DEFINITION
The illusion of movement in which patient feels he is revolving (subjective vertigo ) or surrounding is revolving( objective)
 
Balance and coordination is determined by three main inputs
 
  • The vestibular contribution
  • Visual inputs
  • The sense of proprioception.
SYMPTOMS
 
HISTORY
  • Differentiate Vertigo from Dizziness (In older children, ask to compare symptoms to experiences like on merry-go-rounds)
  • Details of onset and duration
  • Frequency
  • Positional changes (worse in any particular position)
  • Recent drug intake
  • Hearing problems( Acoustic neuroma)
  • Blood pressure
  • Full neurological examination ( especially 8th cranial nerve)
CAUSES
 
Migrainous equivalents( About 25% cases)
  • Associated with headaches.
  • Nausea, vomiting and photophobia,
  • Can be several hours and more likely to occur when the child is tired.
Benign paroxysmal vertigo of childhood
  • Due to an interruption of blood supply to the brain.
  • Generally between the ages of 1 and 4 years
  • Recurrent episodes of  vertigo, nystagmus, ataxia and disequilibrium occur with a duration usually less than 10 minutes,
  • Consciousness is not affected.
  • Once the episode has passed, the child is able to return to normal activities immediately.
 Otitis media with effusion
  • History of increased balance problems and clumsiness in their children
  • Tinnitus/ Earache
Acoustic Neuroma
  • Tumour of 8th cranial nerve
  • Symptoms of sensory neural hearing loss
  • Mild intermittent vertigo /Tinnitus
  • Post auricular or suboccipital pain
  • +/- Facial nerve palsy
Benign Positional Vertigo
  • Due to debris in semi-circular canal
  • Worsening of head movement/ change in position
  • Temporary vertigo
Brain Stem Ischemia
  • Sudden, progressively worse vertigo
  • Ataxia, nausea, vomiting
  • High blood pressure
  • Deviation of eye towards lesion
  • Paraesthesia
Head Trauma
  • Persistent vertigo following trauma
  • Altered consciousness
  • Vision problems/ Diplopia
  • Signs of increased intracranial pressure
  • Seizure, motor/ sensory deficits
Herpes Zoster
  • Infection of the 8th cranial nerve
  • +/- Facial palsy
  • Herpetic vesicular lesion in auditory canal
  • Hearing loss
Labyrinthitis
  • Nausea/ vomiting
  • Sensory neural hearing loss
  • Nystagmus
Meniere’s disease
Criteria
  • Vertigo lasting 20 minutes or longer,
  • Tinnitus or aural fullness in the treated ear
  • Hearing loss on at least one occasion in audiometry, with other causes excluded.
Multiple sclerosis
  • Diplopia/ blurred vision
  • Paraesthesia
  • Muscle weakness/ spasticity
  • Hyper-reflexia, tremors
Seizures
Drugs- Salicylates/ aminoglycosides/ antibiotics/ Quinine/ contraceptives
Ear surgery
 
EXAMINATION
  • Tests for dorsal column function
  • Romberg and sharpened Romberg (standing with the feet in a tandem position with the eyes open and then closed).
  • The headshake, dynamic visual acuity and post-rotatory tests (vestibulo-ocular reflex) pathways
INVESTIGATIONS
  • Blood tests to rule out infections
  • Otoscopy
  • X ray involving middle and inner ear
  • Electroencephalography
  • Electro or video-nystagmography- (caloric irrigations, rotary chair, posturography and vestibular myogenic potentials).
INITIAL MANAGEMENT
  • If sudden onset, severe pain, trauma- refer to ophthalmologist immediately
  • Place patient in comfortable supine position
  • Darkroomm with minimum noise
  • Meclizine or dymenhydrinate
  • In Migraine equivalents- Identify triggers (ophthalmological, sleep quality, stressors).
  • Analgesics with anti-inflammatories.
  • In Benign paroxysmal vertigo of childhood- Parental counselling and support. Generally no treatment is necessary as most children improve by 8 years age.
  • In Otitis media- Refer to ENT for Grommets

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