Hearing, Balance and Communication

ISSN: (Print) (Online) Journal homepage: https://www.tandfonline.com/loi/ihbc20

Vertigo in childhood: an overview

Cristiano Balzanelli, Daniele Spataro & Luca Oscar Redaelli de Zinis

To cite this article: Cristiano Balzanelli, Daniele Spataro & Luca Oscar Redaelli de Zinis
(2021): Vertigo in childhood: an overview, Hearing, Balance and Communication, DOI:
10.1080/21695717.2021.1975985

To link to this article: https://doi.org/10.1080/21695717.2021.1975985

Published online: 16 Sep 2021.

Submit your article to this journal

View related articles

View Crossmark data

Full Terms & Conditions of access and use can be found at

https://www.tandfonline.com/action/journalInformation?journalCode=ihbc20
HEARING, BALANCE AND COMMUNICATION
https://doi.org/10.1080/21695717.2021.1975985

REVIEW ARTICLE

Vertigo in childhood: an overview

Cristiano Balzanellia, Daniele Spatarob and Luca Oscar Redaelli de Zinisc
Vertigo Center, San Bernardino Polyclinic of Sal
o, Brescia, Italy; bENT Department, ARNAS Gribaldi of Catania, Catania, Italy;
a

Pediatric Otolaryngology Head Neck Surgery Unit, Children Hospital – ASST Spedali Civili of Brescia, Brescia, Italy
c

ABSTRACT KEYWORDS
Objective: The current chapter will focus on epidemiological, etiological, and clinical data to Vertigo; dizziness;
optimize diagnostic and therapeutic approach of balance disorders in childhood. imbalance; children
Methods: Personal experience and analysis of the literature.
Results: The vestibular system is one of the first functioning systems of the human body. The vesti-
bulo ocular reflex (VOR) is present at birth, and its values approaches those of a normal adult by 2
months of age. The vestibulospinal and vestibulocollic mechanism and the effectiveness of the ves-
tibular system in postural control develop along a more protracted time course. Postural stability is
mainly controlled by visual inputs in infants and children, whereas somatosensory inputs are primary
in adults. Children begin to properly use somatosensory information at 3-6 years of age. Competence
of the sensory systems to manage intersensory conflict is reached around 15 years of age.
Conclusion: Balance disorders, at any stage of a children neurodevelopment, can be very debilitating,
worsening their basic daily activities and they can lead to psycho-neurological, affective, and behav-
ioral dysfunctions.

Epidemiology hippocampal control allow the critical analysis of the

congruence between the afferent sensory input to the
Published epidemiological data of balance disorders in
CNS (sight, proprioception, spatial memory) and the
paediatric age are extremely variable and close to 10%
efferent motor ones, in order to allow the most suitable
in most clinical studies. In half of the cases, it occurs
motor response (navigation), of the all subverted in the
at least once a year and within 10 years, while in
event of a uni- or bilateral vestibular lesion, congenital
25–50% of cases it is associated with migraine. In
or acquired, with consequent inevitable implications in
fact, vestibular migraine and paroxysmal childhood
the child’s daily life [13]. The deficit of the VOR, the
vertigo are frequent causes of vertigo in childhood,
VCR, and/or the VSR induce in fact a difficulty in
followed by acute unilateral vestibular loss (vestibular
maintaining the visual image on the retina and in
neuritis, labyrinthitis), idiopathic and psychogenic
processing the position of the body in space, an incor-
vertigo, paroxysmal positional vertigo and a mixture
rect assessment of distances and a high risk of falls.
of other possible causes (post-traumatic, orthostatic
Furthermore, the reduced hippocampal input can lead
hypotension/syncope, ‘bilateral vestibulopathy’, upper
to behavioural disorders, such as poor affectivity,
respiratory tract infections, epileptic forms, postural
aggression, anxiety, insomnia, depression, up to mul-
disorders, etc.) [1–12]. Epidemiological data of a
tiple cognitive deficits in memory, attention and learn-
number of published reviews are reported in Table 1.
ing. Poor manual skills, delay in speaking, reading,
walking, cycling, drawing, going up and down the
Patho-physiology stairs and spatial disorientation may result [13–15].
The motor skills of a subject from childhood to adult-
hood develop progressively according to maturation Clinics
steps of the Cochleo-vestibular System, the vestibular
Vestibular migraine
reflexes (Vestibulo-Oculomotor Reflex – VOR;
Vestibulo-Collic Reflex – VCR; Vestibulo-Spinal Reflex The diagnostic criteria of the Vestibular Migraine in
– VSR), the CNS, the Limbic System and the Childhood are described by Lempert et al. in 2012
Musculoskeletal System. Vestibular input and and recently revisited in the ‘Consensus Document of

CONTACT Luca Oscar Redaelli de Zinis luca.redaellidezinis@unibs.it Pediatric Otolaryngology Head Neck Surgery Unit, Children Hospital – ASST
Spedali Civili of Brescia, Piazzale Spedali Civili 1, 25123, Brescia, Italy
ß 2021 International Association of Physicians in Audiology
2 C. BALZANELLI ET AL.

Table 1. Aetiological classification of vertigo types in the involvement (rare), and conductive hearing loss, due
paediatrics – review [1,2,7–10,12]. to the presence of effusive otitis media. An audio-
 Migraine 11–35.5% logical study with otoscopy, pure tone audiometry
 Paroxysmal Vertigo of Childhood 3.6–13.7%
 Benign Paroxysmal Positional Vertigo 2.64–14.7% and tympanogram is therefore always necessary. The
 Epilepsy 1.9–6% resolution of acute symptoms occurs within a few
 Vestibular Neuritis 0.7–14.5%
 Metabolic disorders 2–16.7% days, but the functional recovery of residual dizziness
 Tumours 1.9–33% can take weeks and can be facilitated by suitable
 Perylimphatic Fistula 0.7–16%
 Trauma 3.2–30.1% rehabilitation exercises, such as in adults [20].
 Psychogenic vertigo 9.7–12.9%
 Others (Meniere’s, otitis, visual, postural diseases) 5.5–38.2%
 Idiopathic 10–19.4% Benign paroxysmal vertigo of childhood
The first description was by Basser in 1964, and it is
the Classification Committee of Vestibular Disorders of
the most frequent form of vertigo under the age of 6
the Barany Society and the International Headache
and in 2/3 of cases, there is a personal or family his-
Society’ [16] and they include (A) at least five epi-
tory of migraine according to IHS criteria. The aeti-
sodes with vestibular symptoms of moderate-intensity,
ology is unknown and the disease resolves
lasting between five minutes and 72 h, (B) a current
spontaneously in most cases within 7–10 years, but in
or past history of migraine with or without aura, and
(C) at least half of episodes are associated with at 70% of cases, migraine with IHS features occurs from
least one migraine feature. adolescence onwards [8,11]. Usually, vertigo occurs
The child shows intense motion sickness since suddenly and without aura or hearing loss. It is often
2–3 years of age and familiar migraine is present in associated with autonomic disorders, hyperacusis, and
over 70% of cases. He could present photophobia, photophobia. The child freezes instantly, sometimes
paraesthesia, otovestibular and autonomic symptoms he/she falls seated, he/she could remain stationary for
lasting few hours [11,17]. Oto-neurological signs are a few seconds or few minutes, and then he/she
often negative, but migraine and dizziness can occur quickly resumes his/her activities, without consequen-
simultaneously. It is possible to differentiate an ces or after-effects, as if nothing had happened. Like
‘Associated’ form of migraine (if headache and dizzi- cyclic vomiting and torticollis, it can be considered an
ness occur together) and an ‘Equivalent’ form (if ver- early symptomatic manifestation of migraine in chil-
tigo occurs in early childhood and headache in dren. It generally does not require specific treatment,
adolescence) [18,19]. Recent multicentric studies on but an accurate differential diagnosis is required [21].
very big samples have confirmed that migraine and According to the recent ‘Consensus Document of the
migraine defined as vertigo are statistically correlated, Classification Committee of Vestibular Disorders of the
especially in females and that they have common Barany Society and the International Headache
phenotypic characteristics, in terms of sex, age of Society’ [16], the Benign Paroxysmal Vertigo of
onset, number, frequency, intensity, and clinical char- Childhood has been reclassified introducing a new
acteristics of the episodes [11]. term and classification of recurrent vertigo in chil-
dren, named ‘Recurrent Vertigo of Childhood – RVC’.

Unilateral acute vestibular loss

Benign paroxysmal positional vertigo
It is an inflammatory manifestation of the vestibular
nerve or the entire membranous labyrinth (vestibular As in adults, it is determined by head movements or
neuritis or labyrinthitis), mostly of viral or bacterial postural changes, due to abnormal stimulation of the
origin (Herpes Simplex, Herpes Zoster Oticus, ampullary receptors by corpuscular material (otoliths)
Streptococcus Pneumoniae, Meningococcus, detached from the utricle for unknown reasons.
Haemophilus Influentiae). Expansive lesions or vascu- Dizziness is intense, fleeting and rotational, often
lar insults are possible but extremely rare. The onset associated with autonomic symptoms. The typical
of symptoms is usually acute-subacute. Rotatory ver- paroxysmal nystagmus provoked by stereotyped bed-
tigo is intense, persistent and it is associated with sta- side positioning manouevres allows to confirm the
tionary unidirectional horizontal (-torsional) clinical diagnosis and to plan the treatment by means
nystagmus, worsened by head mobilization. There are of the suitable ‘repositioning manoeuvres’, in order to
often neurovegetative and sometimes auditory disor- facilitate the otolithic migration towards the utricle,
ders, both sensorineural hearing loss, due to neuritic with the rapid resolution dizzying symptoms in most
 HEARING, BALANCE AND COMMUNICATION 3

of the cases. BPPV is about 10 times less common in Table 2. Congenital causes of vertigo [15].
children due to less otolithic detachment and often it Syndromic congenital causes
 Usher syndrome (I, III type)
resolves rapidly and spontaneously. Relapses are rarer  Pendred Syndrome
and post-maneuver residual dizziness is not usually  Mondini Syndrome
 Cogan Syndrome
described. Due to the abrupt onset of symptoms, dur-  CHARGE (Coloboma, Heart effects, Atresia, Retardation of growth and
ing the evaluation the child gets scared very often, he/ development, Genital abnormalities, Ear abnormalities)
she could scream and cry, so if the history is suggest-
ive of a BPPV it is essential to inform the parents
previously [3,22].
bone and mechanical/functional damage to the
inner ear. Urgent surgical treatment may be dis-
Psychogenic vertigo posed of in selected cases.
 Inner ear malformations: these malformations do
Psychogenic vertigo is characterized by the presence
of chronic imbalance or acute vertiginous episodes not always lead to balance disturbances. However,
without clinical evidence [6]. It has been recently clas- a minor head injury or infection can lead to ver-
sified by the Barany Society as Persistent Postural- tigo and/or imbalance, in reason of an alteration
Perceptual Dizziness (PPPD) [23]. In many cases, the of the fine functional compensatory mechanisms.
personal or family history is positive for panic attacks, Malformations of the inner ear can be isolated
agoraphobia, claustrophobia, situational phobias, anx- and/or bilateral; sometimes they can be part of a
iety, depression. The symptoms are often vague and syndromic picture (Table 2). The anomalies can
express voluntary or unaware somatization of discom- range from minimal anatomical alterations to the
fort experienced in his/her familial, social, scholastic, complete absence of the inner ear and are accom-
emotional environment. Sometimes, the symptoms get panied by hearing loss.
worst in the presence of the parents. The absence of  Meniere’s disease: very rare in Paediatrics and it
standardized evaluation methods probably leads to an occurs mostly over 8–10 years of age. Symptoms
underestimation of this form of the disorder, but dif- include hearing loss, tinnitus, fullness, acute ves-
ferential diagnosis is essential [12]. tibular loss and anxious-depressive symptoms, as
in adults. The oto-neurological evaluation, espe-
cially in the onset phase, can be normal, with the
Other causes exception of the epicritic period, and a form of
A miscellaneous of other less common causes of migraine may occur in the following years [11,24].
paediatric dizziness is listed below:  Ototoxicity: various drugs and substances can
induce to chronic imbalance due to bilateral laby-
 Neurological diseases: they are very rare and rinthine hypo-areflexia, instability, tinnitus and/or
include systemic drug poisoning, Para-neoplastic symmetrical sensorineural hearing loss on mid/
Syndromes (neuroblastomas), Arnold-Chiari acute tones, such as quinolone or macrolide antibi-
Syndrome, Spino-cerebellar Atrophy, Internal Ear otics, carbocysteine, ibuprofen, cisplatin.
Tumours (NF II), Atero-venous Malformations  Internal diseases: balance disorders in childhood
(AVM), Demyelinating Diseases (DM), Meningo- can be secondary to thyroid dysfunctions, glycemic
encephalopathies, Head traumas outcomes, Neuro- dysregulation, pheochromocytoma, cardiac or pul-
degenerative Diseases (Familial Ataxia), Posterior monary dysfunctions, anaemia, malabsorption syn-
Fossa Tumours (astrocytoma, medulloblastoma, dromes, abuse of stimulants such as caffeine,
ependymoma, glioma), Epilepsy. cocaine, amphetamines, alcohol, benzodiazepines
 Visual, dental or postural disorders: visual, occlusal (depending on age).
or postural dysfunction in the growing child can
lead to altered proprioception of muscle and/or
tendon nature and to balance disorders, sometimes
Diagnostic techniques
deserving of specific and rehabilitative treatment.
 Head Trauma: every head injury with otorrhagia/ Vestibular examinations must be selected and carried
hearing loss and/or vertigo, must undergo a com- out on the basis of the age and degree of cooperation
plete oto-neurological evaluation and urgent neu- of the young patient. We can identify the age groups
roimaging for a possible fracture of the temporal for the selection and reliability of vestibular tests:
4 C. BALZANELLI ET AL.

Less than 3 years old age  Vibration Induced Nystagmus (VIN); Head
Shaking Testing (HST);
Evaluation within the year of life through the pres-
 Rotatory Pendular Testing;
ence/symmetry/persistence of Primitive Reflexes
 Caloric stimulation with electro-nystagmographic
(Crawl Test, Vestibule-Oculomotor, Doll’s eyes, Head
(ENG) and/or video-nystagmographic (VNG)
Ringing, Step, Stretched-arms, Parachute, Grip, Moro’s
recording/analysis;
Reflex) [14]. Beyond the year of life, the primitive
 Clinical Head-Impulse-Test (cHIT), or Video
reflexes have disappeared, but at the same time, the Head-Impulse-Test (vHIT).
child’s physical development does not allow the appli-
cation of the diagnostic tests used at a more mature (B) Postural reflexes:
age. Observing his/her head–trunk–limbs movements,
his/her postural attitude, strength, and coordination  Stretched arms test and Unterberger–Fukuda step-
during spontaneous movements and playing–wal- ping test;
king–running, is the only way to evaluate his/her pos-  Posturometry (static or dynamic).
tural/vestibular skills. Moreover, eyes movements
must be evaluated with distracting manoeuvres, fixing (C) Other tests:
playful objects, balls or pencils, stimulating his/
her interest.  Cervical and ocular myogenic vestibular evoked
potentials, with stimulation by air (air-C-VEMPs
and air-O-VEMPS) or by bone (bone-C-VEMPs
Over than 3 years old age
and bone-O-VEMPs). This method allows an
From this age, it is possible to use almost any diag- evaluation of the saccule and utricle function
nostic test used in adulthood. In fact, the collabor- respectively [9,25,26].
ation of the young patient is always sufficient and
often better than that obtained by adults (Figures 1 It must be underlined that the so-called ‘new tech-
and 2). The clinical-instrumental investigations that nologies’ (vHIT and VEMPs) are a quick, simple, and
can be performed are listed (not discussed) sensitive means to identify even mild selective lesions
here below: affecting each individual vestibular receptor. In par-
(A) Eyes movements: ticular, vHIT is a completely non-invasive test that
can also be administered in very young children,
 Spontaneous, positional, and position- allowing the detection of canalar deficits with very
ing nystagmus; few head impulsive stimuli [27]; VEMPs allow the
 Smooth Pursuit and Saccadic eyes movements; identification of selective otolithic deficits affecting
 Visual suppression test; the utricle and saccule [28].
Further diagnostic investigations are required in
the case of negative vestibular tests: neuropsychiatric,
cardiological, psychiatric/psychological, orthopaedic,
physiatric, ophthalmological, dental, internist examin-
ation, neuro-imaging (CT/MRI of the brain with/
without Gadolinium), EEG.

Figure 1. Nystagmus observation by means of infra-red video-

nystagmoscopy in a 4 years old child. Figure 2. Video Head impulse testing in a 6 years old child.
 HEARING, BALANCE AND COMMUNICATION 5

Treatment Disclosure statement

The treatment of vertigo in paediatric age is strictly No potential conflict of interest was reported by
dependent on the identification of the aetiology and the author(s).
must be carefully considered. The first measure to be
implemented is to eliminate any factors triggering the ORCID
symptoms (such as eye or postural problems, fatigue,
Luca Oscar Redaelli de Zinis http://orcid.org/0000-0001-
stress), reassuring parents and children about the neg- 6524-1815
ligible possibility of serious pathologies.

References
Pharmacologic therapy
[1] Riina N, Ilmari P, Kentala E. Vertigo and imbalance
It must be carefully evaluated and adapted to each in children: a retrospective study in a Helsinki uni-
individual case, implementing it only if strictly neces- versity otorhinolaryngology clinic. Arch Otolaryngol
sary, in order to minimize side effects, such as drow- Head Neck Surg. 2005;131(11):996–1000.
[2] Erbek SH, Erbek SS, Yilmaz I, et al. Vertigo in child-
siness, attention and learning deficits, falls,
hood: a clinical experience. Int J Pediatr
depression, allergic manifestations, etc. The active Otorhinolaryngol. 2006;70(9):1547–1554.
ingredients that can be used in the paediatric field are [3] Marcelli V, Piazza F, Pisani F, et al. Neuro-otological
similar to those used in adults, with appropriate dose features of benign paroxysmal vertigo and benign
adjustments related to weight and age [6,9,29]: paroxysmal positioning vertigo in children: a follow-
up study. Brain Dev. 2006;28(2):80–84.
[4] Balatsouras DG, Kaberos A, Assimakopoulos D, et
 Medicines with sedative or antiemetic action
al. Etiology of vertigo in children. Int J Pediatr
(Ciproheptadine; Dimenhydrinate; Transdermal Otorhinolaryngol. 2007;71(3):487–494.
Scopolamine; Metoclopramide; Levo-Sulpiride; [5] Wiener-Vacher SR. Vestibular disorders in children.
Domperidone); Int J Audiol. 2008;47(9):578–583.
 Mixed-action drugs (Cinnarizine, Flunarizine, [6] Jahn K. Vertigo in children. Clinical presentation,
Betahistine, Tryptophan); course and treatment. Nervenarzt. 2009;80(8):
900–908.
 Pain relievers, steroids (Ibuprofen, Paracetamol, [7] Humphriss RL, Hall AJ. Dizziness in 10 year old
Prednisone). children: an epidemiological study. Int J Pediatr
Otorhinolaryngol. 2011;75(3):395–400.
[8] Gioacchini FM, Alicandri-Ciufelli M, Kaleci S, et al.
Rehabilitative therapy Prevalence and diagnosis of vestibular disorders in
In consideration of the child’s age and degree of psy- children: a review. Int J Pediatr Otorhinolaryngol.
2014;78(5):718–724.
cho-physical development, early mobilization is essen- [9] Jahn K, Langhagen T, Heinen F. Vertigo and dizzi-
tial as soon as a diagnostic hypothesis is formulated. ness in children. Curr Opin Neurol. 2015;28(1):
Exercises can be customized and proposed in a play- 78–82.
ful, repeated and controlled execution, proposing [10] Davitt M, Delvecchio MT, Aronoff SC. The differen-
positions and situations evoking vertigo, for example tial diagnosis of vertigo in children: a systematic
review of 2726 cases. Pediatr Emerg Care. 2020;
using a ball, performing simple somersaults or video-
36(8):368–371.
games equipped with platforms, in order to facilitate [11] Teggi R, Colombo B, Albera R, et al. Clinical fea-
recovery towards visual stabilization and psycho- tures, familial history, and migraine precursors in
motor-coordination processes [20,29]. patients with definite vestibular migraine: the VM-
The possible vestibular impairment and the need phenotypes projects. Headache. 2018;58(4):534–544.
for rehabilitative treatment in children with sensori- [12] Wiener-Vacher SR, Quarez J, Priol AL.
Epidemiology of vestibular impairments in a pediat-
neural hearing loss undergone to mono- or bilateral ric population. Semin Hear. 2018;39(03):229–242.
cochlear implantation (CI) are debated [30]. Although [13] Guidetti G. The role of cognitive processes in ves-
the effective plasticity of the CNS in paediatric age tibular disorders. Hearing, Balance and
allows functional recovery and sensory replacement Communication. 2013;11(1):3–35.
strategies in most cases, nowadays it is desirable that [14] Cumberworth VL, Patel NN, Rogers W, et al. The
maturation of balance in children. J Laryngol Otol.
every Centre dealing with CI management has the
2007;121(5):449–454.
possibility of evaluating and rehabilitating each indi- [15] O’Reilly R, Grindle C, Zwicky EF, et al.
vidual patient before and after surgery, especially in Development of the vestibular system and balance
the case of bilateral CI [31]. function: differential diagnosis in the pediatric
6 C. BALZANELLI ET AL.

population. Otolaryngol Clin North Am. 2011;44(2): [24] Akagi H, Yuen K, Maeda Y, et al. Meni
ere’s disease
251–271. in childhood. Int J Pediatr Otorhinolaryngol. 2001;
[16] Van de Berg R, Widdershoven J, Bisdorff A, et al. 61(3):259–264.
Vestibular migraine of childhood and recurrent ver- [25] Curthoys IS, Manzari L, Smulders YE, et al. A
tigo of childhood: diagnostic criteria consensus review of the scientific basis and practical applica-
document of the Committee for the Classification of tion of a new test of utricular function – ocular ves-
Vestibular Disorders of the Barany Society and the tibular-evoked myogenic potentials to bone-
International Headache Society. J Vestib Res. 2021; conducted vibration. Acta Otorhinolaryngol Ital.
31(1):1–9. 2009;29(4):179–186.
[17] Strupp M, Versino M, Brandt T. Vestibular [26] Rosengren SM, Welgampola MS, Colebatch JG.
migraine. Handb Clin Neurol. 2010;97:755–771. Vestibular evoked myogenic potentials: past, present
[18] Pagnini P, Verrecchia L, Giannoni B, et al. and future. Clin Neurophysiol. 2010;121(5):636–651.
Migraine-related vertigo (MV). Acta [27] Wenzel A, H€ ulse R, Thunsdorff C, et al. Reducing
Otorhinolaryngol Ital. 2003;23(75):19–27.
the number of impulses in video head impulse test-
[19] Lempert T, Olesen J, Furman J, et al. Vestibular
ing – it’s the quality not the numbers. Int J Pediatr
migraine: diagnostic criteria. J Vestib Res. 2012;
Otorhinolaryngol. 2019;125:206–211.
22(4):167–172.
[28] Manzari L, Burgess AM, Macdougall HG, et al.
[20] Medeiros IR, Bittar RS, Pedalini ME, et al.
Objective measures of vestibular function during an
Vestibular rehabilitation therapy in children. Otol
Neurotol. 2005;26(4):699–703. acute vertigo attack in a very young child. Eur Arch
[21] Batson G. Benign paroxysmal vertigo of childhood: a Otorhinolaryngol. 2012;269(12):2589–2592.
review of the literature. Paediatr Child Health. 2004; [29] Rine RM, Wiener-Vacher S. Evaluation and treat-
9(1):31–34. ment of vestibular dysfunction in children.
[22] Balzanelli C, Spataro D, Redaelli de Zinis LO. NeuroRehabilitation. 2013;32(3):507–518.
Benign positional paroxysmal vertigo in children. [30] Jacot E, Van Den Abbeele T, Debre HR, et al.
Audiol Res. 2021;11(1):47–54. Vestibular impairments pre- and post-cochlear
[23] Staab JP, Eckhardt-Henn A, Horii A, et al. implant in children. Int J Pediatr Otorhinolaryngol.
Diagnostic criteria for persistent postural-perceptual 2009;73(2):209–217.
dizziness (PPPD): consensus document of the [31] Ciorba A, Bovo R, Trevisi P, et al. Postoperative
Committee for the Classification of Vestibular complications in cochlear implants: a retrospective
Disorders of the Barany Society. J Vestib Res. 2017; analysis of 438 consecutive cases. Eur Arch
27(4):191–208. Otorhinolaryngol. 2012;269(6):1599–1603.