Pediatric emergency medicine trisk 137

The differential diagnosis of headache and vertigo also includes a brainstem or
cerebellar mass, hemorrhage, and infarction. These uncommon disorders are best
assessed by MRI.

Benign Paroxysmal Vertigo of Childhood
Considered by many to be a form of migraine, benign paroxysmal vertigo of
childhood is most common in children between the ages of 1 and 5 years. Patients
have recurrent attacks, usually one to four per month, and occasionally in
clusters. Onset is sudden—the child often cries out at the start of each episode—
and is associated with emesis, pallor, sweating, and nystagmus. Episodes are
brief, lasting up to a few minutes, and may be mistaken for seizures.
Consciousness and hearing are preserved, and the neurologic examination is
otherwise normal. The electroencephalogram (EEG) is normal. The disorder
spontaneously remits after 2 to 3 years.
TABLE 24.2
COMMON CAUSES OF VERTIGO
Suppurative or serous labyrinthitis
Benign paroxysmal vertigo
Migraine
Vestibular neuronitis
Ingestions
Seizure
Motion sickness


TABLE 24.3
COMMON CAUSES OF PSEUDOVERTIGO
Depression
Anxiety
Hyperventilation
Orthostatic hypotension

Hypertension
Heat stroke
Arrhythmia
Cardiac disease
Anemia
Hypoglycemia
Pregnancy
Ataxia
Visual disturbances
Psychogenic disturbance

Ototoxic Drugs
Most agents that disturb vestibular function will also disturb auditory function.
Specific agents include aminoglycoside antibiotics, furosemide, ethacrynic acid,
streptomycin, minocycline, salicylates, and ethanol. Toxic doses of certain
anticonvulsants and neuroleptics can produce measurable disturbances of
vestibular function, although associated complaints of vertigo are rare.

Trauma
Several mechanisms account for posttraumatic vertigo. The most obvious is
fracture through the temporal bone with damage to the labyrinth (see Chapters
106 ENT Trauma and 113 Neurotrauma ). Presentation includes vertigo, hearing
loss, and hemotympanum. CT scanning or MRI of the temporal bone should be
obtained when there is hemotympanum or posttraumatic evidence of vestibular
dysfunction.
More subtle causes of posttraumatic vertigo include trauma-induced seizures,
migraine, or a postconcussive syndrome. Vestibular concussion typically follows
blows to parietooccipital or temporoparietal regions and presents with headache,

nausea, vertigo, and nystagmus. Although it generally remits with time,
intermittent and recurrent episodes can occur. Hyperextension and flexion
(“whiplash”) injuries can be associated with vestibular dysfunction, probably
caused by basilar artery spasm with subsequent impairment of their labyrinth and
cochlear connections. Symptoms may mimic basilar artery migraine or cerebellar
stroke.

Seizures
Two types of seizures are associated with vertigo: vestibular seizures (seizures
causing vertigo) and vestibulogenic seizures (“reflex” seizures brought on by
stimulating the semicircular canals or vestibules by sudden rotation or caloric
testing). Vestibular seizures, the more common type, consist of sudden onset of
vertigo with or without nausea, emesis, and headache, and are followed by loss or
alteration of consciousness. The EEG is abnormal and anticonvulsants may be of
benefit.

Motion Sickness
Motion sickness is precipitated by a mismatch in information provided to the
brain by the visual and vestibular systems during unfamiliar rotations and
accelerations. The most common situation occurs when a child travels in a car or
airplane and is deprived of a visual stimulus that confirms movement. Symptoms
include vertigo, nausea, and nystagmus. Attacks can be prevented by allowing
patients to watch the environment move in a direction opposite to the direction of
body movement (such as encouraging a child to look out the window while riding
in a car).

Ménière Disease
Uncommon in children younger than 10 years, Ménière disease is characterized
by episodic attacks of vertigo, hearing loss, tinnitus, nystagmus, and autonomic
symptoms of pallor, nausea, and emesis. The underlying cause is believed to be

an overaccumulation of endolymph within the labyrinth, which causes a rupture
(endolymphatic hydrops). Typical attacks last from 1 to 3 hours and usually begin
with tinnitus, a sense of fullness within the ear, and increasing hearing
impairment. The patient may have intermittent attacks for years, and there may be
permanent hearing loss.

Miscellaneous Causes
Vertigo may occur at any point in the clinical course of multiple sclerosis when
the central demyelination interferes with the vestibular nuclei in the brainstem or


its efferents or afferents. Diagnosis is confirmed by MRI and lumbar puncture.
Paroxysmal torticollis of infancy consists of spells of head tilt associated with
nausea, emesis, pallor, agitation, and ataxia. Episodes are brief and self-limited
and may recur for months or years. The cause is unclear, although some authors
see it as a prelude to benign paroxysmal vertigo. Perilymphatic fistula is an
abnormal communication between the labyrinth and the middle ear, with leakage
of perilymphatic fluid through the defect. It may be congenital or acquired by
trauma, infection, or surgery. The diagnosis may be suspected when vertigo and
acute hearing loss is provoked by sneezing or coughing, actions that can increase
perilymphatic drainage. Diagnosis is confirmed by middle ear exploration.
Benign paroxysmal positional vertigo (BPPV) is rare in children, but has been
reported in the literature in a patient as young as 3 years old. Patients typically
complain of vertigo with changes in head position, especially upon waking in the
morning and sitting up in bed. Episodes usually last less than 1 minute. Finally,
vertigo may be associated with diabetes mellitus and chronic renal failure.

EVALUATION AND DECISION
Differentiation of True Vertigo and Pseudovertigo
Evaluation of children with dizziness begins by distinguishing between those with

true vertigo and those with pseudovertigo ( Tables 24.1 and 24.3 ). True vertigo is
always associated with a subjective sense of rotation of the environment relative
to the patient or of the patient relative to the environment. All vertigo is made
worse by moving the head, and acute attacks are usually accompanied by
nystagmus.

True Vertigo
History and Physical Examination
Once true vertigo ( Fig. 24.1 ) is identified, its severity, time course, and pattern
must be established. In general, the most severe attacks of vertigo have peripheral
causes, whereas central causes tend to be more recurrent, chronic, and
progressive. Sudden onset of sustained vertigo suggests central or peripheral
trauma, infection, stroke, or ingestion. Recurrent episodic attacks suggest
seizures, migraine, or benign paroxysmal vertigo. More persistent episodes
suggest brainstem or cerebellar mass lesions.
Recurrent, transient, altered mental status suggests seizure or basilar migraine.
Episodes of prior head injury suggest concussion syndromes. Recent upper
respiratory tract infections may suggest vestibular neuronitis. History of ototoxic