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Diagnosis of Vertigo, benign paroxysmal, in childhood

Vertigo, benign paroxysmal, in childhood Diagnosis: Book Excerpts

• Differential Diagnosis - Vertigo
• History and physical examination - Vertigo
• History and physical examination - Vertigo
• History - Vertigo
• History - Vertigo
• Clinical Features and Diagnosis - Vertigo
• History and physical examination - Vertigo

Diagnostic Tests for Vertigo, benign paroxysmal, in childhood: Online Medical Books

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Vertigo: Differential Diagnosis
(In A Page: Pediatric Signs and Symptoms)

• Benign paroxysmal positional vertigo (BPPV)
  –Each episode lasts seconds to minutes
• Vestibular neuritis
  –Viral infection of the vestibular nerve
• Otitis media
• Migraine
  –Vertigo may precede, follow, or present with the headache and aura
• Acute labyrinthitis
  –Acute onset with nausea and vomiting
  –Lasts for days and slowly resolves
  –45% cluster with viral infections
• Posttraumatic
  –Perilymphatic fistula
  –Labyrinthine concussion
  –Associated with postconcussive syndrome
  –Worsened by change in head position, cough, sneeze, swallow, straining, and airplane travel
• Cerebellar tumors
  –Tumors may be associated with tinnitus, facial weakness, and nystagmus
• Toxins/drugs: Antibiotics (aminoglycosides), salicylates, alcohol, phenytoin, quinine, arsenic, tricyclic antidepressants
• Autoimmune: Collagen vascular disease, Wegener granulomatosis
• Posterior circulation dissection
  –Often associated with a history of neck extension or rotational injury
• Cerebellar hemorrhage: Acute onset of vertigo, headache, nausea, and vomiting
• Multiple sclerosis
  –Vertigo is the presenting symptom in 5%
  –Hearing loss rare
  –Most common in young women
• Temporal lobe or complex partial seizures
• Ménière disease
• Familial periodic ataxia syndromes
  –Recurrent bouts of vertigo brought on by emotional stress or physical exertion
• CNS infection: Syphilis, Lyme disease
• Motion sickness
• Vertigo mimics: Presyncope, disequilibrium from decreased vision or proprioception
• Psychogenic
  –Panic or anxiety disorder

Workup and Diagnosis

• History
  –Duration, headache, nausea, vomiting, worsening with activity or movement (postural hypotension, hyperventilation)
  –Nausea and vomiting are classically more prominent with peripheral vertigo
  –Associated neurologic deficits (extremity weakness, numbness, incoordination, dysarthria, diplopia, tinnitus, hearing loss, loss of consciousness)
  –Facial numbness/weakness
  –History of autoimmune disease, hyperlipidemia, stroke, migraine, seizure, cancer, prior ear surgery

• Physical exam may be normal in asymptomatic periods
• Cardiac and peripheral vascular examination for murmurs, arrhythmias, orthostatic changes in pulse and blood pressure (±ECG, Holter, Echo, Doppler)
• Nystagmus, truncal ataxia, and limb incoordination are sometimes found in cerebellar infarction or neoplasm
• Vertigo of a panic attack can sometimes be elicited by having the patient hyperventilate
• Dix-Hallpike maneuver: Rapidly lay the patient down from sitting allowing the head to hang over the side of the bed while turning to the left or right; positive test shows vertigo with rotatory nystagmus within 30 seconds; if the etiology is peripheral, the nystagmus shows extinction with positioning maneuvers
• MRI and MRA can help evaluate the posterior circulation

» READ BOOK EXCERPT ONLINE »

Source: In A Page: Pediatric Signs and Symptoms, 2007

Vertigo: History and physical examination
(Handbook of Signs & Symptoms (Third Edition))

Ask your patient to describe the onset and duration of his vertigo, being careful to distinguish this symptom from dizziness. Does he feel that he’s moving or that his surroundings are moving around him? How often do the attacks occur? Do they follow position changes, or are they unpredictable? Find out if the patient can walk during an attack, if he leans to one side, and if he’s ever fallen. Ask if he experiences motion sickness and if he prefers one position during an attack. Obtain a recent drug history, and note any evidence of alcohol abuse.

Perform a neurologic assessment, focusing particularly on eighth cranial nerve function. Observe the patient’s gait and posture for abnormalities.

» READ BOOK EXCERPT ONLINE »

Source: Handbook of Signs & Symptoms (Third Edition), 2006

Vertigo: History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))

Ask your patient to describe the onset and duration of his vertigo, being careful to distinguish this symptom from dizziness. Does he feel that he’s moving or that his surroundings are moving around him? How often do the attacks occur? Do they follow position changes, or are they unpredictable? Find out if the patient can walk during an attack, if he leans to one side, and if he’s ever fallen. Ask if he experiences motion sickness and if he prefers one position during an attack. Obtain a recent drug history, and note any evidence of alcohol abuse.

Perform a neurologic assessment, focusing particularly on eighth cranial nerve function. Observe the patient’s gait and posture for abnormalities.

» READ BOOK EXCERPT ONLINE »

Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006

Vertigo: History
(The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter)

The patient’s age, underlying comorbidities, and symptom classification category will help limit the diagnostic possibilities. Further specificity is gained by eliciting the following:

A. Temporal pattern. Are the symptoms episodic or continuous? If episodic, how long do they last? Peripheral origin vertigo is often intermittent and of sudden onset compared with the usual, more gradual onset of central vertigo. A continuous history suggests CNS pathology, drug or toxin effects, metabolic dysfunction, or psychiatric disease. BBPV episodes last less than a minute; vertebrobasilar transient ischemic attacks last minutes to an hour; Ménière’s disease persists 1 to 24 hours; and vestibular neuronitis or acute labyrinthitis continues several days.

 B. Precipitating or exacerbating factors. Has there been recent head trauma (implying perilympathic fistula) or viral illness (labyrinthitis)? What is the relationship to sudden head movement or turning over in bed (BPPV), coughing or sneezing (perilymphatic fistula), postural changes (orthostasis), exercise (arrhythmias), foods (salty meals exacerbating Ménière’s), walking and turning (multiple sensory deficits), micturition or pain (vasovagal reaction), and emotional upset (hyperventilation)?

C. Associated symptoms. Marked nausea, vomiting, diaphoresis, aural fullness, and recruitment (perception of sounds being too loud) are typical of peripheral vestibular disorders. Episodic vertigo associated with tinnitus and gradual (unilateral) hearing loss involving low frequencies preferentially suggests Ménière’s disease. Asymmetric weakness, cranial nerve or cerebellar dysfunction, diplopia, or dysarthria suggests brainstem or CNS disease. Headache, scotomata, or tunnel vision points to migraine. Numbness or paresthesias may indicate neuropathy contributing to multiple sensory deficits (Chapter 4.6). A single, abrupt episode of severe vertigo with negative Dix-Hallpike (DH) testing (section III.A) that gradually subsides over days implies labyrinthitis (if hearing is affected) or vestibular neuronitis (if hearing is unaffected). Mild vertigo with prominent tinnitus, unilateral hearing loss, and loss of corneal reflex is worrisome for an acoustic neuroma.

 D. Medications or toxins. Many medications can cause “dizziness,” although few (aminoglycosides, lead, mercury) cause vertigo. Assess toxin exposure by exploring job and recreational activities.

Physical examination (PE)

This will emphasize orthostatic vital signs, the eyes, ears, and neurologic and cardiovascular systems.

 A. Detection of nystagmus is critical because it is the only objective sign of vertigo (5). Nystagmus can occur spontaneously or in response to changes in eye or body position. Peripheral vestibular disorders usually cause horizontal or rotatory nystagmus, whereas CNS pathology is reflected by vertical nystagmus—an ominous sign. In true vertigo caused by BPPV, DH maneuvers will often confirm the diagnosis (sensitivity 60% to 90%, specificity 90% to 95%) (2,3). The patient is moved rapidly from a sitting to a supine position with the head turned at a 30-degree angle, first to one side and then to the other. A positive DH test includes precipitation of vertigo, latency of onset by a few seconds, rotational nystagmus, resolution within a minute, and lessened symptoms and nystagmus with prolonged latency on repeated testing (i.e., fatiguability). Lack of latency and fatiguability characterize vertigo caused by serious central lesions.

 B. Neurologic examination serves to detect brainstem or CNS pathology.

C. Otoscopy can detect otitis media or cholesteatoma. Nystagmus with vertigo following positive or negative pressure applied to the tympanic membrane (pneumatic otoscopy) suggests a perilymphatic fistula.

D. Other provocative tests (forced hyperventilation, vestibulo-ocular reflex testing, vigorous horizontal head shaking) are not routinely helpful.

» READ BOOK EXCERPT ONLINE »

Source: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, 2000

Vertigo: History
(Signs & Symptoms: A 2-in-1 Reference for Nurses)

Ask your patient to describe the onset and duration of his vertigo, being careful to distinguish this symptom from dizziness. Does he feel that he’s moving or that his surroundings are moving around him? How often do the attacks occur? Do they follow position changes, or are they unpredictable? Find out if the patient can walk during an attack, if he leans to one side, and if he has ever fallen. Ask if he experiences motion sickness and if he prefers one position during an attack. Obtain a recent drug history. Note any evidence of alcohol abuse.

» READ BOOK EXCERPT ONLINE »

Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007

Vertigo: Clinical Features and Diagnosis
(The Diagnostic Approach to Symptoms and Signs in Pediatrics)

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.

» READ BOOK EXCERPT ONLINE »

Source: The Diagnostic Approach to Symptoms and Signs in Pediatrics, 2006

Vertigo: History and physical examination
(Nursing: Interpreting Signs and Symptoms)

Ask your patient to describe the onset and duration of his vertigo, being careful to distinguish this symptom from dizziness. Does he feel that he's moving or that his surroundings are moving around him? How often do the attacks occur? Do they follow position changes, or are they unpredictable? Find out if the patient can walk during an attack, if he leans to one side, and if he has ever fallen. Ask whether he experiences motion sickness and if he prefers one position during an attack. Obtain a recent drug history, and note evidence of alcohol abuse.

Perform a neurologic assessment, focusing particularly on eighth cranial nerve function. Observe the patient's gait and posture for abnormalities.

» READ BOOK EXCERPT ONLINE »

Source: Nursing: Interpreting Signs and Symptoms, 2007

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