Paeds · ent-hearing-and-oral-health
Tinnitus, vertigo and balance disorders in children
Also known as Paediatric dizziness · Vestibular migraine of childhood · Benign paroxysmal vertigo of childhood · Vestibular neuritis in children · Paediatric BPPV · Childhood tinnitus · Balance disorders in children
Fellowship guide to tinnitus, vertigo and balance disorders in children: separating the common benign causes, benign paroxysmal vertigo of childhood and vestibular migraine, from the acute peripheral vestibular neuritis and the dangerous central mimics, the bedside distinction of peripheral from central nystagmus, the red-flag screen that drives urgent magnetic resonance imaging, and the management built on reassurance, the Epley manoeuvre for positional vertigo, and early vestibular rehabilitation.
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Red flags
- A child with vertigo and any focal neurological sign, ataxia between attacks, papilloedema, or an abnormal pattern of nystagmus such as gaze-evoked or direction-changing nystagmus has a central cause until proven otherwise and needs urgent magnetic resonance imaging
- Unilateral, asymmetric, or progressive sensorineural hearing loss, with or without tinnitus, raises a retrocochlear lesion such as a vestibular schwannoma in neurofibromatosis type 2 and mandates gadolinium-enhanced magnetic resonance imaging
- Vertigo with an acute vestibular syndrome that fails the head impulse, nystagmus, test of skew rule, with a normal head impulse test, direction-changing nystagmus, or skew deviation, is a posterior circulation stroke until proven otherwise
- Pulsatile tinnitus, or tinnitus with a visible middle-ear mass, raises a vascular lesion or glomus tumour and needs dedicated vascular and temporal-bone imaging rather than reassurance
- Recurrent vertigo with a progressive course, new headache, or developmental regression is never dismissed as a benign periodic syndrome of childhood and is investigated rather than observed
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Clinical exam formats
Board mappings
- Recognises benign paroxysmal vertigo of childhood and vestibular migraine as the common recurrent vertigos of childhood and distinguishes them from dangerous central causes
- Performs the red-flag screen and the peripheral-versus-central assessment of nystagmus at the bedside
- Identifies unilateral or progressive hearing loss with tinnitus as an indication for urgent imaging
- Applies the head impulse, nystagmus, test of skew rule to separate an acute peripheral vestibulopathy from a posterior circulation stroke
- Coordinates the vestibular function, audiological, and imaging workup for recurrent vertigo and for troublesome tinnitus
- Leads a vestibular rehabilitation programme and the judicious, short-course use of vestibular suppressants
- The common recurrent vertigos of childhood, benign paroxysmal vertigo of childhood and vestibular migraine, and their diagnostic criteria
- The peripheral-versus-central nystagmus screen and the indications for urgent magnetic resonance imaging
- The principles of vestibular rehabilitation and the limited role of vestibular suppressants
- Examines the eye movements for spontaneous, gaze-evoked, positional, and direction-changing nystagmus and performs the head impulse test
- Communicates the reassuring prognosis of the benign recurrent vertigos of childhood to an anxious family
- Frames the urgent imaging decision for a child with vertigo and a red flag
- Level 1: Recognition of the common recurrent vertigos of childhood and the red flags for a central cause
- Level 2: Bedside peripheral-versus-central assessment and the audiological and imaging pathway
- Level 3: Multidisciplinary management of vestibular migraine, chronic vestibular hypofunction, and troublesome tinnitus
- Benign paroxysmal vertigo of childhood as the commonest vertigo of a preschool child and its evolution toward migraine
- The diagnostic criteria for vestibular migraine and the head impulse, nystagmus, test of skew rule for the acute vestibular syndrome
- Red flags for a central cause and the indications for urgent magnetic resonance imaging in a dizzy child
- Examination of the eye movements and the head impulse test at the bedside
- Recognition of the Dix-Hallpike response of benign paroxysmal positional vertigo
- Counselling on the benign prognosis of the recurrent vertigos of childhood and the role of vestibular rehabilitation
- Recognition of benign paroxysmal vertigo of childhood, vestibular migraine, and benign paroxysmal positional vertigo
- Exclusion of a central cause through the red-flag screen and the nystagmus examination
- Identification of unilateral hearing loss with tinnitus as an indication for imaging
- Structured assessment of the dizzy child, separating benign from dangerous causes through the tempo and the nystagmus pattern
- Bedside peripheral-versus-central localisation through the head impulse test and the character of the nystagmus
- Coordination of audiological, vestibular, and imaging care and the prescription of vestibular rehabilitation
- Canadian approach to dizziness and vertigo in children and the restrained, selective use of neuroimaging
- Diagnosis and management of vestibular migraine and the benign recurrent vertigos of childhood
- Recognition of the central red flags and the paediatric considerations in vestibular rehabilitation
Overview & Definition
Picture the three-year-old who freezes mid-play, goes pale, clings to a parent, and looks terrified for half a minute before returning to normal, and whose parents fear a seizure. That child carries the whole teaching point of paediatric dizziness. The episode is alarming to the family but is usually benign. The diagnosis is clinical, and the clinician's job is to confirm the safe pattern and to exclude the small minority that are dangerous. The decisive first question is not which drug to give but whether the vertigo is peripheral or central, and whether red flags are present. That single distinction separates reassurance from urgent imaging. [2] [4]
Vertigo is the false sensation of movement, usually a sense of spinning, that arises from a mismatch between the vestibular, visual, and proprioceptive inputs to balance. Dizziness is the broader, non-specific term that children and families use for vertigo, light-headedness, unsteadiness, and a vague floating feeling. The first clinical task is to establish which of these the child means. The vestibular apparatus comprises the three semicircular canals, which sense angular acceleration, and the otolith organs, which sense linear acceleration and gravity. Their signals travel through the vestibulocochlear nerve to the brainstem and cerebellum. A lesion anywhere in this pathway produces vertigo, and the character and duration of the vertigo, the nystagmus pattern, and any hearing loss localise the lesion. [7] [12]
Tinnitus is the perception of sound, such as ringing, buzzing, or hissing, in the absence of an external source, and in children it is common and usually benign. Most paediatric tinnitus arises from a reversible cause, such as cerumen impaction, otitis media with effusion, or noise exposure, and resolves with the cause. A minority signals a serious disorder. Unilateral, pulsatile, or persistent tinnitus, or tinnitus with a hearing loss, is the pattern that demands audiological assessment and, when indicated, imaging to exclude a retrocochlear or a vascular lesion. The framework that unifies vertigo and tinnitus is the peripheral-versus-central split combined with the red-flag screen. The same screen that governs the imaging decision in the dizzy child governs it in the child with troublesome tinnitus. [9] [3]
References12ShowHide
- [1]van de Berg R, et al Vestibular Migraine of Childhood and Recurrent Vertigo of Childhood: Diagnostic criteria Consensus document of the Committee for the Classification of Vestibular Disorders of the Bárány Society and the International Headache Society. J Vestib Res, 2021.PMID 33386837
- [2]Gurberg J, et al Benign paroxysmal vertigo of childhood. Handb Clin Neurol, 2023.PMID 38043965
- [3]Peterson JD, Brodsky JR Evaluation and management of paediatric vertigo. Curr Opin Otolaryngol Head Neck Surg, 2022.PMID 36165009
- [4]Jahn K, et al Vertigo and dizziness in children. Curr Opin Neurol, 2015.PMID 25502049
- [5]An JB, et al Pediatric Benign Paroxysmal Positional Vertigo: Degree of Nystagmus and Concurrent Dizziness Differs from Adult BPPV. J Clin Med, 2024.PMID 38610761
- [6]Wang A, et al Benign Paroxysmal Positional Vertigo in Children and Adolescents With Concussion. Sports Health, 2021.PMID 33528343
- [7]Kerber KA Acute Vestibular Syndrome. Semin Neurol, 2020.PMID 31994145
- [8]Wang C, et al Pediatric Meniere's disease. Int J Pediatr Otorhinolaryngol, 2018.PMID 29447806
- [9]Hoare DJ, et al Tinnitus in Children. J Assoc Res Otolaryngol, 2024.PMID 38709437
- [10]Rine RM Vestibular Rehabilitation for Children. Semin Hear, 2018.PMID 30038459
- [11]Beh SC Vestibular Migraine. Curr Neurol Neurosci Rep, 2022.PMID 36044103
- [12]Neuhauser HK The epidemiology of dizziness and vertigo. Handb Clin Neurol, 2016.PMID 27638063