Although not a common complaint, dizziness does occur in childhood. As in adults, it may be a sensation of lightheadedness due to anxiety or hyperventilation, or real vertigo with hallucination of motion and disorientation in space. In childhood, however, vestibular dysfunction is most frequently manifested as awkwardness, clumsiness, and poor balance reported by the parents. This is an especially common occurrence in children with abnormal middle ear ventilation and middle ear effusion. Less frequent causes of dizziness and disturbance in balance in children are benign paroxysmal vertigo of childhood, perilymph fistula, paroxysmal torticollis of infancy, Meniere's disease, trauma, and migraine as well as additional central nervous system disorders and other diagnostic considerations.
EVALUATION OF THE CHILD
As in any complete medical evaluation, the patient's history is important. However, in evaluating these children the history may be compromised because it is sometimes vague and, understandably, always subject to parental interpretation. Dizziness is characteristically episodic, so that at examination symptoms are usually not present and the examination is normal. Because of these realities, testing of the vestibular system is important both for diagnosis and for monitoring the patient. Electronystagmography with caloric tests has been useful and can be performed by the experienced technician with relative ease. Although the caloric response is not as definitive as it is in an adult because of the immaturity of the child's vestibular system, meaningful interpretations can usually be made, such as unilateral vestibular hypoactivity and the finding of vestibular nystagmus. Computerized rotation testing can also be performed and is particularly helpful in following the course of the illness.
Middle Ear Disease
Abnormal middle ear ventilation and middle ear effusion are the most common causes of balance disturbance in childhood. The pathophysiology is presumed to be the transmission of pressure grathents through the labyrinthine windows to the inner ear fluids and the vestibular sensory receptors.
Since most children with abnormal middle ear ventilation or middle ear effusion do not complain of balance disturbance or the hearing loss that accompanies middle ear effusion, the symptoms are usually reported by the parent who describes clumsiness, awkwardness, and sometimes frequent falling. The diagnosis is made on physical examination of the ear and tympanometry. The tympanic membrane is discolored, varying from light amber to a dark bluish color and fluid bubbles may be visible through the tympanic membrane. If middle ear secretions are present, tympanometry reveals either a flattened peak or a flat curve. ' On the other hand, negative pressure alone is reflected by a tympanogram with essentially normal compliance but with negative pressure demonstrated by a peak shifted to the left of the zero point (the negative side).
The most frequent cause of middle ear effusion is eustachian tube dysfunction due to persistent infection. Therefore, the primary management is antibiotic therapy for several weeks at therapeutic levels. If this is successful, a prophylactic regime of antibiotic therapy over the winter months, when infections are more likely, can be considered to prevent recurrences. The critical points in deciding when to perform a myringotomy to ventilate the middle ear is the state of auditory or vestibular function. Continuing balance disturbance or hearing loss mandate surgical treatment.
Other middle ear diseases may be accompanied by vestibular symptoms. Acute or chronic suppurative otitis media may produce a labyrinthitis, and a cholesteatoma in the middle ear can cause a fistula of the bony labyrinth. If cholesteatoma is evident or suspected, the ear should be surgically explored since cholesteatoma will not resolve with medical management. The child with cholesteatoma must be monitored for many years after surgery since despite the best efforts, cholesteatoma may recur.
Benign Paroxysmal Vertigo of Childhood
Benign paroxysmal vertigo of childhood2 is a clinical entity that occurs most often in preschoolers, but may also be found in elementary school-age children and in the young teenager. The episodes of dizziness are featured by abrupt attacks of a turning sensation that last from a few seconds to a few minutes. The child may cry out in alarm and lose balance. There may be associated autonomic symptoms such as pallor and vomiting and, at times, the episodes may be mistaken for seizures.
Although it had initially been reported that these children had a hypoactive caloric test response in one ear,3 this finding has not been confirmed by recent investigators. The only objective evidence of vestibular dysfunction is the presence of nystagmus that may be noted on an electronystagmographic recording of eye movements or on direct observation. Therefore, since the episodes occur at home, it is helpful to prepare the parents to look for eye movements during an attack of dizziness. Hearing, electroencephalography, and imaging studies are normal.
Although the cause of this disorder has not been defined, it may represent a precursor to migraine or be a migraine equivalent.4·5 The disorder is self-limited so that the management is reassurance and, if the child is old enough, a balance exercise program.
A perilymph fistula can also cause balance disturbance and dizziness.6 This etiology should be suspected if the balance disturbance follows strenuous physical exertion, atmospheric pressure change (such as in flying and diving), or physical trauma to the head and ears. A perilymph fistula due to a congenital abnormality of the inner ear should be suspected in children with unexplained hearing loss. If a perilymph fistula is suspected, an exploratory tympanotomy is the only way to make a definitive diagnosis. Fistula testing performed by changing the pressure in the external ear canal and middle ear while observing or recording eye movements for nystagmus may be positive. However, there is a high percentage of false negative test results and, therefore, fistula testing is not as reliable as an accurate history. If a perilymph fistula is found during surgical exploration and repaired with a tissue graft, it is likely that the vertiginous symptoms will be controlled; however, hearing may not return.
Paroxysmal Torticollis of Infancy
Paroxysmal torticollis of infancy7 is an unusual syndrome, characterized by head tilt with rotation of the head in the opposite direction. The infant may appear upset with pallor and vomiting at the onset, but later may seem quite comfortable unless an attempt is made to straighten the head. The episodes are brief and may recur over a period of several months or, occasionally, a few years.
Aside from the torticollis, physical examination is normal. It has been suggested that this disorder may be of vascular origin and may be the beginning of a progression from torticollis to benign paroxysmal vertigo of childhood to migraine.8 Another concept is that benign paroxysmal vertigo of childhood is related to gastric reflux. An entity known as Sandifer's syndrome9 has been described in which the reflux of acid gastric contents may irritate the esophagus and the hypopharynx causing torticollis. Because of this consideration, infants with torticollis should have esophageal pH studies.
Although rare, Meniere's disease may occur in children. 10,11 It has been reported in early elementary school-age children but is more likely to occur in children over age 10. The symptom complex of Meniere's disease in childhood is the same as it is in adults, but the incidence in children is at least 100 times less frequent. As in adults, the diagnosis of Meniere's disease in childhood is based on the classic triad of episodic rotatory vertigo, sensorineural hearing loss, and low-pitched tinnitus.
Meniere's disease is due to increased endolymphatic pressure called endolymphatic hydrops. Although the cause of the hydrops is not always known, it may be related to systemic problems such as glucose intolerance, hyperlipidemia, lues, and autoimmune disease. In a study of 14 children with Meniere's disease, nine were considered idiopathic and five were classified as secondary because their initial hearing loss followed a specific event such as mumps, meningitis, or temporal bone fracture. It has been proposed that the endolymphatic hydrops is due to an insult to the inner ear and that this insult may have occurred a relatively long time before the onset of symptoms.
Medical management consists of reassurance and a search for systemic diseases that might contribute to inner ear dysfunction. If the episodes of vertigo are disabling, dimenhydrinate in appropriate age-related dosage may be helpful as a vestibular suppressant. A low salt diet and a diuretic may also be considered. If dizziness becomes incapacitating despite all efforts, surgical decompression of the endolymphatic might be discussed with the family.
A head injury may lead to dizziness caused by labyrinthine concussion, temporal bone fracture, perilymph fistula, or cerebral concussion involving the anterior tip of the temporal lobe where there is vestibular representation. Immediately after an injury children may complain of dizziness but are less likely to do so than adults.12 After the physical examination and radiologic imaging study, an evaluation of hearing is important in making a diagnosis and prognosis. Labyrinthine concussion may produce a high frequency hearing loss that is difficult to document in a child. Hearing in this instance may be recovered. Temporal bone fractures may be transverse or longitudinal, and either may be accompanied by vestibular symptoms and cerebrospinal fluid otorrhea. Longitudinal fractures, however, are associated with a conductive hearing loss that may recover as healing takes place or may be surgically treatable, whereas transverse fractures may extend through the cochlea inducing a profound sensorineural hearing loss that will never clear. If cerebral concussion is suspected, a pediatric neurology consultation should be requested.
Regardless of the pathology found, children recover from vestibular insult much more quickly than adults because vestibular compensation is more rapid. It is wise to document the injury and the course of recovery by vestibular testing, especially if litigation is involved.
Migraine may be a more common cause of dizziness in children than previously suspected. n'15 Vertiginous symptoms may accompany classic basilar artery migraine with headache along with other signs and symptoms of brain stem dysfunction such as weakness, paresthesias, and diplopia. Dizziness may also occur in children with migraine-equivalent without headache. This is a reasonable diagnosis if there are signs and symptoms of brain stem ischemia and there is a significant family history of migraine. The symptom complex of migraine may be similar to that of temporal lobe epilepsy (called complex partial seizures). Motor phenomena may be present with either. Temporal lobe epilepsy is associated with some alteration in consciousness whereas migraine is not. Also, a family history of migraine suggests that diagnosis. Because recent studies indicate that migraine may be due to food allergy, an allergy study might be considered in the evaluaton of the child with severe headache or unexplained dizziness.
Additional Central Nervous System Disorders
Although rare in children, dizziness may be the presenting symptom of multiple sclerosis.16 This is estimated to happen in as many as 20% of cases, so this should be considered when evaluating the child with sporadic unexplained dizziness. Because of the remission pattern of the disease, the episodes may be brief, isolated, and ascribed to other causes. There are no associated auditory symptoms.
Dizziness accompanied by alteration or loss of consciousness suggests the possibility of the diagnosis of temporal lobe epilepsy, now called complex partial seizures. These patients have associated visceral and sensory complaints such as auditory or visual hallucinations. However, they do not have hearing loss or tinnitus. Currie17 found this in 12% of the patents under age 10 and 14% under age 1.5 in a large series. The incidence of vertigo in the series was 19%.
Additional central nervous system etiologic possibilities include temporal lobe or pontine tumors, cerebellar disease, and familial ataxia.
Other Diagnostic Considerations
In contemporary society there are many stresses and tensions affecting children such as divorce, custody battles, single parents, day care centers, and drugs. These pressures may account for vertiginous-like symptoms especially in the older child. Anxiety with hyperventilation may cause lightheadedness that is reported as dizziness. Recently there have been reports about a relationship between vestibular disorders and learning disability. In a thorough review of the entire subject, Silver18 concludes that at present there is no evidence supporting these vestibular theories.
There is no question that dizziness and vertiginouslike symptoms occur in children. The real difficulties lie in evaluating and managing the patient and the family. This article outlined differential diagnoses and some treatment options to facilitate this important task.
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