Epidemiology of Dizziness and Balance Problems in Children in the United States: A Population-Based Study

Experience from the First Paediatric Vestibular and Balance Clinic in a Multiracial Asian Setting

Objective

Paediatric vestibular and balance services have recently gained attention across the globe. We present our one-year experience exploring the aetiology of paediatric vestibular disorders in a recently established Paediatric vestibular and balance clinic.

Methods

Children and adolescents under 18 referred to the Paediatric Vestibular and Balance Clinic for evaluation were included.

Results

74 children were included in this study (Mean age: 10.04 ± 3.9). We found a slight female predominance, n = 38 (51.35%). Abnormal vestibular function was observed in 60.8% of children. Vestibular migraine (VM) was the most common aetiologic cause, n = 35 (47.3%), followed by vestibular/balance delay (n = 11).

Conclusion

The most prevalent cause of dizziness was VM, followed by vestibular delay found in children with isolated speech and language delay. We highlight the importance of awareness of various causes of dizziness in children amongst carers and physicians to diagnose and manage it early.

Guidelines of the French Society of Otorhinolaryngology and Head and Neck Surgery (SFORL) for vestibular rehabilitation in children with vestibular dysfunction. A systematic review

INTRODUCTION

The consequence of complete or partial uncompensated vestibular dysfunction in children is usually balance disorders, with the risk of falls and increased fatigue, particularly during tasks requiring postural control. The aim of these recommendations is to establish guidelines for vestibular rehabilitation (VR) in children with vestibular impairment.

MATERIAL AND METHODS

The guidelines were developed based on a systematic review of the international literature, validated by a multidisciplinary group of French-speaking otorhinolaryngologists, scientists, and physiotherapists. They are classified as grade A, B, C, or expert opinion according to a decreasing level of scientific evidence.

RESULTS

A PubMed search of studies published between January 1990 and December 2021 was carried out using the keywords "vestibular," "rehabilitation," and "children". After filtering and reviewing the articles, a total of 10 publications were included to establish the recommendations.

CONCLUSION

It is recommended that a vestibular assessment be carried out before VR, including a study of vestibulo-ocular reflex, otolithic function, and postural control. In cases of vestibular dysfunction, physiotherapy treatment is recommended from an early age to train different aspects of postural control, including anticipatory and reactive postural adjustments. VR adapted to the pediatric population is recommended for children whose vestibular dysfunction leads to functional disorders or symptoms of vertigo for those who have suffered head trauma. It is recommended that children with bilateral vestibular impairment be treated using gaze stabilization exercises for adaptation and substitution. Optokinetic stimulation and virtual reality are not recommended for children and young adolescents.

Does the Dizziness Handicap Inventory-Children and Adolescents (DHI-CA) Demonstrate Properties to Support Clinical Application in the Post-Concussion Population: A Rasch Analysis

The purpose of this cross-sectional validation study was to evaluate the clinical utility of the DHI-CA by (1) examining its dimensionality using exploratory factor analysis (EFA) and (2) calibrating DHI-CA items (using the multidimensional Rasch model) to obtain item difficulty levels. A retrospective chart review was conducted for 132 patients between the ages of 8 and 18 years (mean age = 15.3 ± 2.1 years) from a multidisciplinary post-concussion management tertiary center. Data were extracted on age, sex, and DHI-CA. EFA revealed that 12 out of 25 items did not fit in the subscale that they were originally described under, indicating poor dimensionality. Calibration of items on the Wright Maps revealed that 50% of the items pooled in the lower difficulty level, indicating a potential ceiling effect. Corrected item-rest correlations for the physical, emotional, walking/mobility, and community participation ranged from 0.44-0.66, 0.27-0.61, 0.54-0.57, and 0.32-0.69 (p < 0.001), respectively. The clinical utility of the DHI-CA was found to be questionable due to the presence of double-barreled items and the ceiling effect. Clinicians must supplement data from the DHI-CA with other measures and patient interviews to make informed clinical decisions specific to the post-concussion population until new, robust, and valid measures are developed.

Developmental cadmium exposure disrupts zebrafish vestibular calcium channels interfering with otolith formation and inner ear function

Dizziness or balance problems are estimated to affect approximately 3.3 million children aged three to 17 years. These disorders develop from a breakdown in the balance control system and can be caused by anything that affects the inner ear or the brain, including exposure to environmental toxicants. One potential environmental toxicant linked to balance disorders is cadmium, an extremely toxic metal that occurs naturally in the earth's crust and is released as a byproduct of industrial processes. Cadmium is associated with balance and vestibular dysfunction in adults exposed occupationally, but little is known about the developmental effects of low-concentration cadmium exposure. Our findings indicate that zebrafish exposed to 10-60 parts per billion (ppb) cadmium from four hours post-fertilization (hpf) to seven days post-fertilization (dpf) exhibit abnormal behaviors, including pronounced increases in auditory sensitivity and circling behavior, both of which are linked to reductions in otolith growth and are rescued by the addition of calcium to the media. Pharmacological intervention shows that agonist-induced activation of the P2X calcium ion channel in the presence of cadmium restores otolith size. In conclusion, cadmium-induced ototoxicity is linked to vestibular-based behavioral abnormalities and auditory sensitivity following developmental exposure, and calcium ion channel function is associated with these defects.

The global prevalence of vestibular dysfunction in children and adolescents: a systematic review and meta-analysis

BACKGROUND

Vestibular dysfunction has been extensively studied amongst the older population. Recently, conditions and management of vestibular dysfunction among children and adolescent has gained attention. Yet, a lack of awareness and expertise in managing children and adolescents with vestibular dysfunction has led to a delay in diagnosis as well as a trifling prevalence rate.

AIM

To conduct a systematic review and meta-analyses to estimate the overall pooled prevalence of vestibular dysfunction in children and adolescents.

METHODS

PubMed, Scopus, and Web of Science databases were searched to identify studies published until 29 April 2022. We used a random-effects model to estimate the pooled prevalence with 95% confidence intervals (CIs). Heterogeneity was assessed using the I² statistic and Cochran's Q test. The robustness of the pooled estimates was checked by different subgroups and sensitivity analyses.

RESULTS

We identified 1811 studies, of which 39 studies (n = 323,663) were included in the meta-analysis. Overall, the pooled prevalence of children and adolescents with VD was 30.4% [95% CI 28.5-32.3%]. The age of the participants ranged from 1 to 19 years. Participants of the included 39 studies were from 15 countries. Among the studies, 34 were cross-sectional, and five were case-control designed. There were discrepancies found in the studies with objective (higher prevalence) versus subjective (lower prevalence) evaluations.

CONCLUSION

The prevalence of VD among children and adolescents was found to be 30.4% based on high-quality evidence. Due to the subjective assessment of most studies pooled in the analysis, the results should be interpreted cautiously until future comparative studies with objective assessments are carried out.

A Systematic Review and Meta-analysis of the Effect of Active Video Games on Postural Balance

OBJECTIVE

To conduct a comprehensive systematic review and meta-analysis of the effects of active video game (AVG) interventions on postural balance across all ages in populations with and without neurologic impairments, using all types of platforms.

DATA SOURCE

Six databases (PubMed, PsycINFO, Sport Discus, MEDLINE, Web of Science, and Google Scholar) were reviewed by December 31, 2020.

STUDY SELECTION

The protocol was registered in the International Prospective Register of Systematic Reviews (PROSPERO: CRD42020204191). For inclusion, a study must be original, published in English peer-reviewed venues and employed AVGs as the sole or primary intervention to enhance, maintain, or regain postural balance. At least 2 within- or between-subjects conditions must be included with ≥10 participants per condition.

DATA EXTRACTION

Three reviewers independently performed data extraction and assessed the risk of bias.

DATA SYNTHESIS

129 studies were identified, with 102 eligible for meta-analysis. The total number of tested participants was 6407 (60.0% women, M_age=55.1 years, range=3-99 years, SD=22.6). The average intervention duration was 35.6 min/session with 3.1 sessions/week for 7.6 weeks. The overall effect favored AVG interventions (Hedges' g=0.469; 95% confidence interval [CI]=0.407-0.531). Although the overall study quality was relatively low, the analysis expectedly indicated significantly larger effects (P<.001) for AVG-interventions over passive controls (Hedges' g=0.627; 95% CI=0.466-0.788), but importantly also favored AVG-interventions over conventional treatment (Hedges' g=0.389; 95% CI=0.311-0.468). All clinical populations responded positively, although with different effect sizes (P=.023). Children experienced larger treatment effects (Hedges' g=0.550; 95% CI=0.336-0.764), closely followed by seniors (Hedges' g=0.529; 95% CI=0.402-0.656). The largest intervention effect on balance improvements was seen in healthy people without a medical condition (Hedges' g=0.609; 95% CI=0.465-0.753).

CONCLUSIONS

AVGs can produce postural balance improvements and better postural maintenance. All populations could benefit from AVG interventions.

Effectiveness and acceptance of Vestibulo-Ocular Reflex adaptation training in children with recurrent vertigo with unilateral vestibular dysfunction and normal balance function

Objective

This was a block randomized controlled study to evaluate the effectiveness and acceptance of Vestibulo-Ocular Reflex (VOR) adaptation training in children with recurrent vertigo with unilateral vestibular dysfunction (UVD) and normal balance function.

Methods

Thirty children, aged 4-13 years, diagnosed with recurrent vertigo of childhood (RVC) with UVD (according to a caloric test) and normal balance function were analyzed. These 30 children were divided into 10 blocks based on similar age and severity of vertigo. Three children in each block were randomly assigned to one of three groups to receive 1 month of treatment. Group A received vestibular-ocular reflex (VOR) adaptation training, Group B received Cawthorne-Cooksey training, and a control group received no training. All children were administered pharmacotherapy [Ginkgo biloba leaf extract (drops)]. The Dizziness Handicap Inventory (DHI), Visual Analog Scale of Quality of Life with Vertigo (VAS-QLV), and canal paralysis (CP) on the caloric test were recorded before and after treatment, and the effectiveness of treatment was evaluated. The Visual Analog Scale of Acceptance (VAS-A) was used to evaluate the acceptance of the training in the two groups that received training.

Results

There were 10 children each in Group A, Group B, and the control group; the male to female ratio was 1, and the average age in each group was 9.0 ± 3.2, 8.4 ± 3.0, and 8.3 ± 2.6 years, respectively. The effective rate was 100% in Group A, 65% in Group B, and 60% in Group C. The recovery rate on caloric testing after treatment was 100, 70, and 50%, respectively. DHI scores before and after training were 56.8 ± 12.4 and 8.8 ± 6.1 in Group A, 57.8 ± 12.6 and 18.8 ± 9.7 in Group B, and 56.8 ± 12.4 and 24.0 ± 15.3 in Group C (all P = 0.000). VAS-QLV scores before and after training were 7.5 ± 1.0 and 0.9 ± 0.9 in Group A, 6.4 ± 2.2 and 2.7 ± 1.1 in Group B, and 6.6 ± 1.6 and 2.6 ± 1.4 in Group C (all P < 0.05). The CP values before and after training were 35.7 ± 15.1 and 12.9 ± 8.7 in Group A, 33.6 ± 20.1 and 23.6 ± 19.3 in Group B, and 38.6 ± 21.1 and 24.8 ± 17.9 in Group C (P = 0.001, P = 0.015, and P = 0.050, respectively). Between-group comparisons showed that the decreases in DHI and VAS-QLV scores after training were significantly different (P = 0.015, P = 0.02), while CP values were not (P = 0.139). After training, the DHI value had decreased significantly more in Group A compared with Group C (P < 0.05), but there were no other differences. After training, VAS-QLV scores in Group A had decreased significantly more compared with Group B and C (P < 0.05). In terms of acceptance, the VAS-A score was 7.6 ± 2.2 in Group A and 3.1 ± 2.8 in Group B (P =0.004), The acceptance rate was 70% in group A and 10% in group B. there was no significant correlation between age and VAS-A in either group A or group B (P > 0.05).

Conclusion

This study strongly suggests that vestibular rehabilitation training should be performed in children with vertigo to improve symptoms. For children with RVC with UVD but normal balance function, a single VOR adaptation program can effectively improve vertigo symptoms, and given its simplicity, time-effectiveness, and excellent outcomes, it is associated with better acceptance in children compared to classic Cawthorne-Cooksey training.

Evaluation and management of paediatric vertigo

PURPOSE OF REVIEW

This review summarizes the most current information on cause, evaluation and treatment of dizziness in children.

RECENT FINDINGS

There has been an increased understanding of the multifactorial cause of dizziness in the paediatric population. Quantitative vestibular testing is increasingly used and valuable as a diagnostic adjunct. Vestibular rehabilitation, migraine hygiene, psychological therapies, pharmaceuticals and/or surgery can be used as well tolerated and effective treatments for vertigo in children and adolescents when tailored to cause.

SUMMARY

Paediatric vertigo can be effectively evaluated through careful history taking and physical examination along with adjunctive tests, such as vestibular testing and audiometry, when appropriate. Options for treatment of vestibular disorders in children and adolescents have greatly expanded in recent years allowing for the effective management of nearly all cases of paediatric vertigo, though a multimodal and/or multidisciplinary approach is often needed.

Recurrent Vertigo of Childhood: Clinical features and prognosis

Introduction

“Recurrent Vertigo of Childhood” (RVC) has recently replaced the term “Benign Paroxysmal Vertigo of Childhood” and was defined as recurrent spells of vertigo without evidence of a vestibular migraine of childhood (VMC). RVC and VMC are considered the most frequent causes of vertigo and dizziness in children below 18 years of age. Diagnosis might be challenging since clinical features of RVC and VMC may overlap.

Objective

This study aims to characterize clinical and instrument-based findings in patients with RVC and to evaluate the course of the disorder.

Methods

We prospectively collected clinical and instrument-based data of children/adolescents younger than 18 years, who presented at the German Center for Vertigo and Balance Disorders (DSGZ) at the LMU University Hospital in Munich. All patients underwent a comprehensive neurological, ocular motor, vestibular and cochlear examination. Furthermore, findings from follow-up examinations were analyzed.

Results

Overall 42 children (24 male and 18 female) with RVC were included in the study. The mean age at diagnosis was 7 ± 3.6 years with a mean onset of symptoms at the age of 5.6 ± 3.4 years. Attack duration ranged between 1 min and 4 h. The most common accompanying symptoms included nausea, vomiting, expression of fear, and falls. Non-migrainous headaches were reported by 11 patients during initial presentation, 7 of whom were later diagnosed with migraine. Female patients showed a higher age at symptom onset, a higher attack frequency, and attack duration. Eleven of the 24 patients seen at a 3.5 year follow-up reported a complete cessation of attacks. Patients still experiencing vertigo attacks had a significantly reduced attack frequency, especially those who implemented at least one prophylactic measure.

Conclusion

A precise characterization of symptoms is essential for diagnosing children with RVC. Age at symptom onset does not exceed the age of 12. Gender-specific differences should be considered and may further support the evidence of an association with migraine. The disease course of RVC is benign, nevertheless implementing prophylactic measures such as regular exercise, increased fluid intake, sleep hygiene, and relaxation exercises, can improve attack frequency.

Hirudinea (Annelida) Fauna of Some Wetlands in Bingöl Province

OBJECTIVE

Leeches are important and reliable indicators of water quality and biodiversity in the ecosystem, so the presence of specific leech species is often closely related to basic water conditions and the presence of certain animals. This study was carried out in 2017 and 2018 in order to determine the Hirudinea fauna of some wetlands in Bingöl province. The investigation was conducted on a total of 13 stations.

METHODS

The water parameters of the stations were measured and recorded in situ. The collected specimens were brought alive to the Zoology Laboratory of Bingöl University Biology Department and kept alive under room temperature conditions. The diagnosis of leech samples was made through the living samples, and they were identified at the level of family, genus, and species.

RESULTS

During the study, seven species, belonging to six genera and in four families were recorded. These are; Hirudo verbana Carena, 1820, Glossiphonia complanata (L. 1758), Theromyzon tessulatum (O. F. Müller, 1774), Placopdella costata (Fr. Müller, 1846), Erpobdella octoculata (L., 1758), Erpobdella testacea (Savigny, 1820), Piscicola geometra (L., 1761).

CONCLUSION

The locations where the study was carried out are new records for the detected leech species.

Agreement Between Caloric and Horizontal Video Head Impulse Testing in School-Aged Children Presenting With Dizziness

OBJECTIVE

The purpose of this investigation was to determine the relationship between the horizontal semicircular canal video head impulse test (hvHIT) and the caloric test in a sample of school-age children evaluated due to complaints of dizziness or imbalance. In adults, these two tests provide different but complementary information regarding vestibular function and/or pathology. However, the most common causes of vestibular loss in children are different than those in adults, and it is not clear how these two tests of horizontal semicircular canal function are related in a pediatric population.

METHOD

This is a retrospective study of electronic records of pediatric patients (< 18 years old) who were referred for vestibular function testing and completed both hvHIT and caloric testing. Agreement between both test results was evaluated by examining measures of sensitivity, specificity, and calculating Cohen's kappa.

RESULTS

Results from 117 patients (mean age = 13.7 years, age range: 8-17 years, 37 males) were analyzed. Most patients (97/115 [84.3%]) demonstrated both normal hvHIT and caloric test results. Compared to caloric testing, the hvHIT had poor sensitivity (38.9%) and excellent specificity (98.0%). Cohen's kappa analysis revealed moderate agreement between the methods (coefficient = 0.49 [0.24, 0.73]). Where disagreement between the two tests occurred, the final diagnosis was not contingent on either test result.

CONCLUSIONS

There is a moderate agreement between the hvHIT and the caloric test in pediatric patients presenting to a tertiary care medical center for a vestibular evaluation. Most patients in this cohort presented with normal findings. The specificity of hvHIT was excellent, although the sensitivity was low. This may be related to the low prevalence of peripheral vestibular system disease in this study cohort, and these results do not generalize to centers that serve populations of children where vestibular disorders are more prevalent (e.g., children with sensorineural hearing loss).

Vestibulo-ocular dysfunction in mTBI: Utility of the VOMS for evaluation and management – A review

BACKGROUND: Individuals who have suffered a concussion/mild traumatic brain injury (mTBI) frequently report symptoms associated with vestibular and/or oculomotor dysfunction (VOD) like dizziness, nausea, fatigue, brain fog, headache, gait and neurocognitive impairments which are associated with the development of chronic symptoms. The Vestibular/Ocular Motor Screening (VOMS) tool has been established as a reliable and clinically relevant complement to use alongside a battery of post-concussion tests to improve screening and referral for further evaluation and treatment of VOD. OBJECTIVES: This paper will review the pathoanatomy and symptomatology of common vestibular and oculomotor disorders after concussion, as well as the utility of the VOMS to assist in diagnosis, referral, and management. METHODS: Primary articles were identified using a search via PubMed, Google Scholar, OneSearch, and CINAHL. Search key terms were combinations of “mild traumatic brain injury” or “concussion” or “pursuit” or “accommodation” or “vergence” or “convergence insufficiency” or “saccades” or “vestibulo-ocular reflex” or “vestibular ocular motor screen” or “vestibular rehabilitation”, or “vision rehabilitation” including adult and pediatric populations that were published in print or electronically from 1989 to 2021 in English. Classic papers on anatomy of eye movements, vestibular system and pathological changes in mTBI were also included, regardless of publication date. RESULTS: Objective impairments are commonly found during testing of smooth pursuit, saccades, vergence, accommodation, vestibular ocular reflex, and visual motion sensitivity after mTBI. These deficits can be actively treated with vestibular physical therapy and oculomotor/neuro-optometric vision therapy. VOMS is an efficient and reliable tool that can be used by all healthcare and rehabilitation providers to aid in diagnosis of post-concussion VOD, to help facilitate the decision to refer for further evaluation and treatment to expedite symptomatic post-concussion recovery. CONCLUSIONS: VOD is common after concussion in acute, post-acute, and chronic phases. Once areas of impairments are identified through proper assessment, clinicians can maximize recovery by referring to vestibular physical therapy and/or neuro-optometry to design a targeted treatment program to address individual deficits.

Vestibular Deficits in Deafness: Clinical Presentation, Animal Modeling, and Treatment Solutions

The inner ear is responsible for both hearing and balance. These functions are dependent on the correct functioning of mechanosensitive hair cells, which convert sound- and motion-induced stimuli into electrical signals conveyed to the brain. During evolution of the inner ear, the major changes occurred in the hearing organ, whereas the structure of the vestibular organs remained constant in all vertebrates over the same period. Vestibular deficits are highly prevalent in humans, due to multiple intersecting causes: genetics, environmental factors, ototoxic drugs, infections and aging. Studies of deafness genes associated with balance deficits and their corresponding animal models have shed light on the development and function of these two sensory systems. Bilateral vestibular deficits often impair individual postural control, gaze stabilization, locomotion and spatial orientation. The resulting dizziness, vertigo, and/or falls (frequent in elderly populations) greatly affect patient quality of life. In the absence of treatment, prosthetic devices, such as vestibular implants, providing information about the direction, amplitude and velocity of body movements, are being developed and have given promising results in animal models and humans. Novel methods and techniques have led to major progress in gene therapies targeting the inner ear (gene supplementation and gene editing), 3D inner ear organoids and reprograming protocols for generating hair cell-like cells. These rapid advances in multiscale approaches covering basic research, clinical diagnostics and therapies are fostering interdisciplinary research to develop personalized treatments for vestibular disorders.

The Pharmacological Treatment of Pediatric Vertigo

Vertigo in children is a challenging topic. The lack of dedicated trials, guidelines and papers causes inhomogeneity in the treatment of vertigo in children. Meniere’s disease, migraine equivalents, vestibular neuritis, paroxysmal positional benign vertigo (BPPV), persistent postural-perceptual dizziness (PPPD) and motion sickness may affect children with various degrees of incidence and clinical severity compared to adults. Several drugs are proposed for the management of these conditions, even if their use is subordinated to the child’s age. In this review, we summarize the existing evidence related to the use of drugs for this clinical condition in children as a start point for new trials, stating the urgent need for international guidelines.

Does vestibular loss result in cognitive deficits in children with cochlear implants?

BACKGROUND

In adults, vestibular loss is associated with cognitive deficits; however, similar relationships have not been studied in children.

OBJECTIVE

Evaluate the effect of vestibular loss on working memory and executive function in children with a cochlear implant (CCI) compared to children with normal hearing (CNH).

METHODS

Vestibular evoked myogenic potential, video head impulse, rotary chair, and balance testing; and the following clinical measures: vision, hearing, speech perception, language, executive function, and working memory.

RESULTS

Thirty-eight CNH and 37 CCI participated (26 with normal vestibular function, 5 with unilateral vestibular loss, 6 with bilateral vestibular loss). Children with vestibular loss demonstrated the poorest balance performance. There was no significant reduction in working memory or executive function performance for either CCI group with vestibular loss; however, multivariate regression analysis suggested balance performance was a significant predictor for several working memory subtests and video head impulse gain was a significant predictor for one executive function outcome.

CONCLUSIONS

CCI with vestibular loss did not have significantly reduced working memory or executive function; however, balance performance was a significant predictor for several working memory subtests. Degree of hearing loss should be considered, and larger sample sizes are needed.

Vestibular testing in children - The suppression head impulse (SHIMP) test

INTRODUCTION

The incidence of vestibular disorders and vertigo during childhood is increasing and pediatric clinicians have become more sensitive to children's balance disorders; thus, there is a need for appropriate detection test procedures for peripheral vestibular hypofunction. In order to ensure a reliable diagnosis and minimize misdiagnosis, a standardized clinical procedure via careful history and clinical examination is recommended. However, children, especially, are often unable to verbalize "vertigo" in a concrete manner, which often necessitates a consultation with a pediatrician holding nonspecific symptoms. The so-called suppression of the head impulse test (SHIMPs) represents a modification of the video head impulse test (HIMP) and is used for a more sensitive assessment of residual vestibular functions. In adults, SHIMPs are already an established diagnostic method. Nevertheless, to date, nothing is known about the applicability and standard values in childhood.

MATERIAL AND METHODS

In this monocentric, prospective study, we investigated whether SHIMPs enable a sensitive functional analysis of the vestibular system in healthy children of different ages. For this purpose, SHIMPs were performed in 40 children aged 3-18 years.

RESULTS

In this study, we demonstrated that SHIMPs can be easily performed in children (3-18 years). It is vital that the test be appropriately explained for children to ensure sufficient test tolerance and compliance.

CONCLUSION

SHIMPs are a helpful supplement to clinically established vestibular tests such as the HIMP in pediatric vestibular balance disorder diagnostics and can be integrated into the clinical routine, especially in children who have minimal verbal abilities or understanding of the instructions for HIMP. Similar to the HIMP, SHIMPs are characterized by a short test duration and a high tolerance.

The effect of exercise on balance in patients with stroke, Parkinson, and multiple sclerosis: a systematic review and meta-analysis of clinical trials

BACKGROUND

Stroke, Parkinson, and multiple sclerosis are a range of diseases affecting the nervous system and show balance impairments due to damage of the balance control system. Many early articles have been published on the effect of exercise on balance in patients suffering from neuromuscular diseases. However, a comprehensive study showing a clear result of these three diseases was not found. Hence, the purpose of the present meta-analysis and systematic review is to determine the effect of exercise on balance in people with stroke, Parkinson, and multiple sclerosis.

METHODS

According to the PRISMA 2009 multi-step instructions, keywords related to the purpose of the research were browsed in the MeSH browser databases; IranDoc, MagIran, IranMedex, SID, ScienceDirect, Web of Science (WoS), ProQuest, Medline (PubMed), Scopus, and Google Scholar were searched to extract articles published in Persian and English language. The search process for retrieving the articles in the sources mentioned from January 01, 2000, to December 30, 2020, was done. The heterogeneity index of the studies was determined using the I² test. Given the heterogeneity, the random-effects model was used to combine the articles and the results.

RESULTS

Initially, 7067 articles were found, but after removing duplicate and irrelevant articles, 96 clinical trials with a sample size of the intervention group of 1760 people were included in the study. As a result of the articles' composition, the mean balance score index after exercise in the intervention group showed a significant increase of 0.67 ± 0.12 of the unit (P˂0.01). The highest rate of increase in the balance score after the intervention was reported in patients with myelomeningocele with 1.66 ± 0.3 unit (P˂0.01).

CONCLUSION

Considering the positive effect of using exercise on increasing the balance in patients with stroke, Parkinson, and multiple sclerosis, it is recommended that health care providers implement a regular exercise program to improve the condition of these patients.

A genome-wide meta-analysis uncovers six sequence variants conferring risk of vertigo

Vertigo is the leading symptom of vestibular disorders and a major risk factor for falls. In a genome-wide association study of vertigo (Ncases = 48,072, Ncontrols = 894,541), we uncovered an association with six common sequence variants in individuals of European ancestry, including missense variants in ZNF91, OTOG, OTOGL, and TECTA, and a cis-eQTL for ARMC9. The association of variants in ZNF91, OTOGL, and OTOP1 was driven by an association with benign paroxysmal positional vertigo. Using previous reports of sequence variants associating with age-related hearing impairment and motion sickness, we found eight additional variants that associate with vertigo. Although disorders of the auditory and the vestibular system may co-occur, none of the six genome-wide significant vertigo variants were associated with hearing loss and only one was associated with age-related hearing impairment. Our results uncovered sequence variants associating with vertigo in a genome-wide association study and implicated genes with known roles in inner ear development, maintenance, and disease.

Understanding the differentiation and epigenetics of cochlear sensory progenitors in pursuit of regeneration

PURPOSE OF REVIEW

Sensory hair cells (HCs) of the inner ear are responsible for our ability to hear and balance. Loss of these cells results in hearing loss. Stem cell replacement and in situ regeneration have the potential to replace lost HCs. Newly discovered contributions of transcription factor regulatory networks and epigenetic mechanisms in regulating HC differentiation and regeneration are placed into context of the literature.

RECENT FINDINGS

A wealth of new data has helped to define cochlear sensory progenitors in their developmental trajectories. This includes transcription factor networks, epigenetic manipulations, and cochlear HC subtype specification.

SUMMARY

Understanding how sensory progenitors differ and how HC subtypes arise will substantially inform efforts in hearing restoration.

Understanding the Pathophysiology of Congenital Vestibular Disorders: Current Challenges and Future Directions

In congenital vestibular disorders (CVDs), children develop an abnormal inner ear before birth and face postnatal challenges to maintain posture, balance, walking, eye-hand coordination, eye tracking, or reading. Only limited information on inner ear pathology is acquired from clinical imaging of the temporal bone or studying histological slides of the temporal bone. A more comprehensive and precise assessment and determination of the underlying mechanisms necessitate analyses of the disorders at the cellular level, which can be achieved using animal models. Two main criteria for a suitable animal model are first, a pathology that mirrors the human disorder, and second, a reproducible experimental outcome leading to statistical power. With over 40 genes that affect inner ear development, the phenotypic abnormalities resulting from congenital vestibular disorders (CVDs) are highly variable. Nonetheless, there is a large subset of CVDs that form a common phenotype of a sac-like inner ear with the semicircular canals missing or dysplastic, and discrete abnormalities in the vestibular sensory organs. We have focused the review on this subset, but to advance research on CVDs we have added other CVDs not forming a sac-like inner ear. We have included examples of animal models used to study these CVDs. Presently, little is known about the central pathology resulting from CVDs at the cellular level in the central vestibular neural network, except for preliminary studies on a chick model that show significant loss of second-order, vestibular reflex projection neurons.

Development and evolution of the vestibular apparatuses of the inner ear

The vertebrate inner ear is a labyrinthine sensory organ responsible for perceiving sound and body motion. While a great deal of research has been invested in understanding the auditory system, a growing body of work has begun to delineate the complex developmental program behind the apparatuses of the inner ear involved with vestibular function. These animal studies have helped identify genes involved in inner ear development and model syndromes known to include vestibular dysfunction, paving the way for generating treatments for people suffering from these disorders. This review will provide an overview of known inner ear anatomy and function and summarize the exciting discoveries behind inner ear development and the evolution of its vestibular apparatuses.

Test-Retest Reliability of Low-Cost Posturography for Assessing Postural Stability Control Performance during Standing

Postural stability control performance assessment is necessary in providing important information for individuals who are at risk of falling or who have balance impairment. Instrumented assessment is suggested as a valid and reliable test, but the cost and the difficulty of setup are significant limitations. The aim of this cross-sectional (test-retest reliability) study was to develop and determine the reliability of a low-cost posturography for assessing postural stability control performance during standing. The low-cost posturography was developed with four load cells and an acrylic platform. The center of pressure (COP) displacement and velocity were analyzed using written software. Test-retest reliability was performed with six different standing postural stability tests in twenty healthy volunteers on two different days. Intraclass correlation coefficient (ICC), standard error of measurement (SEM), coefficient of variation (CV), and Bland-Altman plot and limits of agreements (LOA) were used for analyses. The low-cost posturography was accurate (ICC = 0.99, p < 0.001; SEM = 0.003 cm) when compared to the true with calculated X and Y coordinates, with a moderate to excellent test-retest reliability for both COP displacement (ICCs ranged 0.62-0.91, p < 0.05; SEMs ranged 17.92-25.77%) and COP velocity (ICCs ranged 0.62-0.91, p < 0.05; SEMs ranged 18.09-27.69%) in all standing postural stability tests. Bland-Altman plots and LOAs suggested good agreement of tested parameters from the developed low-cost posturography between different days. In conclusion, the developed low-cost posturography had adequate reliability for assessing COP displacement and velocity during standing postural control stability performance tests.

Assessment protocol and reference values of vestibulo-ocular reflex (VOR) gain in the horizontal plane recorded with video-Head Impulse Test (vHIT) in a pediatric population

PURPOSE

To develop an assessment protocol and establish reference values of vestibulo-ocular reflex gain of the horizontal semicircular canal obtained with vHIT in a pediatric population without vestibular changes.

METHODS

Quantitative, non-experimental, analytical study with a non-probabilistic convenience sample. A total of 39 subjects aged 5 to 17 years were selected based on the inclusion and exclusion criteria.

RESULTS

The mean gain obtained of the horizontal right semicircular canal was 0.93 and of the left one, 1.08, with statistically significant differences between the ears. There were no statistically significant differences between the 5-to-10-year and 11-to-17-year subgroups.

CONCLUSION

The vestibulo-ocular reflex gain in children neared the values found in the international scientific literature and the adult population. The protocol developed can guide beginning professionals in the otoneurological evaluation of children.

Vestibular disorders in children: A retrospective analysis of vestibular function test findings

OBJECTIVE

This study was designed to describe the most common vestibular disorders in children and their associated findings on vestibular function testing.

METHOD

Data from 203 children with a mean age of 11.16 ± 3.87 (range, 1-17) years were collected from among 3400 patients who underwent vestibular assessment at a vertigo center in a tertiary hospital over a 3-year period. A retrospective data analysis was performed for 203 children.

RESULTS

Vestibular disorders were diagnosed in 78.3% (n = 159) of 203 children among 3400 patients, which revealed a 3-year incidence of 4.67% in our study. Benign paroxysmal positional vertigo (BPPV) was the most common diagnosis in our group of children (49%; n = 100), which involved both primary BPPV, and secondary BPPV that was associated with other vestibular pathologies. Vestibular migraine (VM) was the second most common diagnosis (41%; n = 83) followed by benign paroxysmal vertigo of childhood (BPVC; 4.5%, n = 9), vestibular neuritis (VN; 4.5%, n = 9), and psychogenic vertigo (4.5%, n = 9). Our study showed that Meniere's Disease (MD; 1.5%, n = 3) and central vertigo (1.5%, n = 3) were less commonly diagnosed in children. Perilymphatic fistula (PLF) was diagnosed and surgically confirmed in only one child.

CONCLUSION

BPPV and VM were the most common pediatric vestibular disorders in our study. Clinicians should be aware of the prevalence, signs, and symptoms of the most common vestibular disorders in children to enable diagnosis, treatment, and rehabilitation. Vestibular function testing with age-appropriate adaptations results in improved differential diagnosis, which guides medical treatment and rehabilitation.

Prevalence, clinical profile, and diagnosis of pediatric dizziness in a tertiary care hospital

INTRODUCTION

Pediatric dizziness is an uncommon complaint presenting to the Otolaryngology clinic. While the term dizziness may be used to describe any altered sensation of orientation to the environment which includes presyncope, light-headedness and ataxia, vertigo refers to a false sensation of motion of self or surroundings. Although a variety of etiologies are known to cause dizziness and vertigo, evaluation of this symptom becomes challenging in children who are unable to clearly explain what they experience, the provoking factors, associated symptoms and the duration of attacks. Vestibular tests are also difficult to conduct in the pediatric age group leading to apathy from the clinician.

OBJECTIVES

To ascertain the prevalence of pediatric vertigo in children under 18 years of age, presenting to the Otolaryngology Clinic of a tertiary care hospital, and to describe the clinical profile, investigations and diagnosis in these children.

METHODS

A prospective cross-sectional, descriptive clinical study was undertaken from January 1, 2018 to April 30, 2019. All children below the age of 18 years presenting to our department with primary complaints of dizziness were included in the study. After a thorough history and physical examination, screening methods and diagnostic tests were conducted to make a diagnosis. Referrals were sought from other specialties when necessary.

RESULTS

The number of children visiting the Department for various ENT ailments during the study period was 10,950. Among these 89 children presented with a primary complaint of dizziness. Their ages ranged from 3 to 18 years; mean age was 11.42 years (SD 3.45). A diagnosis was made in all except two children. The most common cause of dizziness in the age group less than 6 years was benign paroxysmal vertigo of childhood (BPVC) and in the older children was migraine associated vertigo, which was also the commonest overall diagnosis made (28.1%). This was followed by circulation related dizziness like orthostatic hypotension and vasovagal syncope (15.7%).

CONCLUSIONS

The prevalence of pediatric dizziness in children presenting to the Otolaryngology clinic was 0.8%. The diagnosis of pediatric vertigo may be challenging, but careful history and examination along with guided investigations and referrals results in correct diagnosis in almost all patients.

Investigating the Effect of Hearing Aid Use on the Balance Status of Children with Severe to Profound Congenital Hearing Loss Using the Pediatric Clinical Test of Sensory Interaction for Balance

BACKGROUND

 Since the hearing and vestibular organs are close to each other, the correlation between hearing and balance is one of the principal issues, especially in people with hearing loss.

PURPOSE

 In this study, the effect of the auditory system on human balance performance was investigated by comparing the balance status of hearing-impaired children in the aided and unaided situations.

RESEARCH DESIGN

 In this cross-sectional study a group of children were assigned the task to compare the balance sways in two aided and unaided situations.

STUDY SAMPLING

 A total of 90 children aged 7 to 10 years with severe to profound congenital hearing loss and the healthy vestibular system of both genders served as the research population.

DATA COLLECTION AND ANALYSIS

 After a complete evaluation of the hearing and vestibular system and validation of the hearing aid performance, body sway was recorded using the pediatric clinical test of sensory interaction for balance in aided and unaided situations in the presence of background noise from the speaker.

RESULTS

 According to this study, there was no difference in body sway in aided and unaided situations for conditions 1, 2, and 3. In comparison, in conditions 4, 5, and 6 of the test, there was a statistically significant difference in body sway between aided and unaided situations. However, there was no difference in the sway of the body in aided and unaided situations between girls and boys.

CONCLUSION

 According to this study, hearing aids can improve balance in challenging listening environments.

Reliability and validity of Turkish version of pediatric balance scale

Assessment tool is a key point to evaluate balance disturbances in children. The aim of this study was to analyze reliability and validity of Turkish version of pediatric balance scale. The present study included 34 children (13 girls; 21 boys) with balance impairments. The scale consists of 14 items. Eight observers assessed the video records of the participants for interrater agreement. One observer evaluated the records twice in 2 weeks for intrarater agreement. Intraclass correlation coefficient was used for the interobserver and intraobserver agreement. The Functional Reach Test was used to calculate concurrent validity. Mean age of the sample was 11.68 ± 3.53 years. The Turkish version of the scale was found to be reliable, perfectly (intraclass correlation coefficient for interobserver agreement = 0.915). Intraobserver agreement was also reliable, perfectly (ICC = 0.927). The strong correlation between pediatric balance scale and functional reach test was found (r = 0.692; p < 0.001). The Turkish version of the scale is a valid and reliable tool to evaluate children with balance impairments. Moreover, it is easy to use for health providers working with disabled children.

Loss of Consciousness in the Young Child

In the very young child (less than eight years of age), transient loss of consciousness represents a diagnostic and management dilemma for clinicians. While most commonly benign, syncope may be due to cardiac dysfunction which can be life-threatening. It can be secondary to an underlying ion channelopathy, cardiac inflammation, cardiac ischemia, congenital heart disease, cardiomyopathy, or pulmonary hypertension. Patients with genetic disorders require careful evaluation for a cardiac cause of syncope. Among the noncardiac causes, vasovagal syncope is the most common etiology. Breath-holding spells are commonly seen in this age group. Other causes of transient loss of consciousness include seizures, neurovascular pathology, head trauma, psychogenic pseudosyncope, and factitious disorder imposed on another and other forms of child abuse. A detailed social, present, past medical, and family medical history is important when evaluating loss of consciousness in the very young. Concerning characteristics of syncope include lack of prodromal symptoms, no preceding postural changes or occurring in a supine position, after exertion or a loud noise. A family history of sudden unexplained death, ion channelopathy, cardiomyopathy, or congenital deafness merits further evaluation. Due to inherent challenges in diagnosis at this age, often there is a lower threshold for referral to a specialist.

Benign Positional Paroxysmal Vertigo in Children

The aim of this study was to assess the prevalence and analyze clinical parameters of benign positional paroxysmal vertigo (BPPV) in a pediatric age. A cohort of 423 children under the age of 15 (median age 11. interquartile range 9-13) was submitted to vestibular assessment for balance disorders. Dix-Hallpike and Roll-Supine tests were performed to look for positioning nystagmus using video-infrared goggles. BPPV was found in 43 of 423 children evaluated for balance disorders (10.2%). There were 28 females (65.1%) and 15 (34.9%) males. The posterior canal was involved in 79% of cases and the horizontal canal in 21% of cases. No apogeotropic bilateral or anterior canal form were seen. Thus, BPPV is not an infrequent type of vertigo in children and must be evaluated as soon as possible in order to plan the most appropriate maneuver and restore daily activities as soon as possible, avoiding anxiety and fear.

Vestibular Dysfunction and Gross Motor Milestone Acquisition in Children With Hearing Loss: A Systematic Review

OBJECTIVE

To describe the impact of vestibular dysfunction on gross motor development in children with hearing loss.

DATA SOURCES

MEDLINE (PubMed), Embase (Elsevier), Web of Science (Clarivate), and the Cumulative Index of Nursing and Allied Health Literature (EBSCO).

REVIEW METHODS

A systematic review was reported in concordance with the PRISMA guidelines (Preferred Reporting Items for Systematic Reviews and Meta-analyses). Articles on children with hearing loss who underwent at least 1 instrumented measure of vestibular function and had gross motor milestones assessed were included. The Downs and Black checklist was used to assess risk of bias and methodological quality.

RESULTS

Eleven articles were included in the systematic review. Three articles stratified quantitative results of gross motor milestone acquisition by severity of vestibular impairment. Over half of studies were case series published within the last 5 years. This systematic review showed that children with hearing loss and severe, bilateral vestibular dysfunction demonstrate delayed gross motor milestones. However, it was difficult to draw conclusions on whether milder forms of vestibular dysfunction significantly affect gross motor milestone acquisition in children with hearing loss. The reason is that most studies were of low to moderate quality, used different assessment methods, and contained results that were descriptive in nature.

CONCLUSIONS

This emerging area would benefit from future research, such as higher-quality studies to assess vestibular function and gross motor milestones. This would allow for better characterization of the impacts of vestibular impairment, especially milder forms, in children with hearing loss.

How often do neurological disorders lead to dizziness in childhood?

Objective

The aim of the study was to determine the features and differential diagnosis of childhood dizziness and find out the prevalence of neurological diseases in children who were referred to the pediatric neurology outpatient clinic. A secondary aim was to evaluate the outcome of dizziness after 12 months.

Material and Methods

The records of children with a complaint of dizziness that were referred to the pediatric neurology outpatient clinic were retrospectively reviewed, and detailed medical and family history, clinical characteristics, laboratory investigations including vitamin B12 levels, and neuroimaging tests were analyzed. Patients were grouped as neurological disorders and non-neurological disorders. Neurological disorders included vestibular migraine, benign paroxysmal vertigo, and epilepsy, and non-neurological disorders contained the remaining disorders.

Results

The study consisted of 60 children (36 females, 24 males) with a mean age of 11.7±4.1 years. The most common diagnoses were vestibular migraine (21.7%) and orthostatic hypotension (20%). We found that the incidence of neurological diseases was 40% (vestibular migraine, 21.7%; epilepsy, 10%; benign paroxysmal vertigo, 8.3%). When we compared the neurological disorders with non-neurological disorders, there was a significant difference in terms of age at onset and duration of attacks (p=0.001 for both), whereas no significant difference was detected in terms of gender, frequency of attacks, and vitamin B12 levels. We detected ongoing symptoms in 10% of the patients who were diagnosed with vestibular migraine and psychogenic dizziness.

Conclusion

Both non-neurological and neurological diseases are common in etiology of children with dizziness.

Vestibular and balance disorders in Mexican children and adolescents: Review of 8-year clinical records

INTRODUCTION

Vertigo is a seldom studied symptom in the paediatric population, where the prevalence is less than 1%. Vestibular disorders in children are not comparable to those of adults and are often underdiagnosed. Identifying the main causes of these disorders would provide reliable and accurate data of the diseases in certain age groups, improving the diagnostic process.

MATERIAL AND METHODS

Observational, cross-sectional, and retrospective study. Consecutive records of patients, aged 3 to 17years, attended due to vestibular, balance and associated symptoms (vertigo, dizziness, hearing loss, balance disorders and headache), attended by the otoneurology service of a tertiary hospital, between September 2010 and September 2018, were included. Descriptive and inferential statistics were used for the analysis. All p-values reported from these analyses were two-tailed with a significance level <.05.

RESULTS

212 cases were registered from 6,444 consultations (3.3%). The proportion between males and females was similar. The mean age of the group was 14.5 (±3.9) years, the median age of onset of symptoms was 11 (IQR 8-14) years and that of the first consultation was 13 (IQR 10-15) years. As a cardinal symptom, 51.9% attended due to vertigo, 25.5% due to dizziness, 9.9% due to gait instability, 7.5% due to hearing loss and 5.2% due to headache. Of the episodes of vertigo, 61.8% were of peripheral origin, 69 32.5% central and 12 5.7% outside the vestibular system. Benign paroxysmal vertigo of childhood, dysfunction and vestibular migraine accounted for more than 65% of cases. No differences were found between the diagnoses regarding the sex and age of the participants (P>.05).

CONCLUSION

Vestibular and balance disorders are rare in the study population and most of the causes are benign and potentially self-limited disorders.

The Differential Diagnosis of Vertigo in Children: A Systematic Review of 2726 Cases

OBJECTIVES

Vertigo is a relatively common complaint in children with 5.3% of pediatric patients complaining of this symptom. Although the causes of vertigo have been well established in adults, the diagnoses in children have not been well described. The aims of this systematic review are to discover the current information regarding etiologies of vertigo in children and to determine the most common diagnoses that present with vertigo in pediatric patients.

METHODS

PubMed, Scopus, and Embase were searched using the PRISMA guidelines. The inclusion and exclusion criteria were established a priori. All results were analyzed using a Bayesian methodology for point estimation and credible interval calculation.

RESULTS

From the database searches, 1419 titles were reviewed. Twenty-two studies met inclusion criteria. From these studies, a total of 2726 children aged 2 months to 19 years were reported. The top 4 diagnoses associated with childhood vertigo include vestibular migraine (23.8%; credible interval, 22.3%-25.5%), benign paroxysmal vertigo of childhood (13.7%; credible interval, 12.4%-15%), idiopathic or no identified association (11.7%; credible interval, 10.5%-12.9%), and labyrinthitis/vestibular neuronitis (8.47%, credible interval, 7.46%-9.55%) accounting for approximately 57% of cases. Less common diagnoses included Meniere disease and central nervous system tumors.

CONCLUSIONS

Although the most common causes of pediatric vertigo include vestibular migraine and benign paroxysmal vertigo of childhood, the etiologies are myriad. Rates and credible intervals are provided to permit a probabilistic diagnostic approach to these children.

Exploration of a novel physical therapy protocol that uses a sensory substitution device to improve the standing postural balance of children with balance disorders

OBJECTIVE

To explore if an intensive balance training protocol that incorporated the BrainPort sensory substitution device improves the standing postural balance of children with balance disorders.

METHODS

Eight children with balance disorders received 8-weeks of balance training while using the BrainPort device. Pre- and post-intervention changes in the Bruininks-Oseretsky Test of Motor Proficiency balance subtest (BOT-2) scores, standing duration on an unstable surface, and center of pressure (COP) sway were assessed.

RESULTS

Post-intervention, the BOT-2 balance subtest scores increased by 29.6% and demonstrated clinically meaningful improvements. Overall, the standing duration with vision increased. The standing duration on the unstable surface without vision increased significantly from pre- to post-intervention. However, anterior-posterior (AP) and medial-lateral (ML) sway did not change post-intervention. The children also reported new functional activities (i.e. riding a bike, standing on unsteady or narrow surfaces).

CONCLUSION

Balance training with the BrainPort sensory substitution device has the potential to result in clinically relevant improvements in the standing postural balance of children with balance disorders.

Short Communication: The Belly-Tendon Derivation Yields Superior Ocular Vestibular Evoked Myogenic Potential Amplitudes in a Normal Pediatric Sample

Purpose The purpose of the investigation was to determine whether the "belly-tendon" electrode derivation produced ocular vestibular evoked myogenic potentials (oVEMPs) in children that were superior to those recorded with the infraorbital-chin electrode derivation. Method This was a prospective observational study using a sample of convenience at a tertiary care medical center. Subjects were 13 children between the ages of 5 and 12 years. We compared the latency of the N1 wave and the N1-P1 peak-to-peak amplitude for the belly-tendon electrode derivation to the infraorbital-chin electrode derivation. Results The belly-tendon electrode derivation was associated with superior N1-P1 amplitudes compared to the infraorbital-chin electrode derivation. However, the large amplitude was also associated with greater variability compared to the infraorbital-chin derivation. There were no significant electrode derivation-based differences in N1 latency. Additionally, there was no predictable relationship between age and oVEMP amplitude. Conclusion As shown previously in adults, the belly-tendon electrode derivation produces significantly larger oVEMP amplitudes compared to the infraorbital-chin electrode derivation.

Association between vertigo, cognitive and psychiatric conditions in US children: 2012 National Health Interview Survey

OBJECTIVES

Small studies have suggested an association between vertigo and psychiatric comorbidity. The purpose of this study is to evaluate the associations between vertigo and cognitive and psychiatric conditions among a large sample of U.S. children.

METHODS

We conducted a cross-sectional analysis of the 2012 National Health Interview Survey (NHIS) Child Balance Supplement administered to parents/caregivers of children aged 3-17 years. Multivariable logistic regression models were used to evaluate the association between vertigo and specific cognitive and psychiatric conditions.

RESULTS

The 1-year prevalence of vertigo was 1.56% in this nationally-representative sample (N = 10,823) of U.S. children aged 3-17 years. After adjusting for demographic and confounding health variables (otitis media and headaches/migraine), children with vertigo had significantly higher odds of attention deficit disorder (OR = 1.73, 95%CI: 1.06-2.81), learning disability (OR = 3.45, CI: 2.18), developmental delay (OR = 2.59, CI: 1.34-4.98), intellectual disability (OR = 6.60, CI: 2.60-16.79), and are more likely to utilize special education services (OR = 2.46, CI: 1.48-4.10) relative to the rest of U.S. children. Children with vertigo also had higher odds of having difficulty with emotions, concentration, or behavior (OR = 2.92, CI 1.85-4.61), and having a poor attention span (OR = 1.68, CI: 1.01-2.80).

CONCLUSIONS

Vertigo is associated with significantly increased odds of cognitive and psychiatric comorbidity in U.S. children. These findings support the hypothesis that the vestibular system is important for normal cognitive and psychiatric development in children.

Reliability and validity of Turkish version of pediatric balance scale

Assessment tool is a key point to evaluate balance disturbances in children. The aim of this study was to analyze reliability and validity of Turkish version of pediatric balance scale. The present study included 34 children (13 girls; 21 boys) with balance impairments. The scale consists of 14 items. Eight observers assessed the video records of the participants for interrater agreement. One observer evaluated the records twice in 2 weeks for intrarater agreement. Intraclass correlation coefficient was used for the interobserver and intraobserver agreement. The Functional Reach Test was used to calculate concurrent validity. Mean age of the sample was 11.68 ± 3.53 years. The Turkish version of the scale was found to be reliable, perfectly (intraclass correlation coefficient for interobserver agreement = 0.915). Intraobserver agreement was also reliable, perfectly (ICC = 0.927). The strong correlation between pediatric balance scale and functional reach test was found (r = 0.692; p < 0.001). The Turkish version of the scale is a valid and reliable tool to evaluate children with balance impairments. Moreover, it is easy to use for health providers working with disabled children.

Balance Assessment of Children with Sensorineural Hearing Loss

This study aimed to assess the balance function in children with sensorineural hearing loss (SNHL) using different tests to assess vestibulospinal pathway and tests to assess vestibular system and to compare the result obtained with those of children with normal hearing sensitivity. Detailed balance assessment was done for 15 children with severe to profound SNHL and 15 children with normal hearing sensitivity in the age range of 6-10 years. The audiological evaluation included pure-tone audiometry, speech audiometry, immittance evaluation, otoacoustic emission, vestibular evoked myogenic potential (cervical VEMP and ocular VEMP), and tests to assess vestibulospinal pathway and cerebellar function, such as Romberg test, Fukuda stepping test, Tandem gait test, and Finger-to-nose test. cVEMP and oVEMP were absent in 8 ears (27%) of a total of 30 ears with SNHL. Statistical analysis shows no significant difference between latency and amplitude of cVEMP peaks and latency of oVEMP peaks across groups. Significant reduction of oVEMP peaks amplitude was seen in children with SNHL compared to children with normal hearing. Fukuda stepping test showed an abnormal response in 2 children with SNHL (13%) and one child could not perform tandem gait test (7%). Children with SNHL showed an evident abnormality on the balance assessment test results. The abnormal function of the vestibular system and the vestibulospinal pathway can compromise the child's motor development and thus needs investigation early in life.

Prevalence of Pediatric Dizziness and Imbalance in the United States

Objectives

Understand the prevalence of vestibular symptoms in US children.

Study Design

Cross-sectional analysis

Setting

2016 National Health Interview Survey.

Subjects and Methods

Responses from the 2016 National Health Interview Survey for children ages 3 to 17 years were examined to determine the prevalence of vestibular symptoms and provider-assigned diagnoses.

Results

Dizziness or imbalance was reported in 3.5 (95% confidence interval, 3.1-3.9) million patients (5.6%) with a mean age of 11.5 years. Dizziness was reported in 1.2 million patients (2.0%) with a mean age of 12.7 years and balance impairment in 2.3 million patients (3.7%) with a mean age of 10.6 years. Prevalence of dizziness and imbalance did not vary by sex ( P = .6, P = .2). Evaluation by a health professional was reported for 42% of patients with dizziness and 43% of patients with imbalance, with diagnoses reported in 45% and 48% of patients with dizziness and imbalance, respectively. The most common diagnoses reported for dizziness were depression or child psychiatric disorder (12%), side effects from medications (11%), head/neck injury or concussion (8.4%), and developmental motor coordination disorder (8.3%). The most common diagnoses reported for imbalance were blurred vision with head motion, “bouncing” or rapid eye movements (9.1%), depression or child psychiatric disorder (6.2%), head/neck injury or concussion (6.1%), and side effects from medications (5.9%).

Conclusion

The national prevalence of childhood vestibular symptoms is more common than previously thought. Reported diagnoses varied greatly from the literature, suggesting a need for increased awareness of causes of vestibular symptoms in children.

Implementing the chick embryo model to study vestibular developmental disorders

Children with congenital vestibular disorders show delayed motor development and challenges in maintaining posture and balance. Computed tomography images reveal that these children have abnormal inner ears in the form of a sac, with the semicircular canals missing or truncated. Little is known about how this inner ear abnormality affects central vestibular development. At present, mice with the chromodomain helicase DNA-binding protein 7 mutation are the most common model for studying congenital vestibular disorders, despite forming multiple diverse inner ear phenotypes and inducing abnormal cerebellar and visual system development. To identify the effects of a sac-like inner ear on central vestibular development, we have designed and implemented a new model, the anterior-posterior axis rotated otocyst (ARO) chick, which forms a sac-like inner ear in 85% of cases. The ARO chick is produced by anterior-posterior rotation of the otocyst at embryonic day 2. Here, we describe for the first time the 15% of ARO chicks that form three small semicircular canals and rename the ARO chicks forming sacs (ARO/s chicks). The basic features of the vestibular sensory organs in ARO/s chicks are similar to those found in patients’ sacs, and ARO/s hatchlings experience balance and walking problems like patients. Thus, ARO/s chicks have a reproducible inner ear phenotype without abnormalities in vestibular-related structures, making the model a relatively simple one to evaluate the relationship between the sac-like inner ear pathology and formation of the central vestibular neural circuitry. Here, we describe unpublished details on the surgical approaches to produce ARO chicks, including pitfalls and difficulties to avoid.

NEW & NOTEWORTHY This paper describes simple techniques for chick otocyst rotation resulting in a sac-like inner ear (85%), the common phenotype in congenital vestibular disorders. We now describe anterior-posterior axis rotated otocyst chicks, which form three small canals (15%), and rename chicks forming a sac (ARO/s chicks). Basic protocols and potential complications of otocyst rotation are described. With the use of ARO/s chicks, it will be possible to determine how the vestibular neural circuit is modified by sac-like inner ear formation.

Pediatric Vestibular Rehabilitation: A Case Study

BACKGROUND

A 9-year-old child with a 9-month history of complaints of dizziness, headache, and motion sensitivity came to physical therapy. The child complained of difficulties playing on a playground, running, riding in a car, watching "action movies," sitting under fluorescent lights, and making quick head movements.

METHODS

An initial evaluation included a clinical oculomotor examination, vergence testing, static and dynamic visual acuity testing, head impulse testing, subjective visual vertical, balance testing, the pediatric vestibular symptom questionnaire, the Dizziness Handicap Inventory-child caregivers version (DHI-PC) and a visual vertigo analog scale. Physical therapy included virtual reality with Xbox games plus adaptation, habituation, and balance exercises. She was seen once per week and given a home program of exercises 2 to 3 times a day.

RESULTS

After 10 treatment sessions, she reported that playing was easier, headaches had reduced, she could travel as a passenger in a car for long distances without complaints, and that she could watch 3-dimensional action movies without symptoms. Her pediatric vestibular symptom questionnaire scores had reduced from 0.7 to 0.1. The DHI-PC had decreased from 22 to 12 points and her visual vertigo analog scale scores were improved.

CONCLUSIONS

Vestibular rehabilitation improved this child's quality of life. She was able to return to her daily living activities with fewer symptoms.

Spontaneous mutations of the Zpld1 gene in mice cause semicircular canal dysfunction but do not impair gravity receptor or hearing functions

The cupula is a gelatinous membrane overlying the crista ampullaris of the semicircular canal, important for sensing rotation of the head and critical for normal balance. Recently the zona pellucida like domain containing 1 protein (ZPLD1, also known as cupulin) was identified in the cupula of fish. Here, we describe two new spontaneous mutations in the mouse Zpld1 gene, which were discovered by the circling behavior of mutant mice, an indicator of balance dysfunction. The Zpld1 mutant mice exhibited normal hearing function as assessed by auditory brainstem response (ABR) measurements, and their otolithic organs appeared normal. In the inner ear, Zpld1 mRNA expression was detected only in the hair cells and supporting cells of the crista ampullaris. Normal vestibular sensory evoked potential (VsEP) responses and abnormal vestibulo-ocular reflex (VOR) responses demonstrated that the vestibular dysfunction of the Zpld1 mutant mice is caused by loss of sensory input for rotary head movements (detected by cristae ampullaris) and not by loss of input for linear head translations (detected by maculae of the utricle and saccule). Taken together, these results are consistent with ZPLD1 being an important functional component of the cupula, but not tectorial or otoconial membranes.