Pediatric Vestibular Disorders

Vestibular disorders in children are generally considered uncommon. They are not as easily recognized as vestibular disorders in adults, in part because children cannot describe their symptoms as well.

The vestibular system is important for the development of normal movement reactions, motion tolerance, and motor control for postural alignment, balance, and vision. A vestibular system that is damaged by disease or injury in childhood can slow development of equilibrium and protective reflexes and motor-control tasks such as sitting unsupported, standing, and walking. In addition, an impaired vestibulo-ocular reflex (VOR) from vestibular dysfunction can impact a child’s ability to keep pace with schoolwork.

Symptoms and signs that may indicate vestibular dysfunction in children include visual-spatial problems, hearing loss or tinnitus, motion sensitivity, abnormal movement patterns, clumsiness, decreased eye-hand and eye-foot coordination, ataxia, falls, nystagmus, dizziness, nausea, ear pressure, difficulty moving in the dark, and/or delays in performance of developmental activities such as riding a bicycle, hopping, and stair climbing involving alternating left-right leg movements.

Possible causes include:

• Head-neck trauma
• Chronic ear infections or otitis media
• Congenital sensorineural hearing loss
• Cytomegalovirus and other viral infections such as in Ramsay Hunt syndrome
• Malformations from acquired or genetic conditions such as branchio-otorenal syndrome, Mondini dysplasia, and Waardenburg syndrome
• Other genetic disorders such as Usher syndrome-type I (with severe profound sensorineural hearing loss and balance problems and deteriorating vision by age 10) or type III (with balance and vision problems appearing later in life)
• Anoxia (reduced oxygen at birth) or stroke
• Meningitis (inflammation of the membranes covering the brain and spinal cord, sometimes also affecting membranes in the inner ear)
• Neurological disorders or conditions such as cerebral palsy, hydrocephalus, a posterior brain tumor, or Wallenberg syndrome (caused by a stroke from blockage in the vertebral or posterior inferior cerebellar artery of the brain stem)
• Metabolic disorders such as diabetes
• Vascular insufficiencies
• Alcohol intoxication

Children may also develop a vestibular disorder for no known reason. The underlying reasons often cannot be determined even with the most aggressive testing. This does not preclude successful treatment or recovery.

Children can experience the same vestibular disorders as adults. For example, vestibular neuritis or labyrinthitis occurs in children, as well as ototoxicity. Children that experience ototoxicity can have severe imbalance, falls, and visual-motor problems, including oscillopsia (bouncing vision).

Less common in children is Meniere's disease, enlarged vestibular aqueduct, perilymph fistula, autoimmune disease, and vascular insufficiencies.

In addition to the vestibular disorders that adults are subject to, children have two of their own. Childhood paroxysmal vertigo is typically seen in children 2-12 years old and is characterized by true spinning vertigo, nystagmus, nausea, and vomiting. Children tend to “grow out of” this condition, but sometimes it may progress into migraine-associated vertigo in adulthood. Paroxysmal torticollis of infancy consists of head-tilt spells that may be associated with nausea, vomiting, pallor, agitation, and ataxia.

Evaluation and treatment: Age-specific techniques are used for assessment and treatment of vestibular dysfunction in children. A diagnostic work-up might include a history and physical exam, a hearing test, and possibly brain scans to rule out other pathologies. In addition, a vestibular therapist can help evaluate the child's ability to use the vestibular system for balance and visual-motor control, as well as test the child's developmental reflexes that have control mechanisms in the vestibular system.

Using these results, the therapist develops vestibular-therapy exercises, which are tailored to the individual child. Children with vestibular disorders can respond well to such intervention. In fact, children typically respond more quickly than adults, because of their greater plasticity—the ability of their neurological systems to more quickly compensate for and adapt to vestibular deficits. In addition, children tend to be less fearful of movement than adults, so they participate well in the balance and movement aspects of therapy. Vestibular therapy can be effective for reducing or eliminating vertigo, improving visual-motor control, improving balance and coordination, and promoting normal development in children with vestibular disorders.