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Evaluation of dizziness in children and adolescents

INTRODUCTION

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.

DEFINITION

Dizziness describes a disturbed sense of relationship to space [1]. 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) [2]. 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.

DIFFERENTIAL DIAGNOSIS

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 [3-6]. Head injury and central nervous system infection are the most frequent life-threatening etiologies.

Life-threatening conditions

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'.)

                                

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Literature review current through: Jun 2014. | This topic last updated: Apr 10, 2013.
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