Otolaryngology Texas Children’s Hospital

12/13/19

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Henri Traboulsi, MDOtolaryngologyTexas Children’s Hospital

Vestibular Disorders in Children:They Do Exist

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Goals of This Talk

1. Which patients will come to our clinic?

2. Differentiation diagnosis of dizziness in a child? Most common entities?

3. How can I identify a child with a potential vestibular problem?

4. What can I do to screen for vestibular problems?

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The otolith organs

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The semicircular canals

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Dizziness in children is not uncommon

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• Questionnaire applied to 2,165 children

• 314 reported having experienced at least 1 episode of dizziness (14%)

• 44% of which was unexplained or undiagnosed

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5.7% rotary vertigoChildren aged 10

8% vertigo or imbalanceChildren aged 1-15

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Vertigo affects the quality of life of children

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• KIDSCREEN-52 questionnaire

• 32 kids

• Age 8-18

Neuropediatrics

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DizzinessVertigo

Imbalance

Congenital hearing

loss

Migraine/Migraine variants

Ear diseaseConcussion

CNS

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DizzinessVertigo

Imbalance

Congenital hearing

loss

Migraine/Migraine variants

Ear diseaseConcussion

CNS

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Vestibular impairment in children with HL

20-70%

Arnvig et al, 1955 Goldstein et al, 1958 Sandberg et al, 1965

Seems to correlate with degree of hearing loss

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35 patients with CI failure vs 165 without failure

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Vestibular dysfunction and imbalance increases the risk

of CI failure by 8X!!!

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Take Home Messages

• Vestibular dysfunction is very common in patients with hearing loss

• It is important to screen these patients for vestibular impairment

• Might have significant implications for treatment, gross motor development, CI

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DizzinessVertigo

Imbalance

Congenital hearing

loss

Migraine/Migraine variants

Hearing loss

Concussion

Inner ear disease

CNS

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Concussion and Dizziness

• Dizziness is the only on-field symptom that is predictive of a prolonged recovery from pediatric concussion

• 6-fold increase in developing PCS

Guerriero et al, 2012

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Brodsky et al., Otolaryngol Head Neck Surg.2018

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DizzinessVertigo

Imbalance

Congenital hearing

loss

Migraine/Migraine variants

Ear diseaseConcussion

CNS

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The “Vestibular March”

Benign Paroxysmal Torticollis of Infancy

Benign paroxysmal Vertigo of Childhood

Vestibular Migraine15.4%

Brodsky et al, 2018

42%

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Benign Paroxysmal Torticollis of Infancy

Benign paroxysmal Vertigo of Childhood

Vestibular Migraine

Benign Paroxysmal Torticollis of Infancy

Recurrent episodes of head tilting and

imbalance in infants and toddlers

The Migraine Variants

Brodsky et al, 2018

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Benign Paroxysmal Vertigo of Childhood

• Brief sudden, severe attacks of vertigo/imbalance

• Minutes to hours

• Without warning

• Spontaneously resolves

• No LOC

Benign Paroxysmal Torticollis of Infancy

Benign paroxysmal Vertigo of Childhood

Vestibular Migraine

The Migraine Variants

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Benign Paroxysmal Torticollis of Infancy

Benign paroxysmal Vertigo of Childhood

Vestibular Migraine

The Migraine Variants

Diagnostic CriteriaA. At least 5 episodes fulfilling criteria C and DB. A current or past history of 1.1 Migraine without aura or 1.2

Migraine with auraC. Vestibular symptoms of moderate or severe intensity,

lasting between 5 minutes and 72 hoursD. At least half of episodes are associated with at least 1 of the

following 3 migrainous features1. Headache with at lest 2 of the following 4 characteristics:

a) Unilateral locationb) Pulsating qualityc) Moderate or severe intensityd) Aggravation by routing physical activity

2. Photophobia and phonophobia3. Visual aura

E. Not better accounted for by another ICHD-D diagnosis or by another vestibular disorder

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DizzinessVertigo

Imbalance

Congenital hearing

loss

Migraine/Migraine variants

Ear diseaseConcussion

CNS

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Ear Disease

• Middle ear effusions

• Complicated otitis media

• BPPV

• Meniere’s disease

• Vestibular neuronitis

• Trauma

• Cholesteatoma

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What are the typical symptoms of a vestibular dysfunction?

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Imbalance Dizziness

Vestibular Dysfunction

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What can you do as an initial evaluation for these patients?

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Presenting Symptoms• Clumsy/uncoordinated

• Frequent falls

• Strange behavior

• Fear and panic

• Head hanging/tilt

• Learning disability

• Difficulty reading

• Difficulty ambulating in the dark

• Periodic nausea and vomiting

• Clutching to parents

• Unable to ride a bicycle

• Weird eye movement

Seizures Tics Strabismus Developmental delay

“Labels”

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Motor Milestones

Head control(6w è 3m)

Sitting unsupported(6m è 9m)

Walking(12m è 15m)

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Vestibular Testing in Children

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cVEMP

oVEMP

CaloricsRotary chair

vHIT

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Vestibular testing does not give us a diagnosis

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