Patient Presentation
An 8-year-old female came to clinic with a 7 day history of intermittent vertigo. The episodes occurred 3 times where she would suddenly feel like the room was spinning around her or she was riding a roller coaster. She would need to lie down for relief and the episodes lasted about 30 minutes and then resolved. She denied auras, tinnitis, hearing loss, visual field changes, and diplopia. She also complained of nausea and problems walking with the episodes. She was conscious throughout and a teacher told the parents that her eyes were moving funny. She was well rested during the episodes which occurred in the morning and afternoons. She was doing well in school. The family history was positive for her mother who had a history of vertigo in the past and had migraines as an adult. There was no hearing loss, deafness, or other neurological problems in the family. The review of systems was notable for an upper respiratory infection about 3 weeks ago. She had no fevers, chills, cold sores or other problems.
The pertinent physical exam showed a well-appearing child with growth parameters in the 10-50%. She had a small amount of serous fluid in her left ear. Her neurological examination showed her extraocular movements were intact and pupils were reactive to light and accommodation. DTRs were 2+/2+ with downgoing toes. there wee ormal rapid alternating movements, finger to nose testing, tandem gait and Romberg testing. No soft neurological signs were elicited. Nystagmus could not be elicited during sitting or with rapid changes in movement. The diagnosis of serous otitis media and probable benign paroxysmal vertigo of childhood was made. The physician discussed the natural history of the problem including that the episodes could intensify or remit. He also discussed that this type of vertigo often precedes the development of migraines later including migraines with a vertigenous component. She was warned to avoid doing things that may aggravate it such as merry-go-rounds, teeter-totters, other spinning games and activities. The patient’s clinical course over the next year showed that she had several more vertiginous episodes in the following month, but none since. She also had not developed headaches.
Discussion
Dizziness is an abnormal sensation relative to position and space which is often vague. It includes imbalance, motion intolerance, light-headedness, unsteadiness, floating or tilting sensations. Dizziness can be caused by cardiovascular, CNS or systemic diseases. Vertigo is a subtype of dizziness that has a rotary or spinning sensation. Objects rotate around the patient or the patient rotates around the objects.
Vertigo is usually categorized into peripheral or central causes. Central vertigo emanates from a CNS location, and may have other CNS symptoms such as headaches, aura, motor, sensory or visual symptoms such as tinnitis or hearing loss. Symptoms usually last longer and may increase in number, frequency or intensity. Peripheral vertigo emanates from a non-CNS location and usually but not always has no or fewer CNS symptoms. Symptoms also usually are shorter but can be chronic.
Treatment includes treatment of underlying disorders such as seizures, migraine, tumor, etc., IV fluids, vestibular suppressants, and avoiding migraine triggers. Positional maneuvers may be helpful for benign postural positional vertigo.
Learning Point
The differential diagnosis of vertigo includes:
- Peripheral
- Benign paroxysmal vertigo of childhood – Young children present with episodes where they are fearful and grasp onto people or objects or refuse to stand, and additionally have balance problems or falls. Older children may be anxious. Children will often have nystagmus and it is considered an early manifestation of migraines.
- Benign paroxysmal positional vertigo – Thought to be due to ear debris in the semi-circular canals that irritates the vestibular system. Positioning exercises may help to move the debris and stop the irritation.
- Congenital deafness
- Immune-mediated inner-ear disease
- Infectious disease – e.g. Lyme disease, Epstein Barr Virus
- Post- head trauma
- Post- meningitis
- Migraine
- Psychosomatic
- Seizures, vertiginous
- Semicircular canal pathology – e.g. fistula, dehiscence
- Vestibular neuronitis/Labyrinthitiss – There are many overlapping features, but usually vestibular neuronitis is diagnosed if the auditory function is not affected. It is often caused by viruses such as herpes simplex.
- Central
- Chiari malformation
- Cerebrovascular disease – vestibulobasilar disease, cerebellar ischemia or hemorrhage
- Hereditary ataxia
- Tumor – e.g. posterior fossa, acoustic neuroma
- Meniere’s disease
- Multiple sclerosis
- Misperception of real dizziness caused by dysequilibrium, orthostatic hypotension, presyncope/syncope, etc.
Questions for Further Discussion
1. What psychiatric illness could present with perceptual changes such as dizziness or vertigo?
2. How are presyncope and dizziness and vertigo distinguished?
3. What are indications for referral to a neurologist for vertigo?
4. Describe the positioning maneuvers for benign paroxysmal positional vertigo?
Related Cases
- Disease: Benign Paroxysmal Vertigo of Childhood | Dizziness and Vertigo
- Symptom/Presentation: Ataxia, Dizziness, and Vertigo
- Specialty: Neurology / Neurosurgery | Otolaryngology
- Age: School Ager
To Learn More
To view pediatric review articles on this topic from the past year check PubMed.
Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.
Information prescriptions for patients can be found at MedlinePlus for this topic: Dizziness and Vertigo
To view current news articles on this topic check Google News.
To view images related to this topic check Google Images.
Samy HM, Hamid MA. Dizziness, Vertigo, and Imbalance. eMedicine. Available from the Internet at http://emedicine.medscape.com/article/1159385-overview#showall (rev. 1/14/2010, cited 4/5/11).
Atunes MB, Ruckenstein MJ. CNS Causes of Vertigo. eMedicine. Available from the Internet at http://emedicine.medscape.com/article/884048-overview (rev. 9/9/10, cited 4/5/11).
Chan Y. Differential diagnosis of dizziness. Curr Opin Otolaryngol Head Neck Surg. 2009 Jun;17(3):200-3.
Cuvellier JC, Lepine A. Childhood periodic syndromes. Pediatr Neurol. 2010 Jan;42(1):1-11.
ACGME Competencies Highlighted by Case
1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
2. Essential and accurate information about the patients’ is gathered.
3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
4. Patient management plans are developed and carried out.
5. Patients and their families are counseled and educated.
8. Health care services aimed at preventing health problems or maintaining health are provided.
10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.
23. Differing types of medical practice and delivery systems including methods of controlling health care costs and allocating resources are known.
24. Cost-effective health care and resource allocation that does not compromise quality of care is practiced.
Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa Children’s Hospital
Pediatric Education 