Recently I have seen a few preschoolers with true vertigo – one even told me that it felt like he just “spinned on a baseball bat.” For those of you without a clear mental image of what he meant check out this video. Both had a history of recent URI symptoms, and ultimately we diagnosed one with acute otitis media and the other with viral labyrinthitis.
As many cases do these two got me to thinking? Were my gut instincts that the etiology was likely to be benign correct? Or should I be pursuing the potentially more serious diagnoses (mass naturally)?
Vertigo is difficult for patients to describe – especially those younger than grade school age. They may use terms such as:
- Spinning
- Sliding
- Turning
- Dizzy
The history is the most important factor in determining whether you are dealing with true vertigo vs lightheadedness. A history of dehydration and fluid losses suggests the latter of course. Headaches, especially with photophobia, unilateral, and associated with nausea suggest migraines. Always ask about head trauma. Therefore, a proper neurologic exam is a must. The examination should also focus on findings that can affect the vestibular, visual, or proprioceptive systems as these are needed for balance and spatial orientation. Something that I almost never see done in the Pediatric ED, but can be helpful in cases of vertigo is determining the presence or absence of hearing loss. Hint: use a tuning fork and travel back in time to your medschool days…
Hearing loss
- Labyrinthitis
- Ménière disease
- Perilymphatic fistula (secondary to trauma)
- Vascular occlusion
- Temporal bone fracture
No hearing loss
- Infants – benign paroxysmal vertigo or torticollis
- Adolescents – vestibular neuronitis
- Labyrinthine concussion
- Paroxysmal positional vertigo
- Migraine
- Seizures
- Subclavian steal
Table 3: Clinical Presentations of Vertigo
Peripheral |
Central |
|
| Occurrence | Episodic, sudden onset | Constant |
| Direction of spinning/nystagmus | Unidirectional | Variable |
| Nystagmus axis | Horizontal, rotary | Horizontal, vertical oblique, or rotary |
| Nystagmus type | Slow and fast phase | Irregular or equal phase |
| Hearing loss, tinnitus | Possible | No |
| Loss of consciousness | No | Possible |
| Other neurologic signs/symptoms | No | Cranial nerve deficits, cerebellar and pyramidal signs frequent |
Cohen NL. The dizzy patient: update on vestibular disorders. Med Clin North Am. 1991;75(6):1251-1260.
Peripheral causes imply a disorder with either the peripheral nerve or the labyrinth. Central causes of vertigo are related to problems with the vestibular nuclei of the brainstem and which include input from specific areas of the cortex, cerebellum, and spinal cord. In general, peripheral causes predominate with the exception of migraines.
If you cannot readily establish the cause as peripheral (otitis media, labyrinthitis) or have a high suspicion for migraines based on past medical history strongly consider imaging. Head CT would be the first and most practical choice in the ED especially with:
- Chronic, persistent, or worsening vertiginous symptoms
- Altered mental status
- Cranial nerve, sensory, or other neurologic deficits
- Papilledema
- Sensorineural hearing loss
- Persistent headaches
- History of head trauma
- New onset seizures
The initial management of vertigo depends on the underlying cause. You can temporarily suppress symptoms with histamine-blocking agents (meclizine, dimenhydrinate, and promethazine) and antiemetics. Canalith repositioning maneuvers (Epley or Semont maneuvers) are specific therapieswith a high cure rate after 1-2 sessions for those with BPPV that can be performed by a subspecialist for refractory vertigo.
