Childhood Dizzness-Neuropediatric

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Dizzy child Wael B. El Sebaei Consultant pediatric neurology Cairo university

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Dizziness is unacceptable inner feeling of confusion. Because this word “Dizziness” is used to describe different sensations, we need to have a firm grasp of exactly what a person means; when he or she complains “Dizziness”. This is practically difficult specially in a child.

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World is moving around Spinning feeling Feel unsteady Light headedness With or without nausea , vomiting loss of balance or faint

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Dizziness is not a disease , it is a symptom like cough e.g. Is dizziness refers to or denotes something serious, usually no. Although dizziness do accompany some life threatening conditions in C.N.S, but in these cases; other signs and symptoms dominate.

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Dizziness is a problem for doctors, patients and their families. It is the chief complain in 8 millions physicians visits per year, yet the cause is unspecified in over half of patients. It is among diseases which are not confirmed by medical examination of patients or availability of specific almost 100% diagnostic investigation.

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Epilepsy is among these disorders, where meticulous history taking is the corner stone of diagnosis as we all know.

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Dizziness is one area, where doctors and patients fail to see eye to eye . Patients are seen by multiple specialists with different opinions. Every doctor defend his point of view and confined to his opinion. Because of this, and lack of firm diagnostic test, patients are wondering if they are imaging or those doctors know nothing.

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However, dizziness is not different from any problem; it can be solved by a scientific and systemic approach. Close cooperation between otologist, pediatric neurologist and/or neurologist are necessary in approach to dizzy child.

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Balance and gait

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Balance Sense of balance is achieved by a complex interaction of : Inner ear(labyrinth): which monitors direction of motion (turning, rolling, forward, backward, side to side & up and down motion) Eye: where is the body in space (upside down, right side down) & direction of motion. Prorioception: stretch receptors& skin pressure receptors in joints and spine.(sense of position) C.N.S: brain and spinal cord process all the bit of information from other systems to make some coordinated sense of it all.

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The brain integrates data on the current position of the head in relation to the ground or gravity, movement and its acceleration and any perturbation or change in all of them in order to maintain the upright posture. Those information travel to cerebellum& basal ganglia and high brain centers via pathways in spinal cord. Most of these processes work below our level of awareness controlling balance automatically.

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So : Motor system (Frontal lobe) is responsible for initiation and planning of movements. Basal ganglia& cerebellum are responsible for maintain posture. It works through information gathered from sensory inputs; where sense of position, mediated via pathways coming from joint and stretch receptors passing through spinal cord. Vision controls posture in subtle ways, what is of most importance is interaction between vision and ear to maintain visual fixation. The connection is medicated by vestibul0-ocular reflex.

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Vestibular compensation A process that allows the brain to regain balance, control and minimize dizziness symptoms, when there is imbalance between R&L vestibular organs in the inner ear.

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Essentially the brain integrates data on current position of the head in relation to the ground, gravity, body movement, acceleration and any perturbation or change in order to maintain posture. Brain copies with disorienting signals coming from inner ear by learning to relay more on the alternating signals coming from eyes, ankles, legs and neck to maintain posture and balance, vestibular compensation can be successfully achieved even if inner ear is damaged.

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The key way to assist the development of vestibular compensation is by doing vestibular compensation exercises. These exercises involve movements of eyes, head, upper body and then the whole body; under different visual situation (eyes open or closed), looking at steady object or moving ball on different surfaces and on different environments. A key factor is that the brain must sense the process of dizziness to begin the process of vestibular compensation.

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Gait Our gait yields a global picture of our movements. Normal gait is one of the miracles of nature. It is the result of convergence and associative processing of a barrage of inputs from many areas in the nervous system. If we watch those complex robotic walking machine, we see true two legged walkers. The best made machine walks on perfectly level surface in an extremely ungainly matter unacceptable for human and animals. Coordination, integration are not there.

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In dancing (stability, coordination and integration) seen, could not be achieved up till now, by best, perfect& most advanced robot machines.

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Causes of dizziness 1)Central causes ( Brain) Stroke, tumors, M.S, encephalitis , drugs (sedative), aquaustic neuroma , head trauma& cerebrovascular disorders affecting blood flow to brain. 2)Epilepsy : in aura or as or apart of an actual fit. It is not light headedness, not a true vertigo, or a true fainting attack; it is usually associated by partial alteration of consciousness.

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3) Heart & circulation : Aortic valve stenosis& anemia; as circulating blood do not carry enough O2 to brain; specially in children at 1:4 years because of rapid growth and deficient iron intake in usual food unless fortified iron supplement are given. 4)Dizziness associated with faint or near faint: hotly stuffy crowded non ventilated environment, orthostatic hypotension, sight of blood, or injection. Strenuous exercises with emotional stress, anxiety or tension. Standing without moving for long time. Hot showers(blood rashes away from head to cool skin).

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5) Subclavian steal syndrome: Subclavian artery carries blood to arm and brain, sometimes it got blocked, in such away, blood flows from brain into arm. 6)Hyperventilation syndrome: In H.V Co2 goes down, blood vessels in heart and extremities automatically constrict, small blood vessels do not deliver enough blood to brain creating sense of dizziness. 7)Migraine, anxiety &chronic subjective dizziness

Chronic subjective dizziness : 

Chronic subjective dizziness Persons who have persistent dizziness that can not be explained by medical conditions with: Persistent sensation of dizziness for a duration of 3m( light or heavy headedness, no vertigo). Hypersensitivity to one’ own motion not directional specified. Symptoms are made worse with complex visual stimuli such as grocery stores, shopping malls or when performing precision visual tasks such as reading or using computers.

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Absence of physical illness, medications or factors that might cause dizziness. Radiographic imaging of brain are normal & balance function tests show no balance problems.

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Manifestations (Descriptions): In dizziness; different complaints recorded: Loss of balance (disequilibrium, unsteadiness) (wobbly or unsteady) Spinning (vertigo, improper perception of movements) . False sensation of movements of one’s or surroundings. Near faint (usually with black out, pallor, sweaty shaky, fall to ground) Feeling of light headedness. Feel your head back and froth for 20 times; this is the feeling of dizziness.

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Activities most often associated: Getting up from lying down. Turing head. Getting up from sitting. When upset.

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Clues to diagnosis: Careful, meticulous history taking is the corner stone for correct diagnosis: How long do attack lasts, is it related to other conditions or no (stress, changes in position head movements or body movements). Sense of rotation is one of the most important symptoms which should be stressed on, as it indicates “vertigo”. Whether the subject or the surrounding rotates is irrelevant.

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Illusion of rotation ( surroundings): distinguishes vertigo from some other disturbances (migraine and epilepsy)and localizes the lesion to vestibular system.

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Causes of vertigo : Drugs ,toxins, epilepsy (partial seizure or as an aura in many types ), infection in semicircular canal, vestibular neuritis, Menier’s disease, migraine, motion sickness, M.S. psychogenic ( panic attacks ) trauma or temporal bone fracture. BPV, BPPV.

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Vertiginous or not: Is dizziness is vertiginous or not, is a basic question, we must spend considerable time trying to nail down. True vertigo is like “true love", if you could not determine, is this is vertigo or no; most probably, it is not . Important historical points: course, presence of precipitating events, association of hearing impairment, tinnitus or other manifestations must be clarified.

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If you have vertigo, your complaint will be mostly when you move in one direction or in particular position, or with one ear down, spinning seems to be in one direction (clock wise or anti clock wise). Nausea & vomiting often accompanies severe vertigo. If you have dizziness but not vertigo things get more hairy .

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A common problem is “light headedness “; this occur when you get up too fast as if not enough blood is getting to brain. Certainly small amounts of transient light headedness is normal; but if it is persistent; it will be called: Dizziness

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On standing, light headedness may occur in: adolescence, children in a growth spurt, some diabetic, with diseases of peripheral nerves responsible for blood pressure. It is usually worst in morning after prolonged recumbence. Visual darkening may occur with fainting or near faint.

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Majority of persons with vague dizziness have an anxiety equivalent. They are just ‘nervous". This may seem ridiculous at first glance, but it is true. When a vague non descript headache accompanies dizziness; this is nearly always indicate anxiety. Panic attacks and social phobia are are anxiety equivalent. Severe dizziness may be accompanied by palpitation, anxiety and sweating. Rate of anxiety is 4 times higher in patients with migraine than normal population.

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Migraine: At least 30.000.000 million person worldwide experience the debilitating affect of migranious headache . Dizzy spells can occur during or after migraine attacks, with or without vision problems and numbness. In some cases; headache begins so bad that the pain begins as dizziness. Sometimes, vertigo is the main manifestation of migraine (sense of loss of balance; nausea, vomiting) with or without visual and speech problems, stiffness of neck and increased sensitivity to light.

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In migraine 17% of patients reported vertigo at the time of the attack . Those individuals have no difficulty in recognizing vertigo as a manifestation of migraine. Another 10% experience vertigo in the interval between attacks and those also have no difficulty relating vertigo to migraine.

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Brief (minutes) recurrent episodes of vertigo in infants and children are migraine equivalents; despite the absence of headache. However those attacks usually evolve later into classic migraine and there is often strong family history of migraine.

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Transient vestibular symptoms : Acute attacks of dizziness or black out are common in vestibular diseases, and may be difficult to distinguish from partial seizures. Although dreaminess and perceptual changes do not occur, other pointers to vestibular diseases may be present e.g.: deafness, tinnitus, feeling of pressure in the ear or relation of symptoms to position of head.

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Benign paroxysmal vertigo : A disorder of infants and children manifested by attacks of vertigo, maximal at onset, may be prolonged that standing is impossible. The child lies either motionless on the floor or wants holding. Consciousness is maintained throughout the attack, headache is not associated. Predominant symptoms are pallor, fright and nystagmus without ataxia. Episodes last only minutes and recur at irregular intervals Diagnosis : clinically mainly; ENT& neurological examination are needed to exclude other similar conditions.

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BPPV: Brief episodes of vertigo ppt by movements such as bending over ,turning in bed. Nausea may or may not present . Attacks occur several times /day, the disorder although benign may be disabling.

Dizziness : 

Dizziness Tips for management

Physical or mental : 

Physical or mental The case for a strong link between physical and mental illnesses, keeps growing stronger. It is well known that anxiety disorders can increase risk of heart failure, affect GIT symptoms and can hamper the recovery from cancer and other severe disabling diseases. Minimizing patients’ anxiety and annoyance does decrease sense of dizziness irrespective the cause is organic or psychogenic or irrespective vertigo is present or no.

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Do not suffer in silence . Keep on diary. Keep active : do not try to prevent episodes of dizziness by becoming inactive and avoid doing what you think that causes dizziness. This inactivity means that your brain is not exposed to the mismatching signals coming from the two balance system in your inner ear and prevent the process of vestibular compensation, so dizziness will persist and not compensated, meanwhile this will lead to depression, anxiety…..

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SSRI(Selective Reuptake Sertonin Inhibitors): reduce anxiety disorders and lessening dizziness symptoms. CBT( Cognitive Behavioral Therapy). Vestibular Balance Rehabilitation Therapy.

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During the attack: Make patients sits down, or lie down right way, put his or her head between knee to force blood to brain, or just lay on table prone with head slightly down.

Finally: : 

Finally: Dizziness is an unacceptable inner feeling of confusion. It presents diagnostic dilemma, the origin may be the ears or CNS. Presence of vertigo usually denotes that the ears and in particular semicircular canals is responsible. CNS causes entitles long list of disorders, almost all of them have definite different signs and symptoms except migraine variant and some kinds of epilepsy.

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Although dizziness per se does not indicates a life threaten condition; it is disabling and so annoying to patients. Management will be management of cause plus instructions regarding position of the patients to minimize discomfort.

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Thank you

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