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 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.

Causes

Causes of Vertigo
Life-Threatening Causes Common Misc.

FIRE: Focused Initial Rapid Evaluation

  • A Focused Initial Rapid Evaluation (FIRE) should be performed to identify the 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'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.[3][4][5]


 
 
 
 
 
Signs 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
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Specific History
❑Episodic vs Continuous
❑Time of onset: acute/chronic (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/chronic (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's test or Tandem gait: Child puts one foot in front of the other, arms on the sides, vision allowed and then exclude, tests to evaluate the dorsal column.
•  Age-appropriate gross motor (Bruininks- Oseretsky test 4-21yrs)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Workup
•  Audiological evaluation
•  Eye examination
•  Vestibular function test
•  EEG
•  Hematological workup (CBC, electrolytes, glucose, thyroid function tests)
•  Imaging indications:
• Focal neurological symptoms or findings
• Worsening symptoms – Prolonged LOC (> 1 min)
• Failure of symptoms to improve
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Vestibular Function Testing
•   ENG battery
•   Rotation testing
•   Platform post-urography
• Dix-Hallpike - PSSC
•   Gaze testing
•   Caloric ENG – LSSC
• >30% difference between sides indicates a unilateral peripheral lesion 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 to the AAO-HNS guidelines:[6]
 
 
 
 
 
 
 
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.

Ménière's disease- Salt restriction, diuretics, intra-tympanic dexamethasone or gentamicin, endolymphatic sac surgery

Vestibular neuritis- Methylprednisolone tapered over 3 weeks

Do's

  • Following two maneuvers can be done to reduce the intensity of vertigo:[7]
    • 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.[7]
    • 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.[8]
    • 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.

Don'ts

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. Gruber, Maayan; Cohen-Kerem, Raanan; Kaminer, Margalit; Shupak, Avi (2012). "Vertigo in Children and Adolescents: Characteristics and Outcome". TheScientificWorldJournal. Hindawi Limited. 2012: 1–6. doi:10.1100/2012/109624. ISSN 1537-744X. PMC 3259473. PMID 22272166.
  4. Jahn, K.; Langhagen, T.; Schroeder, A.S.; Heinen, F. (2011-07-15). "Vertigo and Dizziness in Childhood − Update on Diagnosis and Treatment". Neuropediatrics. Georg Thieme Verlag KG. 42 (04): 129–134. doi:10.1055/s-0031-1283158. ISSN 0174-304X. PMID 21766267.
  5. Langhagen, Thyra; Lehrer, Nicole; Borggraefe, Ingo; Heinen, Florian; Jahn, Klaus (2015-01-26). "Vestibular Migraine in Children and Adolescents: Clinical Findings and Laboratory Tests". Frontiers in Neurology. Frontiers Media SA. 5. doi:10.3389/fneur.2014.00292. ISSN 1664-2295.
  6. "Clinical Practice Guidelines". American Academy of Otolaryngology-Head and Neck Surgery. 2014-04-02. Retrieved 2020-08-08.
  7. 7.0 7.1 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.
  8. 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.
  9. "Managing Your Vertigo – Symptoms & Treatment". Carle.org. Retrieved 2020-09-12.
  10. Herdman, S. J.; Tusa, R. J. (1996-03-01). "Complications of the Canalith Repositioning Procedure". Archives of Otolaryngology - Head and Neck Surgery. American Medical Association (AMA). 122 (3): 281–286. doi:10.1001/archotol.1996.01890150059011. ISSN 0886-4470.
  11. 11.0 11.1 "Diet To Help You With Your Vertigo - Dizziness Treatment Food". NeuroEquilibrium. 2018-10-02. Retrieved 2020-09-12.