The diagnosis of pediatric vertigo is extremely important. In early childhood, children often come to the clinic with the main symptom of falling easily, but by observing the course of the disease, it is sometimes found that it is actually caused by a brain tumor penetrating the brain ventricle. The types of disease and clinical manifestations of the disease are different for each age group, so it is necessary to summarize the disease in each age group.
Peripheral or inner ear vertigo, such as Meniere’s disease, vestibular neuronitis and benign paroxysmal vertigo, which are common in adults, are almost invisible in children. In this article, we would like to introduce the problems that should be noted in the diagnosis of pediatric vertigo and the characteristic changes during the examination.
I. Characteristics of pediatric vertigo
According to the main symptoms, pediatric vertigo can be divided into three main categories: sensory abnormalities (peripheral and central), motor balance abnormalities due to balance disorders (abnormal vagus damage of postural recovery reflexes and postural reflexes, involuntary movements, increased or decreased muscle tone), and other abnormalities of motor regulation (postural adjustment disorders, psychiatric, etc.).
It is only in early childhood that children report vertigo, eye rolling, and a sense of rotation when an earthquake arrives. This is because the vestibular cerebellum, which is responsible for balance, is not mature until the age of three. As to whether there is any abnormality in balance function, we need to make a comprehensive judgment based on the age of the child, the maturity of the central nervous system, the peripheral balance sensory apparatus, the degree of myelination and maturation of the central nervous system, and the gross and fine movements that can be accomplished at each age.
Diagnosis of neonatal and lactation period
During the neonatal and nursery periods, it should be noted that the primitive reflexes will gradually disappear as they grow and develop, such as the hug reflex. If the reflex is not induced at an age when it can be induced, or if it is induced at an age when it should not be induced, it should be suspected that there is a developmental disorder of motor function. The development of gross movements such as head stability and fine movements such as grip should be checked in early childhood to determine whether there is any abnormality. In addition, the postural recovery reflex can be used to evaluate the sense of balance and the ability to maintain posture.
Diagnosis in early childhood
In early childhood, special attention should be paid to brain tumors, especially cerebellar and brainstem tumors, as well as meningitis, cerebellitis, inner otitis in combination with otitis media, and acute cerebellar ataxia. In particular, brain tumors often have vertigo and fall easily as the first symptoms.
In addition, children with inner ear malformations often complain of unexplained falls and go to orthopedic surgery or neurosurgery, and then to otolaryngology to confirm the diagnosis.
In cases of recurrent vertigo with deafness, it is important to consider the possibility of vestibular aqueduct syndrome, which can be easily diagnosed by CT.
Pediatric benign paroxysmal vertigo is a special type of vertigo in this period. It occurs in children between 1 and 4 years of age, with paroxysmal attacks that last from a few seconds to a few minutes, with rotational vertigo and a clear tendency to fall. It is thought to be related to the mechanism of migraine, which may reflect a state of ischemia in the vestibular nuclei from the pons to the medulla oblongata. The disease may resolve spontaneously over several months to years.
Diagnosis in school age
The most common type of vertigo in school-age children is the standing vertigo caused by postural hypotension, which is a disorder of postural circulatory regulation.
Some diseases with atypical symptoms, such as collar arthropathy, which is caused by abnormal occlusion leading to abnormal balance between the head and the spinal cord, may also manifest as vertigo, tinnitus, and migraine. Recently, there has been an increase in the number of psychogenic vertigo disorders in which the physical examination is unremarkable and the child simply refuses to go to school because of vertigo.
Dizziness is caused by the stimulation of the otolithic apparatus by back and forth, left and right, and up and down movements, and by the stimulation of the three semicircular canals by rotational movements, and is more likely to occur when these stimuli are present together. The vertigo is aggravated by the addition of visual stimuli. This is mainly due to the excitation of the vegetative nervous system, which causes nausea, head weight, and palpitations.
In this regard, the magnitude of the role of the vestibular cerebellum as an inhibitory factor of the vestibular and oculomotor systems is closely related to the development of vertigo. This can also be explained by the fact that infants with poorly developed inhibitory systems do not become intoxicated and that small amounts of alcohol can prevent motion sickness. Extra attention should be paid to hypotensive and allergic children.
Other organic solvents can also cause dizziness and balance disorders. For example, dye diluents and adhesives can cause toluene poisoning, which can damage the vestibular system and lead to balance disorders.
V. Congenital diseases
One of the congenital diseases is congenital nystagmus, although the cause is unknown, it is thought to be related to heredity, pregnancy, and trauma at birth. Clinical manifestations include visual impairment, strabismus, squint, scoliosis, and neurodevelopmental delay. Vision can sometimes be normal. Blind tests without knowledge of the disease may add to the mental burden of the child. Although there is no recognized effective treatment, repeated injections of mucosal anesthetics may be useful.
Malformations other than the inner ear that cause vertigo are mainly cerebellar malformations that cause balance and sensory disturbances. Cerebellar hypoplasia can cause a series of symptoms, such as dysgraphia, abnormal balance and sensation, and slow movement, but usually there is no neurodevelopmental delay, and it is sometimes difficult to diagnose this disease.
Acute vertigo
The common causes of acute vertigo in children include benign episodic vertigo caused by inner ear lesions, vestibular neuronitis, exolymphatic disease, Meniere’s disease, cervical bone fracture after head trauma, inner ear concussion, acute cerebellar ataxia caused by infection, etc. In addition, the development of otitis media from viral otitis media and the use of antibiotics such as minomycin can also lead to vertigo in the acute stage.
VII. Physical examination
The balance examination of children is basically the same as that of adults. However, sometimes it is difficult to do so because the child is not cooperative or the parents do not agree, so a detailed and accurate consultation with the parents is especially important for a correct diagnosis.
The pediatric examination should be performed in an appropriate sequence. Usually, the eye movements are observed first, followed by nystagmus examination at the specific lesion. The Romberg test and rotation test are also used to check for body shaking. If necessary, blood pressure and blood sampling should be performed.
As for the auditory system, the brainstem electrical response audiometry (ABR) is useful for the diagnosis of tumors, neurological disorders, and disorders of consciousness that are difficult to diagnose with CT and other imaging studies.
VIII. Prognosis and treatment
The basic principle of treatment is to remove the cause of vertigo. Antibiotics can be given for inflammation, and symptomatic treatment such as anti-vertigo drugs and antiemetics can be given. In case of persistent vertigo, a mixture of treatments (cocktail) can be applied to suit the symptoms. For example, dental clips can be placed for lower collar arthropathy. For psychogenic vertigo, psychotherapy is necessary, and integrated treatment of multiple departments is necessary.
Balance function training
For chronic balance dysfunction of the inner ear, rehabilitation training can be provided to promote the compensation and adaptation of balance function. For example, rehabilitation exercises such as Bobath, Jeane and Ayres can be performed. Regardless of the period, comprehensive training of visual, deep sensory and joint sensory is necessary.
The diagnosis of vertigo and balance dysfunction in children is based on the observation of the development of the motor system and the age of the child. The most important thing is that they should not be left unattended without any intervention.