Vertigo in Children

VertigoNo one likes to feel dizzy and, certainly, no one likes feeling as if the the room is spinning (unless you are competing in a game of Dizzy-Bat). When an adult has vertigo, I get queasy too. The severe causes can look very similar to the benign ones in adults, but what about with kids? What issues do I need to contemplate in children presenting with vertigo? Let us take a minute to digest a Morsel of goodness on Vertigo in Children:

 

Vertigo: Basics

  • Dizziness is a common complaint. [Davitt, 2017]
  • Vertigo is an illusion of motion.
    • May be described as a “spinning” or “whirling.”
    • “Dizzy” is often the initial complaint, but it is not descriptive enough to be overtly helpful.
      • Unfortunately, children may lack the vocabulary to better describe their feelings.
      • Children may also lack the experience to understand their sensations.
  • Children vs Adults
    • Children will have a more difficult time describing symptoms (although, not all adults are proficient in verbal communication of their symptoms either).
    • Children may be more difficult to appreciate their nystagmus.
    • Children will be more likely have vertigo related to migraines.
    • Children will be less likely to have Meniere’s disease.
    • Children will be less likely to have vascular etiology.

 

Vertigo: Causes

Vertigo in children “does not commonly represent a life-threatening or serious illness.” [Davitt, 2017]

Common Causes in children who have normal tympanic membranes. [Davitt, 2017; Raucci, 2016; Erbek, 2006]

  • Migraine-Associated Vertigo [Davitt, 2017; Raucci, 2016; Erbek, 2006]
    • Most common condition associated with vertigo (other than Otitis Media)
    • Vertigo may present before, during, or without headache.
    • Neuro exam should be normal.
    • More common in children than adults.
  • Benign Paroxysmal Vertigo of Childhood (BPVC)
    • Recurrent, brief attacks of vertigo.
    • Attacks occur without warning and resolve spontaneously.
    • Typically seen in children < 5 years of age. [Raucci, 2016]
    • Can be associated with pallor, perspiration, fearfulness, nausea, vomiting, phonophotophobia, and syncope. [Batu, 2015Erbek, 2006]
    • Vertigo does not have relation to head position (different from BPPV).
    • Vertigo is not associated with loss of consciousness (different from seizure)
    • Has a favorable prognosis and resolves after 6-12 months.
    • May be a part of a migraine complex, like cyclic vomiting and abdominal migraine.
  • Seizure
    • Loss of consciousness associated with vertigo warrants consideration of seizure as cause.
    • Staring episodes are also seen. [Batu, 2015]
  • Labyrinthitis / vestibular neuronitis
    • Follows an upper respiratory tract infection frequently
  • Syncope / Orthostatic hypotension / POTS
  • Psychogenic
    • More prevalent in older children (> 10 years of age)
    • It is always reasonable to screen for underlying psychiatric disorders.
    • Vertigo associated with anxiety, depression, and behavior disorders are seen. [Erbek, 2006]
  • Benign Paroxysmal Peripheral Vertigo (BPPV) [Brodsky, 2017]
    • Consists of short-duration vertigo attacks related to head position.
    • Less common in children than adults, but does occur.
    • More likely to be seen in teenagers.
  • Ocular Causes
    • Amblyopia
    • Astigmatism
    • Oculomotor abnormalities
  • Many encounters will ultimately be described as “Idiopathic

 

Uncommon, But Concerning Causes

Life-threatening disorders presenting with vertigo do occur, but “appear at an extremely low rate.”  [Davitt, 2017]

  •  Trauma
    • Skull fractures
  • Cardiac Causes
  • CNS Causes
    • Tumors
    • Demyelinating disease
    • Fortunately, patients “in whom severe neurological pathologies were diagnosed presented with associated signs or symptoms” and vertigo was not an isolated clinical feature. [Raucci, 2016]

 

Vertigo: Evaluation in the ED

Since the overwhelming majority of cases of vertigo in children will be due to a benign etiology, it is our job to mindfully screen for the rare, life-threatening conditions while being reasonable guardians of our resources.

  • A thorough Neurologic and HEENT exam is imperative. [Raucci, 2016; Erbek, 2006]
    • Otitis is a very common cause of vertigo (~50%)… don’t overlook the simple.
    • Episodes of unsteadiness may be the child exhibiting symptoms of vertigo. [Batu, 2015]
  • Check the Blood Pressure. [Raucci, 2016; Batu, 2015]
    • Seems simple… but it is also easy to overlook.
    • While rare, hypertensive crisis may present with vertigo… so check the BP.
  • Check the ECG. [Batu, 2015]
    • While the likelihood of a cardiac cause is low, don’t underestimate the power of a simple piece of paper with squiggly lines on it.
    • Look for arrhythmia provoking conditions (ex, Prolonged QTc, Brugada)
  • Imaging?
    • It is unlikely that a head CT will be of much value unless your neurologic exam is concerning for hemorrhage or overt mass.
    • MRI will be more useful at imaging the posterior fossa and demyelinating disease… but, with the majority of cases being due to benign and self-limited conditions, emergent imaging is rarely beneficial. [Raucci, 2016; Batu, 2015]
  • Outpatient Referral
    • Recommend ophthalmological evaluation as outpatient. [Batu, 2015]
      • Refractory errors may be the cause of vertigo…
      • They can also exacerbate vertigo even if they are not the cause.
    • Referral to multidisciplinary team may be beneficial. [Erbek, 2006]
      • Outpatient EEG and MRI may be warranted for evaluation of possible seizures.
      • Other benign conditions, like migraines and BPVC, have medical therapies available.

 

Moral of the Morsel

  • The Odds are in Your Favor! Most vertigo in children is related to benign causes (ex, migraines).
  • Don’t overlook the obvious! Check the TMs. Look for trauma.
  • Do simple screening! Check the ECG and BP!
  • Look for signs of underlying Neurological or Cardiac causes.

 

References

Brodsky JR1,2, Lipson S1, Wilber J1,3, Zhou G1,2. Benign Paroxysmal Positional Vertigo (BPPV) in Children and Adolescents: Clinical Features and Response to Therapy in 110 Pediatric Patients. Otol Neurotol. 2018 Mar;39(3):344-350. PMID: 29287036. [PubMed] [Read by QxMD]

Davitt M1, Delvecchio MT, Aronoff SC. The Differential Diagnosis of Vertigo in Children: A Systematic Review of 2726 Cases. Pediatr Emerg Care. 2017 Oct 31. PMID: 29095392. [PubMed] [Read by QxMD]

Raucci U1, Vanacore N2, Paolino MC3, Silenzi R4, Mariani R1, Urbano A3, Reale A1, Villa MP3, Parisi P5. Vertigo/dizziness in pediatric emergency department: Five years’ experience. Cephalalgia. 2016 May;36(6):593-8. PMID: 26378081. [PubMed] [Read by QxMD]

Brodsky JR1, Cusick BA2, Zhou G3. Evaluation and management of vestibular migraine in children: Experience from a pediatric vestibular clinic. Eur J Paediatr Neurol. 2016 Jan;20(1):85-92. PMID: 26521123. [PubMed] [Read by QxMD]

Batu ED1, Anlar B2, Topçu M3, Turanlı G4, Aysun S5. Vertigo in childhood: a retrospective series of 100 children. Eur J Paediatr Neurol. 2015 Mar;19(2):226-32. PMID: 25548116. [PubMed] [Read by QxMD]

Lee CH1, Lee SB, Kim YJ, Kong WK, Kim HM. Utility of psychological screening for the diagnosis of pediatric episodic vertigo. Otol Neurotol. 2014 Dec;35(10):e324-30. PMID: 25144643. [PubMed] [Read by QxMD]

Erbek SH1, Erbek SS, Yilmaz I, Topal O, Ozgirgin N, Ozluoglu LN, Alehan F. Vertigo in childhood: a clinical experience. Int J Pediatr Otorhinolaryngol. 2006 Sep;70(9):1547-54. PMID: 16730074. [PubMed] [Read by QxMD]

Sean Fox

I enjoy taking care of patients and I finding it endlessly rewarding to help train others to do the same. I trained at the Combined Emergency Medicine and Pediatrics residency program at University of Maryland, where I had the tremendous fortune of learning from world renown educators and clinicians. Now I have the unbelievable honor of working with an unbelievably gifted group of practitioners at Carolinas Medical Center. I strive every day to inspire my residents as much as they inspire me.

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