Childhood Vertigo: Look to the Eyes
October 1, 2000 3 minutes read
Childhood Vertigo: Look to the Eyes
Abstract & commentary
Source: Anoh-Tanon M, et al. Vertigo is an underestimated symptom of ocular disorders: Dizzy children do not always need MRI. Pediatr Neurol 2000;23:49-53.
Although distinctly less common than in adults, dizziness is still a common complaint among children. Several studies have suggested that it represents the chief complaint in 0.5-1% of children undergoing neurological consultation. In Blayney and Colman’s series (Clin Otolaryngol 1984;9:77-85), the most common causes of childhood dizziness were serous otitis media, benign positional vertigo, and "unknown." Anoh-Tanon and colleagues now present data suggesting that a sizeable portion of children presenting with dizziness of "unknown" etiology have ocular disorders.
Anoh-Tanon et al screened all 523 children referred for vestibular testing at a single French hospital for ocular disorders due to vertigo, dizziness, or equilibrium disturbances. Among these 523 children, they selected children who had normal somatic and neurological examinations, and normal otorhinolaryngologic (ENT) exams, including comprehensive vestibular testing (i.e., the "unknown" etiology group). Among these children, 27 (approximately 5% of all children referred for testing) were found whose only abnormalities were various abnormalities on ophthalmological examination. These consisted of vergence insufficiency or latent strabismus in 70%, and anisometropia in 41%. Simple ophthalmologic treatment produced significant improvement of symptoms in 21 of the 23 patients available for follow-up. There were certain characteristics of patients with "ocular" vertigo and dizziness that seemed to separate them from other children: 1) lack of sensation of intense rotation; 2) triggering of dizziness by prolonged focused vision (as in reading, watching television, etc.); and 3) associated problems (headaches, visual difficulties and double vision). Anoh-Tanon et al suggest that when one is able to identify a dizzy child meeting these criteria, MRI can often be avoided by performing ophthalmologic testing early in the evaluation.
COMMENTARY
Dizziness, like headache, can be a difficult complaint to evaluate in children as it is an almost entirely subjective complaint, and often totally nonverifiable by examination. Younger children present a special challenge in that they often have difficulty putting the sensations of dizziness and vertigo into words. Consequently, there is little good information regarding how these children should best be evaluated and managed. Most articles on this subject seem to agree that a comprehensive neurological and ENT evaluation (including a battery of vestibular and audiometric tests) is essential in most patients. Based on the current study, it appears that if such evaluations are normal, the next step in the evaluation might include ophthalmologic evaluation, particularly if some or all of the additional clinical features noted above are present.
One should keep in mind that there are many children with "paroxysmal" vertigo who may also have normal audiometric and vestibular testing between attacks. Many of these children will prove to have benign paroxysmal vertigo (now believed to represent a "migraine equivalent") and some may have have simple or complex partial seizures; EEG is probably worthwhile in these cases. When neurological exam is abnormal or ENT evaluation is suggestive of central vertigo, head MRI should be performed.
As long as patients are carefully selected and properly evaluated, the findings of Anoh-Tanon suggest that ophthalmologic evaluation is part of the proper evaluation of children with dizziness and vertigo, and might spare a good number of children from neuroradiological studies. It is possible that these findings might apply to adults, but further studies are needed. —Rosario Trifiletti
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