otolaryngology texas children’s hospital
TRANSCRIPT
12/13/19
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Henri Traboulsi, MDOtolaryngologyTexas Children’s Hospital
Vestibular Disorders in Children:They Do Exist
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Goals of This Talk
1. Which patients will come to our clinic?
2. Differentiation diagnosis of dizziness in a child? Most common entities?
3. How can I identify a child with a potential vestibular problem?
4. What can I do to screen for vestibular problems?
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The otolith organs
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The semicircular canals
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Dizziness in children is not uncommon
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• Questionnaire applied to 2,165 children
• 314 reported having experienced at least 1 episode of dizziness (14%)
• 44% of which was unexplained or undiagnosed
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5.7% rotary vertigoChildren aged 10
8% vertigo or imbalanceChildren aged 1-15
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Vertigo affects the quality of life of children
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• KIDSCREEN-52 questionnaire
• 32 kids
• Age 8-18
Neuropediatrics
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DizzinessVertigo
Imbalance
Congenital hearing
loss
Migraine/Migraine variants
Ear diseaseConcussion
CNS
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DizzinessVertigo
Imbalance
Congenital hearing
loss
Migraine/Migraine variants
Ear diseaseConcussion
CNS
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Vestibular impairment in children with HL
20-70%
Arnvig et al, 1955 Goldstein et al, 1958 Sandberg et al, 1965
Seems to correlate with degree of hearing loss
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35 patients with CI failure vs 165 without failure
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Vestibular dysfunction and imbalance increases the risk
of CI failure by 8X!!!
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Take Home Messages
• Vestibular dysfunction is very common in patients with hearing loss
• It is important to screen these patients for vestibular impairment
• Might have significant implications for treatment, gross motor development, CI
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DizzinessVertigo
Imbalance
Congenital hearing
loss
Migraine/Migraine variants
Hearing loss
Concussion
Inner ear disease
CNS
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Concussion and Dizziness
• Dizziness is the only on-field symptom that is predictive of a prolonged recovery from pediatric concussion
• 6-fold increase in developing PCS
Guerriero et al, 2012
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Brodsky et al., Otolaryngol Head Neck Surg.2018
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DizzinessVertigo
Imbalance
Congenital hearing
loss
Migraine/Migraine variants
Ear diseaseConcussion
CNS
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The “Vestibular March”
Benign Paroxysmal Torticollis of Infancy
Benign paroxysmal Vertigo of Childhood
Vestibular Migraine15.4%
Brodsky et al, 2018
42%
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Benign Paroxysmal Torticollis of Infancy
Benign paroxysmal Vertigo of Childhood
Vestibular Migraine
Benign Paroxysmal Torticollis of Infancy
Recurrent episodes of head tilting and
imbalance in infants and toddlers
The Migraine Variants
Brodsky et al, 2018
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Benign Paroxysmal Vertigo of Childhood
• Brief sudden, severe attacks of vertigo/imbalance
• Minutes to hours
• Without warning
• Spontaneously resolves
• No LOC
Benign Paroxysmal Torticollis of Infancy
Benign paroxysmal Vertigo of Childhood
Vestibular Migraine
The Migraine Variants
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Benign Paroxysmal Torticollis of Infancy
Benign paroxysmal Vertigo of Childhood
Vestibular Migraine
The Migraine Variants
Diagnostic CriteriaA. At least 5 episodes fulfilling criteria C and DB. A current or past history of 1.1 Migraine without aura or 1.2
Migraine with auraC. Vestibular symptoms of moderate or severe intensity,
lasting between 5 minutes and 72 hoursD. At least half of episodes are associated with at least 1 of the
following 3 migrainous features1. Headache with at lest 2 of the following 4 characteristics:
a) Unilateral locationb) Pulsating qualityc) Moderate or severe intensityd) Aggravation by routing physical activity
2. Photophobia and phonophobia3. Visual aura
E. Not better accounted for by another ICHD-D diagnosis or by another vestibular disorder
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DizzinessVertigo
Imbalance
Congenital hearing
loss
Migraine/Migraine variants
Ear diseaseConcussion
CNS
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Ear Disease
• Middle ear effusions
• Complicated otitis media
• BPPV
• Meniere’s disease
• Vestibular neuronitis
• Trauma
• Cholesteatoma
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What are the typical symptoms of a vestibular dysfunction?
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Imbalance Dizziness
Vestibular Dysfunction
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What can you do as an initial evaluation for these patients?
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Presenting Symptoms• Clumsy/uncoordinated
• Frequent falls
• Strange behavior
• Fear and panic
• Head hanging/tilt
• Learning disability
• Difficulty reading
• Difficulty ambulating in the dark
• Periodic nausea and vomiting
• Clutching to parents
• Unable to ride a bicycle
• Weird eye movement
Seizures Tics Strabismus Developmental delay
“Labels”
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Motor Milestones
Head control(6w è 3m)
Sitting unsupported(6m è 9m)
Walking(12m è 15m)
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Vestibular Testing in Children
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cVEMP
oVEMP
CaloricsRotary chair
vHIT
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Vestibular testing does not give us a diagnosis
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