Vertigo
Vertigois a disturbance of spatial orientation in which individuals havethe sensation that they or their surroundings are moving. Abnormalvestibular function, either in the peripheral or central nervoussystem, produces vertigo.Peripheral vestibular system includesutricle, saccule, semicircular canals, and vestibular nerve. Cerebellum,cerebral hemispheres, vestibular nuclei in brainstem, and connectionsbetween these structures constitute central vestibular system.Clinical problem is to determine whichprocess is affecting what portion of vestibular system. Principal Causes of Vertigo
- Peripheralvestibular dysfunction
- Labyrinthitis
- Motion sickness
- Head trauma
- Drugs
- Benign paroxysmal vertigo
- Vestibular neuronitis
- Middle ear and temporal bone masses
- Perilymphatic fistula
- Ménière disease
- Central vestibular dysfunction
- Head trauma
- Intracranial infection
- Seizure disorder
- Basilar artery migraine
- Neoplasm
- Psychologic disturbance
Clinical Features and Diagnosis
Peripheral Vestibular Dysfunction
Labyrinthitis
Acute otitismedia is most common cause of labyrinthitis in childhood. The infection mayextend directly into labyrinth, or inflammatory toxins may causelabyrinthine disturbance.Viral infections (e.g., mumps, measles,and infectious mononucleosis) also may cause labyrinthitis.History of infection followed by vertigoand hearing loss suggests diagnosis. Exam often reveals spontaneousnystagmus with fast component directed toward normal ear. Motion Sickness
Can occur with land, sea, or air travel.Nausea and vomiting are common findings, but vertigo and nystagmusalso can occur.
Head Trauma
May causelabyrinthine injury with or without temporal bone fracture.Frequent findings are falling towardaffected side and hearing loss.Skull radiography and CT of temporalbone are useful in diagnosis. Caloric testing usually reveals decreasedlabyrinthine response on affected side. Drugs
Several drugs, including aminoglycosides,ethacrynic acid, and quinine, may cause hearing loss, but rarelyvertigo.
Benign Paroxysmal Vertigo
Usuallyoccurs in children 2–6 yrs and is characterized by recurrentepisodes of vertigo that occur without warning.Child appears pale, anxious, and unableto maintain upright position.Nystagmus also may occur.Results of neurologic exam are normalbetween episodes. Vestibular Neuronitis
Most frequentcause of vestibular neuronitis, which usually occurs in adolescents,is viral upper respiratory infection.Onset is acute, with nausea, vomiting,vertigo, and nystagmus. Hearing loss does not occur.Episodes are self-limited but may recur.Caloric stimulation produces decreasedor absent response on affected side. Middle Ear and Temporal Bone Masses
Middle earand temporal bone masses (e.g., cholesteatoma and acoustic neuroma) maydamage labyrinth and produce vertigo and hearing loss.CT and MRI locate mass and define itsextent.See Bellet et al. (1992) for furtherdiscussion. Perilymphatic Fistula
Head trauma or sudden change in barometricpressure (flying or diving) may cause rupture of round or oval windowinto vestibule, creating fistula and producing vertigo and hearingloss (see Chap. 26, Hearing Lossand Deafness).
Ménière Disease
Uncommon disorder in children characterizedby recurrent episodes of vertigo, fluctuating hearing loss, andtinnitus. Caloric testing usually reveals reduced vestibular responseon involved side.
Central Vestibular Dysfunction
Head Trauma
Concussion or brain contusion with shearingforces may damage vestibular nuclei and produce vertigo. Calorictesting reveals diminished caloric responses.
Intracranial Infection
Vertigo may sometimes occur with meningitis,encephalitis, and brain abscess. These disorders are discussed in Chap. 3, Alteration in Consciousness.
Seizure Disorder
Vertigo may occur as part of initial manifestationof complex partial seizure.
Basilar Artery Migraine
In this type of migraine, vertigo may precedeor accompany throbbing occipital headache (see Chap. 25, Headache).
Neoplasm
Posteriorfossa tumors may cause vertigo, ataxia, and nystagmus, whereas brainstem gliomasmay cause vertigo, double vision, hearing loss, nystagmus, and cranialnerve dysfunction (III–VIII).MRI is diagnostic study of choice.Histologic diagnosis is definitive. Psychologic Disturbance
Anxiety,depression, conversion reaction, or malingering may produce vertigo.History and physical exam suggest diagnosis.Results of vestibular function testing, electroencephalography,and CT are normal. Diagnostic Approach
Once presenceof vertigo has been established, next step is to determine whetherdisturbance is in peripheral or central vestibular system or whetherit is psychologic.Important information is age of child;whether vertigo is acute, recurrent, or chronic; presence of hearingloss, ear pain, or tinnitus; and any history of recent trauma ordrug ingestion.Complete physical exam should be performed,focusing on otologic and neurologic exams.Vertigo caused by disturbance of peripheralvestibular system often occurs suddenly, lasts short time, and isunassociated with loss of consciousness. Sudden change in head positionfrequently precipitates episode. Nausea, vomiting, tinnitus, hearingloss, and swaying or falling toward affected side are common findings.Nystagmus is inhibited by visual fixation and may change with headposition.Disturbance in central vestibular systemcan cause recurrent or chronic vertigo, which may be accompaniedby cranial nerve deficits, pyramidal signs, and cerebellar signs.If nystagmus occurs, it does not change with head position, noris it inhibited by visual fixation.The history and physical exam are diagnosticin many cases of vertigo. Audiologic testing or brainstem evokedresponses should be performed with suspected hearing loss.CT should be performed if there ishistory of acute head trauma. Otherwise, MRI is study of choiceif neuroimaging is indicated. Electroencephalography is useful ifseizures are suspected. References
- Aicardi J. Diseases of the nervous systemin childhood, 2nd ed. London: Mac Keith Press, 1998.
- Bellet PS, et al. The evaluation of ear canal, middleear, temporal bone, and cerebellopontine angle masses in infants,children, and adolescents. Adv Pediatr 1992;39:167–205.
- Benton C, Bellet PS. The ear and temporal bone. In:Ball WS Jr, ed. Pediatric neuroradiology. Philadelphia: Lippincott-Raven,1997:607–669.
- Cotton RT, Myer CM III, eds. Practical pediatric otolaryngology.Philadelphia: Lippincott-Raven, 1999.
- Eviatar L. Dizziness in children. Otolaryngol ClinNorth Am 1994;27:557–571.
- Eviatar L. Vertigo. In: Swaiman KF, Ashwal S, eds.Pediatric neurology: principles and practice, 3rd ed. St. Louis:CV Mosby, 1999:96–103.
- Fenichel GM. Clinical pediatric neurology: a signsand symptoms approach, 4th ed. Philadelphia: WB Saunders, 2001.
- Furman JS, Cass SP. Benign paroxysmal positional vertigo.N Engl J Med 1999;341:1590–1596.
- Teach SJ. Dizziness. In: Fleisher GR, Ludwig S, eds.Textbook of pediatric emergency medicine, 4th ed. Philadelphia:Lippincott Williams & Wilkins, 2000:217–222.
Book Source Details
- Book Title: The Diagnostic Approach to Symptoms and Signs in Pediatrics
- Author(s): Paul S. Bellet
- Year of Publication: 2006
- Copyright Details: The Diagnostic Approach to Symptoms and Signs in Pediatrics, Copyright © 2006 Lippincott Williams & Wilkins.
Other Book Chapters Related to Balance symptoms
Read excerpts from these other book chapters related to Balance symptoms:
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- "In A Page: Pediatric Signs and Symptoms" (2007)
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- "Handbook of Signs & Symptoms (Third Edition)" (2006)
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- "The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter" (2000)
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- "Signs & Symptoms: A 2-in-1 Reference for Nurses" (2007)
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- "The Diagnostic Approach to Symptoms and Signs in Pediatrics" (2006)
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- "Nursing: Interpreting Signs and Symptoms" (2007)
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Copyright Details: The Diagnostic Approach to Symptoms and Signs in Pediatrics, Copyright © 2008 Williams & Wilkins.
More About Causes of Balance symptoms
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