Vertigo In children

Mohamed I ShabanaProfessor of Audiological Medicine

Cairo University

Vertigo in Children

Developmental

Children under the age of 4 months - Tonic neck reflexes predominate- These reflexes can be demonstrated by passive or active

motions of the head relative to the position of the body- This reflex is due to movement of endolymphatic fluid through

the semiciruclar canals. These tonic neck reflexes are dependent on the integrity of vestibular and proprioceptive systems.

Neck righting: In this test active / passive rotation of head from the midline to one side when the infant is lying supine will cause a rotation of the whole body .

Developmental

4 - 6 months.

 Babies in this age group vary in their developmental achievements. Many normal infants still have residual primitive tonic neck reflexes, while in others, righting responses will appear. Both these conditions are normal.

Developmental

6 - 18 months.

 This is a period of rapid motor and sensory development. The pyramidal tract becomes myelinated. Integration of visual, labyrinthine and proprioceptive stimuli occurs during this phase. Righting reflexes are elicited by an abrupt tilt of the patient to change the

patient's centre of gravity  .

Developmental

Since the optical and vestibular righting responses are identical the baby must be tested blind folded in order to eliminate visual cues. The most important of the righting reflexes is the head righting response. This can be obtained by picking up the infant from prone / supine position and bringing it to upright position by tilting the infant sideways, forwards or backwards. Every abrupt change of the head position in space will elicit vestibular head righting response. At the same time propping reactions of the extremities may be seen.

Prevalence of dizziness in children:

• The population-based prevalence of vertigo and dizziness among school children has been reported to be 15%. In the literature, vertigo in children has received much less attention than vertigo occurring in adults. Even among otologists and child neurologists, the key clinicians providing appropriate diagnosis and treatment for vertiginous children, the differential diagnosis is not well established. The clinical picture of vertigo in children deviates from vertigo in adults, since young children do adapt very well to vertigo and dizziness and compensate a vestibular deficit quicker than adults (Niemensivu et al., 2006).

What is your complaint son??

I am Dizzy

How are they Complaining??

• - Delayed walking• - Clumsiness• - nausea• - episodic pallor and fatigue• - difficulty walking in Darkness, or uneven surface• - Headache blurred vision • - Difficulty reading in moving Vehicle• - Gaze stabilization problems

• Vertigo in children differs from that in adults, because of three main reasons.

• Firstly, vestibular disorders are often ignored in children, because vertiginous manifestations are usually attributed to lack of coordination or behavioural problems.

• Secondly, as children often lack the communication ability

to describe accurately their symptoms, diagnosis is based less in history and much more in clinical examination and laboratory investigations.

• Finally, although most diseases that cause vertigo in adulthood occur in childhood as well, their frequency may be different, depending on the age of the patient.

WHAT ARE OUR KEY ELEMENTS IN the HISTORY??

Parents Knowledge of the causes

Investigations & interpretation

Ravid,elal (2003)

Arabic Version of Pediatric Dizziness Inventory Questionnaire

Presentation for discussion of a Thesis Submitted For Fulfilment of the Master Degree in AudiologyBy:

Mariam Magdy MedhatM.B., B. CH .

 Supervisors:

Prof. Dr. Mohamed Ebrahim ShabanaProfessor of Audiology,

Faculty of Medicine,Cairo University

 

Dr. Abeir Osman DabbousAssistant Professor of Audiology,

Faculty of Medicine,Cairo University

 

Dr. Noha Ali HosniLecturer of Audiology,Faculty of Medicine,

Cairo University, 

Kasr El-Aini Faculty of MedicineCairo University,

2011

Aim of the work• To develop an Arabic paediatric dizziness inventory

questionnaire for the parents of dizzy children to

address the balance complaints of their children by the

information gathered from it. This evaluation will help

to identify any balance dysfunction and to quantify the

impact of dizziness on daily living and to describe the

dizziness complaint, and helps to reach diagnoses of the

balance dysfunction in children and directs us towards

the necessary investigations to confirm this diagnosis.

الدوار استبيان أسئلةاألطفال في

الدوار استبيان أسئلةاألطفال في

في الدوار استبيان أسئلةاألطفال

في الدوار استبيان أسئلةاألطفال

Figure (2) : Distribution of the conclusion reached from the questionnaire in the cases.

945%

15%

315%

15%

15%

210%

15%

15%

15%

Vestibular

Cervical

General

Ocular

General/CVS

Neurological/Ocular

Ocular/Cervical

Vestibular / CVS

Non specific (Ocular/General/Neurological/Audiologicalassociation)

0%10%

20%30%

40%50%

60%70%

80%90%

100%P

erce

nta

ge Not matching

Matching

Figure (6): The ability of the questionnaire to match the diagnosis according to the referral for different categories.

Conclusions:

• We have developed an Arabic pediatric dizziness inventory questionnaire for the parents of dizzy children. A scoring system has been developed to address the balance complaints in children by the information gathered from it. Evaluation of dizzy children using our Arabic pediatric dizziness inventory questionnaire helped to identify balance dysfunction and was able to categorize the dizzy children by the affected system/systems.

• The questionnaire and its scoring system were valid, being

comprehensive enough to collect all the information needed to address the balance problem. The questionnaire was able to quantify the impact of dizziness on daily living, to describe the dizziness complaint that helped to reach a diagnosis of the balance dysfunction in children and to direct the clinician towards the necessary investigations to confirm this diagnosis.

 

Conclusions:

• The Arabic dizzy children questionnaire's categories matched the diagnosis on referral in 75% of cases. The sensitivity of the questionnaire in reaching the diagnosis was calculated at 75%. Its sensitivity in diagnosing vestibular category was 88.89%. The sensitivity in multi-system affection was 83.3%.

• The Arabic dizzy children questionnaire defined a matched

specific diagnosis for the cause of dizziness in 11/20 (55%) of cases.

What are you going

to do

•OBSERVATION

Low muscle tone

– Delay in holding head up

– “Snuggly” baby

– “Floppy baby”

– Arching of back

Delayed disappearance of newborn reflexes

– Moro– ATNR: Asymmetric tonic next response– Usually disappear by 6-7 months

Delayed motor milestones

– Average deaf child walks at 14 months

– Average child with Usher’s Type 1 walks at 20 mos

– Delays sitting, crawling, climbing steps, hopping…

– Speech delays

What do older children look like?

• Clumsy

• Unable to walk on a balance beam

• Problems standing with feet together and eyes closed (Romberg test)

What do older children look like?

• Love spinning, merry-go-rounds, water activities

• Weak VOR: Challenges with reading– Gaze instability causes problems with acuity

Signs of poor vestibular function• Low muscle tone

• Delayed loss of primitive reflexes

• Delayed gross motor milestones

• Developmental delays• Seizures• Nystagmus• Easy fatigability• Torticollis

Causes of dizziness in children  A) Otologic:

Congenital disorders: Syndromic hearing loss and vestibular dysfunction:

– Usher syndrome– Pendred syndrome– Enlarged vestibular Aqueduct syndrome– Congenital Long-QT Syndrome– CHARGE Syndrome

Non-syndromic hearing loss and vestibular dysfunction Congenital anomalies of the skull base

Traumatic disorders:• Head Trauma• Paroxysmal Positional Vertigo• Perilymphatic Fistula• Cochlear Implant Surgery

Examination

History

Syndromes

Over 500 nDNA syndromes known to affect the audiovestibular (AV) system.

• Usher’s Syndrome (Type 1)

• Waardenburg Syndrome

• Pendred syndrome

• CHARGE Syndrome

• Brachio-oto-renal syndrome

Retinitis pigmentosa

  ><                                     ><                                  

Retinitis pigmentosa

http://www.blindness.org/content.asp?id=45

Waardenburg Syndrome

http://www.werathah.com/deafness/waardenburg.htm

Pendred Syndrome

http://www.bmm.charite.de/rueckschau/ribeiro/ribeiro.htm

CHARGE Syndrome

www.charrgesydnrome.org

Causes of dizziness in children

A) Otologic:Inflammatory disorders:• Otitis Media-related vertigo• Chronic Suppurative Otitis Media and Cholesteatoma• Vestibular neuronitis• Labyrinthitis• Bacterial meningitis

Idiopathic: Endolymphatic hydrops:

– Menière's disease– Delayed endolymphatic hydrops

Motion Sickness Autoimmune Disorders

Post Cochlear Implant

Examination

investigation

Causes of dizziness in children

B) Neurological disorders: Migraine variants and complicated migraine :

1- Paroxysmal Torticollis2- Cyclical Vomiting3-Basilar Artery Migraine4-Familial Hemiplegic Migraine5- Abdominal Migraine 6- Idiopathic benign paroxysmal vertigo

Migraine-associated dizziness Epilepsy Episodic ataxia Multiple sclerosis Vascular Occlusion Brain tumors investigation

History

Investigation

Benign Paroxysmal Vertigo

• * Common un recognized condition• * Paroxysm, Recurrent, non epileptic• * Pale, Sweaty, Fearful, May sway• * sudden onset, seconds to minutes duration• * no loss of conscious, with complete

recovery• * Diagnosed By exclusion• * Migraine precursor

Causes of dizziness in children

C) Psychological dizzinessD) Ocular disordersE) Systemic disorders (General causes)F) oto-toxic drugs

Mainly History

Hearing ScreeningDo we have Vestibular screening

How can we examine the children?

Investigation

• CT of temporal bone

• Vestibular testing

• Physical, occupational, ? cognitive therapies

• Genetic appointment– Strongly consider testing for Usher’s mutations

• Vision evaluation– ?ERG

Enlarged Vestibular Aqueducts

Ossification

Dynamic Imbalance Testing

VOR testing• Head thrust maneuver• Post-headshake nystagmus• Dix-Hallpike maneuver• Dynamic Visual Acuity• Gait

Head Thrust test

Dynamic Visual Acuity

Posture Control and Gait

The Foam test

Static Balance Testing

•Posturography

Dynamic Stability in WalkingGait Laboratory

Walking test

Vestibular testing

• Fukuda Stepping Test• Vestibular Ocular Reflex Screening-Swivel

Chair with Video-oculographic (VOG) Recording

• ENG/VNG• Rotary Chair Testing

• VEMPs

ENG/VNG

Caloric irrigation: This test is performed only in children aged 4 and older. Ideally performed with the baby blind folded, in the supine position, with the head ventroflexed at 30 degrees. The child is also restrained. A ten second irrigation is a must for adequate stimulus. Recording should start immediatly after the onset of irrigation.

ENG/VNG

If the child is sleepy or irritable during the test the response may not be accurate. This test is a rather crude way of testing vestibular response to a stimulus. This test is hence performed only in cases of extreme doubts regarding the function of vestibular apparatus.

Make it the last examination

ENG/VNG

There is a maturation pattern in the development of caloric evoked nystagmus response. The amplitude and the number of beats increase in the first three months of life. The intensity of the nystagmus is directly proportional to the gestational age and the weight at birth. The latency of the response decreases with the gestational age and increasing birth weight.

ENG/VNG

Optokinetic stimulation: Optokinetic nystagmus can be evaluated in most

children within three to six months of birth. As the child grows older, they learn to pay more attention to the moving images and better responses can be obtained in them. This nystagmus can be recorded in response to two speeds of rotation i.e. 3 degrees and 16 degrees per second.

ENG/VNG

The frequency, amplitude and speed of the slow component can be analysed in response to the two rotational speeds. The information obtained is helpful in the evaluation of overall quality of neurovestibular function.

DR. ABEIR OSMAN DABBOUSAssistant Professor of Audiology,

Kasr El-Aini, Cairo University.

• The impairment of saccular function, indicated by the abnormal findings in the VEMP , is often associated with SNHL in the pediatric population.

• With the increasing occurrence of pediatric patients with symptoms of dizziness, VEMP testing may be a means to evaluate unilateral vestibular function (Honaker and Samy, 2007).

Vestibular evoked myogenic potential (VEMP)

•The function of this sacculo-collic reflex is to stabilize the head in response to unpredictable displacements (Halmagyi &

Curthoys 2000).

inferior vestibular nerve

medial vestibulospinal tract

ipsilatral SCM

Saccule

accessory nerve

VEMP Method

•Surface Electrodes: –Non-inverting active: middle third

of each SCM muscle ,

–Inverting reference: supra-sternal notch, or at each sternal insertion

–Ground: forehead.

VEMP waveform

(Murofushi and Kaga, 2009 .)

Latency (in msec) ,P1 latency decreases with increasing rate.

VEMP response

N23

P13

Amplitude= 77.81uv

Waveform:•Latency (in msec) ,•Threshold: (dBSPL)•Amplitude (in μV) ,

Our laboratory norms (mean ± 2SD) for the different studied VEMP parameters were:

•N13 latency: 12.89 ± 1.9 msec ;•P23 latency: 21.31 ± 4.02 msec ;•P13-N23 latency Interval: 8.42 ± 3.54 msec ;•P13-N23 amplitude Interval: 80.95 ± 36.84 V;•IAD: -0.01 ± 0.16. (Dabbous, 2007).

• decreases with increasing rate above 5-Hz • EP ratio or the inter-aural difference ratio (IAD):

[(Ar−Al)/ (Ar+Al), x 100], • a ratio of > 3:1 abnormal

Amplitude (in μV),

P13

=14.6

N23

=23.0

P13

=15.2 N23

=22.2

Amplitude= 38.13 uv

Amplitude= 39.94 uv

An example of Normal IAD

Rt

Lt

IAD =0.023

P13 = 12.2

P13 = 14.2

N23 = 20.8

N23 = 22.0

Amplitude= 29.56 uv

Amplitude= 77.81 uv

An example of abnormal IAD

Rt

Lt

IAD = 0.45

VEMP amplitudedepends on:

1. Saccular function 2. Stimulus intensity, air-conduction3. Electrode conduction & location 4. Linearly increases with the EMG level

Clinical utility of VEMP testing : sacculo-vestibular nerve function.

.1assessment of vestibular nerve function:–acoustic neuromas –vestibular neuronitis –multiple sclerosis

.2diagnosis of superior semicircular canal dehiscence syndrome ,

.3evaluation of Menière's syndrome

.4Sensori-neural hearing loss.

VEMPs in a large Vestibular Aqueduct

Most common anomalySudden fluctuation in pressure: 1. progression of SNHL after head trauma,2. VEMP has greater amplitude and lower

threshold (Sheykholesami et al, 2004).

VEMP in diagnosis of Superior Canal Dehiscence Syndrome

•Rare •a ‘third window : ’

–pseudo-conductive HL, ABG at low frequencies,

–Tullio phenomenon of acoustically evoked vertigo &

nystagmus ,–VEMP:

–increased amplitudes–lowered threshold (70 dB)

(Colebatch et al., 1998; Streubel et al., 2001 Brantberg et al., 1999; Ostrowski et al., 2001

Minor et al., 2003; Mikulec et al., 2004.)

Chronic otitis media

• Chronic OM could delay and reduce the energy transfer of sound to the inner ear.

• Improvement of postoperative VEMP response rate and p13 latencies in the patients with and without improvement in postoperative 500 Hz - ABG, provide evidence that the sound energy inducing a VEMP might be different from the energy producing the auditory perception (Wang et al., 2008).

Migraine and its equivalents

• Migraine: the most common cause of episodic vertigo in children.

• Allena et al., (2007) postulated that VEMP abnormalities in migraine are due to reduced serotonergic control of the reflex circuit, in particular of the vestibular nuclei.

• Benign Recurrent (Paroxysmal) Vertigo or benign recurrent vertigo (BRV):– a major cause of vertigo in children– 30% have abnormal caloric responses, – 50% have abnormal VEMP responses (Ozeki et al., 2008).

Our VEMP Studies: in Migraineurs

normal 25%

VEMP abnormalities

75%

delayed latencies of P13

and N23 .

N23

P13

P13

N23

VEMPs in Children with Cochlear Implants

traumatic damage → absent VEMPs or decreased

amplitude

present VEMPs >50%

With CI on: electrical current spread at

C level, apical channels → stimulates the IVN: present

VEMPs or absent VEMPs if requiring higher current intensities, but difficult

(pain or facial nerve stimulation) (Jin et al.,

2008).

Thank you all