Vertigo (Dizziness)
Lawrence W. Brown
INTRODUCTION
Dizziness is caused by a distortion in spatial orientation. The primary sensory modalities of vision, vestibular function, joint position sense, touch-pressure sense, and hearing are normally rapidly integrated by the central nervous system (CNS) into a composite sensation, keeping one aware of the body’s position in space. Incorrect or insufficient sensory information or an error in integration of the perceptions produces distorted orientation, which in turn causes dizziness.
Vertigo is a sensation of spinning or rotation. Milder forms may be described as producing a rocking sensation or vague lightheadedness. Patients may describe the room spinning around them, rather than a sense that they are moving. Usually, vertigo is of sudden onset and associated with loss of balance, nausea, and nystagmus. It may also be associated with diaphoresis and pallor. The sensation can be terrifying to small children.
Vertigo can be caused by a disorder of the CNS, where primary sensory input is integrated, or peripherally, in sensory nerve dysfunction of the vestibular system.
DIFFERENTIAL DIAGNOSIS LISTPeripheral Vertigo
Vestibular neuronitis
Labyrinthitis
Benign paroxysmal positional vertigo (BPPV)
Ménière disease
Medications
Head trauma
Central Vertigo
Benign paroxysmal vertigo (BPV)
Migraine
Seizure
Other
Presyncope
Disequilibrium
DIFFERENTIAL DIAGNOSIS DISCUSSION
The medical history can help refine the differential diagnosis. It is important to describe the course (acute, recurrent, or chronic), precipitating events (position change, trauma, or infection), association with alteration of hearing (tinnitus or hearing impairment), drug exposure, cardiovascular disease, and family history of migraine.
Peripheral Vertigo
Etiology and Clinical Features
Up to 85% of vertigo in children is caused by peripheral etiologies. Findings pointing to a peripheral cause include an episodic or acute course, improvement with visual fixation or holding head still, accompanying hearing complaints, and absence of other complaints worrisome for cranial nerve dysfunction (e.g., difficulty swallowing, double vision, drooling).
Vestibular neuronitis. This common disorder can occur several days after an upper respiratory tract infection, most often in adolescents. There is no associated hearing loss. Vestibular neuronitis is a self-limited, postinfectious neuropathy, and symptoms generally resolve in 7 to 14 days.
Labyrinthitis is a common inflammatory cause of vertigo. This also follows preceding infection, but hearing impairment is present. Furthermore, labyrinthitis often affects younger children (preschool to school age) than vestibular neuronitis. There is a positional component because vertigo worsens with movement. The course is self-limited with resolution after several days. Acute suppurative labyrinthitis is caused by extension of otitis media or mastoiditis. Chronic otitis media can lead to the development of cholesteatoma, which in turn can cause labyrinth damage.
While BPPV is the most common cause of vertigo of peripheral origin in adults, it is a rare disorder in children. Pediatric BPPV is most often seen after head trauma. Dislodged otoliths cause aberrant vestibular input in the setting of head movement. As such, affected patients experience vertigo only with a change in head position. Symptoms are usually recurrent, with each attack lasting several weeks, and typically subside spontaneously within a year, although repositioning maneuver may lead to immediate resolution.
Ménière disease is rare in children, but up to 5% of affected patients will present in childhood. It is an idiopathic disorder of the labyrinth in which there is excessive endolymph in the scala media of the cochlea. Méniére disease is characterized by recurring bouts of tinnitus, vertigo, and hearing loss.
Medications that enter the CNS can cause ataxia, incoordination, and abnormal vestibular function, but vertigo is an unusual symptom in anticonvulsant and neuroleptic toxicity. Other drugs, especially aminoglycosides, can produce vertigo as a result of toxic damage to the peripheral vestibular apparatus.
Head trauma may be followed by persistent vertigo. Vertigo caused by traumainduced perilymphatic fistula is most likely to occur suddenly, and it is accompanied by hearing loss. This diagnosis should be particularly considered in cases of barotrauma. When isolated posttraumatic vertigo without hearing loss occurs, it is more likely caused by dislocation of the otoliths from the macula (see BPPV). Labyrinthine concussion can cause severe and persistent vertigo. This presents with a tendency to fall to the ipsilateral side, and symptoms often last up to 6 weeks.
Treatment
Treatment of peripheral vertigo is symptomatic. Administration of meclizine and diazepam or lorazepam may provide relief in some children; adolescents may
respond to transdermal scopolamine. Note that chronic vertigo usually self-resolves as the result of central compensation for the impaired peripheral signaling. Longterm use of symptomatic medication may impair or delay this compensation, and it may even prevent permanent recovery. Ondansetron and phenothiazines can be used to treat nausea and vomiting. Antibiotics are used to treat acute suppurative labyrinthitis; myringotomy and intravenous antibiotics are indicated for serous labyrinthitis from acute otitis media. Most patients with Méniére disease can be controlled on a low-sodium diet, with or without concomitant diuretics.
respond to transdermal scopolamine. Note that chronic vertigo usually self-resolves as the result of central compensation for the impaired peripheral signaling. Longterm use of symptomatic medication may impair or delay this compensation, and it may even prevent permanent recovery. Ondansetron and phenothiazines can be used to treat nausea and vomiting. Antibiotics are used to treat acute suppurative labyrinthitis; myringotomy and intravenous antibiotics are indicated for serous labyrinthitis from acute otitis media. Most patients with Méniére disease can be controlled on a low-sodium diet, with or without concomitant diuretics.
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