Vertigo resident survival guide (pediatrics)

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Usman Ali Akbar, M.B.B.S.[2]

Synonyms and keywords: Vertigo in childhood, vertigo in children, An approach to vertigo in children

Vertigo resident survival guide (pediatrics) Microchapters
Overview
Causes
FIRE
Diagnosis
Treatment
Do's
Don'ts

Overview

Vertigo can be described as subjection sensation of movement such as spinning, turning, or whirling of patients or respective surroundings. Vertigo is a symptom, not a diagnosis. It results from dysfunction either in the vestibular or central nervous system; thus can be classified as peripheral or central vertigo respectively. Some conditions can present with a subjective feeling of dizziness without vertigo hence named as pseudo-vertigo. Most children or adolescents have secondary vertigo as a result of various conditions such as otitis media, benign paroxysmal vertigo, head trauma, or any CNS infection. Successful management of vertigo usually consists of identifying the root cause and specifically targeting the underlying condition.

Causes

  • Various causes of vertigo in the pediatric population are given in the table below:[1]
Causes of Vertigo
Life-Threatening Causes Common Misc.

FIRE: Focused Initial Rapid Evaluation

A Focused Initial Rapid Evaluation (FIRE) should be performed to identify patients in need of immediate intervention.[2]

Boxes in red signify that an urgent management is needed.

 
 
 
 
 
Identify cardinal findings that increase the pretest probability of vertigo (at least 2 of the following)
❑ Physical sensation of spinning or moving
❑ Nystagmus
❑ Nausea with or without vomiting
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Yes
 
 
 
No
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
History of Head Trauma
 
 
 
Pseudovertigo
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Findings of Abnormal CT-Scan/MRI
 
 
 
Altered level of Consciousness
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
YES
 
NO
 
YES
 
NO
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Fracture of Temoral Bone,enlarged vestibular aqueduct
 
Post-concussion syndrome, Post traumatic migraine
 
If History of fever , Consider CNS infections such as meningitis and encephalitis If abnormal CT-Scan Brain or MRI, consider Migraine, Drug Overdosingm or Post-ictal state
 
Perform Otoscopy
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Positive Otoscopic Findings

The differential should Include
❑ Abnormal Canal

❑ Cerumen Impaction
❑ Foreign Body
❑ Ramsy Hunt Syndrome

❑ Middle ear Effusion
❑ Cholesteatoma

❑ Perilymphatic fistula
 
 
 
History of travel  ?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
If Yes Consider Motion Sickness
 
 
 
Abnormal vestibular testing?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Yes
 
 
 
No
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Abnormal CT-Scan/MRI?
 
 
 
 
Decreased Hearing?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
YES
 
NO
 
YES
 
NO
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
CNS tumor
 
❑ BPPV

❑ Migraine
❑ Seizure

❑ Perilymphatic fistula
 
❑BPPV Vestribular

❑ Neutritis

❑ Stroke
 
❑ Drug Overdose ❑ Meniere Disease


Complete Diagnostic Approach

A complete diagnostic approach should be carried out after a focused initial rapid evaluation is conducted and following initiation of any urgent intervention.


 
 
 
 
 
Sings of Vertigo in Children
❑Frightening-Clutching caretakers
❑Clumsiness
❑ Periodic Nausea/vomiting
❑ Delayed Motor Function
❑ Loss of Postural Control
❑ Difficulty in ambulation
❑ The infant may lie face down against the side of the crib with eyes closed, not wanting to be moved
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
General History
❑History of Prenatal/ Perinatal infection
❑Use of Otoxic Medications
❑ Congential Syndromes
❑Craniofacial anomalies
❑ Loss of Postural Control
❑Family history of hearing loss/vertigo, migraine or demyelinating disease
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Specific History
❑Episodic vs Continuous
❑Time of Onset Acute/slow
❑Triggered vs spontaneous
❑Associated with hearing loss or without hearing loss
❑ Loss of Postural Control
❑ Neurological deficits
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Physical Examination
•  Otologic exam
•  Neurological exam
•  Check visual acuity
•  Static and dynamic imbalance of vestibular function time of Onset Acute/slow
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Gait & Gross Motor Testing

•  Vestibulospinal testing

    –  Fukuda: 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
   –  Romberg test or Tandem gait: child puts one foot in front of the other, arms at sides, vision allowed and then excluded) tests to evaluate the dorsal column
   
•  Age-appropriate gross motor (Bruininks- Oseretsky test 4-21yrs)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Workup
•  Audiology evaluation
•  Eye examination
•  Vestibular function test
•  EEG
•  Hematological workup(CBC, electrolytes,glucose, thyroid tests)
•  Imaging indication
• Focal neurological symptoms or findings
• Worsening symptoms – Prolonged LOC (> 1 min)
• Failure of symptoms to improve
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Vestibular Function Testing
•   ENG battery
•   Rotation testing
•   Platform posturography
• Dix-Hallpike - PSSC
•   Gaze testing
•   Caloric ENG – LSSC
• >30% difference between side indicates a unilateral peripheral lesionion Testing
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Imaging

  CT of Temporal Bone

• Further evaluate craniofacial syndromes & PLF
•   Defects in bony labyrinth, cholesteatoma
• Suspect tumor or previous trauma
• MRI with gadolinium
•   Children with CNS findings
•   Suspect schwannomas and other tumors
• Granulomatous disorders
 
 
 

Treatment

Shown below is an algorithm summarizing the treatment of vertigo according the the AAO-HNS guidelines.[3]

 
 
 
 
 
 
 
Patient with Established Diagnosis of Vertigo
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Central Vertigo
 
 
 
 
 
 
 
Peripheral Vertigo
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Treat according to etiology
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Acute Treatment : 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.

BPPV- Epley particle repositioning maneuver. This maneuver relocates the free-floating debris from the posterior semicircular canal into the vestibule of the labyrinth. Symptomatic relief after a single treatment session is reported in 80% to 90% of patients, although 15% to 30% may have a recurrence of symptoms. The maneuver is repeated until nystagmus no longer can be elicited.

Ménière disease- Salt Restriction,Diuretics,ntratympanic dexamethasone or gentamicin,Endolymphatic sac surgery

Vestibular Neuritis- Methylprednisolone tapered over 3 weeks

Do's

  • Different maneuvers can be done to reduce the intensity of vertigo.
  • Epley-Maneuver : Left sided vertigo. Make the patient sit on the edge of the bed. Turn the head of patient 45 degrees to the left. Place a pillow under his shoulder. Make him lie down on his back with his head still at 45 degree angle. Wait for 30 seconds.Turn the head of patient 90 degrees to the right without raising it. Wait for another 30 seconds. Turn the head and body of the patient to right side towards the floor. Wait for another 30 seconds. Slow make the patient sit up. Reverse the instructions in case of right sided vertigo.[4]
  • Semont Maneuver: Make the patient sit on the edge of the bed. Turn the head 45 degrees to the right and make him quickly lie down towards left side. Wait for 30 seconds. Now quickly move the patient to lie down on the other side of the bed. Keep his/her head at a 45 degree angle and lie for 30 seconds to look at the . Now make him/her slowly sit and wait for few minutes. Reverse this for right sided vertigo.[5]

Don'ts

  • Avoid consuming fluids that have high sugar or salt content in it such as concentrated drinks and soda. These are the foods that trigger vertigo.
  • Limit Caffeine intake. Caffeine has been reported to cause cell depolarization making the cells more easily excitable
  • Following is the list of contraindications to canalith repositioning procedure:
  • Limit salt intake as it causes retention of excess fluid in the body and interferes with vestibular system.
  • Processed food and meats should be avoided.
  • To reduce the risk of fall because of vertigo, advise patients to get rid of loose electrical cords, clutter and slippery rugs and also advise them to wear sturdy non-slip shoes.

References

  1. Devaraja, K. (2018). "Vertigo in children; a narrative review of the various causes and their management". International journal of pediatric otorhinolaryngology. Elsevier BV. 111: 32–38. doi:10.1016/j.ijporl.2018.05.028. ISSN 0165-5876. PMID 29958611.
  2. Shaw, Kathy (2016). Fleisher & Ludwig's textbook of pediatric emergency medicine. Philadelphia: Wolters Kluwer. ISBN 978-1-4511-9395-4. OCLC 953862907.
  3. "Clinical Practice Guidelines". American Academy of Otolaryngology-Head and Neck Surgery. 2014-04-02. Retrieved 2020-08-08.
  4. Hilton, Malcolm P; Pinder, Darren K (2014-12-08). "The Epley (canalith repositioning) manoeuvre for benign paroxysmal positional vertigo". The Cochrane database of systematic reviews. Wiley (12). doi:10.1002/14651858.cd003162.pub3. ISSN 1465-1858. PMID 25485940.
  5. Omron, Rodney (2019). "Peripheral Vertigo". Emergency medicine clinics of North America. Elsevier BV. 37 (1): 11–28. doi:10.1016/j.emc.2018.09.004. ISSN 0733-8627. PMID 30454774.


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