Vertigo resident survival guide (pediatrics)
Synonyms and keywords: Vertigo in childhood, Vertigo in children, An approach to vertigo in children
|Vertigo resident survival guide (pediatrics) Microchapters|
Vertigo can be described as a subjective sensation of movement such as spinning, turning or whirling of patients or respective surroundings. Vertigo is a symptom, not a diagnosis. It results from a dysfunction either in the vestibular or central nervous system; thus can be classified as a 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 positional vertigo, head trauma, or any CNS infection. Successful management of vertigo usually consists of identifying the root cause and specifically targeting the underlying condition.
FIRE: Focused Initial Rapid Evaluation
- A Focused Initial Rapid Evaluation (FIRE) should be performed to identify the patients in need of immediate intervention].
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)|
|History of Head Trauma||Pseudovertigo|
|Findings of Abnormal CT-Scan/MRI||Altered level of Consciousness|
|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
|History of travel ?|
|If Yes Consider Motion Sickness||Abnormal vestibular testing?|
|Abnormal CT-Scan/MRI?||Decreased Hearing?|
|CNS tumor||❑ BPPV |
|❑ Drug Overdose |
❑ Meniere's Disease
Complete Diagnostic Approach
- A complete diagnostic approach should be carried out after a focused initial rapid evaluation is conducted and following the initiation of any urgent intervention.
Gait & Gross Motor Testing
• Vestibulospinal testing
- Shown below is an algorithm summarizing the treatment of vertigo according to the AAO-HNS guidelines:
|Patient with established diagnosis of vertigo|
|Central vertigo||Peripheral vertigo|
|Treat according to the underlying 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 the patients, although 15% to 30% may have a recurrence of symptoms. The maneuver is repeated until the nystagmus can no longer can be elicited.Vestibular neuritis- Methylprednisolone tapered over 3 weeks
- Following two maneuvers can be done to reduce the intensity of vertigo:
- Epley Maneuver:
- For left-sided vertigo, make the patient sit on the edge of the bed. Turn the head of the patient 45 degrees to the left. Place a pillow under his/her shoulder. Have him lie down on his back with his head still at a 45-degree angle. Wait for 30 seconds. Turn the head of the patient 90 degrees to the right without raising it. Wait for another 30 seconds. Turn the head and body of the patient to the right side towards the floor. Wait for another 30 seconds. Slowly have the patient sit up. Reverse the instructions in the case of right-sided vertigo.
- Semont Maneuver:
- Have the patient sit on the edge of the bed. Turn the head 45 degrees to the right and make him quickly lie down towards the left side. Wait for 30 seconds. Now quickly have the patient lie down on the other side of the bed. Keep his/her head at a 45-degree angle and make him lie for 30 seconds to look at the floor. Now have him/her slowly sit and wait for a few minutes. Reverse this whole process for the right-sided vertigo.
- Half-Somersault or Foster Maneuver:
- Kneel the child down and make him/her look up at the ceiling for a few seconds. Touch the child's head with the floor, tucking his/her chin so the head goes towards knees. Wait for any vertigo to stop for about 30 seconds. Turn the child's head in the direction of the affected ear. Wait for 30 seconds. Quickly raise the head for it to be leveled up with the back while the child is on all fours. Keep the head at that 45-degree angle and wait for another 30 seconds. Quickly raise head so it's fully upright, but keep the head turned to the shoulder of the side you're working on. Then slowly make the child stand up. This may need to be repeated a few times for complete relief. Rest for 15 minutes after the first round, before trying the process a second time.
- Brandt-Daroff Exercise:
- Have the child seated in an upright position on the bed. Tilt the head around a 45-degree angle away from the side causing vertigo. Move the child into the lying position on one side with the nose pointed up. Make the child stay in this position for about 30 seconds or until vertigo eases off, whichever is longer. Then move the child back to the seated position. Repeat on the other side.
- Epley Maneuver:
- Avoid consuming fluids with high sugar or salt content such as concentrated drinks and soda. These are the fluids that trigger vertigo.
- Limit caffeine intake. Caffeine has been reported to cause cell depolarization making the cells more easily excitable.
- Following is a list of contraindications to canalith repositioning procedure:
- Limit salt intake as it causes retention of excess fluid in the body and interferes with the vestibular system.
- Processed food and meat should be avoided.
- To reduce the risk of falls because of vertigo, advise patients to get rid of loose electrical cords, clutter, and slippery rugs.
- Also advise the patients to wear sturdy non-slippery shoes to minimize the fall risk secondary to vertigo.
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