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The labyrinth of the inner ear contains organs for both hearing and balance, and it is the focus for diagnosis and rehabilitation of vestibular disorders, including the spinning sensation of vertigo, in both children and adults.
In 2005, Finnish researchers determined the medical characteristics of children with vertigo who visited an otorhinolaryngology clinic over a 5-year period and concluded, "Vertigo is a rare primary complaint of children in an ENT clinic." 1
They conducted a retrospective chart review of more than 16,000 patients and found a total of 119 children with vertigo, or only 0.7% of children visiting the hospital. Benign paroxysmal vertigo of childhood, migraine-associated dizziness, vestibular neuronitis, and otitis media-related dizziness accounted for vertigo in most of the children.
Vestibular Disorders in Children: Signs, Symptoms and Causes
Vestibular disorders in children are not as easily recognized as in adults, in part because children can't verbally describe their symptoms as well.
According to the Vestibular Disorders Association (VEDA), the signs and symptoms indicating vestibular dysfunction are lengthy and include "developmental and reflex delays, visual-spatial problems, hearing loss, tinnitus, motion sensitivity, abnormal movement patterns, clumsiness, decreased eye-hand and eye-foot coordination, ataxia, falls, nystagmus, seizures, dizziness, nausea, ear pressure, difficulty moving in the dark, behavioral changes, and delays in performance of developmental activities such as riding a bicycle, hopping and stair climbing involving alternating left-right leg movements." 2
The possible causes of such disorders, according to VEDA's Web site, are even more lengthy and include "head-neck trauma, chronic ear infections, maternal drug or alcohol abuse during pregnancy, cytomegalovirus, immune-deficiency disorders, migraine with or without headache, meningitis, metabolic disorders (e.g., diabetes), ototoxic medications, neurologic disorders (e.g., cerebral palsy, hydrocephalus), genetic syndromes (e.g., branchio-otorenal syndrome, Mondini dysplasia, Wallenberg syndrome), posterior brain tumors (e.g., malignant medullo-blastomas or the less frequently seen benign acoustic neuromas), and a family history of vertigo, motion sensitivity, hearing loss or vestibular disorders. Dizziness can be the first symptom of depression in a teenager. Alcohol intoxication can produce dizziness, imbalance, staggering and abnormal eye movements." 2
In some cases, the cause of a vestibular disorder remains unknown, thus idiopathic, despite extensive testing. Fortunately, this does not preclude successful treatment or recovery.
Although children experience the same vestibular disorders as adults, such as otitis-media related vertigo and vestibular neuronitis as discussed below, children also experience two unique disorders of their own: benign paroxysmal vertigo of childhood and benign paroxysmal torticollis of infancy, also discussed below.
Otitis Media-Related Vertigo
Otitis media, or inflammation of the middle ear, affects both children and adults. It is the most frequent diagnosis for all children who visit a health care provider's office, and up to 90% of children have at least one episode by age 3. The condition is caused by viruses, bacteria and other pathogens that invade the middle ear, swell and block the Eustachian tubes, and damage cells and tissues contained within the middle ear space. Children ages 6 to 18 months are at highest risk for symptoms including pain, hearing loss, tinnitus and vertigo.
Otitis media-related vertigo may be caused by negative pressure leading to fluid build-up called effusion or by inflammation spreading to the adjacent inner ear, called labyrinthitis. A decade ago, Israeli researchers published an article on the effects of middle ear effusion on the vestibular system in children and concluded, "Vertigo and dizziness are not common in childhood, but are probably present more often than formerly thought." 3
In 156 children ages 4 to 9 with long-lasting middle ear effusion, 58% had balance-related symptoms compared with only 4% of 74 healthy children in the control group. These symptoms resolved in 96% of the children after ventilation tube insertion.
Vestibular Neuronitis
Vestibular neuronitis (VN), or neuritis, is a sudden severe attack of vertigo caused by inflammation of the vestibular nerve, which carries balance information from the inner ear to the brain. It is thought to be the result of viral infections such as mumps, rubella or herpes. A 2006 study by Turkish researchers supports this viral etiology by documenting an active enteroviral infection in the nasopharynx and cerebrospinal fluid of a 7-year-old male diagnosed with VN.4 This particular virus causes sore and strep throats.
The vertigo of VN, often accompanied by nausea and vomiting, usually lasts for several days or weeks. Rarely, it can last for months. Hearing is usually not affected, and the condition frequently resolves on its own. Treatments include antihistamines and corticosteroids.
Benign Paroxysmal Vertigo of Childhood
Benign positional vertigo (BPV) of childhood occurs mainly in preschoolers and is characterized by vertigo, nystagmus, nausea and vomiting. The condition has long been considered a migraine equivalent, and as recently as 2007, Polish researchers studied 14 children with BPV and suggested the disease is probably of vascular origin, with "strong evidence" for a close relationship between BPV and migraine.5
The cause of migraine, usually involving severe and throbbing headaches, remains unknown. Current thinking implicates a cascade of neurologic and vascular events that leads to nerve irritation and dilation of blood vessels within the head and face. It affects up to 10% of children and adolescents by age 15, with symptoms as diverse as headache, vertigo and abdominal pain often presaged by visual auras. Surprisingly, the overall prevalence of vertigo during a migraine attack is reported as high as 42%.
Children tend to grow out of BPV, although vertigo may rarely continue into adulthood by evolving into other vestibular dysfunctions.
Benign Paroxysmal Torticollis of Infancy
Benign paroxysmal toritcollis of infancy is an episodic disorder that occurs suddenly and spontaneously in the first months of life. Torticollis, which means "twisted neck," occurs when the patient's head tilts forward, backward or to one side for hours or days at a time. The condition is associated withother symptoms such as vomiting, sweating, pallor, irritability, headache and unstable gait. Again, the condition may be related to migraine.5
In 2006, Brazilian researchers reported on the condition in six patients whose symptoms began within the first 6 months of life and disappeared by 5 years of age.6 They conclude in the English-translated abstract in the National Library of Medicine that "It is important that the physician be able to recognize this benign disorder to provide appropriate prognosis."
After Diagnosis
Once a vestibular disorder is diagnosed, treatments vary from none needed to medicine, surgery and rehabilitation. Vestibular-therapy exercises when useful can be tailored to the individual child. According to VEDA, children respond well to such intervention, often better than adults, because of their greater adaptability to and less fear of movement; thus vestibular therapy "can be effective for reducing or eliminating vertigo, improving visual-motor control, improving balance and coordination, and promoting normal development." 2
Jess Dancer is professor emeritus of audiology at the University of Arkansas at Little Rock. Contact him at jedancer@ualr.edu regarding your experiences with balance disorders in children.
References
1. Riina N, Ilmari P, Kentala E. Vertigo and imbalance in children: a retrospective study in a Helsinki University otorhinolaryngology clinic. Arch Otolaryngol Head Neck Surg. 2005; 131(11):996-1000.
2. Pediatric Vestibular Disorders. Vestibular Disorders Association. 2007. Available at: www.vestibular.org. Accessed March 30, 2009.
3. Golz A, Netzer A, Angel-Yeger B, et al. Effects of middle ear effusion on the vestibular system in children. Otolaryngol Head Neck Surg. 1998; 119(6):695-699.
4. Ergul Y, Ekici B, Tastan Y, et al. Vestibular neuritis caused by enteroviral infection. Pediatr Neurol. 2006; 34(1):45-46.
5. Mierzwinski J, Polak M, Dalke K, et al. (2007). Benign paroxysmal vertigo of childhood. Otolaryngol Pol. 2007; 61(3):307-310.
6. Casella LB, Casella EB, Baldacci ER, et al. (2006). [Benign paroxysmal torticollis of infancy: diagnosis and clinical evolution of six patients]. Arq Neuropsiquiatr. 2006. 64(B):845-848. [Article in Portuguese]
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