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ORIGINAL ARTICLE
Vertigo and Imbalance in Children
A Retrospective Study in a Helsinki University Otorhinolaryngology Clinic
Niemensivu Riina, MD; Pyykkö Ilmari, MD; Erna Kentala, MD
Objective: To determine medical characteristics of chil-
dren with vertigo who visited an otorhinolaryngology
(ENT) clinic during a 5-year period.
with data stored in the database and the SPSS program
applied for statistical analysis.
Results: Only 0.7% of children visiting the hospital
Design: A retrospective chart review carried out be-
tween 2000 and 2004.
Setting: Helsinki University Central Hospital tertiary re-
during the 5-year period had vertigo. Benign paroxysmal vertigo of childhood, migraine-associated dizziness, vestibular neuronitis, and otitis media–related
dizziness accounted for vertigo in most of the children.
ferral center ENT clinic.
Subjects: A total of 119 children (63 girls and 56 boys),
ranging in age from 7 months to 17 years (mean age, 10.9
years at examination).
Main Outcome Measures: Patients were identified from
the ENT clinic database based on hospital discharge codes,
Conclusions: Vertigo is a rare primary complaint of
children in an ENT clinic. In achieving a diagnosis, the
most valuable tools are medical history, an otoneurologic examination, electronystagmography, and audiography.
Arch Otolaryngol Head Neck Surg. 2005;131:996-1000
I
Author Affiliations:
Departments of
Otorhinolaryngology, Helsinki
University Central Hospital,
Helsinki (Drs Riina and
Kentala), and Tampere
University Hospital, Tampere
(Dr Ilmari), Finland.
N A STUDY OF A SCHOOL - AGED
population, 15% of children were
found to have experienced at least
1 episode of vertigo in the previous year. 1 Earlier reports on
causes of vertigo in children contain a
rather small number of cases.2,3 The differential diagnostic process is extensive in
children with vertigo, and correct diagnosis requires thorough otologic examination as well as neurologic and general
physical examination.2 If the primary complaint is a brief sensation of vertigo related to movements of the head or the gaze,
an ophthalmologist consultation is beneficial.4 Ocular disorders such as vergence anomalies can cause dizziness in
children with normal vestibular function.4 The most common reasons for dizziness in children are benign paroxysmal
vertigo of childhood and migraineassociated dizziness.2,5,6 Otitis media–
related dizziness is also a leading cause for
vertigo in childhood.3,7
Benign paroxysmal vertigo of childhood is quite common but is seldom correctly diagnosed owing to general practitioners’ unfamiliarity with the condition.
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996
Benign paroxysmal vertigo of childhood
is a migraine variant seen in younger children, and its clinical picture lacks headache and thus differs from that of migraineassociated dizziness in older children.8-10
Benign paroxysmal vertigo of childhood
is not induced by head positioning8 and
is thus in no way linked to benign paroxysmal positional vertigo, which is rare in
children.5
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The aim of the present study was to
evaluate the prevalence and characteristics of symptoms in children with vertigo
who visited the otorhinolaryngologic
(ENT) clinic at Helsinki University Central Hospital during a 5-year period to aid
in the diagnosis of the conditions associated with these symptoms.
METHODS
We conducted a retrospective chart review of
119 children with a primary complaint of ver-
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tigo seen in the Helsinki University Central Hospital ENT clinic
between 2000 and 2004. All were identified from the ENT clinic
discharge codes (according to the International Classification
of Diseases, 10th Revision). Most children were seen as outpatients, and only a few needed hospitalization. We collected information on the nature of the symptoms (acute or chronic,
paroxysmal or continuous, attack severity, and number and duration of attacks), provocative factors, ear symptoms (aural fullness, tinnitus, pain, infections, ear operations, and/or hearing
loss), other associated symptoms, head traumas, and other diseases. We also collected data, when available, on laboratory and
otoneurologic tests, imaging studies, and consultation documents from other specialties: neurologic, ophthalmologic, and
psychiatric. We also wanted to know about medical history,
current medications, and family medical history.
The vertigo diagnoses were based on standard published criteria.8,11-14 For benign paroxysmal vertigo of childhood, we used
the Basser8 criteria, with sudden brief attacks of vertigo beginning before school age. The attacks may be accompanied with
nystagmus, nausea, and phonophobia or photophobia. Diagnostic criteria used for migraine-associated dizziness required
(1) recurrent vestibular symptoms, (2) migraine according to
the International Headache Society criteria,11 (3) at least 1 migrainous symptom during at least 2 vertiginous attacks (headache, photophobia, phonophobia, and/or visual aura), and (4)
other causes ruled out by appropriate investigations.12 For
Ménière’s disease we used the criteria set by the American Academy of Otolaryngology–Head and Neck Foundation, Inc,13 which
requires 2 vertigo attacks lasting at least 20 minutes each, documented hearing loss, aural fullness or tinnitus, and exclusion
of other possible causes. Labyrinthine hydrops diagnosis was
used for school-aged children with recurrent vertigo attacks and
aural fullness or tinnitus but neither documented hearing loss
to fit Ménière’s disease diagnosis nor headache required for the
migraine-associated dizziness.
To diagnose benign paroxysmal positional vertigo we required
typical case medical history and a positive finding in the Dix Hallpike maneuver.14 Vestibular neuronitis was diagnosed based on
sudden onset of severe rotatory vertigo, spontaneous horizontorotatory nystagmus, and lack of neurologic signs that could indicate
central nervous system involvement.14 We did not require a
bithermal water caloric test since the vestibular function can recover quickly in children when the vertigo symptoms cease.15,16
From our resultant database we analyzed data with the SPSS
statistical program (version 11; SPSS Inc, Chicago, Ill). Some
information was lacking; particularly, medical and family medical histories were poorly documented. The study was approved by the Helsinki University Hospitals ethics committee.
RESULTS
Our study group of 119 children (63 girls and 56 boys, ranging in age from 7 months to 17 years; mean age, 10.9 years),
was a little less than 1% of all children visiting the ENT
clinic from 2000 to 2004. Their mean age at onset of symptoms was 9.6 years (range of age at symtom onset, 7 months
to 17 years). Age of onset of vertigo peaked at 9 to 15 years.
The most common causes of vertigo were benign paroxysmal vertigo of childhood, migraine-associated dizziness, vestibular neuronitis, and otitis media–related dizziness. For 6 children, the vertigo was psychogenic. The
distribution of diagnoses is summarized in Table 1.
Most patients (77%; n = 92) had normal audiograms
with no asymmetry and hearing thresholds equal to or
better than 20 dB; 22 patients (18%) had an abnormal
Table 1. Diagnoses of 119 Children With Vertigo
No. of
Children
Diagnosis
Benign paroxysmal vertigo of childhood
Migraine-associated vertigo
Vestibular neuronitis
Otitis media–related dizziness
Psychogenic vertigo
Vestibulopathy (unknown)
Posttraumatic vertigo
Inner ear irritation, sudden deafness
Labyrinthine hydrops
Tension neck
Orthostatic hypotension
Epilepsy-related vertigo
Ménière’s disease
Chronic cholesteatoma and surgery
Mal de barquement
Benign paroxysmal positional vertigo
Autoimmune thyroiditis, with hypothyreosis
Insulin shock–related vertigo
Sinusitis-related vertigo
Chiari I malformation
Ataxia (genetic)
Postoperative vertigo (after astrosytoma operation)
CATCH 22 syndrome
Ophthalmic vertigo
Otitis media–related vertigo and migraine-associated vertigo
Mononucleosis
Total
23
17
14
12
6
6
6
4
4
4
4
3
2
2
1
1
1
1
1
1
1
1
1
1
1
1
119
Abbreviation: CATCH 22, cardiac defects, abnormal facies, thymic
hypoplasia, cleft palate, and hypocalcemia.
audiogram (Table 2). An audiogram was unavailable
for 5 children. In 64 children who had undergone either
magnetic resonance imaging or computed tomographic
scans, no organic abnormality appeared that might explain the vertigo symptoms. In 7 children, imaging showed
abnormalities (Figure 1; Table 3).
Data on severity of vertigo were available for 113 children (95%): 3 (3%) reported that the vertigo was not disturbing; 20 (17%) said that it was very disturbing; and
90 children (76%) experienced vertigo as quite disturbing. The duration and frequency of vertigo attacks are
shown in Figure 2.
Of the ear disorders reported by 22 children (18%),
most were recurrent middle ear infections or chronic
middle ear effusion that led to grommet insertions in
16 children (13%). Three children (3%) had had
recurrent otitis media without grommet insertion.
Two children (2%) had congenital cholesteatomas,
which had been treated surgically. One child had had
severe otitis media and mastoiditis, which was surgically treated as well.
A child neurologist in the children’s hospital examined
90 (76%) of these children and found an abnormal neurologic status in 14 (16%). Those with abnormal neurologic status had hypotonia, exceptional sway or balance
problems, difficulties with gross or fine motor skills, or displayed clumsiness. One child had intention tremor and torticollis; 1 had a congenital nystagmus; and 1 had spastic
diplegia, which was treated surgically and with physio-
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Table 2. Deviant Audiometry Findings in 22 Children With Vertigo
Patient
Age, y/
Sex
Type of HL
Extent and
Frequencies of HL
7/M
12/M
10/F
17/M
16/M
15/M
11/M
5/M
15/M
15/F
8/M
14/M
5/F
15/F
17/M
11/M
8/M
13/F
13/F
16/F
17/F
14/M
Conductive
Sensorineural
Sensorineural
Sensorineural
Combined
Sensorineural
Conductive
Sensorineural
Sensorineural
Sensorineural
Conductive
Combined
Conductive
Sensorineural
Sensorineural
Sensorineural
Sensorineural
Sensorineural
Sensorineural
Sensorineural
Combined
Sensorineural
Unilateral, low
Unilateral, all
Bilateral, all
Unilateral, high
Unilateral, high
Unilateral, high
Unilateral, all
Unilateral, high
Unilateral, low
Bilateral, all
Unilateral, all
Unilateral, all
Unilateral, all
Bilateral, high
Bilateral, high
Bilateral, all
Unilateral, high
Bilateral, all
Unilateral, low
Unilateral, low
Unilateral, all
Unilateral, all
Other
Diagnosis
Otitis media–related dizziness
Sudden deafness
BPV (FAS syndrome)
Sudden deafness
Posttraumatic vertigo
Posttraumatic vertigo
Choronic cholesteatoma ear
Sinusitis-related vertigo
Hydrops
Vestibular neuronitis
Posttraumatic vertigo
Posttraumatic vertigo
Chronic cholesteatoma ear
Chiari I malformation
Sudden deafness la
Otitis media–related dizziness and MAD
Postoperative after astrocytoma operation
CATCH 22 syndrome
Ménière’s disease
Ménière’s disease
Otitis media–related dizziness
Otitis media–related dizziness
Earlier hearing loss
Hearing aid
Hearing fluctuation
Hearing fluctuation
Abbreviations: BPV, benign paroxysmal vertigo; CATCH 22, cardiac defects, abnormal facies, thymic hypoplasia, cleft palate, and hypocalcemia; FAS, fetal
alcohol syndrome; HL, hearing loss; MAD, migraine-associated dizziness.
Table 3. Abnormal MRI or CT Findings in 7 Children
With Vertigo
Age, y/
Sex
8/M
15/M
8/M
15/F
11/M
8/M
13/F
Finding
Labyrinthitis in left ear*
Two fracture lines
in temporal bone
Skullbase fracture
Chiari I malformation
Nonspecific postbleeding
sign
Postoperative condition
(after astrosytoma
surgery)
Anomaly in the
semicircular canals†
Diagnosis
Otitis media–related vertigo
Posttraumatic vertigo
Posttraumatic vertigo
Vertigo due to Chiari I
malformation
Otitis media– and migrainerelated vertigo (perinatal
hemiplegia)
Ataxia and balance problems
after craniotomy
CATCH 22 syndrome
Abbreviations: CATCH 22, cardiac defects, abnormal facies, thymic
hypoplasia, cleft palate, and hypocalcemia; CT, computed tomography;
MRI, magnetic resonance imaging.
*Left vestibulum had a longitudinal gadolium-enhanced signal (Figure 1).
†The lateral semicircular canals were saclike structures.
Figure 1. In this magnetic resonance image of an 8-year-old boy, the left
vestibulum (arrow) shows a longitudinal gadolinium-enhanced signal.
therapy. Two children had hemiplegia, one after astrocytoma brain surgery and the other due to perinatal causes.
An ophthalmologist examined 23 children who, based
on medical history, were thought to have eye-related problems. There were 12 normal and 11 abnormal findings:
1 child had congenital spontaneous nystagmus; 4 had pre-
viously been operated on for strabismus; 3 had strabismus corrected with eyeglasses; 1 child with poor eyesight had fetal alcohol syndrome; 1 had cranial nerve
paresis impairing eye movements after an astrocytoma
operation; and 1 child with light intolerance (nystagmus and vertigo) had a final diagnosis of migraineassociated dizziness. Only 1 child’s vertigo was purely
ophthalmologic in origin. He was a 10-year-old boy with
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COMMENT
Our aim was to evaluate the prevalence and characteristics of 119 children with vertigo visiting our ENT clinic
during a 5-year period. Among the 16 050 children (aged
17 years or younger) who visited the clinic during that
period, the children with vertigo made up less than 1%
35
30
Chlidren, No.
25
20
15
10
5
0
Seconds Less Than 1-20 min
1 min
20 min
to 4 h
4-24 h
Days
Constant
Duration
45
40
35
Chlidren, No.
brief daily vertigo attacks provoked by reading and
computer games.
Twenty-nine children had a history of occasional headache. Travel sickness alone and travel sickness combined with history of headache was present in 6 and 9
children, respectively. Epilepsy was diagnosed in 5 children. One child had type 1 diabetes mellitus and was undergoing insulin therapy. One child had hearing loss and
received a hearing aid at age 5 years. One child had a Chiari I malformation that caused vertigo. In addition, an
8-year-old child had VATER association (vertebral, anal,
tracheal, esophageal, and renal anomalies). One child had
CATCH 22 syndrome (cardiac defects, abnormal facies,
thymic hypoplasia, cleft palate, and hypocalcemia), and
there was 1 child with fetal alcohol syndrome as well.
One had autoimmune thyroiditis with goiter requiring
thyroid hormone medication.
Only 24 children (age range, 6-17 years) underwent a
posturography test. Postural sway (eyes open and closed)
was not affected by the child’s age. Electronystagmography (ENG) was performed or attempted in 79 children: in
6 of these, ENG was discontinued because of poor concentration or insufficient cooperation; in 61, the results were
normal; in 12, results showed unilateral reduced vestibular response (side difference ⬎25%); and none showed bilaterally reduced vestibular function. The diagnoses in children with unilateral reduced responses were sudden
deafness, Ménière’s disease, posttraumatic vertigo, cholesteatoma, and vestibular neuronitis. However, 6 of the patients with vestibular neuronitis had normal findings on
ENG, which was performed on average 14 weeks (range,
3-40 weeks) after the symptoms started.
Information on family medical history from patient
records was scanty and was available for only 58 patients. Migraine was present in 31 families among firstdegree relatives.
Of the 21 children sometimes experiencing tinnitus,
3 had hearing loss or tinnitus after ear injury, and one
16-year-old girl had continuous tinnitus. Two children
previously had a head trauma that led to unconsciousness.
One 14-year-old boy fell and this forced a wooden stick
into his ear. Immediately after the trauma, he felt dizziness and nausea and had hearing loss in the affected ear.
In the hospital, he received intravenous antibiotics, pain
medication, and corticosteroids. Examination and exploration of the ear showed a small perforation in the posterior side of the tympanic membrane and a piece of wooden
stick in the middle ear and in the vestibulum as well. There
was a clear perilymphatic fistula, which was treated surgically. He recovered from vertigo after a few months; ENG
showed no caloric responses in the injured ear, and hearing was very poor in the injured ear as well.
30
25
20
15
10
5
0
Once or Annually
Twice in Life
Monthly
Weekly
Daily
Many Times Constant
in a Day
Frequency
Figure 2. Duration and frequency of vertigo attacks.
(0.7%). According to a major epidemiologic study,1 there
should have been many more children with vertigo.
We noticed that close cooperation between different
specialties is essential in establishing a diagnosis. Many
of our study children (n=90; 76%) had first seen a pediatrician or child neurologist in the Children’s Hospital and had already undergone neurologic evaluations.
Some also underwent magnetic resonance imaging and
electroencephalography. The children with vertigo who
also had hearing problems, tinnitus, or possible vestibular dysfunction, and those whose diagnosis was still unclear as well as those with suspected migraineassociated dizziness or benign paroxysmal vertigo of
childhood came to our clinic for consultation and exclusion of an otogenic cause for their vertigo.
During the last 2 years of the study, these children were
seen mainly by the otoneurologist at the ENT department. The children were thoroughly examined and evaluated by audiogram, tympanometry, and ENG whenever
required. Patient medical history was the most important
diagnostic tool, but unfortunately, information on important details of patient and family medical histories were
often missing from medical records. The positive effect of
our study in the clinic was that a more thorough medical
history was obtained with our structured approach. Our
university hospital will soon start using electronic medical records, which can offer fill-in forms for patients with
vertigo. This will eventually help in the compilation of a
structured medical history for these patients, data transfer, and cooperation between specialties.
Otitis media with effusion (OME) is one of the most
common causes of balance disturbance in children.3,5 The
symptoms resolve following ventilation of the middle
ear.17-19 The exact mechanism of balance disturbance in
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OME is unknown. Pressure changes within the middle
ear20 and serous labyrinthitis17 have been suggested to be
responsible for vestibular disturbances in children with
OME. Children with OME are more visually dependent
for balance than are healthy children. They also have increased postural sway in the context of moving visual
scenes, especially at higher-frequency stimulus (0.25 Hz)
measured by root-mean-square calculation.21 Development of vestibular and balance function in children with
recurrent or chronic OME may be impaired even after
an episode of OME. Early intervention is therefore recommended.22 In our study, only 1 child with otitis media–
related vertigo had undergone posturography testing, so
no conclusions can be drawn.
One study of 31 children with medically unexplained neurologic symptoms such as vertigo, dizziness, headache, and fainting showed a high psychiatric
comorbidity rate.23 Over 90% of the patients had at least
1 psychiatric disorder according to Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition criteria: depressive disorders were the most common, followed by conversion and somatization disorders. Emiroglu
et al23 recommend early psychiatric consultation in children with medically unexplained vertigo, dizziness, headache, and fainting. Our study included 6 children whose
medical history and findings in examinations fit vertigo
of psychogenic origin. These children had undergone
many examinations by many different specialists. Finally a child psychiatrist confirmed the diagnosis.
In our ENT clinic, peripheral causes of vertigo such as
OME and vestibular neuronitis were common; these are
also familiar to otologists. Benign paroxysmal vertigo of
childhood and migraine-associated disease, leading causes
of vertigo in our study, were diagnosed by typical symptoms and exclusion of other causes. Benign paroxysmal
vertigo of childhood is characterized by brief and sudden
episodes of vertigo during which the child may experience
nausea, vomiting, nystagmus, and signs that are common
in migraine such as pallor, phonophobia, and photophopia.
The child is never unconscious during the attack and continues to play normally when the attack is over. Benign
paroxysmal vertigo of childhood is considered a migraine
equivalent24 or migraine precursor.25 Benign paroxysmal
vertigo of childhood and paroxysmal torticollis of infancy
are considered part of the periodic juvenile migraine disorders.26 The diagnosis is based on typical medical history
and exclusion of other causes of childhood vertigo. Migraine headaches and their variants or equivalents (benign
paroxysmal vertigo of childhood, cyclic vomiting, and paroxysmal torticollis of infancy) are the most common episodic disorders of children. In addition, acephalic and acute
confusional migraines have a clear relationship to more
typical migrainous phenomena, and all of these migraine
equivalents are relatively commonly seen in a neurology
practice.9 As many as 5% to 10% of children experience
migraines.10 In our study, children with benign paroxysmal vertigo of childhood and migraine-associated dizziness accounted for 34% of the cases.
In conclusion, even though vertigo in children is not very
rare, only a fraction of these children are evaluated by an otolaryngologist. The most common diagnoses identified in the
present study were benign paroxysmal vertigo and migraine-
associated dizziness, followed by vestibular neuronitis and
otitismedia–relatedvertigo.Inachievingadiagnosis,themost
valuable tools were medical and family history, otoneurologic examination, ENG, and audiography.
Submitted for Publication: March 4, 2005; final revision received May 20, 2005; accepted May 25, 2005.
Correspondence: Erna Kentala, MD, Department of Otorhinolaryngology, Helsinki University Central Hospital,
PB 220, 00029 HUS, Helsinki, Finland (Erna.Kentala
@hus.fi).
Financial Disclosure: None.
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