Tinnitus, vertigo and balance disorders in children: SAQ

The first child has benign paroxysmal vertigo of childhood. She is a preschool child with sudden, brief, stereotyped episodes of fright, pallor, and unsteadiness that resolve completely within seconds to minutes and leave a normal interictal examination, with no loss of consciousness and a family history of migraine. This is the classic, safe picture of the commonest cause of vertigo in a preschool child, and the diagnosis is clinical. The second child has an acute vestibular syndrome, and the abnormal head impulse toward the right, the unidirectional horizontal-torsional nystagmus, and the preserved hearing establish an acute vestibular neuritis once the central signs are excluded.

Question 1 (10 marks)

Outline your diagnosis, differential, investigation plan, and management for the three-year-old girl, and explain how you would recognise and act on the red flags that would change that plan. [2]

My diagnosis is benign paroxysmal vertigo of childhood. The four features that make the diagnosis are the preschool age, the sudden onset of brief episodes lasting seconds to minutes, the completely normal examination between the attacks, and the absence of any loss of consciousness. The family history of migraine supports the diagnosis, because the condition is an episodic syndrome that may be associated with migraine, and a proportion of affected children develop migraine or vestibular migraine later in childhood. [2]

My differential is a focal seizure, a posterior fossa tumour, vestibular migraine, and benign paroxysmal positional vertigo. The absence of loss of consciousness and the normal examination between attacks separate the condition from a seizure, and the brief, non-positional nature separates it from positional vertigo. Vestibular migraine presents in an older child with episodes lasting minutes to hours and migraine features, and a posterior fossa tumour is excluded by the normal interictal examination and the negative red-flag screen. [1]

My investigation plan is to perform no routine tests and no imaging. The diagnosis is clinical, and a child who meets the classic pattern with a normal examination and a negative red-flag screen does not need a scan, a blood test, or an electroencephalogram. A pure-tone audiogram is the one reasonable baseline test, to exclude an unsuspected hearing loss, but it is normal in the classic case. I would image only if a red flag appeared. [3]

My management is reassurance and observation. I would counsel the family that the episodes are benign, that they are not seizures, that they reflect the migraine predisposition of the child and the family, and that they resolve before the child starts school in most cases. I would advise the family to return immediately if the pattern changed, if the episodes lengthened, if a headache or a hearing loss appeared, or if the child developed a focal sign, and I would review the child only if the pattern changed. [2]

The red flags that would change my plan are the features of a central cause. A focal neurological sign, an ataxia between attacks, a papilloedema, a new or progressive headache, a gaze-evoked or a direction-changing nystagmus, a vertical nystagmus, or a unilateral or progressive hearing loss would each convert the plan from reassurance to urgent magnetic resonance imaging. The cardinal error is discharging a posterior fossa tumour or a stroke as a benign periodic syndrome of childhood, and the safeguard is the red-flag screen applied to every dizzy child. [7]

Question 2 (10 marks)

Discuss the peripheral-versus-central assessment of the fourteen-year-old boy, justify the diagnosis of vestibular neuritis, and outline the evidence-based management. [7]

My first task is to separate a peripheral from a central cause in the acute vestibular syndrome, using the head impulse, nystagmus, test of skew rule. A peripheral cause gives an abnormal head impulse toward the affected ear, a unidirectional nystagmus that does not change direction with gaze, and no skew deviation, and this boy has the full peripheral pattern. A central cause would give a normal head impulse, a direction-changing or a gaze-evoked nystagmus, or a skew deviation, and any of these would mandate urgent magnetic resonance imaging for a posterior circulation stroke. [7]

My diagnosis is acute vestibular neuritis. The acute onset of severe continuous vertigo, nausea, and vomiting after a viral illness, the abnormal head impulse toward the right, the unidirectional horizontal-torsional nystagmus beating away from the affected ear, the absence of skew, and the preserved hearing together establish the diagnosis. The preserved hearing distinguishes neuritis from labyrinthitis, which would add an acute sensorineural hearing loss or tinnitus and localise the lesion to the labyrinth. [7]

My management is a short course of a vestibular suppressant for the acute vertigo and vomiting, followed by early vestibular rehabilitation. The suppressant, such as prochlorperazine or ondansetron at standard paediatric doses, is used for one to three days alone, because its prolonged use impairs the central compensation that is the route to recovery. The vestibular rehabilitation, with the gaze-stabilisation and the habituation exercises, drives the compensation that restores the balance, and the child is encouraged to move the head rather than to rest strictly. [10]

The prognosis is good with the early rehabilitation that drives the central compensation, and most children recover their balance over weeks. I would review the child to confirm the recovery, and I would image and refer if the vertigo persisted, if a hearing loss appeared, or if any central sign emerged. The principle is that the peripheral cause is managed with a short suppressant and early rehabilitation, while any central sign on the rule is the indication for urgent imaging that I would not delay. [7] [10]