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International Journal of Current Research and Review 



: Vertigo in Pediatric Age: Often Challenge to 


Section: Healthcare 

Santosh Kumar Swain’, Satyabrata Achary, Saurjya Ranjan Das? 

Sci. Journal Impact 
Factor: 6.1 (2018) 
ICV: 90.90 (2018) 



Vertigo or dizziness is perceived to be a common handicapping clinical entity in all the age group of the human being. Vertigo is 
an uncommon symptom in pediatric age group and rarity of this clinical entity may be due to unrecognized in children. It is often 
associated with a range of otological, neurological and psychiatric diseases. In younger children, benign paroxysmal vertigo is 
often seen whereas vestibular migraine is common in adolescent girls. The aetiology of the pediatric vertigo is usually multi- 
factorial, so each pediatric patient with vertigo should be approached in an open mind. Thorough history taking is important for 
getting a diagnosis of pediatric vertigo. Establishing the diagnosis of vertigo or dizziness is often challenging, especially in the 
pediatric age group. This article is a narrative review discussion on prevalence, etiopathology, clinical manifestations and man- 
agement of pediatric vertigo. This review article will make a baseline from where further prospective trials can be designed and 

‘Department of Otorhinolaryngology, IMS and SUM Hospital, Siksha “O” Anusandhan University, K8, Kalinganagar, 
Bhubaneswar-751003, Odisha, India; “Department of Anatomy, IMS and SUM Hospital, Siksha “O” Anusandhan University, K8, 
Kalinganagar, Bhubaneswar-751003, Odisha, India. 

help as a spur for further research in this clinical entity as there are not many studies of pediatric vertigo. 

Key Words: Pediatric age, Vertigo, Vestibular migraine, Benign paroxysmal vertigo, Meniere’s disease, Vestibular neuritis 


Vertigo is common complaint posed to a clinician in routine 
clinical practice. Vertigo is considered as the most common 
causes for referral to neuro physician and Otorhinolaryngol- 
ogists in office-based settings and emergency clinics!. Ver- 
tigo is described as as a subjective sensation of movement, 
typically spinning or turning, in absence of actual movement 
of the body’. Vertigo is not an uncommon clinical symptom 
in pediatric age group, though it may often unrecognized. 
Disorders that cause vertigo in pediatric age vary concern- 
ing one another in many ways. Vertigo or dizziness may 
be a nonspecific squeal of the several impairments includ- 
ing problems in proprioception, vision, vestibular function, 
musculoskeletal and autonomic systems’. Proper history tak- 
ing is often difficult to obtain because of the pediatric age 
and unable to tell their clinical symptoms precisely. There 
is an added challenge faced by the clinician in evaluating 
and managing pediatric vertigo owing to a lack of the proper 
history, practical difficulties during clinical examination and 
a lack of standard objective evaluation methods. Here, this 
review article discusses the aetiology, prevalence, clinical 

presentations, diagnosis and treatment of pediatric vertigo. 
This review article aims to give awareness among the read- 
ers with the difficult clinical entity such as vertigo, particu- 
larly in the pediatric age group. 


We conducted an electronic search of the SCOPUS, Medline 
and PubMed databases for searching the published articles. 
The search terms in the database included vertigo, pediat- 
ric age, dizziness and impairment of balance in children. 
The abstracts of the published articles are identified by this 
search method and other articles were identified manually 
from these citations. This review article reviews vertigo in 
the pediatric age group including the etiopathology, preva- 
lence, presentations, diagnosis and current treatment. This 
review article presents a baseline from where further pro- 
spective trials can be designed and help as a spur for further 
research in this clinical entity where not many studies are 

Corresponding Author: 

ISSN: 2231-2196 (Print) 
Received: 20.06.2020 

ISSN: 0975-5241 (Online) 
Revised: 22.07.2020 

Prof. Santosh Kumar Swain, Department of Otorhinolaryngology, IMS and SUM Hospital, Siksha “O” Anusandhan University, K8, 
Kalinganagar, Bhubaneswar-751003, Odisha, India; Email: 

Accepted: 24.08.2020 Published: 22.09.2020 

Int J Cur Res Rev | Vol 12+ Issue 18 + September 2020 

Swain et al.: Vertigo in pediatric age: often challenge to clinicians 


Dizziness and balance disorders are thought to be uncom- 
mon in the pediatric age group. This may be due to poor un- 
derstanding of the epidemiology of vertigo or balance prob- 
lems in children °. The literature for pediatric vertigo is scant. 
Prevalence of vertigo in the pediatric age group ranges from 
8% to 15% *. In otolaryngology clinic, the prevalence of the 
pediatric vertigo patients constitutes around 0.7% 5. A study 
in Scotland with 2165 pediatric patients with an age range 
from 5 to 15 years found the one-year prevalence of one epi- 
sode of rotary vertigo to be 18% along with the prevalence of 
reducing to 5% for minimum three episodes [6]. One study 
sampled 1050 children with an age range from 1 to 15 years 
in Finland and found the lifetime prevalence of vertigo to 
be 8% and that for poor body balance to be 2% *. Episodic 
vertigo and dizziness are usually uncommon in pediatric 
age group than in the adult population. Valid estimation of 
the prevalence of vertigo among pediatric age group must 
be determined when someone considers that such clinical 
symptoms could have some adverse psychosocial associa- 
tions like anxiety and avoidance behaviour, which leads to 
child’s educational impairment and poor quality of life ’. It is 
also vital that physicians should keep it in mind and aware of 
those characteristic features of vertigo or dizziness in pediat- 
ric patients, so that appropriate intervention can be provided. 

Etiology and types of vertigo in pediatric age 
The aetiology of vertigo in children is multi-factorial, so the 
management depends on accurate diagnosis. Vertigo in the 
children is broadly classified into Acute nonrecurring spon- 
taneous vertigo, recurrent vertigo and non-vertiginous diz- 
ziness, disequilibrium and ataxia. Vestibular migraine and 
benign paroxysmal vertigo are commonly found cause for 
vertigo in pediatric age. The common differential diagnosis 
of vertigo in the pediatric age group is discussed below.Ta- 
ble.1 showing the differential diagnosis in higher than two 
thousand pediatric patients with vertigo and dizziness ob- 
tained by a group of clinicians ê. 

Table 1: Etiological profile of vertigo in children 

Serial Diagnosis 


1 Vestibular migraine 

2 Benign paroxysmal vertigo of children 
3 Vestibular neuritis 

4 Post-traumatic/head trauma 
5 Otitis media 

6 Meniere’s disease 

7 Psychogenic vertigo 

8 Epileptic vertigo 

9 Unclassified 

Vestibular migraine 

Majority of the pediatric vertigo is due to vestibular mi- 
graine. The patient typically presents with headache, cycli- 
cal vomiting, abdominal pain, vertigo, recurrent episodes of 
pyrexia or head banging, attacks of pallor and somnolence. 
The diagnosis of the vestibular migraine in children needs 
awareness where a meticulous history for headache and care- 
ful family history towards migraine is an important part of 
the diagnosis. However, vestibular migraine remains a diag- 
nosis of exclusion. Neuhauser and Lempert (2009) used the 
term vestibular migraine as it stresses the vestibular manifes- 
tations of migraine °. It is often seen in adolescent girls and 
is usually associated with menstrual periods. The vertigo is 
associated with a headache which lasts for hours with nau- 
sea and vomiting as well as photophobia and phonophobia. 
Sensory stimuli like intense smell, bright lights and loud 
noise may precipitate the attack. A history of motion sick- 
ness is often associated with a family history of migraine. 
The otologic, neuro-otologic, general physical and vestibular 
examinations are often normal in between the episodes of the 
vestibular migraine "°. 

Benign paroxysmal vertigo (BPV) 

The characteristic features of the BPV in pediatric age are 
recurrent brief attacks of vertigo without any warning and 
resolving spontaneously in otherwise normal child "!. BPV 
is a common cause of vertigo in pediatric patients, showing 
with a prevalence of 2.6% '. It is often reported classically 
at less than four years of age and uncommon after 8 years of 
the age "°. The etiopathology of this clinical entity is still not 
known. It appears to occur due to vascular changes which 
produce transient hypoxia at the vestibular nuclei and the 
vestibular pathways. This type of pathophysiology of BPV is 
similar to the pathophysiology of the migraine; so the major- 
ity of pediatric patients with BPV will develop migraine in 
later part of the life "°. There are no presentations of altered 
consciousness, neurological abnormalities and audiovestibu- 
lar changes during the attack. The vestibular evoked myo- 
genic potential | (VEMP) and caloric test results support the 
diagnosis. In the majority of BPV patients, thermal caloric 
tests show asymmetry '*. The prognosis of BPV is usually 
favourable and tends to disappear spontaneously before ado- 
lescence age. 

Post-traumatic vertigo 

Children having post-traumatic vertigo without any deafness 
in the pediatric age could be due to labyrinthine concussion 
whiplash syndrome, vertiginous seizures, basilar artery mi- 
graine or non-specific dizziness '*. In the case of temporal 
bone fracture, inner ear disruption may happen which results 
in vestibular dysfunction and leakage of the cerebrospinal 
fluid. Temporal bone trauma may lead to perilymphatic fis- 
tula which can occur even without evidence of the fracture 

137 Int J Cur Res Rev | Vol 12 « Issue 18 + September 2020 

Swain et al.: Vertigo in pediatric age: often challenge to clinicians 

line in temporal bone and often associated with the fluctuat- 
ing type of deafness!®. Surgical closure of the labyrinthine 
fistula can reduce the vertiginous symptoms completely but 
the deafness may not be recovered !’. After trauma to the 
labyrinth, pediatric patients may exhibit abnormal results of 
the vestibular tests in approximately half of the cases, even 
children are asymptomatic '*. After trivial trauma in case of 
children with congenital inner ear anomalies such as Mon- 
dini’s dysplasia, enlarged vestibular aqueduct and genetic 
disease like CHARGE syndrome are predispose to vertigo 
along with hearing loss °. The prognosis of the post-trau- 
matic cases with vestibular dysfunction is variable and un- 

Vestibular neuritis 

The aetiology of the vestibular neuritis is somewhat con- 
troversial; many authors have suggested that is due to viral 
infections although bacterial and other variety of infections 
have also been suggested 7°. One study found around 47% of 
the upper respiratory tract infection before the onset of the 
vestibular neuritis *'. The exact aetiology of vestibular neuri- 
tis is controversial, although an association with herpes sim- 
plex virus has been found. Pediatric patients suffering from 
vestibular neuritis often present with similar symptoms as 
their adult counterparts. Vestibular neuritis is rarely found in 
children less than 10 years of the age ”!. It presents with sud- 
den onset of severe vertigo, nystagmus, nausea and vomiting. 
This vertigo is worsened by head movements and children or 
patients usually prefer to lie down, often with the affected ear 
up. They do not present with hearing loss and tinnitus. Ves- 
tibular laboratory investigation shows the unilateral reduced 
vestibular response to the thermal caloric test. The clinical 
symptoms of the child will resolve within a few days. The 
management of this patient includes supportive and symp- 
tomatic treatment with early ambulation. A short treatment 
with vestibular suppressants such as meclizine (>12 years) or 
dimenhydrinate (>2 years) may be prescribed but should be 
limited as it often delays central compensation 7”. 

Vestibular paroxysmia (VP) 

This is an interesting type of the vestibular entity because of 
the involvement or compression of the vestibular or eighth 
cranial nerve also termed as disabling positional vertigo ”. 
In 1994, Brandt and Dieterich coined the term vestibular 
paroxysmal ™. Although it is rare in clinical practice, the VP 
can cause vertigo in the pediatric patient as well. It usually 
presents frequent episodes of vertigo, multiple times in a 
day, lasting for seconds to minutes with or without the pres- 
ence of postural variation. The attacks of vertigo can be up 
to thirty times or more in a day. Magnetic resonance imaging 
(MRI) and/or angiography helps demonstrate the neurovas- 
cular compression of the vestibulocochlear nerve and also to 
rule out cerebellopontine angle tumours ”. In the majority of 

the cases, vascular lop by anterior inferior cerebellar artery 
is seen to compress the nerve, however posterior inferior cer- 
ebellar artery and vertebral artery or vein are rarely involved. 
Low dose sodium channel blocker such as carbamazepine is 
shown to help control vertigo in pediatric age of VP. Micro- 
vascular decompression is an absolute option for relieving 
the vestibular symptoms but indicated only in certain cases 
such as a failed pharmacotherapy, fear of surgical morbidity 
and difficulty in deciding the size of the lesions. 

Meniere’s disease (MD) 

MD is an uncommon disease among the pediatric age group 
and accounts for <3% of all the MD patients *°. Out of all 
aetiology for vertigo in the pediatric age group, MD is found 
in 1.5-4% of pediatric age 7’. MD or endolymphatic hydrops 
(Fig.1) in children present with episodic vertigo, fluctuating 
deafness, aural fullness and tinnitus. The pure tone audiom- 
etry reveals sensorineural hearing loss with the involvement 
of low-frequency sound. But children often unable to com- 
municate about aural fullness and tinnitus, so MD should not 
be excluded in case of absence of aural fullness and ringing 
sound in the ear. The pediatric patients with MD are usually 
older than 10 years of the age and very few cases have been 
reported in less than 7 years of age °. The pathophysiology 
of MD is associated with allergy both in children and adults 
and the treatment of the allergy will cure the symptoms of 
MD. The management of MD in both adults and pediatric 
patients are similar and include labyrinthine sedatives, low 
salt diet, intra-tympanic gentamycin and less commonly en- 
dolymphatic sac decompression ”. 

Figure 1: Distension of the endolymphatic duct in Meniere’s 

Middle ear effusion and otitis media 
Pediatric patients with vertigo may occur due to middle ear 
effusion and otitis media. °°! As many pediatric patients with 

Int J Cur Res Rev | Vol 12 + Issue 18 e September 2020 

Swain et al.: Vertigo in pediatric age: often challenge to clinicians 

abnormal ventilation of the middle ear cleft do not present 
vertigo, the symptoms are often presented by their parents 
who say clumsiness, awkwardness and falling. In case of the 
middle ear pathologies, the released toxins seen in the mid- 
dle ear fluid absorbed into the inner ear fluid and lead to 
serious labyrinthitis *°. Others have proposed that alteration 
of the pressure in the middle ear cause displacement of the 
oval window and round windows which move the inner ear 
fluids *!. One study documented a greater chance of sway 
in a group of 41 pediatric patients with otitis media in com- 
parison to pediatric patients with no ear disease °. Similarly, 
one more study documented that body sway was more pro- 
nounced in pediatric patients with otitis media in comparison 
to the control group. However, the authors also documented 
that elimination of these by treating otitis media by myrin- 
gotomy and insertion of the grommet *°. 


Despite significant development of the technology in diag- 
nostic tools, the diagnosis is still based mainly on proper 
history taking and examination findings. However, the di- 
agnosis of pediatric vertigo differs from the adult age group 
because of the etiologies are often unique to the vertigo of 
the children *. Around 90% of the pediatric patients with 
vertigo are categorized as “unspecified dizziness”, show- 
ing that the diagnostic accuracy and treatment options in 
the pediatric age group with vertigo should be improved *. 
Getting the exact diagnosis of pediatric vertigo can be dif- 
ficult, specifically in very young pediatric patient whose 
ability to tell the symptoms is very less. Patience and time 
are required for the proper diagnosis of pediatric vertigo. Pa- 
tient history and clinical examinations including otological 
and neuro-otological examinations help in diagnosis. Patient 
history has a vital role in the evaluation of vertigo and the 
diagnosis of vertigo. The pediatric patient often unable to 
describe the symptoms, so parent’s observation of vertigo 
should be taken into consideration for diagnosis. Although 
rare, the child may present with vertigo on exposure to loud 
noise as in superior semicircular canal dehiscence syndrome 
36. Jn the pediatric age group, common etiologies for ver- 
tigo are benign paroxysmal vertigo of childhood(BPVC) and 
migraine-associated vertigo(MAV), although the frequencies 
of occurrence vary between different studies >’. The charac- 
teristics of the BPVC are brief and recurrent episodes of ver- 
tigo in absence of any warning and resolving spontaneously 
in a normal child **. The criteria for diagnosis are at least 5 
attacks of vertigo along with minimum one of the follow- 
ing: nystagmus, vomiting, ataxia, pallor, fearfulness; in ad- 
dition to normal audiometric findings, normal examination 
and vestibular functions in between attacks needed. Seizures, 
posterior fossa neoplasms and vestibular lesions should be 
ruled out °°. BPVC has better prognosis as clinical symptoms 

tend to be absent after six to twelve months *’. In addition to 
thorough neuro-otologic and systemic examination, vestibu- 
lar tests like cervical vestibular evoked myogenic potential 
(cVEMP), posturography, electronystagmography (ENG), 
rotatory chair test and caloric test. A complete hearing as- 
sessment is mandatory in the pediatric patient with vertigo 
which includes Otoacoustic emissions (OAEs), hearing test 
or behavioural audiometry, brainstem evoked response audi- 
ometry (BERA), auditory steady-state response (ASSR) and 
impedance audiometry. Magnetic resonance imaging (MRI) 
is preferred imaging for assessing vertigo in the pediatric 
age group. Clinicians should advice neuro-imaging stud- 
ies for children with vertigo who have neurologic signs and 
symptoms, risk factors of cerebrovascular lesions or progres- 
sive unilateral sensorineural hearing loss or tinnitus *°. MRI 
avoids ionizing radiation of computed tomography (CT) 
scan and gives a greater sensitivity for posterior fossa and 
labyrinthine defects *!. The negative aspects of the MRI are 
cost and requirement of sedation in the pediatric patient. His- 
tory of head trauma and focal neurological deficit brings up 
the indication for MRI. Evaluation of the blood pressure and 
electrocardiography (ECG) is useful to rule out a cardiovas- 
cular disease like arrhythmia or long QT syndrome. Diseases 
of the eye and refractive errors should be ruled out even with 
a known cause for vertigo, as these may cause worse symp- 
tomatology *. 


The difficulty and enigma in the treatment of the pediatric 
vertigo are because it is not a definite disease but a symptom 
which usually diagnosed late in children. The treatment of 
vertigo in the pediatric age should be individualized. Based 
on the aetiology, the treatment includes medications, physi- 
cal therapy, psychiatric treatment and less commonly sur- 
gery. There is still a paucity of documentation on the drug 
treatment of vertigo even in the current scenario since there 
have been no multicentric, well-controlled studies to show 
the advantages of treatment over no treatment #. The treat- 
ment of the vestibular migraine includes watchful waiting 
and education of the children of vertigo and their parents 
in addition to stress reduction, encouragement for adequate 
sleep, psychological counselling, rehabilitation therapy if 
required as well as dietary restrictions of foods own to pro- 
voke. Medical treatment of vestibular migraine includes sim- 
ple analgesic and/or vestibular suppressant such as meclizine 
during the attack. In children with benign paroxysmal ver- 
tigo, vestibular suppressants are usually not very useful due 
to the very short duration of the attack. In vestibular neuritis, 
vestibular rehabilitation and corticosteroids are often help- 
ful and facilitate recovery of the disease, particularly when 
prescribed initial period of the disease. Ophthalmological 
evaluation and correction are also important as visual prob- 

139 Int J Cur Res Rev | Vol 12 « Issue 18 + September 2020 

Swain et al.: Vertigo in pediatric age: often challenge to clinicians 

lems can lead to vertigo or dizziness. Management of the 
Meniere’s disease in pediatric age is reassurance and expla- 
nations of this condition to the caregivers along with low salt 
diet and a diuretic **. The requirement of surgery in pediatric 
Meniere’s disease is uncommon. 


Vertigo in the pediatric age group has myriad of clinical pres- 
entations and possible diagnoses. The aetiology of vertigo in 
the pediatric age group is often multi-factorial, so a pediatric 
patient is approached with an open mind. A thorough evalu- 
ation of vertigo in children though difficult is mandatory. 
Disorders that cause vertigo in the pediatric age group vary 
concerning one another in many ways. The peripheral ves- 
tibular disorders rarely cause symptoms lasting more than a 
few minutes although Meniere’s disease and vestibular neu- 
ritis lasting for hours. Vestibular migraine causes symptoms 
lasting for virtually any duration. Vertigo in children can be 
highly challenging for evaluation and treatment. Relying on 
vestibular tests alone may cause misleading of the diagno- 
sis. The physicians must judiciously utilize all the diagnostic 
modalities at his/her disposal before dismissing less com- 
monly encountered diagnosis. 


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