Vertigo resident survival guide (pediatrics)

Resident Survival Guide

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

• Various causes of vertigo in the pediatric population are given in the table below:

Causes of Vertigo

Life-Threatening Causes	Common	Misc.
Head trauma (labyrinthine concussion, whiplash syndrome, basilar artery migraine) CNS infection Intake of a specific Poison Drug Adverse Effect Stroke Brain tumor Congenital ear abnormalities (Mondini's malformation, enlarged vestibular aqueduct)	Binocular vision abnormalities Benign paroxysmal positional vertigo of childhood Vestibular neuritis Migraine Somatoform vertigo   Motion sickness Otitis media complicated by labyrinthitis	Mastoiditis Meniere's disease Middle ear trauma Multiple sclerosis Perilymph fistula Ramsay Hunt syndrome Seizure

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) ❑ 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.

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

General History ❑History of prenatal/perinatal infection ❑Use of ototoxic medications ❑Congenital 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/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:

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:
  • 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.

Don'ts

• 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:
  • Severe carotid stenosis
  • Unstable heart disease
  • Severe neck disease, such as cervical spondylosis with myelopathy or advanced rheumatoid arthritis.
• 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.