VERTIGO
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
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