Enlarged vestibular aqueduct may precipitate benign paroxysmal positional vertigo in children

Congenital deafness and vestibular disorders: a systematic literature review

Introduction

Congenital deafness is a pathological entity that represents an economical and social burden, affecting up to 0.2% of newborns in Europe. Sensorineural hearing loss (SHL) is caused by a variety of factors, including congenital abnormalities, perinatal infectious diseases and genetic syndromes. The inner ear's vestibular system, nestled alongside the auditory organs, is crucial for balance maintenance. Its close connection with the auditory system means that disturbances in one often coincide with disturbances in the other, highlighting their intertwined functions. With this review we aim to describe objective vestibular tests found in literature and to study their use for diagnosis of vestibular disturbances in patients affected by congenital deafness.

Methods

The review is conducted with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) 2020 guidelines. The search string used was: [(congenital deafness) OR (congenital hearing loss) OR (congenital hypoacusia)] AND [(vestibular disorders) OR (vertigo)]. An initial abstract reading selection was made, and a subsequent comprehensive full-text reading. For each article, we identified the type of vestibular test utilized and its corresponding outcome.

Results

Out of the initial-papers identified through the search string-articles met the eligibility criteria for further analysis through abstract and full-text reading. After further selection-articles were chosen for detailed examination, focusing on the data of patients.

Conclusion

Congenital hearing loss profoundly affects a child's development, especially in language and communication skills, and it is frequently associated with a pathological vestibular system. Early identification allows timely intervention with personalized therapies. In current literature, there is still no gold standard test to identify balance disorders in patients with congenital hearing loss. There is considerable variability on the subject due to the inclusion of diverse patients with various diagnoses, alongside a wide range of available technologies. Managing such conditions necessitates collaboration among healthcare providers, ensuring comprehensive care through prompt diagnosis and personalized treatment plans. Ongoing research aims to further improve screening methods and develop precision medicine approaches tailored to individual needs.

Enlarged vestibular aqueduct as a cause of postneonatal deafness

INTRODUCTION

The enlarged vestibular aqueduct (EVA) is the most frequent malformation of the inner ear associated with sensorineural hearing loss (5-15%). It exists when the diameter in imaging tests is greater than 1.5 mm at its midpoint. The association between hearing loss and EVA has been described in a syndromic and non-syndromic manner. It can appear as a familial or isolated form and the audiological profile is highly variable. The gene responsible for sensorineural hearing loss associated with EVA is located in the same region described for Pendred syndrome, where the SCL26A4 gene is located.

OBJECTIVE

To describe a series of children diagnosed with EVA in order to study their clinical and audiological characteristics, as well as the associated genetic and vestibular alterations.

METHOD

Retrospective study of data collection of children diagnosed with EVA, from April 2014 to February 2023.

RESULTS

Of the 17 cases, 12 were male and 5 were female. 5 of them were unilateral and 12 bilateral. In 5 cases, a cranial traumatism triggered the hearing loss. Genetic alterations were detected in 3 cases: 2 mutations in the SCL26A4 gene and 1 mutation in the MCT1 gene. 13 patients (76.5%) were rehabilitated with hearing aids and 9 of them required cochlear implantation.

DISCUSSION

The clinical importance of AVD lies in the fact that it is a frequent finding in the context of postneonatal hearing loss. It is convenient to have a high suspicion to diagnose it with imaging tests, to monitor its evolution, and to rehabilitate early.

Outcome of canalith repositioning manoeuvre in benign paroxysmal positional vertigo in children and adolescents: A systematic review

BACKGROUND

Benign paroxysmal positional vertigo (BPPV) is a debilitating condition that has been significantly described in adults. Recent data points out that BPPV occurs in children as well. Canalith repositioning manoeuvre (CRM) has shown promising results amongst adult patients with BPPV.

OBJECTIVE

We reviewed the literature to determine the outcome of CRM in children and adolescents with BPPV.

METHODS

A literature search was conducted over 1 month (March 2022). The primary outcome was defined as the resolution of positional nystagmus and symptoms, and secondary outcomes were determined by the presence of recurrence and the number of attempts of CRM.

RESULTS

Ten articles were selected based on our objective and selection criteria. A total of 242 patients were included, with a mean of 10.9 years. BPPV was diagnosed based on history and positional nystagmus in all patients (100%). CRM was performed in 97.9% of patients, whereby 80.5% recovered following a single attempt of CRM. Recurrence of symptoms was identified in 10% of patients with no reported major complications.

CONCLUSION

CRM has demonstrated promising results in children and adolescents. The quality of evidence is limited until a better-quality study involving randomised controlled studies with a larger sample size is completed.

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.

Vestibular anomalies and dysfunctions in children with inner ear malformations: A narrative review

About 20% of children with congenital hearing loss present malformations of the inner ear. In the past few years much has been understood about the morphology and function of the anterior part of the labyrinth, since hearing loss may have a dramatic effect on the overall development of a child. Nowadays, for most of them, a chance for hearing rehabilitation is available, making hearing loss a treatable condition. The anomalies range from the lack of development of the whole inner ear to specific anomalies of isolated structures. Despite the frequent concomitant involvement of the posterior part of the labyrinth, this part of the inner ear is frequently neglected while discussing its morphology and dysfunction. Even though vestibular and balance function/dysfunction may have a significant impact on the global development of children, very little is known about these specific disorders in patients with inner ear malformations. The aim of this review is to summarize the available literature about vestibular anomalies and dysfunctions in children with inner ear malformations, discussing what is currently known about the topic.

Clinical Implication of Caloric and Video Head Impulse Tests for Patients With Enlarged Vestibular Aqueduct Presenting With Vertigo

Background: By examining the clinical features and results of video head impulse test (vHIT) and caloric tests in patients with enlarged vestibular aqueduct (EVA) presenting with vertigo, we aimed to investigate the function of angular vestibulo-ocular reflex (VOR) and its clinical implications.

Methods: Nine patients with EVA manifesting with vertigo were enrolled. The medical history, audiological examination, imaging, and the results of the caloric test and the vHIT were analyzed.

Results: Of the nine patients with EVA (eight bilateral and one unilateral case), five were pediatric cases. All 17 ears exhibited sensorineural hearing loss (SNHL). Enlarged vestibular aqueduct patients can present with recurrent (seven cases) or single (two cases) vertigo attack, trauma-induced (two cases), or spontaneous (seven cases) vertigo. Diminished caloric responses were observed in 77.8% (7/9) of the patients (four cases unilaterally and three bilaterally), while unilateral abnormal vHIT results in 11.1% (1/9) patients. Abnormal caloric and normal horizontal vHIT responses were found in 66.7% (6/9) of EVA patients.

Conclusions: Vestibular manifestations in EVA are diverse. Enlarged vestibular aqueduct patients with vertigo can present with a reduced caloric response and normal horizontal vHIT, and this pattern of angular VOR impairment was also found in other hydropic ear diseases.

Systematic Review on Vestibular Symptoms in Patients With Enlarged Vestibular Aqueducts

OBJECTIVE

Enlarged vestibular aqueduct (EVA) is a congenital condition that can lead to various outcomes in pediatric patients including hearing loss and vestibular dysfunction. Our goal was to critically appraise the literature on the proportion of patients with EVA who report vestibular dysfunction, determine relevant risk factors for the development of these symptoms, and describe vestibular tests and interventions used to improve outcomes.

METHODS

A systematic review was performed in accordance with the PRISMA guidelines. We queried the EMBASE, Ovid Medline, and Cochrane Library databases for relevant literature. Studies were included if they had n > 10, reported vestibular symptoms or vestibular function testing in patients with EVA, and were published in English. Nonhuman studies, systematic reviews, and review articles were excluded.

RESULTS

Of 808 identified studies, 20 met inclusion criteria. Subjective vestibular symptoms included dizziness, episodic vertigo, and imbalance. Seventeen studies reported subjective vestibular symptoms, ranging from 2% to 71% of patients between studies. Seventeen studies performed some form of vestibular function test, including physical exam maneuvers (Dix-Hallpike), caloric testing, electronystagmography, and vestibular evoked myogenic potentials. Of those who had vestibular function testing, 7% to 92% had an abnormal result. Two studies identified head trauma as a risk factor. One study successfully treated patients with BPPV using the Epley maneuver, but other vestibular symptoms were not targeted with treatment.

CONCLUSION

The degree to which vestibular symptoms impact patients with EVA varies significantly. Performing vestibular function testing may help identify asymptomatic patients with vestibular dysfunction. Future studies should target improving treatment of vestibular symptoms in EVA patients. Laryngoscope, 2021.

Rare Disorders of the Vestibular Labyrinth: of Zebras, Chameleons and Wolves in Sheep's Clothing

The differential diagnosis of vertigo syndromes is a challenging issue, as many - and in particular - rare disorders of the vestibular labyrinth can hide behind the very common symptoms of "vertigo" and "dizziness". The following article presents an overview of those rare disorders of the balance organ that are of special interest for the otorhinolaryngologist dealing with vertigo disorders. For a better orientation, these disorders are categorized as acute (AVS), episodic (EVS) and chronic vestibular syndromes (CVS) according to their clinical presentation. The main focus lies on EVS sorted by their duration and the presence/absence of triggering factors (seconds, no triggers: vestibular paroxysmia, Tumarkin attacks; seconds, sound and pressure induced: "third window" syndromes; seconds to minutes, positional: rare variants and differential diagnoses of benign paroxysmal positional vertigo; hours to days, spontaneous: intralabyrinthine schwannomas, endolymphatic sac tumors, autoimmune disorders of the inner ear). Furthermore, rare causes of AVS (inferior vestibular neuritis, otolith organ specific dysfunction, vascular labyrinthine disorders, acute bilateral vestibulopathy) and CVS (chronic bilateral vestibulopathy) are covered. In each case, special emphasis is laid on the decisive diagnostic test for the identification of the rare disease and "red flags" for potentially dangerous disorders (e. g. labyrinthine infarction/hemorrhage). Thus, this chapter may serve as a clinical companion for the otorhinolaryngologist aiding in the efficient diagnosis and treatment of rare disorders of the vestibular labyrinth.

Analyses of the Relation between BPPV and Thyroid Diseases: A Nested Case-Control Study

BACKGROUND

This study investigated relationship between multiple thyroid disorders and benign paroxysmal positional vertigo (BPPV), adjusting for levothyroxine medication.

METHODS

The Korean National Health Insurance Service-Health Screening Cohort data from 2002 to 2015 were used. A total of 19,071 patients with BPPV were matched with 76,284 participants of a control group in a ratio of 1:4 for age, sex, income, and region of residence. The previous histories of thyroid disorders such as goiter, hypothyroidism, thyroiditis, hyperthyroidism, and autoimmune thyroiditis were investigated in both the BPPV and control groups. The odds ratios (ORs) for BPPV in thyroid diseases were calculated using conditional logistic regression analyses.

RESULTS

The histories of goiter (5.5% vs. 4.1%), hypothyroidism (4.7% vs. 3.7%), thyroiditis (2.1% vs. 1.6%), and hyperthyroidism (3.1% vs. 2.5%) were higher in the BPPV group than in the control group (all p < 0.001). Goiter, hypothyroidism, thyroiditis, and hyperthyroidism were associated with BPPV (adjusted OR = 1.28 (95% CI = 1.17-1.39) for goiter, 1.23 (95% CI = 1.10-1.37) for hypothyroidism, 1.13 (95% CI = 1.02-1.26) for hyperthyroidism, each p < 0.05).

CONCLUSIONS

BPPV was associated with thyroid disorders such as goiter, hypothyroidism, thyroiditis, and hyperthyroidism.

Adverse effects of semicircular circle angles variation on Epley repositioning procedure: a study on reconstruction of Micro-CT images 3D

Background: For patients with posterior semicircular canal (PSC) BPPV, Epley re-position maneuver and some improvement methods are the most efficient treatment methods. But there were still 9.43% patients who were not benefit from Epley re-position maneuver.Objective: To measure the angles of semicircular canals and evaluate its effect on Epley maneuver.Methods: Fifteen skull specimens, containing 30 temporal bone specimens were included. After Micro-CT scanning, 3D reconstruction was loaded with the CT image. The angles between each semicircular canal and each standard skull plane were measured. Furthermore, the angles' effect on Epley maneuver was evaluated according to the three-dimension (3D) model.Results: Angles of PSC plane: Frankfurt plane was 71.54 ± 6.51, sagittal plane was 53.77 ± 5.36°, and the coronal plane was 43.33 ± 3.56°. Angles between PSC and the sagittal plane of skulls had an adverse effect on Epley maneuver, when it was less than 45°.Conclusion: 1. Variation could be found in angles between the semicircular canals and the standard planes of skulls, which meant variation of semicircular canals' location existing in skulls. 2. The variation of angles between PSC and sagittal plane could have an adverse effect on the Epley maneuver when the angle was less than 45°, which may cause the Epley maneuver to be invalid.

Review of the pathology underlying benign paroxysmal positional vertigo

The pathophysiological mechanism underlying benign paroxysmal positional vertigo (BPPV) is related to free-floating debris/otoliths in the semicircular canal (canalolithiasis) or debris/otoliths attached to the cupula (cupulolithiasis). These debris/otoliths are considered to originally accumulate after detachment from the neuroepithelium of the utricular macula secondary to a type of degeneration. An idiopathic form, which is assumed to occur spontaneously, is diagnosed when the causative pathology is obscure. However, an association between various other systemic or inner ear conditions and BPPV has been reported, indicating the existence of secondary BPPV. This study was performed to present the first review of the pathology underlying BPPV following a complete PubMed/Medline search. In total, 1932 articles published from 1975 to 2018 were reviewed. The articles were classified according to 17 potentially causative factors (aging; migraine; Meniere's disease; infection; trauma; idiopathic sudden sensorineural hearing loss; sleeping habits; osteoporosis and vitamin D insufficiency; hyperglycemia and diabetes mellitus; chronic head and neck pain; vestibule or semicircular canal pathology; pigmentation disorders; estrogen deficiency; neurological disorders; autoimmune, inflammatory, or rheumatologic disorders; familial or genetic predisposition; and allergy). A discussion of the underlying cause of BPPV for each factor is presented.

Benign Paroxysmal Positional Vertigo (BPPV) in Children and Adolescents: Clinical Features and Response to Therapy in 110 Pediatric Patients

OBJECTIVE

This study aimed to characterize the clinical features and outcomes of benign paroxysmal positional vertigo (BPPV) in the pediatric population.

STUDY DESIGN

Retrospective case review.

SETTING

Tertiary care center.

PATIENTS

One hundred ten patients, aged 5 to 19 years old, diagnosed with BPPV.

MAIN OUTCOME MEASURES

Patient demographics, comorbidities, canal involvement, response to treatment, and incidence of recurrence.

RESULTS

BPPV was diagnosed in 19.8% of patients seen for dizziness during the study period. Patient age ranged 5 to 19 years old (mean =13.4 ± 3.4 yr). Female:male ratio was 3:2. The most prevalent comorbidities were concussion (n = 42, 38.2%) and migraine disorders (n = 33, 30.0%). Average time to diagnosis from symptom onset was 178.2 ± 190.8 days. The posterior canal was most frequently affected (n = 80, 72.7%), followed by the lateral canal (n = 37, 33.6%) and superior canal (n = 21, 19.1%), and 36.4% (n = 40) of patients had multiple canals affected. Treatment requiring more than or equal to five maneuvers to achieve resolution was observed in 11.8% of cases (n = 13). Recurrence was observed in 18.2% of cases. A logistic regression analysis demonstrated that patients with vestibular migraine or benign paroxysmal vertigo of childhood had five times higher odds of recurrence of BPPV, p = 0.003, 95% [1.735, 15.342], than those who did not have either.

CONCLUSIONS

BPPV is a relatively common cause of dizziness in the pediatric population. Children and adolescents with BPPV can be successfully treated with repositioning maneuvers but may be at risk for treatment resistance and recurrence. Increased awareness of BPPV in pediatric patients may reduce delays in identification and treatment.

Benign paroxysmal positional vertigo in children

OBJECTIVE

To describe the clinical features of benign paroxysmal positional vertigo (BPPV) in children.

DESIGN

A retrospective study.

SETTING

Six children diagnosed with BPPV between March 2014 and March 2015 were retrospectively evaluated. BPPV was diagnosed using the Dix-Hallpike and supine roll tests and treated with either the modified Epley particle repositioning procedure or Lempert or Gufoni manoeuvre. Follow-up was performed at 1-week intervals until vertigo and nystagmus disappeared during positional testing.

PARTICIPANTS

A total of six children were followed up for a period of 10-22 months.

MAIN OUTCOME MEASURES

Clinical features such as history, nystagmus and symptoms of vertigo, dizziness and nausea.

RESULTS

Six children were diagnosed with BPPV using positional testing and treated with the modified Epley or Lempert/Gufoni particle repositioning procedures. Four children were diagnosed with posterior canal BPPV, while the remaining two were diagnosed with horizontal canal BPPV. One girl reported a history of head trauma, one girl had a family history of vertigo, and one boy reported hearing loss in the same ear as that affected by BPPV. Overall, 83.33% of children (5/6) were completely relieved of vertigo following one treatment session. The remaining child was asymptomatic after two sessions. No child reported relapse of vertigo during the follow-up period.

CONCLUSIONS

BPPV can be diagnosed accurately by taking a detailed medical history and by use of positional testing. BPPV in children can be successfully identified and treated.

Position of the Internal Aperture of Vestibular Aqueduct in Patients With Enlarged Vestibular Aqueduct

OBJECTIVE

To investigate the position of the internal aperture of vestibular aqueduct and its relationship to hearing level in patients with enlarged vestibular aqueduct (EVA).

METHODS

The size of the common crus and the position of the internal aperture of vestibular aqueduct were compared among control subjects, EVA patients with and without other inner ear malformations. Auditory steady-state response thresholds were compared between EVA patients with different positions of internal apertures.

RESULTS

The common crus in EVA patients was shorter than in control subjects (p < 0.05). The internal aperture of the vestibular aqueduct opened solely into the common crus in control subjects, simultaneously into the common crus and vestibule in almost 45% of EVA patients, solely into the common crus, and the vestibule in almost 30 and 25% of EVA patients, respectively. Auditory steady-state response thresholds at 2000 and 4000 Hz were higher in EVA patients whose internal apertures of vestibular aqueducts opened simultaneously into the common crus and vestibule than in those whose internal apertures opened solely into the common crus.

CONCLUSION

The common crus is shorter in EVA patients than in control subjects. The internal aperture of the vestibular aqueduct opens solely into the common crus in control subjects. It opens simultaneously into the common crus and vestibule in almost half of the EVA patients. The EVA patients whose internal apertures of vestibular aqueducts open solely into the common crus may have better hearing than those whose internal apertures open simultaneously into the common crus and vestibule.

Nystagmus in Enlarged Vestibular Aqueduct: A Case Series

Enlarged vestibular aqueduct (EVA) is one of the commonly identified congenital temporal bone abnormalities associated with sensorineural hearing loss. Hearing loss may be unilateral or bilateral, and typically presents at birth or in early childhood. Vestibular symptoms have been reported in up to 50% of affected individuals, and may be delayed in onset until adulthood. The details of nystagmus in patients with EVA have not been previously reported.

The objectives were to describe the clinical history, vestibular test findings and nystagmus seen in a case series of patients with enlarged vestibular aqueduct anomaly.

Chart review, included computed tomography temporal bones, infrared nystagmography with positional and positioning testing, caloric testing, rotary chair and vibration testing.

Clinical history and nystagmus varied among the five patients in this series. All patients were initially presumed to have benign paroxysmal positional vertigo, but repositioning treatments were not effective, prompting referral, further testing and evaluation. In three patients with longstanding vestibular complaints, positional nystagmus was consistently present. One patient had distinct recurrent severe episodes of positional nystagmus. Nystagmus was unidirectional and horizontal. In one case horizontal nystagmus was consistently reproducible with seated head turn to the affected side, and reached 48 d/s. Nystagmus associated with enlarged vestibular aqueduct is often positional, and can be confused with benign paroxysmal positional vertigo. Unexplained vestibular symptoms in patients with unilateral or bilateral sensorineural hearing loss should prompt diagnostic consideration of EVA.