Transcript dizzness in children

DIZZNESS IN CHILDREN
林口長庚急診醫學部 ： 吳孟書 醫師
Tell Me What You Mean by Dizzy ?
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True vertigo
Pseudovertigo
L’ght-headedness
Presyncope
Intoxication
Ataxia
Visual disturbance
Unsteadiness
Stress
Anxiety
Fear
Pathophysiology
VOR slow component
eye
Medial
rectus
eye
Lateral
rectus
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
CN VIII nucleus
Semicircular canals
CN VIII nerve
Vestibulospinal tract
Causes of Vertigo in Children
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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
aLife-threatening
causes of vertigo
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Central Causes
Tumora
Meningitisa
Encephalitisa
IICPa
Multiple sclerosis
Traumaa
Seizure (usually complex partial)
Migraine
Strokea
Motion sickness
Paroxysmal torticollis of infancy
Common Causes of Vertigo
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Suppurative or serous labyrinthitis
Benign paroxysmal vertigo
Migraine
Vestibular neuronitis
Ingestions
Seizure
Motion sickness
Common Causes of Pseudovertigo
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Depression
Anxiety
Hyperventilation
Orthostatic hypotension
Hypertension
Heat stroke
Arrythmia
Cardiac disease
Anemia
Hypoglycemia
Pregnancy
Ataxia
Visual disturbance
Infections
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Direct invasion
Inflammatory toxins
Cholesteatoma
Viral vestibular neuronitis
Nystagmus
Lie motionless
1-3 weeks
prednisolone
Migraine
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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
Benign Paroxysmal Vertigo
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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
Ototoxic Drugs
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Aminoglycoside
Antibiotics
Furosemide
Ethacrynic acid
Streptomycin
Minocycline
Salicylates
Ethanol
Post-Traumatic Vertigo
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Temporal bone fracture
Vertigo, hearing loss, hemotympanum
Other subtle causes : trauma-induced seizure,
migraine, or a postconcussion syndrome
Whiplash ingury
Seizure
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Vestibular seizure (seizure cause vertigo)
3.
EEG – abnormal
Sudden onset, withor thiout associated s/s
Followed by loss or alteration of consciousness
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Vestibulogenic seizure (“reflex” seizure)
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Motion Sickness
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A miss-match in information provided to the
brain by visual and vestibular systems during
unfamiliar rotation and acceleration.
Vertigo, nausea/vomit , and nystagmus
Meniere’s Disease
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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
Perilymphatic Fistula
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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
Multiple Sclerosis
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Demyelination in the brainstem causing
vertigo
Ataxia
Optic neuritis
Nystagmus more predominant than vertigo
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
Yes
No
Hearing loss/ tinnitus
May occur
Does not occur
Abnormal tympanic
membrane
May occur
Does not occur
CNS symptoms/ signs
Absent
Usually present
Nystagmus
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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
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Central nystagmus: change direction when gaze
direction change; no increase of intensity when removal of
visual fixation
True Vertigo
Pseudovertigo
Medicine treatment
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Antihistamines
Diphenhydramine (Vena): 1-1.5 mg/kg q6h po or im
Meclizine : 25mg q12h po, used in children more than 12 years old
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Concomitant use of BZDs
Diazepam : 0.1-0.3 mg/kg/day divided every 6-8 hours, po
Thanks a lot !!
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Let your patients
complaining vertigo
leave ER only when
they could walk by
their self and have no
neurological signs
and symptoms.