Abstract
Background
Vertigo/Dizziness in childhood is not a rare cause of visits to the emergency department (ED). We analyzed a selected group with vertigo/dizziness to identify signs and symptoms that may help to guide the diagnostic approach and management.
Methods
A total of 616 children admitted for vertigo to the ED over a five-year period were retrospectively reviewed. Their medical history, clinical characteristics, laboratory and neuroimaging tests, final diagnoses and management were analyzed.
Results
Migraine and syncope were the most frequent causes. Two patients were affected by life-threatening cardiac syncope, while structural life-threatening central nervous system diseases were found in 15 patients, none of whom presented with vertigo as an isolated clinical finding.
Conclusions
Most cases of vertigo/dizziness in childhood that consist mainly of migraine and syncope are of benign origin. The prompt identification of neurological or cardiological signs or symptoms associated with vertigo in children is mandatory to rule out life-threatening conditions.
Introduction
Vertigo/Dizziness (VD) is neither uncommon in pediatric age nor a rare cause of visits to the emergency department (ED). It is defined as an unreal sensation of movement, which may in medical terms be referred to as a peculiar kind of dizziness that makes you feel as if you, or the things around you, are moving or spinning, even though there is no movement. Other subtypes of dizziness that differ from vertigo include disequilibrium, lightheadedness and “other dizziness” (1). Children with suspected VD are different from adults owing to the peculiar causes of VD and the difficulty encountered in obtaining an accurate history in this developmental stage (2).
VD in adults accounts for 3.5% of ED admissions (3). Data in pediatric populations are, however, limited, particularly in the ED setting. Moreover, these studies tend to cover brief periods, to focus on specific causes of VD, or to consider patients from specialty outpatient services, such as neurology or otorhinolaryngology departments (4–8). The prevalence in school age is estimated to be 15% (9). A review of all International Classification of Diseases, ninth revision (ICD-9) codes related to vestibular and balance disorders in more than 560,000 distinct pediatric patient visits over a four-year period revealed a cumulative prevalence of 0.45% (10). A meta-analysis in childhood revealed that benign paroxysmal vertigo of childhood (BPVC) (18.7%) and migraine (17.6%) were the most frequent causes of VD, followed by head trauma, which accounted for 14% of the cases (11).
Nonetheless, the differential diagnosis is challenging, particularly because children may encounter communication difficulties in describing the symptoms they experience (12,13). Emergency physicians should be aware that the broad etiology spectrum of VD, and consequently also the incidence in children (5.7% at 10 years of age), may be markedly different from that in adults (2,5). VD in the pediatric population is usually benign and has a favorable prognosis, with 25%–50% being related to migraine, though the incidence of somatoform vertigo syndromes increases in adolescence (5). To our knowledge, no study has yet been conducted on the presentation and management of VD in the pediatric ED setting. The aim of our study was to collect the most significant information in the ED of a tertiary pediatric hospital.
Material and methods
We conducted a retrospective study of patients, aged between 3 and 18 years, who presented with a primary complaint of vertigo to the ED of the Bambino Gesù Children’s Hospital in Rome between January 2009 and December 2013, after obtaining approval from the institutional ethics committee. There is an ongoing scientific collaboration and an agreement between the ED of the Bambino Gesù Children’s Hospital and the Post-graduate School in Pediatrics of the Chair of Pediatrics, Faculty of Medicine and Psychology of Sapienza University of Rome. The following data were extracted from each medical record: age, gender, triage code, family history, symptoms, physical examination findings, specialist consultations, imaging techniques such as computed tomography (CT) scan and magnetic resonance imaging (MRI), final diagnosis, hospital admission, and duration of hospitalization, as applicable. Screening and diagnostic tests performed, length of stay, and disposition were also extracted for each ED visit. CT and MRI were combined in a single variable, i.e. CT/MRI. Discharge diagnoses of all the patients were based on established criteria and guidelines, if available, and classified according to diagnostic categories as follows: a) airway infection; b) otologic etiology subdivided in otitis, labyrinthitis/vestibular neuritis/vestibulopathy, other otologic causes; c) neurologic etiology subdivided in migraine and BPVC (as migraine equivalent), demyelinating/vascular disease, brain tumor, epilepsy; d) cardiovascular disease subdivided in neurocardiogenic syncope, cardiac syncope, hypertension; e) psychiatric disorders; f) other categories or miscellaneous; g) undefined vertigo.
Statistical analysis
We describe the clinical and demographic characteristics of all the patients enrolled, providing details of the overall sample as well as of each of the two subgroups (patients with a migraine diagnosis and those without). The two groups were compared by means of the Chi square test for categorical variables, and Student’s t test after reviewing for appropriateness of the continuous variables.
We applied logistic regression analysis models to assess the predictive variables associated with a diagnosis of migraine. Adjusted odds ratios (OR) and 95% confidence intervals (CI) were used as measures of effect. The statistical significance was set at p < 0.05. SPSS software (version 22.0) was used to perform all the statistical analyses.
Results
Clinical and demographic characteristics of the overall sample and of the two subgroups (migraine and non- migraine).
BPVC: benign paroxysmal vertigo of childhood; CT: computed tomography; MRI: magnetic resonance imaging; n.s.: not significant.
The final diagnoses made in the ED are shown in Figure 1.
Distribution of the various etiologies for vertigo.
Neurological and cardiovascular disorders, which were found respectively in 214 patients (34.7%) and 128 patients (20.8%), were the most frequent causes of vertigo. The most common neurological disorders were migraine, which accounted for 151 (24.6%) of the cases, and BPVC, which accounted for 39 (6.3%) of the cases (Figure 1). The most common cardiovascular cause was syncope or pre-syncope, which accounted for 124 patients (20.1%).
Life-threatening conditions were detected in two patients with cardiac syncope and in 15 patients with neurological conditions (brain tumors in six patients and demyelinating/vascular diseases were identified in nine patients, all of whom manifested neurological signs or symptoms (red flags)).
A brain CT/MRI study was performed in 128 (20.8%) patients, 72 of whom displayed additional neurological signs or symptoms while 56 did not; 17 of these patients underwent both investigations. Neuroimaging was performed more frequently in children with a longer duration of symptoms (20.4 ± 60.2 vs 10.1 ± 42.7 days, p = 0.03) and in younger children (116.5 ± 44.6 vs 141.1 ± 38.9 months, p < 0.005).
Logistic regression analysis to assess the predictive variables associated with a diagnosis of migraine.
M: male; F: female; CT: computed tomography; MRI: magnetic resonance imaging.
Discussion
VD in children is not uncommon and may have a wide spectrum of different causes (4,5). Pediatricians must be skilled in differentiating the common causes of VD from uncommon but more serious, life-threatening conditions.
In our population, migraine or BPVC accounted for 30.9% of the cases, with BPVC being diagnosed in 6.3%. According to the literature, BPVC is the most common cause of VD in children between 2 and 6 years of age, and has a prevalence of around 2.6% in children between 5 and 15 years (14). BPVC should not be considered a mere precursor of migraine but as part of a migraine syndrome (15). Indeed, these conditions were included in migraine equivalents in the latest International Classification of Headache Disorders (third edition, ICHD-3), together with cyclical vomiting syndrome, abdominal migraine and benign paroxysmal torticollis (16). In the numerous cases in which the causes are not properly identified, patients may undergo unnecessary and potentially dangerous radiological investigations aimed at excluding life-threatening conditions (17).
Migraine was the most frequent diagnosis made in pediatric patients with VD presenting at the ED (6–10,18,19). Migraine in our study accounted for 30.9% of the cases, whereas the reported prevalence in previous studies ranged from 12% to 34% in children (not conducted in the emergency setting) (4–8,18–21), and was 6% in adults (3).
Peripheral vestibular disorders such as benign paroxysmal positional vertigo, vestibular neuritis and Ménière’s disease are frequent in adults but proved to be less common in children (4,5,8).
Although neuroimaging studies (CT/MRI) are increasingly being requested in the ED setting for the evaluation of adult patients with VD, the proportion of central nervous system diagnoses has not increased (3). In our study, we performed neuroimaging in 20.8% of patients, with neurological life-threatening conditions being diagnosed in 2.5%. Although CT is an important first-line neuroimaging technique (usually available in all EDs), MRI is the most suitable neuroimaging technique (if available), especially since CT may be negative in demyelinating and vascular (ischemic stroke) diseases. Indeed, demyelinating disease in three patients in our case series was detected only by means of MRI. It is important to stress that all the patients in our cohort in whom severe neurological pathologies were diagnosed presented with associated signs or symptoms (red flags) and that VD was not an isolated clinical finding in any of them.
Our study revealed that syncope in the ED setting is more frequently associated with VD in children than in adults. Although syncope is prevalently of benign origin (neurocardiogenic syncope), it is mandatory to exclude, as was done in two of our patients, a life-threatening cardiac origin of this condition according to clinical guidelines and an appropriate algorithm designed for children (22). Hypertension is another cardiovascular condition that should be considered in children with VD as it carries, despite being associated with vertigo relatively rarely, a high risk for subsequent severe damage (23).
In our series a history of head or cervical trauma preceded the appearance of VD in the patients studied, whereas neuroimaging was performed in 22 (30.1%) patients, six (8.2%) of whom were found to have a skull fracture, though without brain involvement.
Strengths and limitations
The strengths of our study include the relatively large number of children enrolled with VD. To the best of our knowledge, this is the first study to systematically address VD pediatric patients in the emergency setting in a tertiary pediatric hospital.
There are potential limitations of this study that should to be taken into account when interpreting the data, including the presence of confounding factors, as tends to be inevitable in any retrospective series. Moreover, as there was no ED protocol for VD patients during the study period, it was up to individual emergency physicians to decide the patients’ management. In addition, it should be emphasized that some causes of life-threatening events should not be overlooked, such as those that may be present in the subgroups of undefined VD (Figure 1). A larger multicenter prospective study involving several hospitals is needed to confirm our findings before EDs implement these predictors as a definitive screening tool.
Conclusion
Our study demonstrates that migraine or BPVC and syncope were the most frequent disorders in a pediatric population who presented to the ED for VD. A thorough history collection and clinical examination are essential to identify patients who require further investigations. On the basis of our findings, the decision to perform further investigations to exclude life-threatening diseases that require an early diagnosis and an appropriate treatment needs to be taken prevalently according to the presence of associated signs or symptoms.
Footnotes
Article highlights
Vertigo/dizziness (VD) in childhood is not a rare reason for visits to emergency departments (EDs).
Our study is the largest series (616 children) of VD pediatric patients aged 3–18 years presenting at the ED of a tertiary hospital.
Most VDs are of benign origin, with migraine and syncope accounting for the majority of admissions to the ED.
Early recognition of associated neurological or cardiological signs or symptoms is mandatory to identify individuals who merit further investigation to rule out life-threatening conditions.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.
Declaration of conflicting interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Acknowledgements
Authors’ contributions are as follows: UR and PP participated in the conception and design of the study, the acquisition of data and interpretation of data; they also coordinated and drafted the first version of the manuscript, and critically revised its intellectual content. They approved and submitted the final version of the manuscript.
NV participated in the design of the study, in the statistical analysis and interpretation of data and critically revised the intellectual content of the final manuscript.
MCP, RS, RM and AU collected and interpreted data and participated in critically revising the intellectual contents of the final manuscript. All the authors read and approved the final manuscript.
AR and MPV coordinated the study, critically revised and approved the final version of the manuscript, and critically revised its intellectual content.