IN A STUDY OF A SCHOOL-AGED

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 children with vertigo who visited an otorhinolaryngology (ENT) clinic during a 5-year period. Design: A retrospective chart review carried out between 2000 and 2004. Setting: Helsinki University Central Hospital tertiary referral center ENT clinic. Subjects: A total of 119 children (63 girls and 56 boys), ranging in age from 7 months to 17 years (mean age, 10.9 years at examination). Main Outcome Measures: Patients were identified from the ENT clinic database based on hospital discharge codes, with data stored in the database and the SPSS program applied for statistical analysis. Results: Only 0.7% of children visiting the hospital during the 5-year period had vertigo. Benign paroxysmal vertigo of childhood, migraine-associated dizziness, vestibular neuronitis, and otitis media related dizziness accounted for vertigo in most of the children. Conclusions: Vertigo is a rare primary complaint of children in an ENT clinic. In achieving a diagnosis, the most valuable tools are medical history, an otoneurologic examination, electronystagmography, and audiography. Arch Otolaryngol Head Neck Surg. 2005;131:996-1000 Author Affiliations: Departments of Otorhinolaryngology, Helsinki University Central Hospital, Helsinki (Drs Riina and Kentala), and Tampere University Hospital, Tampere (Dr Ilmari), Finland. IN A STUDY OF A SCHOOL-AGED population, 15% of children were found to have experienced at least 1 episode of vertigo in the previous year. 1 Earlier reports on causes of vertigo in children contain a rather small number of cases. 2,3 The differential diagnostic process is extensive in children with vertigo, and correct diagnosis requires thorough otologic examination as well as neurologic and general physical examination. 2 If the primary complaint is a brief sensation of vertigo related to movements of the head or the gaze, an ophthalmologist consultation is beneficial. 4 Ocular disorders such as vergence anomalies can cause dizziness in children with normal vestibular function. 4 The most common reasons for dizziness in children are benign paroxysmal vertigo of childhood and migraineassociated dizziness. 2,5,6 Otitis media related dizziness is also a leading cause for vertigo in childhood. 3,7 is quite common but is seldom correctly diagnosed owing to general practitioners unfamiliarity with the condition. is a migraine variant seen in younger children, and its clinical picture lacks headache and thus differs from that of migraineassociated dizziness in older children. 8-10 is not induced by head positioning 8 and is thus in no way linked to benign paroxysmal positional vertigo, which is rare in children. 5 CME course available at www.archoto.com The aim of the present study was to evaluate the prevalence and characteristics of symptoms in children with vertigo who visited the otorhinolaryngologic (ENT) clinic at Helsinki University Central Hospital during a 5-year period to aid in the diagnosis of the conditions associated with these symptoms. METHODS We conducted a retrospective chart review of 119 children with a primary complaint of ver- 996

tigo seen in the Helsinki University Central Hospital ENT clinic between 2000 and 2004. All were identified from the ENT clinic discharge codes (according to the International Classification of Diseases, 10th Revision). Most children were seen as outpatients, and only a few needed hospitalization. We collected information on the nature of the symptoms (acute or chronic, paroxysmal or continuous, attack severity, and number and duration of attacks), provocative factors, ear symptoms (aural fullness, tinnitus, pain, infections, ear operations, and/or hearing loss), other associated symptoms, head traumas, and other diseases. We also collected data, when available, on laboratory and otoneurologic tests, imaging studies, and consultation documents from other specialties: neurologic, ophthalmologic, and psychiatric. We also wanted to know about medical history, current medications, and family medical history. The vertigo diagnoses were based on standard published criteria. 8,11-14 For benign paroxysmal vertigo of childhood, we used the Basser 8 criteria, with sudden brief attacks of vertigo beginning before school age. The attacks may be accompanied with nystagmus, nausea, and phonophobia or photophobia. Diagnostic criteria used for migraine-associated dizziness required (1) recurrent vestibular symptoms, (2) migraine according to the International Headache Society criteria, 11 (3) at least 1 migrainous symptom during at least 2 vertiginous attacks (headache, photophobia, phonophobia, and/or visual aura), and (4) other causes ruled out by appropriate investigations. 12 For Ménière s disease we used the criteria set by the American Academy of Otolaryngology Head and Neck Foundation, Inc, 13 which requires 2 vertigo attacks lasting at least 20 minutes each, documented hearing loss, aural fullness or tinnitus, and exclusion of other possible causes. Labyrinthine hydrops diagnosis was used for school-aged children with recurrent vertigo attacks and aural fullness or tinnitus but neither documented hearing loss to fit Ménière s disease diagnosis nor headache required for the migraine-associated dizziness. To diagnose benign paroxysmal positional vertigo we required typical case medical history and a positive finding in the Dix Hallpike maneuver. 14 Vestibular neuronitis was diagnosed based on sudden onset of severe rotatory vertigo, spontaneous horizontorotatory nystagmus, and lack of neurologic signs that could indicate central nervous system involvement. 14 We did not require a bithermal water caloric test since the vestibular function can recover quickly in children when the vertigo symptoms cease. 15,16 From our resultant database we analyzed data with the SPSS statistical program (version 11; SPSS Inc, Chicago, Ill). Some information was lacking; particularly, medical and family medical histories were poorly documented. The study was approved by the Helsinki University Hospitals ethics committee. RESULTS Our study group of 119 children (63 girls and 56 boys, ranging in age from 7 months to 17 years; mean age, 10.9 years), was a little less than 1% of all children visiting the ENT clinic from 2000 to 2004. Their mean age at onset of symptoms was 9.6 years (range of age at symtom onset, 7 months to 17 years). Age of onset of vertigo peaked at 9 to 15 years. The most common causes of vertigo were benign paroxysmal vertigo of childhood, migraine-associated dizziness, vestibular neuronitis, and otitis media related dizziness. For 6 children, the vertigo was psychogenic. The distribution of diagnoses is summarized in Table 1. Most patients (77%; n=92) had normal audiograms with no asymmetry and hearing thresholds equal to or better than 20 db; 22 patients (18%) had an abnormal Table 1. Diagnoses of 119 Children With Vertigo No. of Diagnosis Children 23 Migraine-associated vertigo 17 Vestibular neuronitis 14 Otitis media related dizziness 12 Psychogenic vertigo 6 Vestibulopathy (unknown) 6 Posttraumatic vertigo 6 Inner ear irritation, sudden deafness 4 Labyrinthine hydrops 4 Tension neck 4 Orthostatic hypotension 4 Epilepsy-related vertigo 3 Ménière s disease 2 Chronic cholesteatoma and surgery 2 Mal de barquement 1 Benign paroxysmal positional vertigo 1 Autoimmune thyroiditis, with hypothyreosis 1 Insulin shock related vertigo 1 Sinusitis-related vertigo 1 Chiari I malformation 1 Ataxia (genetic) 1 Postoperative vertigo (after astrosytoma operation) 1 CATCH 22 syndrome 1 Ophthalmic vertigo 1 Otitis media related vertigo and migraine-associated vertigo 1 Mononucleosis 1 Total 119 Abbreviation: CATCH 22, cardiac defects, abnormal facies, thymic hypoplasia, cleft palate, and hypocalcemia. audiogram (Table 2). An audiogram was unavailable for 5 children. In 64 children who had undergone either magnetic resonance imaging or computed tomographic scans, no organic abnormality appeared that might explain the vertigo symptoms. In 7 children, imaging showed abnormalities (Figure 1; Table 3). Data on severity of vertigo were available for 113 children (95%): 3 (3%) reported that the vertigo was not disturbing; 20 (17%) said that it was very disturbing; and 90 children (76%) experienced vertigo as quite disturbing. The duration and frequency of vertigo attacks are shown in Figure 2. 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 16 children (13%). Three children (3%) had had recurrent otitis media without grommet insertion. Two children (2%) had congenital cholesteatomas, which had been treated surgically. One child had had severe otitis media and mastoiditis, which was surgically treated as well. A child neurologist in the children s hospital examined 90 (76%) of these children and found an abnormal neurologic status in 14 (16%). Those with abnormal neurologic status had hypotonia, exceptional sway or balance problems, difficulties with gross or fine motor skills, or displayed clumsiness. One child had intention tremor and torticollis; 1 had a congenital nystagmus; and 1 had spastic diplegia, which was treated surgically and with physio- 997

Table 2. Deviant Audiometry Findings in 22 Children With Vertigo Patient Age, y/ Sex Type of HL Extent and 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 sign 8/M Postoperative condition (after astrosytoma surgery) 13/F Anomaly in the semicircular canals Otitis media and migrainerelated vertigo (perinatal hemiplegia) Ataxia and balance problems after craniotomy CATCH 22 syndrome 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. therapy. Two children had hemiplegia, one after astrocytoma brain surgery and the other due to perinatal causes. An ophthalmologist examined 23 children who, based on medical history, were thought to have eye-related problems. There were 12 normal and 11 abnormal findings: 1 child had congenital spontaneous nystagmus; 4 had previously been operated on for strabismus; 3 had strabismus corrected with eyeglasses; 1 child with poor eyesight had fetal alcohol syndrome; 1 had cranial nerve paresis impairing eye movements after an astrocytoma operation; and 1 child with light intolerance (nystagmus and vertigo) had a final diagnosis of migraineassociated dizziness. Only 1 child s vertigo was purely ophthalmologic in origin. He was a 10-year-old boy with 998

brief daily vertigo attacks provoked by reading and computer games. Twenty-nine children had a history of occasional headache. Travel sickness alone and travel sickness combined with history of headache was present in 6 and 9 children, respectively. Epilepsy was diagnosed in 5 children. One child had type 1 diabetes mellitus and was undergoing insulin therapy. One child had hearing loss and received a hearing aid at age 5 years. One child had a Chiari I malformation that caused vertigo. In addition, an 8-year-old child had VATER association (vertebral, anal, tracheal, esophageal, and renal anomalies). One child had CATCH 22 syndrome (cardiac defects, abnormal facies, thymic hypoplasia, cleft palate, and hypocalcemia), and there was 1 child with fetal alcohol syndrome as well. One had autoimmune thyroiditis with goiter requiring thyroid hormone medication. Only 24 children (age range, 6-17 years) underwent a posturography test. Postural sway (eyes open and closed) was not affected by the child s age. Electronystagmography (ENG) was performed or attempted in 79 children: in 6 of these, ENG was discontinued because of poor concentration or insufficient cooperation; in 61, the results were normal; in 12, results showed unilateral reduced vestibular response (side difference 25%); and none showed bilaterally reduced vestibular function. The diagnoses in children with unilateral reduced responses were sudden deafness, Ménière s disease, posttraumatic vertigo, cholesteatoma, and vestibular neuronitis. However, 6 of the patients with vestibular neuronitis had normal findings on ENG, which was performed on average 14 weeks (range, 3-40 weeks) after the symptoms started. Information on family medical history from patient records was scanty and was available for only 58 patients. Migraine was present in 31 families among firstdegree relatives. Of the 21 children sometimes experiencing tinnitus, 3 had hearing loss or tinnitus after ear injury, and one 16-year-old girl had continuous tinnitus. Two children previously had a head trauma that led to unconsciousness. One 14-year-old boy fell and this forced a wooden stick into his ear. Immediately after the trauma, he felt dizziness and nausea and had hearing loss in the affected ear. In the hospital, he received intravenous antibiotics, pain medication, and corticosteroids. Examination and exploration of the ear showed a small perforation in the posterior side of the tympanic membrane and a piece of wooden stick in the middle ear and in the vestibulum as well. There was a clear perilymphatic fistula, which was treated surgically. He recovered from vertigo after a few months; ENG showed no caloric responses in the injured ear, and hearing was very poor in the injured ear as well. COMMENT Our aim was to evaluate the prevalence and characteristics of 119 children with vertigo visiting our ENT clinic during a 5-year period. Among the 16 050 children (aged 17 years or younger) who visited the clinic during that period, the children with vertigo made up less than 1% Chlidren, No. Chlidren, No. 35 30 25 20 15 10 5 0 45 40 35 30 25 20 15 10 5 0 Seconds Less Than 1 min 1-20 min 20 min to 4 h Duration 4-24 h Days Constant Once or Annually Monthly Weekly Daily Many Times Constant Twice in Life in a Day Frequency Figure 2. Duration and frequency of vertigo attacks. (0.7%). According to a major epidemiologic study, 1 there should have been many more children with vertigo. We noticed that close cooperation between different specialties is essential in establishing a diagnosis. Many of our study children (n=90; 76%) had first seen a pediatrician or child neurologist in the Children s Hospital and had already undergone neurologic evaluations. Some also underwent magnetic resonance imaging and electroencephalography. The children with vertigo who also had hearing problems, tinnitus, or possible vestibular dysfunction, and those whose diagnosis was still unclear as well as those with suspected migraineassociated dizziness or benign paroxysmal vertigo of childhood came to our clinic for consultation and exclusion of an otogenic cause for their vertigo. During the last 2 years of the study, these children were seen mainly by the otoneurologist at the ENT department. The children were thoroughly examined and evaluated by audiogram, tympanometry, and ENG whenever required. Patient medical history was the most important diagnostic tool, but unfortunately, information on important details of patient and family medical histories were often missing from medical records. The positive effect of our study in the clinic was that a more thorough medical 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 vertigo. This will eventually help in the compilation of a structured medical history for these patients, data transfer, and cooperation between specialties. Otitis media with effusion (OME) is one of the most common causes of balance disturbance in children. 3,5 The symptoms resolve following ventilation of the middle ear. 17-19 The exact mechanism of balance disturbance in 999

OME is unknown. Pressure changes within the middle ear 20 and serous labyrinthitis 17 have been suggested to be responsible for vestibular disturbances in children with OME. Children with OME are more visually dependent for balance than are healthy children. They also have increased postural sway in the context of moving visual scenes, especially at higher-frequency stimulus (0.25 Hz) measured by root-mean-square calculation. 21 Development of vestibular and balance function in children with recurrent or chronic OME may be impaired even after an episode of OME. Early intervention is therefore recommended. 22 In our study, only 1 child with otitis media related vertigo had undergone posturography testing, so no conclusions can be drawn. One study of 31 children with medically unexplained neurologic symptoms such as vertigo, dizziness, headache, and fainting showed a high psychiatric comorbidity rate. 23 Over 90% of the patients had at least 1 psychiatric disorder according to Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition criteria: depressive disorders were the most common, followed by conversion and somatization disorders. Emiroglu et al 23 recommend early psychiatric consultation in children with medically unexplained vertigo, dizziness, headache, and fainting. Our study included 6 children whose medical history and findings in examinations fit vertigo of psychogenic origin. These children had undergone many examinations by many different specialists. Finally a child psychiatrist confirmed the diagnosis. In our ENT clinic, peripheral causes of vertigo such as OME and vestibular neuronitis were common; these are also familiar to otologists. Benign paroxysmal vertigo of childhood and migraine-associated disease, leading causes of vertigo in our study, were diagnosed by typical symptoms and exclusion of other causes. Benign paroxysmal vertigo of childhood is characterized by brief and sudden episodes of vertigo during which the child may experience nausea, vomiting, nystagmus, and signs that are common in migraine such as pallor, phonophobia, and photophopia. The child is never unconscious during the attack and continues to play normally when the attack is over. Benign paroxysmal vertigo of childhood is considered a migraine equivalent 24 or migraine precursor. 25 Benign paroxysmal vertigo of childhood and paroxysmal torticollis of infancy are considered part of the periodic juvenile migraine disorders. 26 The diagnosis is based on typical medical history and exclusion of other causes of childhood vertigo. Migraine headaches and their variants or equivalents (benign paroxysmal vertigo of childhood, cyclic vomiting, and paroxysmal torticollis of infancy) are the most common episodic disorders of children. In addition, acephalic and acute confusional migraines have a clear relationship to more typical migrainous phenomena, and all of these migraine equivalents are relatively commonly seen in a neurology practice. 9 As many as 5% to 10% of children experience migraines. 10 In our study, children with benign paroxysmal vertigo of childhood and migraine-associated dizziness accounted for 34% of the cases. In conclusion, even though vertigo in children is not very rare,onlyafractionofthesechildrenareevaluatedbyanotolaryngologist. The most common diagnoses identified in the present study were benign paroxysmal vertigo and migraineassociated dizziness, followed by vestibular neuronitis and otitismedia relatedvertigo. Inachievingadiagnosis, themost valuable tools were medical and family history, otoneurologic examination, ENG, and audiography. Submitted for Publication: March 4, 2005; final revision received May 20, 2005; accepted May 25, 2005. Correspondence: Erna Kentala, MD, Department of Otorhinolaryngology, Helsinki University Central Hospital, PB 220, 00029 HUS, Helsinki, Finland (Erna.Kentala @hus.fi). Financial Disclosure: None. REFERENCES 1. Russell G, Abu-Arafeh I. Paroxysmal vertigo in children: an epidemiological study. Int J Pediatr Otorhinolaryngol. 1999;49(suppl 1):S105-S107. 2. Ravid S, Bienkowski R, Eviatar L. A simplified diagnostic approach to dizziness in children. Pediatr Neurol. 2003;29:317-320. 3. Blayney AW, Colman BH. Dizziness in childhood. Clin Otolaryngol. 1984;9:77-85. 4. Bucci MP, Kapoula Z, Yang Q, Wiener-Vacher S, Bremond-Gignac D. Abnormality of vergence latency in children with vertigo. J Neurol. 2004;251:204-213. 5. Bower CM, Cotton RT. 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