How Young Is Too Young to Evaluate Children for Dizziness? As our knowledge of childhood vestibular disorders grows, so do calls for audiologists to test for dizziness and recommend treatment. All Ears on Audiology
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All Ears on Audiology  |   July 01, 2017
How Young Is Too Young to Evaluate Children for Dizziness?
Author Notes
  • Steven M. Doettl, AuD, CCC-A, is an associate professor and coordinator of the Dizziness Clinic for the doctor of audiology program at the University of Tennessee Health Science Center in Knoxville. sdoettl@uthsc.edu
    Steven M. Doettl, AuD, CCC-A, is an associate professor and coordinator of the Dizziness Clinic for the doctor of audiology program at the University of Tennessee Health Science Center in Knoxville. sdoettl@uthsc.edu×
  • Devin L. McCaslin, PhD, CCC-A, is a senior associate consultant at the Vestibular and Balance Laboratory in the Department of Otorhinolaryngology, Division of Audiology, at the Mayo Clinic in Rochester, Minnesota. mccaslin.devin@mayo.edu
    Devin L. McCaslin, PhD, CCC-A, is a senior associate consultant at the Vestibular and Balance Laboratory in the Department of Otorhinolaryngology, Division of Audiology, at the Mayo Clinic in Rochester, Minnesota. mccaslin.devin@mayo.edu×
Article Information
Balance & Balance Disorders / All Ears on Audiology
All Ears on Audiology   |   July 01, 2017
How Young Is Too Young to Evaluate Children for Dizziness?
The ASHA Leader, July 2017, Vol. 22, 18-20. doi:10.1044/leader.AEA.22072017.18
The ASHA Leader, July 2017, Vol. 22, 18-20. doi:10.1044/leader.AEA.22072017.18
The phone rings in your audiology office, and you’re not surprised that it’s another inquiry about a dizzy child from a pediatric otolaryngologist or pediatrician. Audiologists are increasingly seen as “go-to” providers for assessing vestibular status in children.
Assessing and managing this population is a rapidly expanding area of audiology practice—growth spurred by evidence that results of vestibular evaluation of young children can guide medical and rehabilitative treatment.
But there’s a problem: Despite growing numbers of audiologists evaluating for pediatric vestibular disorders, some still meet the call for this service with trepidation. They have questions: Do kids get “dizzy”? How young is too young to test and what tests should be used? What recommendations should follow from testing?
Audiologists raising such questions need not be so apprehensive. Vestibular research has advanced significantly, providing symptom and quality-of-life metrics, as well as age-specific normative data. As a result, audiologists are in a position to confidently provide services in this area—and this traditionally underserved population of children can receive appropriate care as never before.
Do kids get dizzy?
About 5 to 8 percent of children experience vertigo in the general population, research indicates (see sources below). While significant, these numbers may not fully account for this population, as dizziness in children can be difficult to accurately quantify. It is often overlooked because of shortfalls in reporting symptoms or misattribution of symptoms to misbehavior or poor coordination.
The challenge for clinicians is that they often rely on symptom reports from primary caregivers and family members. This is where new questionnaires and outcome measures can fill in gaps. Such tools include the Vanderbilt Dizziness Handicap Inventory for Patient Caregivers (DHI-PC)—a reliable tool for quantifying the impact of dizziness in children ages 5–12 from the caregiver perspective. In addition, the recently developed Pediatric Vestibular Symptom Questionnaire (PVSQ) is able to discriminate vestibular pathology in children with 95-percent sensitivity (see sources below).
The most common reported vestibular disorders in children include vestibular migraine, benign paroxysmal vertigo of childhood, vestibular neuritis, benign paroxysmal positional vertigo (BPPV) and otitis media (see sources). BPPV has traditionally been thought of as rare in children. But recently it’s been reported to account for between 4 percent to 12 percent of cases of vertigo in children (see sources below). Among adolescents, we typically see more adult-like pathologies, such as Ménière’s disease or nonvestibular pathologies such as cardiac abnormalities. Other providers often refer patients to audiologists to rule out vestibular anomalies en route to a nonvestibular diagnosis (see sources).

Upwards of 60 percent of children with reported dizziness have vestibular dysfunction identified via balance function testing.

Differential diagnosis
As our knowledge of childhood vestibular disorders grows, audiologists are increasingly called on to provide differential diagnoses. Upwards of 60 percent of children with reported dizziness have vestibular dysfunction, identified via balance function testing (see sources).
Traditional thought suggests that children younger than 6 may not be able to complete the testing of eye function that we use to determine what’s happening in the inner ear. One of these tests is videonystagmography (VNG), which tracks eye movements via camera as patients complete various tasks or are exposed to various stimuli. Another is rotary chair testing (RCT), which uses a camera to assess the magnitude of eye movements in response to rotation. There’s been concern that the data obtained from these tests may not be relevant using adult protocols and normative values. However, these tests can produce useful results with even younger children, as we now have published pediatric protocols and normative data (see sources below). The chart on page 19 suggests adaptations to these and other tests on children.
In addition to VNG and RCT testing, vestibular evoked myogenic potentials (VEMPs, a test measuring neck responses to sound) and video head impulse testing (measuring how changes in head position affect the vestibular ocular reflex) have also proven useful and valid with children.
Also valid are many of the low-tech manual tests of vestibular and balance function in children. These techniques use behavioral methods, such as assessing standing balance and/or visual function while moving, and may provide valuable qualitative information for screening or diagnostic confirmation. Manual tests can help build rapport with patients, making these tests especially useful when patients resist quantitative procedures (see sources).
Using a diverse and dynamic set of skills, protocols and tools to assess childhood dizziness results in improved differential diagnosis. And that leads to improved outcomes. As with adult patients, pediatric vestibular rehabilitation is a validated management strategy. However, its success requires accurate and efficient diagnosis.

No patient is too young for a vestibular assessment. If there’s any reasonable suspicion of vestibular dysfunction, we should evaluate the child.

Vestibular dysfunction and hearing loss
The expansion of vestibular testing options for children, specifically VEMP, also helps identify those at high risk for vestibular dysfunction. For instance, we know that vestibular deficits are associated with such syndromes as CHARGE, Usher syndrome, and enlarged vestibular aqueduct syndrome.
We know less about how vestibular dysfunction relates to hearing loss. But we’re starting to learn more: Research suggests that about 70–85 percent of children with hearing loss demonstrate vestibular abnormalities—a much higher rate than in the general population (see sources below). In addition, research has validated the use of vestibular rehabilitation in this population (see sources).
Past thinking may have held that neural plasticity would mitigate vestibular deficits in these children. However, there is now evidence that children with hearing loss do not develop motor skills as well as their normal hearing peers (see sources). This evidence, coupled with our expanded vestibular testing capabilities, make the case for early identification.
Too young?
Given all we know and can test for, what’s the answer to the “how young is too young” question? No patient is too young for a vestibular assessment. If there’s any reasonable suspicion of vestibular dysfunction, audiologists can and should evaluate the child. This is especially important in children for whom the risk of potential vestibular dysfunction is higher than normal.
If we confirm vestibular dysfunction in the child, we then recommend appropriate medical referral and management and/or vestibular rehabilitation, just as we would with any adult.
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July 2017
Volume 22, Issue 7