Vestibular Assessment of the Dizzy Child OSLHA 2012 Mostafa Youssif, MD, MSc, PhD candidate candidate, CCC-A Introduction 10 years ago: 1- Vertigo and balance disorders in children are considered to be rare rare, is it true? 2- Balance disorders in children may be difficult to recognize and diagnose. Vertigo and balance problems in children are considered id d tto b be rare, iis it ttrue? ? In study in Finland done by Kentala et al., 2005: • One O thousand th d and d fift fifty children hild aged d ffrom 1 tto 15 years from one child welfare unit and three schools in Helsinki University Hospital District received a questionnaire acquiring about their dizzy symptoms symptoms. • Results: Of 1050 eligible children, 938 (89%) or a caregiver completed a simple screening questionnaire, questionnaire 8% had experienced vertigo and 23% of these it was so severe vertigo that it prevented their present activity. Reason for vertigo was unknown in one third of the children and 69% could name a provocative factor for their vertigo. Conclusion: Balance problems are not rare in children and can limit their daily activities. (Kentala et al al., 2005) Balance disorders in children may b diffi be difficultlt tto recognize. i • Children often are unable to describe their symptoms and they may just seem y clumsy. • The episodes may be of short duration. • Autonomic symptoms may be prominent. (such as vomiting which may be as gastroenteritis). misdiagnosed g g ) • Symptoms may be thought of as a behavioral disorder. Causes of underestimation of vestibular and d balance b l problem bl in i children: hild • Poor recognition g of symptoms. y p • Insufficient knowledge about the different causes of vertigo and of their incidences in children children. • Insufficient knowledge about the vestibular system and its importance in postural and motor control in children. • lack of sophisticated and standardized tests available to assess the pediatric vestibular system (Wiener-Vacher, 2006). Differential diagnosis of dizziness in children Acute nonrecurrent spontaneous episodes • • • • Labyrinthine concussion Perilymphatic fistulae V tib l neuronitis Vestibular iti Labyrinthitis (acute) Recurrent episodes • • Meniere s disease Meniere’s Migraine-associated dizziness • Benign paroxysmal vertigo of childhood • • • Seizure disorder Periodic ataxia An iet Anxiety Nonvertiginous dizziness, dysequilibrium, and ataxia • • • • • • • Bilateral vestibular loss Otitis Ot t s media ed a Motion sickness CNS lesions Drug-induced (including ototoxicity) Psychiatric problems Ocular disorders (Casselbrant C lb t and dF Furman 2003) WIENER-VACHER (2005) Evaluation of the dizzy child History: y • • • • • • • • • • • Clumsiness Loss of postural control Nausea, vomiting g Seems frightened Feels like merry-go-round Hearing loss Tinnitus Ear fullness Vision changes Carsickness Seizures (Niemensivu et al 2006). Physical examination: • Otologic • Neurologic • Clinical Cli i l vestibular tib l examination i ti ((vestibular tib l office tests). Laboratory: Vestibular tests • • • • Electronystagmography El t t h Rotation Posturography VEMP Audiometric tests • • • • Thresholds Word recognition A dit Auditory brainstem b i t response Otoacoustic emissions Imaging • • MRI CT vestibular examination. Bedside tests (vestibular office tests) • The bedside Th b d id vestibular tib l ttestt b battery tt consists i t off severall simple i l screening i tests that are designed to evaluate the Vestibulo-ocular reflex (VOR) and vestibulospinal reflex (VSR) – Advantages: • Easy: can done by any clinician in the out patient clinic • Cheap: No need for expensive or sophisticated equipments. i t • Quick and well tolerated especially for children. • Sensitive: the sensitivityy and specificity p y of some of the bedside tests in adult is very high (yet its sensitivity in children not extensively studied). Bedside vestibular tests Example: • Romberg test • Fukuda F k d stepping t i ttest. t • Head-impulse test (HIT). • Head shake test. Romberg test Romberg g test is mainly y examine the VSR Technique: • Subject stand with feet slightly apart and arms folded across their chest with eyes open for 30 seconds. seconds • Then eyes closed for 30 seconds. • Abnormal: A p positive Romberg g test is one in which patients are stable with eyes open but lose balance with eyes closed. Sharpened Romberg test: • The subject is asked to do the same thing but stand with feet heelto-toe . Romberg test Suggested gg modification for children: • It is more practical to let the child see the arms of the examiner around him before closing his eye this give more security to the child child. • Use eye band if possible, • Tryy to avoid instructing g the child not to move (sometimes the child likes to move to see your reaction). it is better to instruct that it is a statue game still tthe ga e and a d the t e more o e he/she e/s e will be st e better bette score will get, this make the child do his effort to be still to win the game. Fukuda stepping test, Technique: q • The subject steps in place for 50 steps with arms extended and eyes closed Abnormal: • Progressive turning toward one side of more than 30 degree g is abnormal. • A positive Fukuda stepping test is frequently found in patients who have a UVL, but it is also found in patients who have a leg length discrepancy or other structural abnormalities of the legs. Fukuda stepping test, Suggested modification for children: • Make your test more fun: The child is instructed to march like zombies or sleeping soldiers. • For F younger children hild (5 or under), d ) use eye band to ensure that he/she keeps eyes l d W ld refer f tto thi closed. We would this as “Batman’s mask”, etc Head-impulse Head impulse test (head thrust test): HIT examine the ability of the patient to maintain fixation on a target during extremely fast angular movement of the head which give some insight into th integrity the i t it off the th lateral l t l SCC iipsilateral il t l tto th the di direction ti off th the h head d tturn. Technique: • Instruct the subject j to fixate at yyour nose. • Tilt the head 30 degree forward to position the lateral SCC in the horizontal plane. • Passive quick head movement: rotate the head rapidly 15 to 20 degree to one side then to the other • Results: Normally movement of the eye 180 degree out h tto th d movement. t off phase the h head • Abnormal: catch up saccade (refixation) which indicate a decreased VOR. Head-impulse Head impulse test (head thrust test): Suggested modifications for children: • Put the child on high chair so his head in the same level of the examiner head (or the examiner can go in his knees if he think the child will not feel secure in high chair). • Use something attractive to the child for fixation as using a sticker on the nose and ask the child to keep looking on the princess or the spider man this make it more fun for the children than asking just to fixate on the examiner nose. Head-shaking Head shaking nystagmus test • When the head is shaken vigorously for 10 to 30 cycles then stopped a transient vestibular nystagmus will emerge in patients stopped, with unilateral peripheral vestibular lesions. Technique: • Ask A k the th subject bj t to t close l his/her hi /h eyes ((or using i Frenzel lenses), • Tilt the e subjec subject head ead do down 30 deg degree. ee • then oscillate their heads 20 times horizontally. Abnormal results: Observation of nystagmus after head shaking indicates a vestibular imbalance (velocity storage is more from one side). Head-shaking Head shaking nystagmus test Modifications suggested gg for children: Nearly there is no special modification needed needed, however sometimes there is a need for smaller and lighter Frenzel l lenses , If Frenzel lenses are not available and you y think the child cannot keep his eye closed you can use eye cover. Physical Exam Eye movements Oscillopsia (sensation of movement of objects that are known to be stationary) Nystagmus N t z Involuntary repetitive oscillation of the eyes z Characterized by direction, plane, intensity and provoking maneuvers z Should Sh ld b be d done with ith Frenzel F l glasses l ENG/VNG • Formed of 3 parts: – Oculomotor testing. – Positional and Positioning testing testing. – Caloric test. Assess both peripheral and central vestibular system through the vestibular-ocular reflex (VOR) ENG/VNG • Use attractive characters with red dot at center such as the red nose of master potato Suggested modification for children: hild • Allow the child to feel the water byy his/her finger g before irrigation to get adapted to the temperature and relieve the anxiety. • Working W ki on collecting ll i d data ffor the h sensitivity i i i and d specificity of using monothermal caloric in children to reduce the testing time and discomfort. Also in using 42 degree Celsius instead of 44 degree Celsius. • Be creative in your instructions before the test and in tasking during response recording. Rotary chair • Sinusoidal harmonic acceleration (SHA) test. • Step-velocity S l i test. • The easiest and most commonly used for testing children. Conventionally e t o a y tthe e • Co child sits in his/her parent’s lab. Suggested modification for children: hild • Young children are positioned iin a car b booster seat to ensure that their heads could reach the head stabilizer. • Make the test more fun for the child: usually we refer to this test as “blasting off in the Rocket Ship”. And the child wear the special “astronaut cameras” or the “batman mask” • Micromedical p provides a pediatric sized mask to avoid slipping. • Sometimes S ti we keep k th the door open with direct communication with the child (after making sure of complete darkness and vision denial with the mask). Computerized Dynamic Platform P h Posturography • Posturography g p y quantitatively assesses a person’s upright balance function • It is used to check for disorders of the vestibular system by separately examining the visual visual, vestibular, and somatosensory systems. Computerized Dynamic Platform P Posturography h • Neurocom equipment has normative data as young as 3 years old. • Small sizes of safety suits are available for young children. • Make your test more fun: The child is told to “stand still like a statue” to play the parachute game. p g • It is recommended to blindfold the younger children for conditions 2 and 5. Vestibular Evoked Myogenic P i l (VEMP) Potentials (VEMP): • VEMPs are responses p in the muscles, such as the sternocleidomastoid muscle ((SCM), ) to sound, vibration, or electrical stimulation which is part of the vestibulocollic reflex. • it can be used for clinical testing of the vestibular end-organs, especially the saccule and inferior vestibular nerve nerve. • (Intelligent Hearing S t Systems, Inc) I ) has h an EMG contraction feedback software which allow the children to view an animated cartoon if they were holding the designated contraction. • If the child failed to hold the contraction, the cartoon p paused and wave averaging stopped until the contraction returned to the desired level. Cases for discussion Wiener-Vacher (2005) Case 1 • • • • • A 6 year old girl F ll d Fell down ffrom a mezzanine, i lloss off consciousness i + cranial i l traumatism + right otorrhagia, right hematotympanum, vertigo for 48 hours, emergency room: normal scanner, no exam y later: torticolis,, hypoacusia, yp , no vertigo g Ten days Examination: hematotympanum, no right stapedial reflex, mixed right deafness, right vestibular areflexia in the caloric test, not compensated, Tullio sign on the right side to loud sounds nystagmus or tilting of the head or fall on the side in response to 120 dB sound typically at 1 kHz), right directional preponderance in the OVAR test which is a sign of otolithic irritability. The first scanner is re-examined and show a pneumolabyrinthe (not seen at first) first), absent in second scanner (done 10 days after the trauma • Surgical exploration found: a fissure of the stapes platina which is sealed without stapedectomy • Outcome: Complete auditory and vestibular recovery recovery, stable after 3 years Case 2 • A7y year old g girl • Since 1 month, several episodes of vertigo, nausea, and headache lasting ½ to 1 hours, photophobia. photophobia • Primarily at school, at the end of the day, after television, reading. • Oto-neuro-vestibular test: normal • Scanner: normal • Ophthalmological examination: hypermetropia and convergence problems; • Eyeglasses and orthoptic therapy were prescribed and attacks of migraine solved with a simple Anti-migrainous Anti migrainous treatment: non-steroidal anti-inflammatory drug and analgesic Case 3 • 3 year old boy boy, feverish tonsillitis tonsillitis, abdominal pains, vomiting: diagnosis of gastroenteritis in the emergency room • 15th day, complains of left hypoacusia (on telephone); left total deafness, deafness diagnosed as neuritis. • normall scans. • Fourth month month, check-up check up visit, visit uncompensated vestibular deficit; • at the 13th month, month the same; new scanner: calcifying labyrinthitis Case 4 • • • • • An 18 month old boy P Permanent t acquired i d ttorticolis ti li since i th the age off 13 months th Difficulty walking (began at age of 12 months) Neurological signs: no vertigo but instability Left total deafness, left spontaneous nystagmus, Halmagyi test + on right side • Visual negligence in the right hemifield (visible for ocular and optokinetic pursuit) ht d t i off th b • Sli Slight dysmetria the upper lilimbs • Hyporeflexia in the caloric test and left directional preponderance • Scanner and MRI: cerebellar astrocytoma • Treatment: Surgery (3X), radiotherapy and chemotherapy Acknowledgment • Dr Dr. Violette Lavender (CCHMC). (CCHMC) • Dr. Robert Keith (University of Cincinnati)