Timothy C. Hain, MD Page last modified: April 9, 2016
Dizziness is a infrequent problem in children and accounts for only about 1% of visits to pediatric ENG clinics (Riina et al, 2005). Migraine and migraine variants are the largest single cause of dizziness in children.
As in the adult, children with dizziness may have:
- Ear disturbances (such as ear infection)
- Brain Disturbances (such as migraine, tumors)
- Medical Problems (such as low blood pressure)
- Psychological problems (such as teenagers seeking to avoid going to school)
- Have an unknown source of symptoms
Although dizziness is an unusual cause of a doctors visits, according to Niemensivu et al (2006), 8% of a large sample of children in Helsinki reported vertigo. This is higher than the 5% figure reported for "vestibular vertigo" in the general population. On the other hand, Erbeck et al (2006) stated that "vertigo rarely occurs during childhood despite its frequency in adults".
The most reliable data likely comes from Li et al (2016) who reported after examining the NHIS (n=10954), that roughly 5% of children (aged 3-17) had dizziness and balance problems. Of the 586 children with self-described dizziness or imbalance, only 33% of them had a diagnosis. Risk factors include developmental delay, hearing difficulties, visual disturbances, headaches, and being a teenager
Frequently the physician must rely on family members for the history. Things to ask about include
1). Loss of consciousness or change in appearance. This is suggestive of seizure or syncope.
2). Gait disturbance. This is suggestive of an ear or brain disturbance.
3). Loss of gross or fine motor skills. This is suggestive of a cerebellar disorder
4). Nystagmus (jumping of the eyes). This is strong evidence for an organic source of symptoms (i.e. not psychogenic), and also suggests that the child has either an ear or central source. Sometimes it is helpful to ask parents to bring in a video of their child's "darting" eyes.
5). Delayed motor milestones -- slowness to hold his or her head upright, crawl, stand, and then walk are suggestive of a vestibular disorder. (Gans, 2012)
|3 months||7 months||9 months||12 months||24 months|
|Raises head and chest when lying on stomach||Sits with and then without support of hands||Crawling on hands and knees||Sits without assistance||Walks alone by 18 mo|
|Starts to use eyes and hands in coordination||Supports weight on legs||Walking with assistance||Crawls forward on belly by pulling with arms and pushing with legs||Begins to Run|
|Begins to support head||Ability to track moving objects improves||Upper body -- turns from sitting to crawling position||Creeps on hands and knees and supports trunk||Can push a wheeled toy|
|Pushes down with legs when feet placed on floor||Rolls over||Pulls self up to standing position|
|Moves eyes in all directions||Supports head when sitting||Walks holding onto furniture|
|Sands momentarily without support|
As in the adult, examination of the dizzy child must consider the many possible causes of dizziness, which cut across many specialties. We use the same general format as in examination of adults. In children, however, the process is more difficult as the examination changes according to age, and the history is sometimes more difficult to elicit.
While all of the tests that one can do in an adult, can also be done in children, ones that require sustained attention or cooperation may be simply impractical.
We favor using testing modalities that are quick and highly productive, such as hearing testing (audiometry), OAE's, VEMP testing, and MRI imaging of the brain. Obviously, testing that requires cooperation such as VEMP testing, is generally impossible or uninterpretable in very young children.
We generally do not send children for rotatory chair or ENG testing, although these can be done with considerable effort. Should we send a child for a rotatory chair (i.e. if we suspected bilateral vestibular loss), we might simply confine it to the spinning portion itself. Similarly, in an ENG, we might limit it to the caloric portion as this is the main bit of information that may be impossible to get from the clinical examination.
Children with central vertigo
(Riina et al, 2005)
|# out of a total of 119 with vertigo seen in ENT setting (46 in total)||Percent found by Erbec, 2006||Percent found in Ravid, 2003|
|Benign paroxysmal vertigo of Childhood||23||12||16%|
Benign Paroxysmal Vertigo of Childhood, is a disorder of uncertain origin, possibly migrainous.
It's initials (BPV) are easily confused with those of Benign Paroxysmal Positional Vertigo (BPPV), but it is not caused by the same mechanisms. This disorder consists of spells of vertigo and disequilibrium without hearing loss or tinnitus (Basser, 1964). Attacks may occur anywhere between once/week and once/year. Attacks are unrelated to position or activity -- this can cause some confusion as it is not simply a childhood form of BPPV. There is no associated hearing loss, and there is no alteration of consciousness.
Choung et al (2003) reported it was the second most common cause of vertigo in children (25.5%) after migraine (30.9%). Ravid et al (2003) had similar results (16% vs 39%). Balatsouras et al (2007) reported BPV in 16.7%, and migraine in 20.4%
The majority of reported cases occur between 1 and 4 years of age, but this syndrome seems indistinguishable from benign recurrent vertigo (BRV, see following) in adults which is presently attributed to migraine, or so-called "vestibular Menieres", which is also attributed to migraine. The differential diagnosis includes Menieres disease, vestibular epilepsy, perilymphatic fistula, posterior fossa tumors, and psychogenic disorders.
ENG testing is variable, and we are unenthusiastic about doing ENG's in this population anyway as they are very difficult to test.
Chiari Malformation (type I).
Although Chiari malformations are present at birth, in most instances, symptoms do not develop till mid-life. Many Chiari malformations are found on MRI scanning, that have no clinical consequences at all. In patients who are symptomatic, they generally complain of progressive unsteadiness, posterior headache, and sometimes, trouble tracking. Rarely patients also have a syrinx (hole) in the cervical spinal cord and also complain of bands of numbness, generally without pain.
Migraine is the most common cause of dizziness in children (Riina et al, 2005; Choung et al, 2003).
It presents in two forms -- migraine associated vertigo (see here), and BPV (see above) Cyproheptadine is a drug commonly used in this population. Most migraine prevention drugs used in adults can also be used in children (e.g. topiramate), but data is presently lacking as to the effectiveness of these approaches. Often no treatment other than education is the best option.
Migraine equivalents -- head banging, vomiting, abdominal pain, pyrexia, pallor and intermittent somnolence. As these children mature, these symptoms are replaced by more classic migraine symptoms.
Choung et al (2003) reported that migraine caused vertigo in only 30% of their 55 pediatric patients. Balatsouras et al (2007) reported that 50% of their children suffered from migraine, and 70% had motion sickness.
Multiple sclerosis is rare in children under the age of 10. The diagnosis is made in the same way that it is made in adults.
Paroxysmal Torticollis of Infancy may be a variant of BPV.
It consists of attacks where the head is tilted to one side. The child may be in no distress unless the head is straightened. It lasts, on average, 2-3 days. This syndrome may be related to utricular imbalance, or a 4th nerve palsy.
Other sources of central dizziness are much less common. It can be secondary to vascular events involving the cerebellum and brainstem, it may be a harbinger of dangerous associated conditions such as medulloblastoma of the cerebellum, cystic astrocytoma and brainstem glioma. Many other neurologic disorders may cause vertigo by disruption of the brainstem/cerebellar pathways such as the Chiari malformation. Patients with central vertigo are often distressed by ataxia, nausea, and illusions of motion for years.
Spasmus Nutans is defined to occur in childhood and is characterized by a pendular nystagmus, head-shaking, torticollis and ataxia. Typical onset is around 6 months of age. It usually resolves spontaneously in 1-4 years.
|Pendular nystagmus of Spasmus Nutans.|
Pseudotumor cerebri (benign intracranial hypertension).
This is a common disorder in which spinal fluid pressure is increased but without a tumor. Symptoms include headache, visual field loss (enlarged blind spot), nausea, vomiting, hearing loss and tinnitus. Diagnosis is generally obtained by ophthalmoscopy in which papilloedema is seen.
Vertiginous seizures are similar in children to those seen in adults.
They present as brief spells, with or without loss of consciousness (Tusa et al, 1990). They are common in children after closed head injuries (5-7%), and especially so in patients with brain contusions or intracranial hematoma. EEG is needed for diagnosis. In the case illustrated below, a child became dizzy, developed nystagmus, and briefly became unresponsive.
|EEG of child with a vestibular seizure. On the bottom right the electrical activity of the brain changes markedly (Tusa et al, 1990).|
Choung et al (2003) reported that seizures caused vertigo in only 2% of their 55 pediatric patients.
Brain tumors are extremely rare causes of pediatric vertigo, with a prevalence of only about 5/100,000. In children, tumors causing vertigo are nearly always (90%) of the brain itself. Tumors of the cranial nerve roots are rare. About 41% of all pediatric intracranial tumors are in the posterior fossa, and thus may cause dizziness or imbalance. Cerebellar tumors comprise nearly 85-90% of pediatric posterior fossa tumors, while brainstem tumors make up nearly all of the rest.
Choung et al (2003) reported that a CP angle tumor caused vertigo in only 2% of their 52 pediatric patients. Balatsouras et al (2007) similarly found only one patent out of about 50 (a medulloblastoma of the cerebellum).
Children with otologic vertigo
(Riina et al, 2005)
|# out of a total of 119 with vertigo seen in ENT setting (34 in total)||Percent of Balatasouras, 2007|
Otologic dizziness is a common type of dizziness in the children. The majority of patients have a positional nystagmus, and are diagnosed as having "BPV" for Benign positional vertigo. (Uneri and Turkdogan, 2003).
Generally speaking children do not have the classic nystagmus of posterior canal BPPV, but nevertheless some cases are reported -- for example Erbek et al (2006) reported 12% of their 50 pediatric patients had BPPV.
The term "BPV" is also used for "Benign Paroxysmal Vertigo", and there it means simply transient spells of spinning without audiological complaints. In adults, a similar syndrome might be called "vestibular neuralgia" and attributed to microvascular compression, or other processes that irritate the vestibular nerve.
Dizziness accompanying middle ear infections is another common otologic dizziness. This is treated with antibiotics and is rarely persistent or serious.
A monophasic self-limited condition typified by vertigo, nausea, ataxia and nystagmus. It is rarely reported in children -- it is rare under the age of 10, and adolescents are the most common pediatric group. About 5% of patients with vestibular neuritis are children. Both vertigo at rest and positional vertigo are often present. Spontaneous nystagmus differentiates this disorder from BPPV. Severe vertigo usually only lasts two to three days. This condition can be diagnosed by an ENG, which is possible in adolescents. Spontaneous nystagmus and unilateral weakness may be observed. As adolescents have a much higher prevalence of psychogenic vertigo, we are quick to obtain objective testing.
Choung et al (2003) reported that vestibular neuritis caused vertigo in only 2% of their 52 pediatric patients. Ravid et al reported 14% of their 62 pediatric patients.
Otitis media is one of the most common causes of imbalance in children.
Symptoms generally resolve following treatment of infection or insertion of a ventilation tube. Pressure changes within the middle ear and serous labyrinthitis have been suggested as potential causes. (Riina et al, 2005)
Lateral sinus thrombosis (of the brain) is an uncommon complication of chronic otitis media, in which a vein close to the inner ear becomes infected and clots. This causes symptoms both due to the infection and increase in pressure in the brain. Symptoms include ear pain, fever -- especially the "picket fence" pattern, papilledema, increased white cell count, anemia, emaciation. This is a very serious illness with a 15-36% death rate.
Because of the infection, patients may develop meningitis, cerebellar abcess, and septic emboli. Diagnosis can be made with CAT scan (with contrast), and/or MRI scan. Treatment is mastoidectomy and long term antibiotics.
Bilateral vestibular paresis is most commonly caused by exposure to ototoxic medications, particularly courses of gentamicin lasting 2 weeks or longer.
It may also be associated with congenital deafness due to inner ear malformation (such as the Mondini malformation). Outside of congenital malformations associated with bilateral deafness, this condition is extremely rare in children. This condition is diagnosed by ENG and rotatory chair testing.
Congenital syndromes with vestibular disturbances include (Gans, 2012)
- Usher (bilateral deafness, retinitis)
- Branchiootorenal (preauricular pits or tags, branchial cysts, hearing loss, abnormal kidney)
- Pendred (severe hearing loss, abnormal bony labyrinth, abnormal thyroid)
- Neurofibromatosis type 2 (bilateral vestibular nerve tumors)
- CHARGE (coloboma-heart-atresia-retarded-genital-ear)
- Marshall (saddle nose, myopia, early onset cataracts, short stature)
- Waardenburg (congenital hearing loss, pigment changes of iris, hair and skin, vestibular disturbances)
- Von Hippel-Lindau (hemangioblastoma, renal cell carcinoma)
Meniere's disease is rarely reported in children.
Only 2/119 patients were diagnosed as Meniere's in a study of dizziness in children by Riina et al (2005). Nevertheless, as there is no real litmus test for Meniere's disease, children with hearing loss, tinnitus and vertigo without other diagnoses may present from time to time.
As in adults, Meniere's disease is diagnosed mainly via a history of fluctuating hearing, aural fullness, tinnitus, and episodic vertigo. Vertigo lasts for hours.
There is a variant of Meniere's called "pseudo-Meniere's of childhood", in which children have typical symptoms but recover hearing completely. In our view, this is most likely a migraine variant.
Choung et al (2003) reported that Meniere's disease caused vertigo in only 4% of their 55 pediatric patients. Ravid et al (2003) found no cases of Meniere's in their 62 patients. Balatsouras et al (2007) reported only 1 case out of about 50 patients. Erbek et al (2006) found again only 1 of their 50 pediatric patients with Meniere's.
Rare in children in general, it is frequently found in children with congenital malformations of the inner ear such as the Mondini deformity or congenital abnormalities of the head (craniofacial anomalies). Other sources of fistula, as in adults, are head trauma, barotrauma. Erbeck et al (2006) reported one of their 50 dizzy patients had PLF.
A related disorder is labyrinthine fistula, due to chronic otitis media. These children have chronic draining ears and generally a mixed hearing loss.
Generally syphilis in childhood is congenital. A profound bilateral symmetrical sensorineural hearing loss is the most common presentation, without vestibular dysfunction. Accompanying symptoms of congenital syphilis are interstitial keratitis, notched incisors, frontal bossing, high arched palate, saber shins, nasal deformities, and mulberry molars.
Temporal Bone Fractures
|Longitudinal temporal bone fracture||Oblique temporal bone fracture|
About 7% of children admitted to the hospital with head injuries will have a temporal bone fracture. About 80% of them will be longitudinal. These result in hemotympanum (blood behind ear drum) without profound sensorineural hearing loss. However, there will be a temporary conductive hearing loss. The facial nerve is injured in about 20% of longitudinal fractures.
Transverse temporal bone fractures result in a profound sensorineural hearing loss. Vertigo is common in patients with transverse fractures. The mechanism of injury is normally a frontal or occipital blow.
Medical Dizziness in Children
Medical etiologies of dizziness are very diverse but mainly include hypotension and cardiac events, infection, low blood glucose, and medication. Here dizziness interfaces with syncope. Only 4 out of 119 children in the study of Rowena et al (2005) had orthostatic hypotension as a cause, but this statistic is likely low due to the setting in the ENT clinic.
Both occult cardiac arrhythmias and acute myocardial infarctions may manifest as dizziness. Orthostatic blood pressure changes and pulse changes are common in adolescents. Ravid et al (2003) reported orthostatic hypotension in 9% of their 62 pediatric dizzy patients, and syncope in 3%.
Medications are a common contributor to dizziness and ataxia. Centrally acting medications (antidepressants, seizure medications), and drugs that affect blood pressure are the most common sources.
Psychogenic Dizziness in Children
Psychogenic dizziness is uncommon in small children but is frequent in adolescents.
In the study of Riina et al (2005), 6 of 119 were diagnosed with psychogenic dizziness. Depression, conversion and somatization have been reported as the most common causes. (Emeriglu et al, 2004). In the author's experience, historical findings suggesting psychogenicity are inability to attend school in spite of a lack of objective findings on physical examination, and observation of unusual interactions with parents. Referral to adolescent psychiatry can be very helpful. Erbeck et al (2006) reported 10% of their 50 pediatric dizzy patients had "psychogenic vertigo".
One might argue that there is little difference between "unlocalized dizziness" and "psychogenic dizziness", in as much as neither condition has any objective features that might differentiate between one and the other.
Anxiety syndromes and panic syndrome often respond to treatment with benzodiazepines, but usually require larger doses than the amounts used for vestibular suppression.
At all ages, about 10-30% patients with dizziness will go undiagnosed or be diagnosed with a disorder that cannot be confirmed or localized with any objective methodology. In series with lower frequencies reported that this, one can often find that the authors used vaguely defined diagnoses as a substitute. Migraine associated vertigo is particularly problematic as migraine is a common condition in the population at large (about 10%). Similarly, post-traumatic vertigo is often unlocalized dizziness under another name. These patients usually need to be followed more closely than patients in whom a clear diagnosis is available. Empirical trials of medication, psychiatric consultation, and vestibular physical therapy may be helpful options.
Choung et al (2003) reported that 18.2% of their 55 pediatric dizzy patients were "unclassified". Balatsouras et al (2007) reported that 9.2% of their patients were "unknown".
Dizziness in children has diverse causes. Migraine is the most common source. The diagnostic process must distinguish between otologic, central, medical, and psychogenic etiologies. Furthermore, in a substantial fraction of patients, a clear etiology may not be determined.
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