The document discusses vertigo in children and outlines different causes including developmental, traumatic, inflammatory, idiopathic, neurological, psychological, ocular, and systemic factors. It describes examination techniques for evaluating dizziness in children such as dynamic imbalance testing, static balance testing, posturography, and vestibular testing including VNG, rotary chair, and VEMPs. The investigation of vertigo in children aims to identify the affected system through history, physical examination, and targeted vestibular and other testing to confirm the diagnosis and direct appropriate treatment.

1. Vertigo In children
Mohamed I Shabana
Professor of Audiological Medicine
Cairo University

2. Vertigo in Children

3. Developmental
Children under the age of 4 months
- Tonic neck reflexes predominate
- These reflexes can be demonstrated by passive or active
motions of the head relative to the position of the body
- This reflex is due to movement of endolymphatic fluid
through the semiciruclar canals. These tonic neck
reflexes are dependent on the integrity of vestibular and
proprioceptive systems.
Neck righting: In this test active / passive rotation of head
from the midline to one side when the infant is lying supine
will cause a rotation of the whole body .

4. Developmental
4 - 6 months.
Babies in this age group vary in their
developmental achievements. Many normal
infants still have residual primitive tonic neck
reflexes, while in others, righting responses
will appear. Both these conditions are normal.

5. Developmental
6 - 18 months.
This is a period of rapid motor and sensory
development. The pyramidal tract becomes
myelinated. Integration of visual, labyrinthine
and proprioceptive stimuli occurs during this
phase. Righting reflexes are elicited by an
abrupt tilt of the patient to change the
patient's centre of gravity.

6. Developmental
Since the optical and vestibular righting responses
are identical the baby must be tested blind folded
in order to eliminate visual cues. The most
important of the righting reflexes is the head
righting response. This can be obtained by
picking up the infant from prone / supine position
and bringing it to upright position by tilting the
infant sideways, forwards or backwards. Every
abrupt change of the head position in space will
elicit vestibular head righting response. At the
same time propping reactions of the extremities
may be seen.

7. Prevalence of dizziness in children:
• The population-based prevalence of vertigo and dizziness
among school children has been reported to be 15%. In the
literature, vertigo in children has received much less
attention than vertigo occurring in adults. Even among
otologists and child neurologists, the key clinicians
providing appropriate diagnosis and treatment for
vertiginous children, the differential diagnosis is not well
established. The clinical picture of vertigo in children
deviates from vertigo in adults, since young children do
adapt very well to vertigo and dizziness and compensate a
vestibular deficit quicker than adults (Niemensivu et al.,
2006).

8. What is your complaint son ??
I am Dizzy

9. How are they Complaining??
• - Delayed walking
• - Clumsiness
• - nausea
• - episodic pallor and fatigue
• - difficulty walking in Darkness, or uneven
surface
• - Headache blurred vision
• - Difficulty reading in moving Vehicle
• - Gaze stabilization problems

10. • Vertigo in children differs from that in adults, because of
three main reasons.
• Firstly, vestibular disorders are often ignored in children,
because vertiginous manifestations are usually attributed to
lack of coordination or behavioural problems.
• Secondly, as children often lack the communication ability
to describe accurately their symptoms, diagnosis is based
less in history and much more in clinical examination and
laboratory investigations.
• Finally, although most diseases that cause vertigo in
adulthood occur in childhood as well, their frequency may
be different, depending on the age of the patient.

12. WHAT ARE OUR KEY ELEMENTS IN the
HISTORY??
Knowledge of the
Parents
causes
Investigations &
interpretation

13. Ravid,elal (2003)

15. Arabic Version of
Pediatric Dizziness Inventory Questionnaire
Presentation for discussion of a Thesis Submitted For Fulfilment of the Master Degree in Audiology
By:
Mariam Magdy Medhat
M.B., B. CH.
Supervisors:
Prof. Dr. Mohamed Ebrahim Shabana
Professor of Audiology,
Faculty of Medicine,
Cairo University
Dr. Abeir Osman Dabbous
Assistant Professor of Audiology,
Faculty of Medicine,
Cairo University
Dr. Noha Ali Hosni
Lecturer of Audiology,
Faculty of Medicine,
Cairo University,
Kasr El-Aini Faculty of Medicine
Cairo University,
2011

16. Aim of the work
• To develop an Arabic paediatric dizziness inventory
questionnaire for the parents of dizzy children to
address the balance complaints of their children by the
information gathered from it. This evaluation will help
to identify any balance dysfunction and to quantify the
impact of dizziness on daily living and to describe the
dizziness complaint, and helps to reach diagnoses of the
balance dysfunction in children and directs us towards
the necessary investigations to confirm this diagnosis.

21. Figure (2) : Distribution of the conclusion reached from the
questionnaire in the cases.
1 Vestibular
1 5%
1 5%
Cervical
5%
General
2
10%
Ocular
9
45%
General/CVS
1
5% Neurological/Ocular
1
5% Ocular/Cervical
3 Vestibular / CVS
15% 1
5% Non specific (Ocular/General/
Neurological/Audiological
association)

22. Figure (6): The ability of the questionnaire to match the diagnosis according to
the referral for different categories.
100%
90%
80%
70%
60%
Percentage
Not matching
50%
Matching
40%
30%
20%
10%
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23. Conclusions:
• We have developed an Arabic pediatric dizziness inventory questionnaire
for the parents of dizzy children. A scoring system has been developed to
address the balance complaints in children by the information gathered
from it. Evaluation of dizzy children using our Arabic pediatric dizziness
inventory questionnaire helped to identify balance dysfunction and was
able to categorize the dizzy children by the affected system/systems.
• The questionnaire and its scoring system were valid, being
comprehensive enough to collect all the information needed to address
the balance problem. The questionnaire was able to quantify the impact
of dizziness on daily living, to describe the dizziness complaint that
helped to reach a diagnosis of the balance dysfunction in children and to
direct the clinician towards the necessary investigations to confirm this
diagnosis.

24. Conclusions:
• The Arabic dizzy children questionnaire's categories matched
the diagnosis on referral in 75% of cases. The sensitivity of
the questionnaire in reaching the diagnosis was calculated at
75%. Its sensitivity in diagnosing vestibular category was
88.89%. The sensitivity in multi-system affection was 83.3%.
• The Arabic dizzy children questionnaire defined a matched
specific diagnosis for the cause of dizziness in 11/20 (55%) of
cases.

25. What are
you going
to do

26. •OBSERVATION

27. Low muscle tone
– Delay in holding head up
– “Snuggly” baby
– “Floppy baby”
– Arching of back

28. Delayed disappearance of newborn
reflexes
– Moro
– ATNR: Asymmetric tonic next response
– Usually disappear by 6-7 months

30. Delayed motor milestones
– Average deaf child walks at 14 months
– Average child with Usher’s Type 1 walks at 20 mos
– Delays sitting, crawling, climbing steps, hopping…
– Speech delays

31. What do older children look like?
• Clumsy
• Unable to walk on a balance beam
• Problems standing with feet together and eyes
closed (Romberg test)

32. What do older children look like?
• Love spinning, merry-go-rounds, water
activities
• Weak VOR: Challenges with reading
– Gaze instability causes problems with acuity

33. Signs of poor vestibular function
• Low muscle tone
• Delayed loss of primitive reflexes
• Delayed gross motor milestones
• Developmental delays
• Seizures
• Nystagmus
• Easy fatigability
• Torticollis

35. Causes of dizziness in children
A) Otologic:
 Congenital disorders:
 Syndromic hearing loss and vestibular dysfunction:
–
–
Usher syndrome
Pendred syndrome
Examination
– Enlarged vestibular Aqueduct syndrome
– Congenital Long-QT Syndrome
– CHARGE Syndrome
 Non-syndromic hearing loss and vestibular dysfunction
 Congenital anomalies of the skull base
 Traumatic disorders:
• Head Trauma
• Paroxysmal Positional Vertigo
• Perilymphatic Fistula
• Cochlear Implant Surgery History

36. Syndromes
Over 500 nDNA syndromes known to affect the
audiovestibular (AV) system.
• Usher’s Syndrome (Type 1)
• Waardenburg Syndrome
• Pendred syndrome
• CHARGE Syndrome
• Brachio-oto-renal syndrome

37. Retinitis pigmentosa
<>

38. Retinitis pigmentosa
http://www.blindness.org/content.asp?id=45

39. Waardenburg Syndrome
http://www.werathah.com/deafness/waardenburg.htm

40. Pendred Syndrome

41. CHARGE Syndrome
www.charrgesydnrome.org

42. Causes of dizziness in children
A) Otologic:
Inflammatory disorders:
• Otitis Media-related vertigo
• Chronic Suppurative Otitis Media and Cholesteatoma
•
•
Vestibular neuronitis
Labyrinthitis
Examination
• Bacterial meningitis
Idiopathic:
 Endolymphatic hydrops:
– Menière's disease
– Delayed endolymphatic hydrops investigation
 Motion Sickness
 Autoimmune Disorders
Post Cochlear Implant

43. Causes of dizziness in children
B) Neurological disorders:
 Migraine variants and complicated migraine :
1- Paroxysmal Torticollis
2- Cyclical Vomiting History
3-Basilar Artery Migraine
4-Familial Hemiplegic Migraine
5- Abdominal Migraine
Investigation
6- Idiopathic benign paroxysmal vertigo
 Migraine-associated dizziness
 Epilepsy
 Episodic ataxia
 Multiple sclerosis
 Vascular Occlusion investigation
 Brain tumors

44. Benign Paroxysmal Vertigo
• * Common un recognized condition
• * Paroxysm, Recurrent, non epileptic
• * Pale, Sweaty, Fearful, May sway
• * sudden onset, seconds to minutes duration
• * no loss of conscious, with complete
recovery
• * Diagnosed By exclusion
• * Migraine precursor

45. Causes of dizziness in children
C) Psychological dizziness
D) Ocular disorders
E) Systemic disorders (General causes)
F) oto-toxic drugs
Mainly History

46. Hearing Screening
Do we have Vestibular screening

49. How can we examine the children?

50. Investigation
• CT of temporal bone
• Vestibular testing
• Physical, occupational, ? cognitive therapies
• Genetic appointment
– Strongly consider testing for Usher’s mutations
• Vision evaluation
– ?ERG

51. Enlarged Vestibular Aqueducts

52. Ossification

53. Dynamic Imbalance Testing
VOR testing
• Head thrust maneuver
• Post-headshake nystagmus
• Dix-Hallpike maneuver
• Dynamic Visual Acuity
• Gait

55. Head Thrust test

56. Dynamic Visual Acuity

59. Posture Control and Gait

60. The Foam test

68. Static Balance Testing
Posturography •

69. Dynamic Stability in Walking
Gait Laboratory

70. Walking test

71. Vestibular testing
• Fukuda Stepping Test
• Vestibular Ocular Reflex Screening-Swivel
Chair with Video-oculographic (VOG)
Recording
• ENG/VNG
• Rotary Chair Testing
• VEMPs

72. ENG/VNG
Caloric irrigation: This test is performed only in
children aged 4 and older. Ideally performed
with the baby blind folded, in the supine
position, with the head ventroflexed at 30
degrees. The child is also restrained. A ten
second irrigation is a must for adequate
stimulus. Recording should start immediatly
after the onset of irrigation.

73. ENG/VNG
If the child is sleepy or irritable during the test
the response may not be accurate. This test
is a rather crude way of testing vestibular
response to a stimulus. This test is hence
performed only in cases of extreme doubts
regarding the function of vestibular apparatus.
Make it the last examination

74. ENG/VNG
There is a maturation pattern in the
development of caloric evoked nystagmus
response. The amplitude and the number of
beats increase in the first three months of
life. The intensity of the nystagmus is directly
proportional to the gestational age and the
weight at birth. The latency of the response
decreases with the gestational age
and increasing birth weight.

75. ENG/VNG
Optokinetic stimulation:
Optokinetic nystagmus can be evaluated in most
children within three to six months of
birth. As the child grows older, they learn to
pay more attention to the moving images and
better responses can be obtained in
them. This nystagmus can be recorded in
response to two speeds of rotation i.e. 3
degrees and 16 degrees per second.

76. ENG/VNG
The frequency, amplitude and speed of the slow
component can be analysed in response to the
two rotational speeds. The information
obtained is helpful in the evaluation of overall
quality of neurovestibular function.

82. DR. ABEIR OSMAN DABBOUS
Assistant Professor of Audiology,
Kasr El-Aini, Cairo University.

83. • The impairment of saccular function,
indicated by the abnormal findings in the
VEMP , is often associated with SNHL in the
pediatric population.
• With the increasing occurrence of pediatric
patients with symptoms of dizziness, VEMP
testing may be a means to evaluate unilateral
vestibular function (Honaker and Samy,
2007).

84. Vestibular evoked myogenic potential (VEMP)
inferior vestibular nerve
Saccule
medial vestibulospinal tract
accessory
nerve
ipsilatral SCM
The function of this sacculo-collic reflex is to stabilize the •
head in response to unpredictable displacements (Halmagyi &
Curthoys 2000).

85. VEMP Method
Surface Electrodes : •
Non-inverting active: middle third –
of each SCM muscle,
Inverting reference: supra-sternal –
notch, or at each sternal insertion
Ground: forehead. –

87. VEMP waveform
(Murofushi and Kaga, 2009).
Latency (in msec),
P1 latency decreases with increasing rate.

88. VEMP response
Waveform:
Latency (in msec), •
Threshold: (dBSPL) •
Amplitude (in μV), •
N23
Amplitude= 77.81uv
Our laboratory norms (mean 2SD) for the different
P13 studied VEMP parameters were:
N13 latency: 12.89 1.9 msec; •
P23 latency: 21.31 4.02 msec; •
P13-N23 latency Interval: 8.42 3.54 msec; •
P13-N23 amplitude Interval: 80.95 36.84 V; •
IAD: -0.01 0.16. (Dabbous, 2007). •

89. Amplitude (in μV),
• decreases with increasing rate above 5-Hz
• EP ratio or the inter-aural difference ratio (IAD):
[(Ar−Al)/ (Ar+Al), x 100],
• a ratio of > 3:1 abnormal

90. An example of Normal
IAD
N23
P13
= 23.0 Amplitude= 38.13 uv
= 14.6
Rt
IAD =0.023
Lt
P13 Amplitude= 39.94 uv
N23
= 15.2
= 22.2

91. N23 = 20.8
An example of
abnormal IAD
Amplitude= 77.81 uv
Rt
P13 = 12.2
N23 = 22.0
IAD = 0.45
Lt
Amplitude= 29.56 uv
P13 = 14.2

92. VEMP amplitude
depends on:
1. Saccular function
2. Stimulus intensity, air-conduction
3. Electrode conduction & location
4. Linearly increases with the EMG level

93. Clinical utility of VEMP testing :
sacculo-vestibular nerve function.
assessment of vestibular nerve function: .1
acoustic neuromas –
vestibular neuronitis –
multiple sclerosis –
diagnosis of superior semicircular canal dehiscence .2
syndrome,
evaluation of Menière's syndrome .3
Sensori-neural hearing loss. .4

94. VEMPs in a large Vestibular Aqueduct
Most common anomaly
Sudden fluctuation in pressure:
1. progression of SNHL after head trauma,
2. VEMP has greater amplitude and lower
threshold (Sheykholesami et al, 2004).

95. VEMP in diagnosis of
Superior Canal Dehiscence Syndrome
Rare •
a ‘third window’ : •
pseudo-conductive HL, ABG at –
low frequencies,
Tullio phenomenon of –
acoustically evoked vertigo &
nystagmus,
VEMP : –
increased amplitudes –
lowered threshold (70 dB) –
(Colebatch et al., 1998; Streubel et al., 2001
Brantberg et al., 1999; Ostrowski et al., 2001
Minor et al., 2003; Mikulec et al., 2004).

96. Chronic otitis media
• Chronic OM could delay and reduce the energy
transfer of sound to the inner ear.
• Improvement of postoperative VEMP response rate
and p13 latencies in the patients with and without
improvement in postoperative 500 Hz - ABG,
provide evidence that the sound energy inducing a
VEMP might be different from the energy producing
the auditory perception (Wang et al., 2008).

97. Migraine and its equivalents
• Migraine: the most common cause of episodic vertigo in
children.
• Allena et al., (2007) postulated that VEMP abnormalities in
migraine are due to reduced serotonergic control of the reflex
circuit, in particular of the vestibular nuclei.
• Benign Recurrent (Paroxysmal) Vertigo or benign
recurrent vertigo (BRV):
– a major cause of vertigo in children
– 30% have abnormal caloric responses,
– 50% have abnormal VEMP responses (Ozeki et al., 2008).

98. Our VEMP Studies: in Migraineurs
N23
normal P13
25%
N23
VEMP
abnormalities P13
75%
delayed
latencies of P13
and N23.

99. VEMPs in Children with Cochlear Implants
traumatic damage →
absent VEMPs or decreased
amplitude
With CI on:
electrical current spread at
C level, apical channels →
stimulates the IVN: present
VEMPs or absent VEMPs if
requiring higher current
present VEMPs >50% intensities, but difficult
(pain or facial nerve
stimulation) (Jin et
al., 2008).

100. Thank
you
all