Vertigo and Imbalance in Children: a Retrospective Study in a Helsinki

ORIGINAL ARTICLE Vertigo and Imbalance in Children A Retrospective Study in a Helsinki University Otorhinolaryngology Clinic

Niemensivu Riina, MD; Pyykkö Ilmari, MD; Erna Kentala, MD

Objective: To determine medical characteristics of chil- with data stored in the database and the SPSS program dren with vertigo who visited an otorhinolaryngology applied for statistical analysis. (ENT) clinic during a 5-year period. Results: Only 0.7% of children visiting the hospital Design: A retrospective chart review carried out be- during the 5-year period had vertigo. Benign paroxys- tween 2000 and 2004. mal vertigo of childhood, migraine-associated dizziness, vestibular neuronitis, and otitis media–related Setting: Helsinki University Central Hospital tertiary re- dizziness accounted for vertigo in most of the children. ferral center ENT clinic. Conclusions: Vertigo is a rare primary complaint of Subjects: A total of 119 children (63 girls and 56 boys), children in an ENT clinic. In achieving a diagnosis, the ranging in age from 7 months to 17 years (mean age, 10.9 most valuable tools are medical history, an otoneuro- years at examination). logic examination, electronystagmography, and audiography. Main Outcome Measures: Patients were identified from the ENT clinic database based on hospital discharge codes, Arch Otolaryngol Head Neck Surg. 2005;131:996-1000

N A STUDY OF A SCHOOL-AGED Benign paroxysmal vertigo of childhood population, 15% of children were is a migraine variant seen in younger chil- found to have experienced at least dren, and its clinical picture lacks head- 1 episode of vertigo in the previ- ache and thus differs from that of migraine- ous year.1 Earlier reports on associated dizziness in older children.8-10 causes of vertigo in children contain a Benign paroxysmal vertigo of childhood I 2,3 8 rather small number of cases. The dif- is not induced by head positioning and ferential diagnostic process is extensive in is thus in no way linked to benign parox- children with vertigo, and correct diag- ysmal positional vertigo, which is rare in nosis requires thorough otologic exami- children.5 nation as well as neurologic and general physical examination.2 If the primary com- CME course available at plaint is a brief sensation of vertigo re- www.archoto.com lated to movements of the head or the gaze, an ophthalmologist consultation is ben- 4 The aim of the present study was to eficial. Ocular disorders such as ver- evaluate the prevalence and characteris- gence anomalies can cause dizziness in tics of symptoms in children with vertigo children with normal vestibular func- 4 who visited the otorhinolaryngologic tion. The most common reasons for diz- (ENT) clinic at Helsinki University Cen- ziness in children are benign paroxysmal tral Hospital during a 5-year period to aid vertigo of childhood and migraine- Author Affiliations: 2,5,6 in the diagnosis of the conditions associ- associated dizziness. Otitis media– ated with these symptoms. Departments of related dizziness is also a leading cause for Otorhinolaryngology, Helsinki 3,7 University Central Hospital, vertigo in childhood. METHODS Helsinki (Drs Riina and Benign paroxysmal vertigo of child- Kentala), and Tampere hood is quite common but is seldom cor- University Hospital, Tampere rectly diagnosed owing to general practi- We conducted a retrospective chart review of (Dr Ilmari), Finland. tioners’ unfamiliarity with the condition. 119 children with a primary complaint of ver-

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©2005 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/28/2021 tigo seen in the Helsinki University Central Hospital ENT clinic between 2000 and 2004. All were identified from the ENT clinic Table 1. Diagnoses of 119 Children With Vertigo discharge codes (according to the International Classification of Diseases, 10th Revision). Most children were seen as outpa- No. of tients, and only a few needed hospitalization. We collected in- Diagnosis Children formation on the nature of the symptoms (acute or chronic, Benign paroxysmal vertigo of childhood 23 paroxysmal or continuous, attack severity, and number and du- Migraine-associated vertigo 17 ration of attacks), provocative factors, ear symptoms (aural full- Vestibular neuronitis 14 ness, tinnitus, pain, infections, ear operations, and/or hearing Otitis media–related dizziness 12 loss), other associated symptoms, head traumas, and other dis- Psychogenic vertigo 6 eases. We also collected data, when available, on laboratory and Vestibulopathy (unknown) 6 otoneurologic tests, imaging studies, and consultation docu- Posttraumatic vertigo 6 ments from other specialties: neurologic, ophthalmologic, and Inner ear irritation, sudden deafness 4 psychiatric. We also wanted to know about medical history, Labyrinthine hydrops 4 current medications, and family medical history. Tension neck 4 The vertigo diagnoses were based on standard published cri- Orthostatic hypotension 4 teria.8,11-14 For benign paroxysmal vertigo of childhood, we used Epilepsy-related vertigo 3 the Basser8 criteria, with sudden brief attacks of vertigo begin- Ménière’s disease 2 ning before school age. The attacks may be accompanied with Chronic cholesteatoma and surgery 2 nystagmus, nausea, and phonophobia or photophobia. Diag- Mal de barquement 1 nostic criteria used for migraine-associated dizziness required Benign paroxysmal positional vertigo 1 Autoimmune thyroiditis, with hypothyreosis 1 (1) recurrent vestibular symptoms, (2) migraine according to 11 Insulin shock–related vertigo 1 the International Headache Society criteria, (3) at least 1 mi- Sinusitis-related vertigo 1 grainous symptom during at least 2 vertiginous attacks (head- Chiari I malformation 1 ache, photophobia, phonophobia, and/or visual aura), and (4) Ataxia (genetic) 1 12 other causes ruled out by appropriate investigations. For Postoperative vertigo (after astrosytoma operation) 1 Ménière’s disease we used the criteria set by the American Acad- CATCH 22 syndrome 1 13 emy of Otolaryngology–Head and Neck Foundation, Inc, which Ophthalmic vertigo 1 requires 2 vertigo attacks lasting at least 20 minutes each, docu- Otitis media–related vertigo and migraine-associated vertigo 1 mented hearing loss, aural fullness or tinnitus, and exclusion Mononucleosis 1 of other possible causes. Labyrinthine hydrops diagnosis was Total 119 used for school-aged children with recurrent vertigo attacks and aural fullness or tinnitus but neither documented hearing loss Abbreviation: CATCH 22, cardiac defects, abnormal facies, thymic to fit Ménière’s disease diagnosis nor headache required for the hypoplasia, cleft palate, and hypocalcemia. migraine-associated dizziness. To diagnose benign paroxysmal positional vertigo we required typical case medical history and a positive finding in the Dix Hall- Table 2 14 audiogram ( ). An audiogram was unavailable pike maneuver. Vestibular neuronitis was diagnosed based on for 5 children. In 64 children who had undergone either sudden onset of severe rotatory vertigo, spontaneous horizontoro- tatory nystagmus, and lack of neurologic signs that could indicate magnetic resonance imaging or computed tomographic central nervous system involvement.14 We did not require a scans, no organic abnormality appeared that might ex- bithermal water caloric test since the vestibular function can re- plain the vertigo symptoms. In 7 children, imaging showed cover quickly in children when the vertigo symptoms cease.15,16 abnormalities (Figure 1; Table 3). From our resultant database we analyzed data with the SPSS Data on severity of vertigo were available for 113 chil- statistical program (version 11; SPSS Inc, Chicago, Ill). Some dren (95%): 3 (3%) reported that the vertigo was not dis- information was lacking; particularly, medical and family medi- turbing; 20 (17%) said that it was very disturbing; and cal histories were poorly documented. The study was ap- 90 children (76%) experienced vertigo as quite disturb- proved by the Helsinki University Hospitals ethics committee. ing. The duration and frequency of vertigo attacks are shown in Figure 2. RESULTS Of the ear disorders reported by 22 children (18%), most were recurrent middle ear infections or chronic middle ear effusion that led to grommet insertions in Our study group of 119 children (63 girls and 56 boys, rang- 16 children (13%). Three children (3%) had had ing in age from 7 months to 17 years; mean age, 10.9 years), recurrent otitis media without grommet insertion. was a little less than 1% of all children visiting the ENT Two children (2%) had congenital cholesteatomas, clinic from 2000 to 2004. Their mean age at onset of symp- which had been treated surgically. One child had had toms was 9.6 years (range of age at symtom onset, 7 months severe otitis media and mastoiditis, which was surgi- to 17 years). Age of onset of vertigo peaked at 9 to 15 years. cally treated as well. The most common causes of vertigo were benign parox- A child neurologist in the children’s hospital examined ysmal vertigo of childhood, migraine-associated dizzi- 90 (76%) of these children and found an abnormal neu- ness, vestibular neuronitis, and otitis media–related dizzi- rologic status in 14 (16%). Those with abnormal neuro- ness. For 6 children, the vertigo was psychogenic. The logic status had hypotonia, exceptional sway or balance distribution of diagnoses is summarized in Table 1. problems, difficulties with gross or fine motor skills, or dis- Most patients (77%; n=92) had normal audiograms played clumsiness. One child had intention tremor and tor- with no asymmetry and hearing thresholds equal to or ticollis; 1 had a congenital nystagmus; and 1 had spastic better than 20 dB; 22 patients (18%) had an abnormal diplegia, which was treated surgically and with physio-

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Patient Age, y/ Extent and Sex Type of HL Frequencies of HL Other Diagnosis 7/M Conductive Unilateral, low Otitis media–related dizziness 12/M Sensorineural Unilateral, all Sudden deafness 10/F Sensorineural Bilateral, all BPV (FAS syndrome) 17/M Sensorineural Unilateral, high Sudden deafness 16/M Combined Unilateral, high Posttraumatic vertigo 15/M Sensorineural Unilateral, high Posttraumatic vertigo 11/M Conductive Unilateral, all Choronic cholesteatoma ear 5/M Sensorineural Unilateral, high Sinusitis-related vertigo 15/M Sensorineural Unilateral, low Hydrops 15/F Sensorineural Bilateral, all Earlier hearing loss Vestibular neuronitis 8/M Conductive Unilateral, all Posttraumatic vertigo 14/M Combined Unilateral, all Posttraumatic vertigo 5/F Conductive Unilateral, all Chronic cholesteatoma ear 15/F Sensorineural Bilateral, high Chiari I malformation 17/M Sensorineural Bilateral, high Sudden deafness la 11/M Sensorineural Bilateral, all Hearing aid Otitis media–related dizziness and MAD 8/M Sensorineural Unilateral, high Postoperative after astrocytoma operation 13/F Sensorineural Bilateral, all CATCH 22 syndrome 13/F Sensorineural Unilateral, low Hearing fluctuation Ménière’s disease 16/F Sensorineural Unilateral, low Hearing fluctuation Ménière’s disease 17/F Combined Unilateral, all Otitis media–related dizziness 14/M Sensorineural Unilateral, all Otitis media–related dizziness

Abbreviations: BPV, benign paroxysmal vertigo; CATCH 22, cardiac defects, abnormal facies, thymic hypoplasia, cleft palate, and hypocalcemia; FAS, fetal alcohol syndrome; HL, hearing loss; MAD, migraine-associated dizziness.

Table 3. Abnormal MRI or CT Findings in 7 Children With Vertigo

Age, y/ Sex Finding Diagnosis 8/M Labyrinthitis in left ear* Otitis media–related vertigo 15/M Two fracture lines Posttraumatic vertigo in temporal bone 8/M Skullbase fracture Posttraumatic vertigo 15/F Chiari I malformation Vertigo due to Chiari I malformation 11/M Nonspecific postbleeding Otitis media– and migraine- sign related vertigo (perinatal hemiplegia) 8/M Postoperative condition Ataxia and balance problems (after astrosytoma after craniotomy surgery) 13/F Anomaly in the CATCH 22 syndrome semicircular canals†

Abbreviations: CATCH 22, cardiac defects, abnormal facies, thymic hypoplasia, cleft palate, and hypocalcemia; CT, computed tomography; MRI, magnetic resonance imaging. *Left vestibulum had a longitudinal gadolium-enhanced signal (Figure 1). †The lateral semicircular canals were saclike structures.

Figure 1. In this magnetic resonance image of an 8-year-old boy, the left vestibulum (arrow) shows a longitudinal gadolinium-enhanced signal. viously been operated on for strabismus; 3 had strabismus corrected with eyeglasses; 1 child with poor eye- therapy. Two children had hemiplegia, one after astrocy- sight had fetal alcohol syndrome; 1 had cranial nerve toma brain surgery and the other due to perinatal causes. paresis impairing eye movements after an astrocytoma An ophthalmologist examined 23 children who, based operation; and 1 child with light intolerance (nystag- on medical history, were thought to have eye-related prob- mus and vertigo) had a final diagnosis of migraine- lems. There were 12 normal and 11 abnormal findings: associated dizziness. Only 1 child’s vertigo was purely 1 child had congenital spontaneous nystagmus; 4 had pre- ophthalmologic in origin. He was a 10-year-old boy with

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©2005 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/28/2021 brief daily vertigo attacks provoked by reading and computer games. 35 Twenty-nine children had a history of occasional head- 30

ache. Travel sickness alone and travel sickness com- 25 bined with history of headache was present in 6 and 9 20 children, respectively. Epilepsy was diagnosed in 5 children. One child had type 1 diabetes mellitus and was un- 15 Chlidren, No. dergoing insulin therapy. One child had hearing loss and 10 received a hearing aid at age 5 years. One child had a Chi- 5

ari I malformation that caused vertigo. In addition, an 0 Seconds Less Than 1-20 min 20 min 4-24 h Days Constant 8-year-old child had VATER association (vertebral, anal, 1 min to 4 h tracheal, esophageal, and renal anomalies). One child had Duration CATCH 22 syndrome (cardiac defects, abnormal facies, thymic hypoplasia, cleft palate, and hypocalcemia), and 45 there was 1 child with fetal alcohol syndrome as well. 40 One had autoimmune thyroiditis with goiter requiring 35 thyroid hormone medication. 30 Only 24 children (age range, 6-17 years) underwent a 25 posturography test. Postural sway (eyes open and closed) 20 was not affected by the child’s age. Electronystagmogra- Chlidren, No. 15 phy (ENG) was performed or attempted in 79 children: in 10 6 of these, ENG was discontinued because of poor con- 5 0 centration or insufficient cooperation; in 61, the results were Once or Annually Monthly Weekly Daily Many Times Constant normal; in 12, results showed unilateral reduced vestibu- Twice in Life in a Day lar response (side difference Ͼ25%); and none showed bi- Frequency laterally reduced vestibular function. The diagnoses in children with unilateral reduced responses were sudden Figure 2. Duration and frequency of vertigo attacks. deafness, Ménière’s disease, posttraumatic vertigo, cholesteatoma, and vestibular neuronitis. However, 6 of the pa- (0.7%). According to a major epidemiologic study,1 there tients with vestibular neuronitis had normal findings on should have been many more children with vertigo. ENG, which was performed on average 14 weeks (range, We noticed that close cooperation between different 3-40 weeks) after the symptoms started. specialties is essential in establishing a diagnosis. Many Information on family medical history from patient of our study children (n=90; 76%) had first seen a pe- records was scanty and was available for only 58 pa- diatrician or child neurologist in the Children’s Hospi- tients. Migraine was present in 31 families among first- tal and had already undergone neurologic evaluations. degree relatives. Some also underwent magnetic resonance imaging and Of the 21 children sometimes experiencing tinnitus, electroencephalography. The children with vertigo who 3 had hearing loss or tinnitus after ear injury, and one also had hearing problems, tinnitus, or possible vestibu- 16-year-old girl had continuous tinnitus. Two children lar dysfunction, and those whose diagnosis was still un- previously had a head trauma that led to unconscious- clear as well as those with suspected migraine- ness. associated dizziness or benign paroxysmal vertigo of One 14-year-old boy fell and this forced a wooden stick childhood came to our clinic for consultation and ex- into his ear. Immediately after the trauma, he felt dizzi- clusion of an otogenic cause for their vertigo. ness and nausea and had hearing loss in the affected ear. During the last 2 years of the study, these children were In the hospital, he received intravenous antibiotics, pain seen mainly by the otoneurologist at the ENT depart- medication, and corticosteroids. Examination and explo- ment. The children were thoroughly examined and evalu- ration of the ear showed a small perforation in the poste- ated by audiogram, tympanometry, and ENG whenever rior side of the tympanic membrane and a piece of wooden required. Patient medical history was the most important stick in the middle ear and in the vestibulum as well. There diagnostic tool, but unfortunately, information on impor- was a clear perilymphatic fistula, which was treated sur- tant details of patient and family medical histories were gically. He recovered from vertigo after a few months; ENG often missing from medical records. The positive effect of showed no caloric responses in the injured ear, and hear- our study in the clinic was that a more thorough medical ing was very poor in the injured ear as well. history was obtained with our structured approach. Our university hospital will soon start using electronic medical records, which can offer fill-in forms for patients with COMMENT vertigo. This will eventually help in the compilation of a structured medical history for these patients, data trans- Our aim was to evaluate the prevalence and character- fer, and cooperation between specialties. istics of 119 children with vertigo visiting our ENT clinic Otitis media with effusion (OME) is one of the most during a 5-year period. Among the 16 050 children (aged common causes of balance disturbance in children.3,5 The 17 years or younger) who visited the clinic during that symptoms resolve following ventilation of the middle period, the children with vertigo made up less than 1% ear.17-19 The exact mechanism of balance disturbance in

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©2005 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/28/2021 OME is unknown. Pressure changes within the middle associated dizziness, followed by vestibular neuronitis and ear20 and serous labyrinthitis17 have been suggested to be otitismedia–relatedvertigo.Inachievingadiagnosis,themost responsible for vestibular disturbances in children with valuable tools were medical and family history, otoneuro- OME. Children with OME are more visually dependent logic examination, ENG, and audiography. for balance than are healthy children. They also have in- creased postural sway in the context of moving visual Submitted for Publication: March 4, 2005; final revi- scenes, especially at higher-frequency stimulus (0.25 Hz) sion received May 20, 2005; accepted May 25, 2005. measured by root-mean-square calculation.21 Develop- Correspondence: Erna Kentala, MD, Department of Oto- ment of vestibular and balance function in children with rhinolaryngology, Helsinki University Central Hospital, recurrent or chronic OME may be impaired even after PB 220, 00029 HUS, Helsinki, Finland (Erna.Kentala an episode of OME. Early intervention is therefore rec- @hus.fi). ommended.22 In our study, only 1 child with otitis media– Financial Disclosure: None. related vertigo had undergone posturography testing, so no conclusions can be drawn. REFERENCES One study of 31 children with medically unex- 1. Russell G, Abu-Arafeh I. 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