Vertigo

Vertigo in children is a difficult diagnosis to make and to evaluate. The causes of vertigo in children differ from those seen in adults and its presence may easily be overlooked or attributed to their developmental statues and lack of coordination.   Children will commonly present with the chief complaint of dizziness which can be broken into four categories: vertigo, presyncope, disequilibrium, and light-headedness. True vertigo is defined as the illusion of movement, usually rotation, though linear displacement or tilting may also be experienced. True vertigo can be further divided in subjective vertigo in which the patient experiences the illusion of movement in relation to the environment and objective vertigo where the environment is felt to move relative to a stationary patient. Vertigo is typically accompanied by symptoms such as nausea, vomiting, pallor, and diaphoresis without loss of consciousness. The pathology responsible for vertigo may reside in several locations, with the vestibular system most prominent among them. Damage to the visual and proprioceptive systems may also be responsible in addition to more central CNS lesions. These sites of pathology can be broadly grouped into peripheral vertigo or that arising from the vestibular system in the inner ear and central vertigo arising from the remainder of the nervous system.

Evaluation

As with every complaint encountered the first and most important step in evaluation is obtaining a thorough history. One must first establish the presence of vertigo versus some other form of dizziness by eliciting a history of the sensation of spinning or movement. This may prove challenging in younger children where it may be useful to evoke playground synonyms such as spinning, swinging, like a merry-go-round etc. In children unable to communicate this sensation a history of associated symptoms such as ataxia, nausea, vomiting, the desire to lie still, or eye twitching may aid in the diagnosis. Eliciting further neural, aural, traumatic or febrile symptoms will aid in narrowing the differential diagnosis. Evidence of hearing loss, tinnitus, recent trauma or infection, a history of AOM, meningismus, use of medications or drugs, or the presence of other focal neurologic signs all contribute to the diagnosis and discovering its underlying etiology. Age of the patient also may be helpful, children <5 are more likely to have AOM, benign paroxysmal vertigo or paroxysmal torticollis of infancy, children <10 rarely have Meniere disease, MS, or benign paroxysmal positional vertigo.

A thorough physical exam should be performed with particular emphasis on the neurologic and HEENT exams. Vital signs should be evaluated for signs of increased intracranial pressure (bradycardia, hypertension, irregular respirations). One must pay attention to signs of middle ear infection (bulging, red TM with decreased movement), auditory malformations, cholesteatoma or a perilymphatic fistula. A fistula test may be performed in which the child looks straight ahead and continuous positive followed by negative pressure is applied to the auditory canal using a pneumatic otoscope. In the presence of a fistula the eyes may drift slowly away from the positive pressure and towards the negative pressure. Nystagmus should be observed for and classified to aid in the distinction of peripheral vs. central vertigo. With peripheral vertigo nystagmus will generally be unidirectional with a fast phase towards the normal ear, horizontal and suppressed by visual fixation. Several other maneuvers may be used to evaluate balance and vestibular function:

• Romberg or tandem Romberg (child puts one foot in front of the other, arms at sides, vision allowed and then excluded) tests to evaluate the dorsal column
• Unterberg-Fukuda test – arms straight in front at shoulder height, vision excluded, instructed to march in place for 50 steps, in the presence of chronic peripheral vertigo the child will march slowly towards the side of the lesion
• Hallpike-Dix maneuver – child sitting midway on flat exam table, instructed to look ahead at all times, examiner turns child's head to side and quickly places child backwards with head over the edge of the table. In patients with positional vertigo horizontal rotary nystagmus will be seen with the fast phase to the downward ear.
• Caloric testing – warm or cold water infused into ear while patient's head is tilted at 30°. Normal response is fast phase towards infused ear with warm water or away with cold water, lack of response on one side indicates peripheral lesion on that side, central lesions may cause caloric hyposensitivity.  
• Further specialized tests such as electronystagmography, rotating chair tests, vestibular autorotation tests, or posturography are indicated when central vs. peripheral vertigo cannot be established or when vertigo is prolonged or incapacitating.

All patients with vertigo should also undergo hearing tests or auditory brainstem evoked response testing for younger patients. CBC, GTT, TFTs, and a BMP with calcium, phosphorus and magnesium may further be obtained when the diagnosis remains in question. In the event of neurologic findings CT, MRI or angiography are indicted. With loss of consciousness an EEG should be obtained.

The Differential Diagnosis

In evaluating a child with vertigo the first step must be to rule out any life threatening conditions that may lead to the observed complaint. Head trauma can lead to vertigo by blows to the temporoparietal or parietooccipital skull leading to vestibular concussions, whiplash injuries leading to spasm of the labyrinth or direct penetrating trauma to the inner ear. CNS infections may consist of a component of vertigo (though very rarely the primary complaint) in conjunction with more serious meningitic signs, fever and altered mental status. Intracranial masses especially those surrounding the fourth ventricle, basilar artery stroke though quite rare along with overdose with drugs including barbiturates, ethanol, ketamine and phenylcyclidine may also present with vertigo and nystagmus.

With life threatening conditions ruled out it is useful to group causes of vertigo into four broad categories, acute vertigo with hearing loss, acute without hearing loss, chronic with neurologic impairment and chronic without neurologic impairment.

• Acute (paroxysmal) vertigo with hearing loss – Most common among these causes is acute otitis media which may also present acutely without hearing loss. Additional pathology in this category includes labyrinthitis (the infection of the inner ear) which presents as vertigo with nausea/vomiting that lessens with the child lying on the unaffected side and resolves over the course of several days, perilymapthic fistula (damage to the oval or round windows over the cochlea leading to leakage of perilymph) which may present associated with minor head trauma or abrupt changes in barometric pressure, Meniere disease (rare in children) with recurrent vertigo, tinnitus and hearing loss, in addition to trauma leading to temporal bone fracture or vascular occlusion.
• Acute (paroxysmal) vertigo without hearing loss – Acute otitis media may also present in this manner. Other causes include vestibular neuronitis generally following respiratory infections and commonly seen in adolescents with nausea/vomiting, vertigo and postural instability in self limited episodes that recur with decreasing intensity, benign paroxysmal vertigo and torticollis most commonly seen between 1-2 yrs and presenting with sudden extreme unsteadiness with nystagmus and generally without nausea, in addition to labyrinthine concussions, benign positional vertigo (very rare in children), migraines (especially basilar artery) and seizures.
• Chronic vertigo with neurologic abnormalities – The diseases in this category are much less common and generally diagnosed primarily on the nature of the neurologic findings. They include acoustic neuromas (generally with NF2), posterior fossa tumors, medications, cholesteatoma, cerebral infarction, demyelinating processes, and vertebrobasilar insufficiency.
• Chronic vertigo without neurologic abnormalities – Disorders in this category include endocrine diseases, tension type headaches, mood disorders, sever anemia and sickle cell disease, polycythemia and cardiac arrhythmias.

Management

The management of vertigo in the child is largely symptomatic in the absence of a more sinister etiology. Most cases will recover spontaneously without intervention over weeks to month. In the interim children with acute vertigo may be treated with antiemetics including metoclopramide and prochlorperazine in severe cases. Vestibular sedation with medications such as meclizine, dimenhydrinate, promethazine, and diazepam may be used acutely but should not be prescribed long term.

Chronic or recurrent cases may respond to a course of clonazepam or carbamazepine in addition to balance or gait training. Rarely surgical management may be indicated as in the case of severe Meniere disease or vestibular nerve and labyrinth disorders

References

1. Eviatar L. and Eviatar A. Vertigo in Children: Differential Diagnoses and Treatment. Pediatrics 1977
2. MacGregor D. L. Vertigo. Pediatrics in Review 2002
3. Heidenreich K.D. Benign Paroxysmal Postitional Vertigo. NEJM 2010
4. Benun J. Balance and Vertigo in Children Pediatrics in Review 2011