|Year : 2020 | Volume
| Issue : 2 | Page : 74-78
Vertigo in children: Our experiences at a tertiary care teaching hospital of eastern India
Santosh Kumar Swain, Sampada Munjal, Nibi Shajahan
Department of Otorhinolaryngology, IMS and SUM Hospital, Siksha “O” Anusandhan University, Bhubaneswar, Odisha, India
|Date of Submission||17-Mar-2020|
|Date of Acceptance||11-Jun-2020|
|Date of Web Publication||11-Sep-2020|
Prof. Santosh Kumar Swain
Department of Otorhinolaryngology, IMS and SUM Hospital, Siksha “O” Anusandhan University, Bhubaneswar, Odisha, India Kalinga Nagar, Bhubaneswar - 751 003, Odisha
Source of Support: None, Conflict of Interest: None
Objective: The aim of this study is to evaluate the vertigo among pediatric age presenting to the vertigo clinic at the department of otorhinolaryngology of a tertiary care teaching hospital. Materials and Methods: Patient records of 108 children under the age of 18 years with vertigo as the chief complaint examined at vertigo clinic, the department of otorhinolaryngology of tertiary care teaching hospital between January 2015 and March 2020. All the data were retrospectively reviewed. The clinical presentations, laboratory tests including audiological and vestibular tests were analyzed. Results: This study consisted 108 children with 66 girls (61.11%) and 42 boys (38.88%) between the age of 4 and 18 years (mean age, 12.4 years). The most common etiology for pediatric vertigo in this study was vestibular migraine (VM) followed by benign paroxysmal vertigo of children and vestibular neuritis. The duration of vertigo attacks occurred in seconds in 29 children (26.85%), min in 45 children (41.66%), hours in 27 children (25%), and more than 24 h in 7 children (6.48%). Conclusion: VM was found to be a more common diagnosis in pediatric vertigo, although several peripheral vestibular causes were diagnosed. Proper evaluation of vertigo in children should be done with thorough neuro-otologic examination. Other multidisciplinary team members should be there during evaluation of vertigo in children to avoid unnecessary delay in diagnosis and treatment.
Keywords: Benign paroxysmal vertigo of childhood, pediatric age, vertigo, vestibular migraine
|How to cite this article:|
Swain SK, Munjal S, Shajahan N. Vertigo in children: Our experiences at a tertiary care teaching hospital of eastern India. J Sci Soc 2020;47:74-8
| Introduction|| |
Vertigo is rare in pediatric age group despite its frequency in adult group. Vertigo in pediatric age is important as it can be the symptom of wide spectrum of vestibular disorders. Vertigo or dizziness is defined as a subjective sense of imbalance which may or may not include a sensation of rotation. The first case of pediatric vertigo was documented in 1962 but majority of the studies have been reported in adult age group. The diagnosis of the pediatric vertigo is often difficult because of number of age associated factors. The inability of the pediatric patients with vertigo to explain the details of the symptoms may hide the diagnosis especially in younger children. In addition to this, the vestibular tests such as clinical, laboratory, and neurophysiological are uniformly reliable in young or pediatric patients. Physicians usually relay on the observations of family members or parents. Parents usually provide important data of associated symptoms and signs as nystagmus, about consciousness, gait abnormality, and alteration in motor skill. Certain diagnosis and symptoms related to vertigo are common in children than in adult age. For instance, migraine-associated vertigo is more common in pediatric age group, while Meniere's disease (MD) is uncommon in children. The most important factor for delay in diagnosis of the pediatric vertigo is lack of awareness regarding its symptomatology and treatment algorithms among the treating physicians. There is limited study on vertigo in pediatric age group and also debate on diagnostic criteria and management in this age group. In this study, we assessed the vertigo among pediatric age group.
| Materials and Methods|| |
This is a retrospective study done at the department of otorhinolaryngology of a tertiary care teaching hospital where the data collections done of the children with age <18 years. This study was done between January 2015 and March 2020. This study was approved by Institutional Ethics Committee with reference number IMS/SOAU/22/2015. A detailed history was taken from patients, parents and guardians including past history of vertigo, frequency, duration, onset, aggravating position, aural fullness, tinnitus, hearing loss, gait disturbance, migraine, and seizure history. Detailed physical examinations were done including ear, spontaneous, and gaze-evoked nystagmus, head impulse test, and cerebellar function tests. All the children underwent tests such as positional and positioning maneuvers, caloric test, smooth pursuit, saccadic and optokinetic tests, vestibular evoked myogenic potential, auditory brainstem response (ABR) e and video-impulse tests along with pure tone audiometry (PTA) (children with age more than 5 years), speech audiometry and impedance audiometry. In case of suspected central causes of vertigo, the patient was referred to neurologist. In very few selected cases, electrocardiogram (ECG), electrocardiograph (EEG), and imaging-like magnetic resonance imaging (MRI) were also done. The diagnosis of benign paroxysmal vertigo of childhood (BPVC) and vestibular migraine (VM) was done according to the diagnostic criteria of Lempert et al. and international headache society 2013 beta version. Vertigo or dizziness associated with circulation such as orthostatic vertigo and vasovagal syncope were included in cardiogenic vertigo after assessment by pediatric cardiologist. The psychogenic vertigo was diagnosed after assessment with psychiatrist. The participants were divided into three groups: preschool age (up to 6 years of age), elementary school age (7–12 years old), and adolescents (13–18 years old).
| Results|| |
There were 108 children in this study comprising 66 girls (61.11%) and 42 boys (38.88%). The average age of the participating patient was 12.4 years. Of the 108 children, 14 were preschool age (12.96%), 36 patients were elementary school age (33.33%), and 58 patients were in the adolescent age group (53.70%). The duration of vertigo attacks occurred in seconds in 29 children (26.85%), minutes in 45 children (41.66%), hours in 27 children (25%), and more than 24 h in 7 children (6.48%). There were several associated symptoms with pediatric vertigo. In this study, children of vertigo showing associated symptoms such as nausea and vomiting in in 85 children (78.70%), headache in 41 children (37.96%), hearing loss in 15 children (13.88%), tinnitus in 7 children (6.48%), aural fullness in 7 children (6.48%), vision impairment in 3 children (2.77%), altered consciousness in 2 children (1.85%), and diaphoresis in four patient (3.70%) [Table 1]. There were a history of upper respiratory tract infections or common cold in 18 children (16.66%) and history of seizures in 4 children (3.70%). Ophthalmologic examination showed vision impairment in 3 children (2.77%) where all 3 children showed refractive errors. However, in none of the children with vertigo purely ophthalmologic in origin was found, because other causes were evident in all cases. There were upper respiratory tract infections of 2 weeks prior to vertigo attacks noted in 18 children (16.66%), trauma in 5 children (4.62%). There was family history of migraine in 22 children (20.37%) and also history motion sickness in 5 children (4.62%). Audiometric assessment of the children with vertigo revealed abnormal PTA in 15 children (13.88%). In the 9 children (8.33%), we found with mild-to-moderate sensorineural hearing loss. Out of 9 cases of sensorineural hearing loss, we detected three children of congenital deaf and two after perinatal meningitis infection. Out 15 children with hearing loss, 6 showed conductive type of deafness (3 unilateral and 2 bilateral) and one had bilateral mixed hearing loss. Ten children had abnormal tympanogram [Table 2]. Five of these children had otitis media which was thought to be cause of the vertigo, whereas the two children had secretory otitis media, which proved to be an accidental presentation. Otoacoustic emissions (OAE) were absent in all the children with hearing loss, with exception of three cases with mild sensorineural hearing loss in which OAE were present. However, the calculation of response and reproducibility was lower than normal in three more cases with normal hearing. ABR showed abnormal in five patients including raised latencies of waves I and V, prolonged I–V and III–V inter peak latencies and occasional absence of the waves. All these five children with abnormal ABR findings showed normal findings in MRI imaging of the brain. Cold caloric test was hypoactive in 78 children (72.22%). The history, clinical findings of all children with vertigo revealed the VM (33.33%) as the most common diagnosis in this study followed by benign paroxysmal vertigo (BPV) (22.22%) of the children and vestibular neuritis (16.66%) [Table 3].
|Table 2: Abnormal audiological and vestibular profile of the children with vertigo|
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| Discussion|| |
Vertigo in pediatric ages is considered to be uncommon, but the actual prevalence has not been assessed in a large group of children with vertigo. The incidence of vertigo in children is estimated to be <1%. In case of pediatric age with vertigo, it is found that, several peripheral and central vestibular disorders may be implicated, so exhaustive clinical and laboratory tests are required for correct diagnosis. Despite technological advancement in medicine, the diagnosis for the vertigo is still based mainly on the patient's history and clinical examination. The differential diagnosis of vertigo in pediatric age group differs from that of the adult age group because of several etiologies are unique to pediatric age and pathologies are rather different in children and adults. The predominant types of vertigo in the pediatric age group are BPVC, VM and otitis media/middle ear effusion-related vertigo. The presence of vertigo is more common in female genders which are consistent with different studies which reported the girls with vertigo coming to otolaryngology clinic more commonly than boys.
One of the most common causes of vertigo in children is VM. In several studies of children with vertigo, more than 50% present with dizziness along with headache and migraine constitute the most common primary cause of headache in children. The pathogenesis for VM can be explained by transitory vasospasm leading to labyrinthine or central vestibular pathway ischemia. One study suggested that vertigo in VM may be unilateral, reversible neurochemical derangement in peripheral vestibular pathway. Typically, children with VM present with episodic attacks of rotatory vertigo staying for minutes to hours and accompanied with headache, photophobia, and phonophobia. In this study, the most common etiology for causing vertigo was VM (33.33%). BPV in pediatric age group is considered as a common cause of vertigo, occurring with a prevalence of around 2.6%. BPV is characterized by sudden, brief attacks of vertigo along with nystagmus. The child of BPV either drops to the floor of the ground or tightly clutches the support for avoiding falling. There are other accompanying symptoms of BPV are nausea, vomiting, and pallor whereas the impairment of consciousness and headache is absent. The duration of vertigo lasts for seconds to minutes and the child become symptom free between the attacks. The prognosis of BPV in pediatric age is favorable and this disappears spontaneously by the age of 5–7 years. However, many children with BPV subsequently develop migraine. In addition to this, there is family history of migraine in around 50% of cases of BPV and the vertigo attacks may be relieved with antimigraine medications. BPV in pediatric age is considered as a migraine equivalent by many authors. The origin of vertigo in BPV is not understood completely and reported to be found either in posterior temporal cortex or in brain stem. In this study, majority of BPV children showing reduced caloric response. There were 22.22% children presenting vertigo due to BPV.
The cause of the vestibular neuritis is somewhat controversial; many authors have suggested that it is due to viral infections although bacterial and other variety of infections have also been suggested. One study found around 47% of the upper respiratory tract infection before onset of the vestibular neuritis. In this study, 16.66% of the pediatric vertigo is due to vestibular neuritis. The exact etiology of vestibular neuritis is controversial, although an association with herpes simplex virus has been found. Pediatric patients suffering from vestibular neuritis often present with similar symptoms as their adult counter parts. Vestibular neuritis is rarely found in children <10 years of the age. It presents with sudden onset of severe vertigo, nystagmus, nausea, and vomiting. This vertigo is worsened by head movements and children or patients usually prefer to lie down, often with the affected ear up. They do not present with hearing loss and tinnitus. Vestibular laboratory investigation shows unilateral reduced vestibular response to bithermal caloric test. The clinical symptoms of the child will resolve within a few days. The management of this patient includes supportive and symptomatic treatment with early ambulation. A short treatment with vestibular suppressants such as meclizine (≥12 years) or dimenhydrinate (≥2 years) may be prescribed, but should be limited as it often delay central compensation.
The posttraumatic vertigo in children without hearing loss may occur due to concussion of the labyrinth, basilar artery migraine, whiplash syndrome, vertiginous seizures, or nonspecific vertigo. In case of temporal bone fracture, labyrinthine disruption may occur which may lead to vestibular dysfunction and hearing loss, with or without facial nerve paralysis and cerebrospinal fluid otorrhea. Trauma of the temporal bone may cause perilymphatic fistula and often associated with fluctuating hearing loss. In case of perilymphatic fistula, surgical repair often relieve vertigo but the hearing loss may not be recovered. After trauma, pediatric patients tend to show abnormal vestibular tests in approximately half of the cases, even though the clinical presentations may be very less., Pediatric patients with congenital labyrinthine malformation like CHARGE syndrome predispose to giddiness along with hearing loss even after a trivial trauma. The recovery rate of the vestibular function after trauma is variable and unpredictable. In this study, posttraumatic vertigo contributes 4.62% of the pediatric vertigo.
Vertigo in children may be caused by middle ear effusion and otitis media, which constitutes two most common diseases in pediatric age group. The symptoms in abnormal middle ear effusion may be described by parents as clumsiness, awkwardness, and sometimes frequent falling. This is explained by absorption of middle ear toxin to the inner ear leading to serous labyrinthitis. Another explanation states that pressure changes in the middle ear cavity leads to displacement of the labyrinthine fluids. MD is characterized by idiopathic episodic vertigo and auditory symptoms. As per the American Academy of Otolaryngology, the diagnosis of definite MD need at least two attacks of vertigo lasting longer than 20 min and tinnitus and/or fullness in the affected ear as well as hearing loss on at least one occasion. MD is rare in pediatric age. The incidence of MD in children with vertigo was reported as 1.5% by Hausler et al. and 3.1% by Fujii et al. Pediatric patients with seizure disorders often present with dizziness and imbalance. It is not surprising; a history of seizures is significantly associated with balance problems and dizziness in both male and female children. Previous abnormalities of electroencephalogram along with a history of dizziness confirms the diagnosis, vertigo was common in epileptic patients than in control group.
Vertigo and dizziness often produce a considerable health-care burden to the general population., Hence, this study will be helpful to establish the etiological, clinical profile, and treatment among the pediatric vertigo. It also improves the awareness among physicians those are dealing with pediatric patients regarding the challenging symptom such as vertigo.
| Conclusion|| |
There are myriads of clinical presentations and possible diagnosis of the vertigo in children. The etiology of the vertigo in pediatric age is often multi-factorial, so the child with vertigo should be approached with open mind. Early diagnosis of the cause vertigo in children can guide rehabilitative efforts. A thorough evaluation of the vertigo in pediatric age though difficult is mandatory. Vertigo in pediatric age is highly challenging for diagnosis and treatment. Relying on only vestibular tests may cause misleading of the diagnosis. The clinicians must judiciously utilize all the diagnostic modalities at his/her disposal before dismissing less commonly found diagnosis.
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