal along with give much stress to the parents. Despite there are significant advancement of technology in diagnostic tools, the diagnosis is still based on the patient's history and physical examination. The differential diagnosis of the pediatric vertigo differ from the adult age group because of the several causes of vertigo are unique to children while some other etiologies are rather differ in pediatric and adult age group. Children are usually unable to describe the symptoms related to the vestibular disorders and may show clumsiness. The vertigo in children may be of short duration, autonomic symptoms or symptoms due to behavioral disorders. Vestibular disorders in children can be divided into three categories such as acute nonrecurring spontaneous vertigo, recurrent vertigo and nonvertiginous dizziness, disequilibrium and ataxia. The predominant causes of the vertigo in pediatric age group are benign paroxysmal vertigo of childhood (BPVC), vestibular migraine (VM), otitis media (OM) and OM with effusion. Detailed patient history and complete neuro-otological examination help to provide the diagnosis. However, the vertigo or dizziness is in the children are often challenging for a clinicians. The aim of this review article is to discuss about epidemiology, etiopathology, clinical presentations and current management of the vertigo in pediatric age group.
| Methods of Medical Literature Search|| |
We conducted an electronic search of the Google Scholar, SCOPUS, Medline and PubMed databases for searching the published articles. The search terms in the database included pediatric vestibular impairment, vertigo, pediatric age, dizziness and impairment of balance in children. The abstracts of the published articles are identified by this search method and other articles were identified manually from these citations. This review article reviews the vertigo during childhood including the etiopathology, prevalence, presentations, diagnosis and current treatment. This review article presents a baseline from where further prospective trials can be designed and help as a spur for further research in this clinical entity where not many studies are done.
| Epidemiology|| |
The prevalence of the vestibular disorders among children is difficult to evaluate properly because of the symptomatology are not often specific and sometimes misleading. The prevalence of the vertigo in the pediatric age group is not well documented in the medical literature. The prevalence of the vestibular impairments is lower in children than in adult age group. The prevalence of the vertigo in children ranges from 8% to the 15%. Vertigo is the chief complaint in only 0.7% of the children attending to the otolaryngology clinic. One study showed the prevalence of the vestibular disorders is lower 0.4% and 0.45%. The risk factors for vertigo and dizziness in the pediatric age group have not been well studied. One study showed children aged 12–17 years have higher prevalence of the dizziness in comparison to the younger children. Girls have a higher prevalence of the dizziness and vertigo and were at higher risk due to some risk factors, particularly for frequent headache or migraine.
| Etiopathology|| |
The causes of the vertigo during childhood are numerous and include an endless list of etiology [Table 1]. The etiology is broadly divided into the conditions associated with hearing loss and those with isolated vertigo. Vertigo may result from impairment of any or combination of the three sensory inputs such as vestibular, ocular and proprioception. The pathogenesis of the pediatric vertigo may not be fully clear. One study revealed that isolated vertigo in pediatric age group thought to be BPVC may actually be migraine and such pediatric patients go on to develop the migrainous headaches in later part of the life. In BPVC, the exact etiology is not yet precisely known, it thought that a variant or an equivalent of a pediatric migraine. Transient ischemia to the vestibular nuclei and/or vestibular pathway has been proposed to be the etiology for BPVC. It has no relation with benign paroxysmal positional vertigo (BPPV) which is rare in pediatric age., This theory is supported by the absence of the otoconial debris in the posterior semicircular canal of the pediatric temporal bone. There are certain drugs can cause dizziness. Aminoglycosides can cause ototoxicity, especially gentamycin which may cause oscillopsia. In children, phenytoin often used for treatment of the epilepsy and may cause vertigo and nystagmus as signs of intoxication. When a child comes with complaint of dizziness, the regular medication should be viewed as a possible cause for the iatrogenic vertigo. The etiology for motion sickness is thought to be a sensory mismatch between the vestibular cues and vision. Motion sickness is more common in patients with migraine. At the younger age, the common disease which can cause vestibular symptoms is migraine. The tendency of the migraine related vertigo is more at the age of puberty and adolescents, this vestibular impairment is also more in males than females. In a child with normal tympanic membrane, the common causes for vertigo are migraine and benign paroxysmal vertigo. Vestibular neuritis is an important cause for vertigo in children. Vestibular neuritis is a condition where acute inflammation occurs typically in superior vestibular nerve which leads to unilateral peripheral vestibular loss which preferentially affects anterior semicircular canal, lateral semicircular canal and utricle. The specific etiological agent for vestibular neuritis is controversial, though it is associated with herpes simplex virus. Enlarged vestibular aqueduct is a rare cause of the pediatric vertigo, which is associated with progressive hearing loss and often triggered by minor trauma to the head. It may be found in association with Mondini's deformity. Posttraumatic vertigo without hearing loss in pediatric age could be due to a labyrinthine concussion, whiplash syndrome, vertiginous seizures and basilar artery migraine. Orthostatic hypotension is an etiology for giddiness in 3%–9% of the symptomatic children. Orthostatic hypotension is due to autonomic dysfunction. The rare causes of vertigo are given in [Table 2].
| Clinical Presentations|| |
The vertigo and dizziness are less commonly found symptoms in pediatric age group than in adult population and this may be due to vertigo is less studied in children. The clinical presentation of the vestibular disorders in pediatric age varies widely. The common neuro-otological symptoms include vertigo, dizziness, nausea and vomiting. These symptoms are found as acutely but some children may experiences these as chronic complaints. Clinical presentations of the vestibular impairment in children are seen as combination of four phenomena such as perceptual (vertigo or dizziness), oculomotor (nystagmus), postural (dystaxia) and vegetative (nausea and vomiting). The younger the child at presentation, the more difficult for the clinician to evaluate the child and often the diagnosis is missing or the symptom may go unnoticed by the parents. The symptoms such as sound induced vertigo, decreased hearing or hyperacusis are important clues for diagnosis of the superior semicircular canal dehiscence syndrome or perilymphatic fistula whereas the positional vertigo is an important feature of the BPPV. The symptoms of the peripheral vestibular disorders in concussion patients are usually due to fracture of the temporal bone or labyrinthine concussion where patient show the room spinning vertigo which is aggravated by head movements and oscillopsia (sensation of the visual fields movement).This patient often has decreased hearing. Motion sickness often present with pallor, diaphoresis, nausea, vomiting and dizziness. These symptoms are induced by the passive motion like riding in a car or by visual movement during standing still. Severe motion sickness is seen in approximately 49% of the children with migraine compared with 10% of the controlled children. The differential diagnosis of the vertigo in the pediatric age group is extensive. Middle ear effusion and OM are the very common causes of the vertigo in children. One study documented that migraine is the most common etiology for vertigo in children. The clinical manifestations of the migraine related vestibular symptoms are often varied. BPPVC is one of the commonest etiologies for vertigo in pediatric age. In this case, children present with recurrent brief attacks of vertigo with duration of few minutes. It is found without warning and resolves spontaneously in otherwise healthy child. Although BPVC is reported in children between 2 and 12 years, the majority of the affected child is of <4 years of age. Girls are commonly affected with BPVC than boys. The clinical examination and investigations in BPVC are essentially within normal limits, without any hearing or vestibular deficit. However, even in normal hearing, abnormal auditory brainstem response has been documented in around 66% of the BPVC pediatric patients. VM is a disease found in older children whereas the BPVC is common cause of vertigo or dizziness in children up to the age of 6 years. BPVC is uncommon in children older than 10 years and VM is uncommon in children younger than 10 years. The clinical manifestations of VM are recurrent vestibular symptoms temporarily associated with a migraine. The duration of the vertigo in VM is between 5 min and 72 h. In VM, the vertigo may occur before, during or after a migraine headache. The Meniere's disease is characterized by episodic attacks of vertigo, sensorineural hearing loss, tinnitus and aural fullness. As per American Academy of Otolaryngology, the diagnosis of the definite Meniere's disease need at least two episodes of the vertigo lasting for more than 20 min and tinnitus and/or fullness of the affected ear as well as the documented hearing gloss in atleast one occasion. The symptoms in Meniere's disease often occurs in the middle age particularly in between 30 and 50 years of the age and usually rare in pediatric age. Nevertheless, this clinical entity may show a possible cause of the vertigo in children. The incidence of the Meniere's disease often starts with vertigo and was reported as 1.5% by Hausler et al. In vestibular neuritis, the clinical presentations are sudden onset of rotatory vertigo, imbalance and nausea which lasts for a few days. Vestibular neuritis may be considered as a differential diagnosis of the pediatric patients with acute onset of the vertigo. Children with OM may present vertigo along with hearing loss. In OM, there is inflammation of the middle ear cleft, may involve inner ear. However the nonsuppurative secretory OM or middle ear effusion may also cause vertigo and hearing loss. Vestibular paroxysmia (VP) is a rare cause of vertigo in children. Clinically VP present with frequent episodes of the vertigo in a day and each episode last for seconds to minutes with or without postural variation. The episodes of the vertigo in VP can be up to thirty times or more in a day.
| Diagnosis|| |
Diagnosis of the vertigo or dizziness in children often require unnecessary and costly investigations such as computed tomography (CT) scan, magnetic resonance imaging (MRI) because of the poor understanding of the underlying pathologies and their related symptoms. In a child present with vertigo, exhaustive clinical and laboratory work up is required for getting the correct diagnosis. Thorough neuro-otological and systemic examinations can be over-emphasized during evaluation of the vertigo in pediatric patients. In older children, vestibular function tests may be performed. Dix-Hallpike test helps to diagnose the BPPV by changing the position of the head of patient and inducing the movements of the otoconial debris. In Romberg's test, somatosensory input of the children is tested where the child is asked to stand erect with feet together and eyes open. It is more significant when the eyes are closed. A positive sign is noted when a swaying of the child occurs or sometimes falling to one side. A positive Romberg's test indicates sensory ataxia. Untenberger's test is an useful test for assessing the vestibular dysfunction. In this test, the patient is asked to walk in place with eye closed. Falling to one side indicates labyrinthine dysfunction of that side. The vestibular tests include cervical Vestibular Evoked Myogenic Potential (VEMP), electronystagmography, posturography, rotatory chair test and caloric test. The VEMP testing assesses evaluation whether the saccule and inferior vestibular nerve are intact and with normal function. The classical method for bithermal caloric test uses warm (44°C) and cold (30°C) as described by Fitzgerald and Hallpike may be done if the child cooperates. It may show canal paresis or directional preponderance in case of the unilateral vestibular dysfunction. Complete audiological assessment is mandatory in all the pediatric patients of vertigo along with hearing loss. The audiological tests include Otoacoustic emissions, pure tone audiometry, behavioral audiometry (BOA), Brainstem Evoked Response Audiometry, auditory steady state response and impedence audiometry. For very young child, BOA and play audiometry may be useful for hearing assessment. For older children (>5 years), pure tone audiometry can be used for hearing assessment. Hearing impairment in a pediatric patient with vertigo, especially with sensorineural hearing loss could be syndromic or due to ototoxic medications or trauma to the inner ear. Imaging also plays an important role for getting the diagnosis of the vertigo in children. The further investigations for pediatric patients with vertigo include radiological investigations such as high resolution CT of the temporal bones, MRI of the brain and inner ear to rule out the inner ear anomalies which constitutes around 20% of the congenital hearing loss cases. As the vestibular tests are difficult to perform in very young children, so appropriate battery of laboratory and radiological tests can be utilized in the view of possible diagnosis. The laboratory test is done when a nonvestibular condition is anticipated such as metabolic abnormalities or blood dyscrasia causing vertigo. The laboratory test include complete blood count, thyroid function test, serum glucose, lipid profile, fluorescent treponemal antibody absorption test, erythrocyte sedimentation rate, rheumatoid factor and antinuclear antibody tests. The diagnosis of the vestibular disorders must be established early as prompt physical therapy can minimize the delays of the posturomotor control which can be deleterious for other cognitive development like body presentation, writing ability and space orientation. In VP, MRI and/or angiography is helpful to demonstrate the neurovascular compression of the vestibulocochlear nerve and to rule out the cerebellopontine angle tumors. In majority of the cases, anterior inferior cerebellar artery loop is seen to compress the nerve, however rarely posterior inferior cerebellar artery, the vertebral artery or a vein may be involved to compress the nerve.
| Treatment|| |
The difficulty in the treatment of the pediatric vertigo is due to the fact that it is not a definite disease but a symptom which usually diagnosed late in pediatric age. The treatment of the vertigo in the children should be individualized. On the basis of the causes, it can be treated with pharmacotherapy, physical therapy, psychotherapeutic measures and rarely surgery. There is still a paucity of documentation on the drug treatment of vertigo even in present scenario, since there have been no multicentric, well controlled studies to show the advantages of treatment over no treatment. The treatment of the VM include watchful waiting and education of the children of vertigo and their parents in addition to stress reduction, encouragement for adequate sleep, psychological counseling, rehabilitation therapy if required as well as dietary restrictions of foods own to provoke. Medical treatment of VM includes simple analgesic and/or vestibular suppressant such as meclizine during the attack. Common prophylactic medications in VM include calcium channel blockers, beta blocker, anticonvulsant and antidepressant. In children with benign paroxysmal vertigo, vestibular suppressants are usually not very useful due to very short duration of attack. In vestibular neuritis, vestibular rehabilitation and corticosteroids are often helpful and facilitate recovery of the disease, particularly when prescribed early in the clinical course of the disease. Ophthalmological evaluation and correction are also important as visual problems can lead to vertigo or dizziness. Management of the Meniere's disease in children includes reassurance and explanations of this condition to the parents in addition to salt restriction and a diuretic. The requirement of surgery in children with Meniere's disease is rare. In VP, low dose sodium channel blockers such as carbamazepine is extremely useful for controlling the vertigo in children. Micro-vascular decompression is helpful to provide absolute relief of the vestibular symptoms in VP. But this surgery in VP is opted in case of failure of the pharmacotherapy because of the morbidity associated with surgery.
| Conclusion|| |
There are numerous etiologies for vertigo and dizziness in pediatric age group. It is always vital to obtain a thorough history taking and explaining to the parents and children about the meaning and nature of the vertigo. A thorough evaluation of the vertigo or dizziness in pediatric patient though difficult, is mandatory. Disorders that cause vertigo in children vary with respect to one another in several ways. The peripheral vestibular disease is rarely cause symptoms lasting more than a few minutes although Meniere's disease and vestibular neuritis lasting for hours. VM causes symptoms lasting for virtually longer duration. Vertigo in children can be highly challenging for clinician to manage the patient. Relying on vestibular tests alone may cause misleading of the diagnosis. The clinicians must judiciously utilize all the diagnostic modalities at his/her disposal before dismissing less commonly encountered diagnosis.
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[Table 1], [Table 2]