Evaluation of dizziness in children and adolescents
- Theresa Walls, MD, MPH
Theresa Walls, MD, MPH
- Assistant Professor of Pediatrics
- George Washington University School of Medicine
- Stephen J Teach, MD, MPH
Stephen J Teach, MD, MPH
- Section Editor — Pediatric Signs and Symptoms
- Professor of Pediatrics and Emergency Medicine
- George Washington University School of Medicine and Health Sciences
- Section Editors
- Douglas R Nordli, Jr, MD
Douglas R Nordli, Jr, MD
- Section Editor — Pediatric Neurology
- Professor of Neurology and Pediatrics
- Northwestern University Feinberg School of Medicine
- Gary R Fleisher, MD
Gary R Fleisher, MD
- Editor-in-Chief — Adult and Pediatric Emergency Medicine
- Section Editor — Pediatric Signs and Symptoms
- Egan Family Foundation Professor
- Harvard Medical School
- Glenn C Isaacson, MD, FAAP
Glenn C Isaacson, MD, FAAP
- Section Editor — Pediatric Otolaryngology
- Professor, Department of Otolaryngology, Head and Neck Surgery and Pediatrics
- Temple University School of Medicine
- Deputy Editor
- James F Wiley, II, MD, MPH
James F Wiley, II, MD, MPH
- Senior Deputy Editor — Adult and Pediatric Emergency Medicine
- Senior Deputy Editor — Primary Care Sports Medicine (Adolescents and Adults)
- Professor of Pediatrics and Emergency Medicine/Traumatology
- University of Connecticut School of Medicine
Although a common pediatric complaint in ambulatory settings, dizziness is a vague term that can describe many conditions, including lightheadedness (presyncope), anxiety, intoxication, ataxia, visual disturbance, hyperventilation, weakness, depression, and true vertigo. Young children may not be able to describe their symptoms well, making their evaluation challenging. However, a thorough history and physical examination can establish a diagnosis in most cases.
Dizziness describes a disturbed sense of relationship to space . True vertigo refers to the perception that the patient is rotating relative to the environment (subjective vertigo) or that the environment is rotating relative to the patient (objective vertigo) . It results from a disturbance somewhere in the vestibular system, which has both peripheral and central nervous system components. Pseudovertigo describes complaints of dizziness without any rotary component.
The semicircular canals and vestibule (together known as the labyrinth) make up the peripheral vestibular system and are located within the inner ear, adjacent to the cochlea in the petrous portion of the temporal bone (figure 1). These organs send impulses to the central components of the vestibular system, located in the brainstem, cerebellum, and cortex, via the eighth cranial nerve (figure 2). Efferent impulses travel through the vestibulospinal tract to the peripheral muscles and also within the medial longitudinal fasciculus to cranial nerves III, IV, and VI. A disturbance anywhere in the vestibular system may cause patients to have vertigo and associated signs and symptoms such as hearing loss, perceptual changes in vision (eg, blurry vision), and nystagmus.
Children may use "dizziness" to describe a wide range of symptoms; it is useful to divide diagnoses into those that represent true vertigo with a sensation of spinning from pseudovertigo (table 1) (see 'Definition' above). The most common causes of true vertigo in children are otitis media, migraine headache, and benign paroxysmal vertigo of childhood [3-7]. Head injury and central nervous system infection are the most frequent life-threatening etiologies.
Head trauma — Head injuries from falls, sports, and motor vehicle accidents are common among children. A fracture of the temporal bone may damage the labyrinth and classically presents with dizziness, hearing loss, and hemotympanum. A direct blow to the temporoparietal or parietooccipital regions can cause a vestibular concussion, which produces nausea, vertigo, and nystagmus in addition to the classic symptoms of a concussion. A whiplash (hyperflexion and extension) injury may injure the basilar artery, which partially supplies the labyrinth, causing spasm and producing vestibular symptoms. Blunt or penetrating trauma to the middle ear may disrupt the oval window and cause a perilymph fistula. Loud sounds or pneumatic otoscopy cause true vertigo in such patients. (See "Concussion and mild traumatic brain injury", section on 'Post-traumatic vertigo' and "Evaluation and management of middle ear trauma", section on 'Adjacent structures'.)
- Dizziness. In: Dorland's Medical Dictionary, 29th, WB Saunders, Philadelphia 2000. p.538.
- Teach SJ. Dizziness. In: Textbook of Pediatric Emergency Medicine, 6th, Fleisher GR, Ludwig SL, Henretig FM. (Eds), Lippincott Williams & Wilkins, Philadelphia 2010. p.226.
- Bower CM, Cotton RT. The spectrum of vertigo in children. Arch Otolaryngol Head Neck Surg 1995; 121:911.
- Choung YH, Park K, Moon SK, et al. Various causes and clinical characteristics in vertigo in children with normal eardrums. Int J Pediatr Otorhinolaryngol 2003; 67:889.
- Ravid S, Bienkowski R, Eviatar L. A simplified diagnostic approach to dizziness in children. Pediatr Neurol 2003; 29:317.
- 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; 131:996.
- Gioacchini FM, Alicandri-Ciufelli M, Kaleci S, et al. Prevalence and diagnosis of vestibular disorders in children: a review. Int J Pediatr Otorhinolaryngol 2014; 78:718.
- Casselbrant ML, Mandel EM. Balance disorders in children. Neurol Clin 2005; 23:807.
- Saka N, Imai T, Seo T, et al. Analysis of benign paroxysmal positional nystagmus in children. Int J Pediatr Otorhinolaryngol 2013; 77:233.
- Tusa RJ, Saada AA Jr, Niparko JK. Dizziness in childhood. J Child Neurol 1994; 9:261.
- DIFFERENTIAL DIAGNOSIS
- Life-threatening conditions
- - Head trauma
- - Central nervous system infection
- - Intracranial tumor or abscess
- - Stroke
- - Drug overdose and other poisons
- Common conditions
- - Otitis media
- - Migraine syndromes
- - Benign paroxysmal vertigo of childhood (BPVC)
- - Adverse effects of medications
- - Motion sickness
- - Paroxysmal torticollis of infancy
- - Pseudovertigo
- Other conditions
- - Vestibular neuritis
- - Benign paroxysmal positional vertigo
- - Meniere disease
- - Perilymphatic fistula
- - Seizures
- - Ramsay Hunt syndrome
- - Multiple sclerosis
- - Congenital defects
- Physical examination
- - Vital signs
- - Ear examination
- - Nystagmus
- - Other vestibular signs
- - Neurologic examination
- Ancillary studies