Ménière's disease in children aged 4-7 years

Clinical Profile, Trends, and Management in Pediatric Patients with Audiovestibular Disorders: Can We Predict Emotional Disability in Pediatric Patients with Episodes of Vertigo and Dizziness?

BACKGROUND

Audiovestibular disorders in childhood occur with considerable frequency. However, the difficulty of obtaining medical history, the nonspecificity of symptoms, and the lack of cooperation during complementary tests often contribute significantly to diagnostic biases, attributing clinical presentations to psychosomatic disorders. The objectives of this work are, firstly, to characterize, from an auditory and vestibular perspective, the most frequent causes of vertigo in childhood and a possible relationship with emotional symptoms. On the other hand, to propose the usefulness of the MSSQ-Short questionnaire as a predictive variable in the evolution of children diagnosed with recurrent vertigo of childhood (RVC).

METHODS

An observational cross-sectional study was designed with retrospective data collection at three tertiary hospitals.

RESULTS

Among the 117 patients recruited between 2016 and 2024, 32 patients (27.35%) were diagnosed with an anxious-depressive syndrome prior to audiovestibular testing. The mean age was 11.19 ± 5.61 years and the most frequent final diagnoses were vestibular migraine (VM) with 41.03% and RVC with 23.93%. Patients with VM, compared with RVC, are approximately 1.12 times more likely to have psychosomatic pathology (CI 0.39 to 3.25). The most sensitive and frequently altered test was VEMPS (39.32%), with statistical significance in VM and otic capsule dehiscence, while regarding the MSSQ-Short questionnaire, the linear regression of 0.28 indicates an increase in clinical duration with high questionnaire scores.

CONCLUSIONS

Vestibular disorders causing dizziness and vertigo are challenging to diagnose, often due to lack of cooperation and/or symptom nonspecificity. A thorough medical history and complementary tests, including audiovestibular and imaging studies, are advisable, thus avoiding systematically attributing children's complaints to other psychosomatic disorders.

Evolution of pediatric vertigo/dizziness during the past two decades

BACKGROUND

Increasing life expectancy and declining birth rate are two key drivers of population aging globally, resulting in a falling population.

OBJECTIVE

This study investigated the evolution of pediatric patients with vertigo/dizziness during the past two decades.

METHODS

From 2001 to 2010, a total of 17,123 new patients with vertigo/dizziness visited our neurotological clinic. Of them, 472 (2.8%) were children (Group A). In contrast, 260 children (1.3%) out of 20,404 new patients with vertigo/dizziness were experienced during the period 2011-2020 (Group B). All patients underwent an inner ear test battery before diagnosis.

RESULTS

The incidence of pediatric vertigo/dizziness in relation to overall neurotological cases significantly decreased from the first decade (2.8%) to the second decade (1.3%). Approximately 80% prevalence of pediatric vertigo/dizziness cases were referred to as vestibular migraine and benign paroxysmal vertigo of childhood regardless of Group A or B. Correlation between annual birth rate (x) and incidence of pediatric vertigo/dizziness cases in relation to overall neurotological cases (y) represented as y = 6.488x - 0.037 via linear regression analysis.

CONCLUSION

The evolution of pediatric vertigo/dizziness revealed decreased incidence from 2.8% (2001-2010) to 1.3% (2011-2020), which may be related to the declined annual birth rate from 11.7‰ (2001) to 7.0‰ (2020).

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.

Vestibular Migraine of Childhood and Recurrent Vertigo of Childhood: Diagnostic criteria Consensus document of the Committee for the Classification of Vestibular Disorders of the Bárány Society and the International Headache Society

This paper describes the diagnostic criteria for “Vestibular Migraine of Childhood”, “probable Vestibular Migraine of Childhood” and “Recurrent Vertigo of Childhood” as put forth by the Committee for the Classification of Vestibular Disorders of the Bárány Society (ICVD) and the Migraine Classification subgroup of the International Headache Society. Migraine plays an important role in some subgroups of children with recurrent vertigo. In this classification paper a spectrum of three disorders is described in which the migraine component varies from definite to possibly absent. These three disorders are: Vestibular Migraine of Childhood, probable Vestibular Migraine of Childhood and Recurrent Vertigo of Childhood. The criteria for Vestibular Migraine of Childhood (VMC) include (A) at least five episodes with vestibular symptoms of moderate or severe intensity, lasting between five minutes and 72 hours, (B) a current or past history of migraine with or without aura, and (C) at least half of episodes are associated with at least one migraine feature. Probable Vestibular Migraine of Childhood (probable VMC) is considered when at least three episodes with vestibular symptoms of moderate or severe intensity, lasting between five minutes and 72 hours, are accompanied by at least criterion B or C from the VMC criteria. Recurrent Vertigo of Childhood (RVC) is diagnosed in case of at least three episodes with vestibular symptoms of moderate or severe intensity, lasting between 1 minute and 72 hours, and none of the criteria B and C for VMC are applicable. For all disorders, the age of the individual needs to be below 18 years old. It is recommended that future research should particularly focus on RVC, in order to investigate and identify possible subtypes and its links or its absence thereof with migraine.

Episodic Vestibular Symptoms in Children With a Congenital Cytomegalovirus Infection: A Case Series

OBJECTIVE

Congenital cytomegalovirus (cCMV) infection is the most common non-genetic cause of sensorineural hearing loss in children. Although cCMV-induced vestibular loss is demonstrated in several studies, the occurrence of vertigo has been described in only two cases to date. The aim of this paper is to discuss the underlying pathophysiology of recurrent vestibular symptoms in children with cCMV, based on five cases investigated in our center and an extensive research of the literature.

STUDY DESIGN

Retrospective case series.

SETTING

Tertiary referral center.

PATIENTS

This case series describes five pediatric cCMV-patients (three boys, two girls). Four of them were symptomatic at birth, one was asymptomatic. Three patients underwent cochlear implantation. The age of onset of the vestibular symptoms varied from 2;0 to 7;3 years of age.

INTERVENTION

None.

MAIN OUTCOME MEASURES

Details regarding the patient history and results of cranial imaging, audiological, vestibular, and neurological assessments were collected retrospectively.

RESULTS

The selected cases suffered from recurrent vestibular symptoms. All patients had delayed onset, fluctuating, and/or progressive hearing loss. In all cases, the attacks were accompanied with nausea and vomiting and occurred without clear-cut trigger. Migraine and epilepsy often were proposed as first diagnosis, although they could not be confirmed eventually. Four out of five patients were diagnosed with a peripheral vestibular deficit.

CONCLUSIONS

Diagnosis of vestibular symptoms in children with cCMV is complex, given the multiple morbidities than can occur. Peripheral vestibular causes should be considered in the diagnosis, as important vestibular deficits are demonstrated in this population.

Vertigo in children; a narrative review of the various causes and their management

Vertigo is a not an uncommon symptom in children, but often the treating doctors are unsure of the diagnosis and the management of these cases. This narrative review of the literature discusses the brief etiopathology, the clinical manifestations and the management algorithm of most of the conditions causing vertigo in children. The relevant information has been condensed into a table for the perusal of the readers, which would assist in the appropriate management of these children.

Pediatric Meniere's disease

OBJECTIVE

This study adopted an inner ear test battery comprising audiometry, and ocular vestibular evoked myogenic potential (oVEMP), cervical VEMP (cVEMP), and caloric tests to investigate the sequence of inner ear deficits in pediatric Meniere's disease (MD).

METHODS

From 2005 to 2016, a total of 24 MD children aged <15 years old underwent otoscopy, CT scan, blood test, and an inner ear test battery. Nine subjects were males and 15 were females, with mean age of 12 years. Right ear was affected in 3 patients, left ear in 5 patients, and both ears in 16 patients (67%). Eight (33%) of the 24 MD children had positive family history.

RESULTS

Inner ear deficits in MD children ran from abnormal hearing (25%) to abnormal cVEMP (20%), oVEMP (13%), and caloric (12%) tests, exhibiting a significantly declining sequence from the cochlea, to the saccule, utricle and semicircular canals. Analysis between the laterality and family history revealed a significantly positive correlation.

CONCLUSION

Pediatric MD is rare, accounting for 2.3% prevalence in MD patients. The inner ear deficits in pediatric MD showed a significantly declining sequence from the cochlea, to the saccule, utricle and semicircular canals, mimicking the sequence in adult MD. One-third MD children had positive family history, which may explain the high rate of bilateral affliction and symmetrical hearing levels on both ears.

Variants in the KCNE1 or KCNE3 gene and risk of Ménière's disease: A meta-analysis

BACKGROUND

Ménière's disease (MD) is defined as an idiopathic disorder of the inner ear characterized by the triad of tinnitus, vertigo, and sensorineural hearing loss. Although many studies have evaluated the association between variants in the KCNE1 or KCNE3 gene and MD risk, debates still exist.

OBJECTIVE

Our aim is to evaluate the association between KCNE gene variants, including KCNE1 rs1805127 and KCNE3 rs2270676, and the risk of MD by a systematic review.

METHODS

We searched the literature in PubMed, SCOPUS and EMBASE through May 2015. We calculated pooled odds ratios (OR) and 95% confidence intervals (CIs) using a fixed-effects model or a random-effects model for the risk to MD associated with different KCNE gene variants. The heterogeneity assumption decided the effect model.

RESULTS

A total of three relevant studies, with 302 MD cases and 515 controls, were included in this meta-analysis. The results indicated that neither the KCNE1 rs1805127 variant (for G vs. A: OR = 0.724, 95%CI 0.320, 1.638, P= 0.438), nor the KCNE3 rs2270676 variant (for T vs. C: OR = 0.714, 95%CI 0.327, 1.559, P = 0.398) was associated with MD risk.

CONCLUSIONS

Based on current evidence from published studies, neither of the two variants from KCNE was significantly associated with the risk of MD. Larger studies with mixed ethnicity subjects and stratified by clinical and sub-clinical characteristics are needed to validate our findings.

Meniere's disease

Meniere's disease (MD) is a disorder of the inner ear that causes vertigo attacks, fluctuating hearing loss, tinnitus and aural fullness. The aetiology of MD is multifactorial. A characteristic sign of MD is endolymphatic hydrops (EH), a disorder in which excessive endolymph accumulates in the inner ear and causes damage to the ganglion cells. In most patients, the clinical symptoms of MD present after considerable accumulation of endolymph has occurred. However, some patients develop symptoms in the early stages of EH. The reason for the variability in the symptomatology is unknown and the relationship between EH and the clinical symptoms of MD requires further study. The diagnosis of MD is based on clinical symptoms but can be complemented with functional inner ear tests, including audiometry, vestibular-evoked myogenic potential testing, caloric testing, electrocochleography or head impulse tests. MRI has been optimized to directly visualize EH in the cochlea, vestibule and semicircular canals, and its use is shifting from the research setting to the clinic. The management of MD is mainly aimed at the relief of acute attacks of vertigo and the prevention of recurrent attacks. Therapeutic options are based on empirical evidence and include the management of risk factors and a conservative approach as the first line of treatment. When medical treatment is unable to suppress vertigo attacks, intratympanic gentamicin therapy or endolymphatic sac decompression surgery is usually considered. This Primer covers the pathophysiology, symptomatology, diagnosis, management, quality of life and prevention of MD.

The genetics of Ménière's disease

Our understanding of the genetic basis of Ménière’s disease (MD) is still limited. Although the familial clustering and the geographical and racial differences in incidence strongly suggest a certain role for genetic factors in the development of MD, no convincing evidence for an association with any gene exists, at present. In this review, starting from rational bases for a genetic approach to MD, we explored the numerous reports published in literature and summarize the recent advances in understanding of the genetic fundaments of the disease.

Prevalence and diagnosis of vestibular disorders in children: a review

OBJECTIVES

To systematically review and discuss the main pathologies associated with vertigo and dizziness in children, paying particular attention to recent advances in diagnosis and therapy.

METHODS

One appropriate string was run on PubMed to retrieve articles dealing with the topics mentioned above. A cross-check was performed on citations and full-text articles found using the selected inclusion and exclusion criteria. A non-comparative meta-analysis concerning the rate of singular vertiginous forms was performed.

RESULTS

Ten articles were identified comprising a total of 724 subjects. Overall, the articles we analyzed indicated benign paroxysmal vertigo of childhood (18.7%) and migraine-associated vertigo (17.6%) as the two main entities connected with vertigo and dizziness in children. Head trauma (14%) was the third most common cause of vertigo. The mean (95% CI) rate of every vertiginous form was also calculated in relation to the nine studies analyzed with vestibular migraine (27.82%), benign paroxysmal vertigo (15.68%) and vestibular neuritis (9.81%) being the three most common forms. There appeared to be a paucity of recent literature concerning the development of new diagnostic methods and therapies.

CONCLUSIONS

On the basis of the literature study, when evaluating a young patient with vertigo and dizziness, the otolaryngologist should be aware that, in children, these symptoms are often connected to different pathologies in comparison to the entities observed in the adult population.

[Vertigo in children and adolescents. Part 1: Epidemiology and diagnosis of peripheral vestibular disorders]

Migraine equivalents are the most common cause of vertigo in children and adolescents. Vertigo and balance disorders occur frequently in children during the course of otitis media, middle ear effusion and viral infections. If otitis media is associated with reduced hearing and vertigo, labyrinthitis must be considered. Craniocerebral injury is another important cause of vertigo in children. In contrast, spontaneous benign paroxysmal positional vertigo is rare among children. The isolated cases of endolymphatic hydrops that occur in children are usually secondary. Perilymph fistula can have congenital, infectious or trauma-related causes. The following characteristics are useful for differentiating between different vertiginous syndromes: type and duration of vertigo, triggering/aggravating/alleviating factors and accompanying symptoms. A neuro-ophthalmologic examination is essential to rule out central vestibular disorders.