1. DIZZNESS IN CHILDREN
林口長庚急診醫學部 ： 吳孟書 醫師

2. Tell Me What You Mean by Dizzy ?
True vertigo
Pseudovertigo
L’ght-headedness
Presyncope
Intoxication
Ataxia
Visual disturbance
Unsteadiness
Stress
Anxiety
Fear

3. Pathophysiology eye eye Cerebellum Semicircular canals Medial rectus
Lateral rectus
VOR slow component
eye
eye
Cortex fast component to the healthy side
CN III nerve
CN VI nerve
CN III nucleus
MLF
CN VI nucleus
Cerebellum
Central projection to superior temporal gyrus and the frontal lobe
Semicircular canals
CN VIII nucleus
Vestibulospinal tract
CN VIII nerve

4. Causes of Vertigo in Children
Peripheral Causes
Suppurative or serous labyrinthitis
External ear impaction
Ramsay Hunt syndrome
Cholesteatoma
Perilymphatic fistula
Vestibular neuronitis
Benign paroxysmal vertigo
Ingestionsa
Temporal bone fracturea
Posttraumatic vestibular concussion
Meniere’s disease
Central Causes
Tumora
Meningitisa
Encephalitisa
IICPa
Multiple sclerosis
Traumaa
Seizure (usually complex partial)
Migraine
Strokea
Motion sickness
Paroxysmal torticollis of infancy
aLife-threatening causes of vertigo

5. Common Causes of Vertigo
Suppurative or serous labyrinthitis
Benign paroxysmal vertigo
Migraine
Vestibular neuronitis
Ingestions
Seizure
Motion sickness

6. Common Causes of Pseudovertigo
Depression
Anxiety
Hyperventilation
Orthostatic hypotension
Hypertension
Heat stroke
Arrythmia
Cardiac disease
Anemia
Hypoglycemia
Pregnancy
Ataxia
Visual disturbance

7. Infections Direct invasion Inflammatory toxins Cholesteatoma
Viral vestibular neuronitis
Nystagmus
Lie motionless
1-3 weeks
prednisolone

8. Migraine 19% of classic migraine patients in their aura
Basilar migraine
Migraine equivalent (without pain)
D/D: brain stem or cerebellar mass, hemorrhage, and infarction
MRI

9. Benign Paroxysmal Vertigo
Most common in children between 1 and 5 years
Recurrent attack
Sudden onset
Brief episode : few minutes
Sweating, pallor, emesis, and nystagmus
EEG – normal
Neurological examination – normal

10. Ototoxic Drugs Aminoglycoside Antibiotics Furosemide Ethacrynic acid
Streptomycin
Minocycline
Salicylates
Ethanol

11. Post-Traumatic Vertigo
Temporal bone fracture
Vertigo, hearing loss, hemotympanum
Other subtle causes : trauma-induced seizure, migraine, or a postconcussion syndrome
Whiplash ingury
A brain CT should be obtained.

12. Anticonvulsants may be benefit.
Seizure
Vestibular seizure (seizure cause vertigo)
EEG – abnormal
Sudden onset, withor thiout associated s/s
Followed by loss or alteration of consciousness
Vestibulogenic seizure (“reflex” seizure)
Anticonvulsants may be benefit.

13. Watch the environment move in a opposite direction
Motion Sickness
A miss-match in information provided to the brain by visual and vestibular systems during unfamiliar rotation and acceleration.
Vertigo, nausea/vomit , and nystagmus
Watch the environment move in a opposite direction
"look out the window"

14. Meniere’s Disease Uncommon in children younger than 10 years
Episodic attacks of vertigo, hearing loss, tinnitus, nystagmus, and automatic symptoms
Between episodes, patients may complain of impaired balance
Endolymphatic hydrops
May evolve to permanent hearing loss

15. Perilymphatic Fistula
An opening in the round or oval window
Trauma, infection, or a sudden change of CSF pressure
Suggested by sudden onset of vertigo associated with flying, scuba diving, severe straining, heavy lifting, coughing, or sneezing.
Hennebert test by pneumatic otoscopy

16. Multiple Sclerosis Demyelination in the brainstem causing vertigo
Ataxia
Optic neuritis
Nystagmus more predominant than vertigo

17. Classification of Vertigo
Peripheral
Central
Onset
Sudden
Slow
Severity of vertigo
Intense spinning
Ill defined, less intense
Pattern
Paroxysmal, intermittent
Constant
Aggravated by position/movement
Yes No
Associated nausea/diaphoresis
Frequent
Infrequent
Nystagmus
Rotatory-vertical, horizontal
Vertical
Fatigue of symptoms/ sings
Hearing loss/ tinnitus
May occur
Does not occur
Abnormal tympanic membrane
CNS symptoms/ signs
Absent
Usually present

18. Nystagmus Two components –fast and slow phase Named as fast phase
Horizontal nystagmus – point to healthy side
Pure vertical nystagmus – brainstem abnormality
Peripheral nystagmus:remain in the same direction when the direction of gaze changes; increase intensity of nystagmus when removal of visual fixation
Central nystagmus: change direction when gaze direction change; no increase of intensity when removal of visual fixation

19. True Vertigo

20. Pseudovertigo

21. Medicine treatment Antihistamines Concomitant use of BZDs
Diphenhydramine (Vena): mg/kg q6h po or im
Meclizine : 25mg q12h po, used in children more than 12 years old
Concomitant use of BZDs
Diazepam : mg/kg/day divided every 6-8 hours, po

22. Thanks a lot !!
Let your patients complaining vertigo leave ER only when they could walk by their self and have no neurological signs and symptoms.