The vestibular system in children · 2019. 7. 1. · 2016 (vHIT) Dasgupta series 2017 (vHIT)...
Transcript of The vestibular system in children · 2019. 7. 1. · 2016 (vHIT) Dasgupta series 2017 (vHIT)...
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The vestibular system in children
Dr Soumit Dasgupta
Consultant Audiovestibular Physician and Neurotologist
Alder Hey Children’s NHS Foundation Trust, Liverpool
UK
Hony. Lecturer, Audiology and Deafness
University of Manchester
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This session
• The vestibular system in children
• Assessment of balance function in children
• Paediatric vestibular disorders
• Case studies
• Conclusions
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Vestibular system in children
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0 years
15 years
8 years
4 years
Somatosensory
Visual
Binocularity/fusion
Adult like Adult like
Vestibular
Rotatory chair like
Central
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Functions
Maintains posture, produces kinetic contractions to generate
ocular stability, cognitive and spatial discrimination and helps
maintain muscle tone
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Decompensation and manifestation of balance
disorders
Poor
compensation
Inadequate/
inappropriate CNS
activity Psychological
dysfunction
Inadequate/impaired
musculoskeletal
activity
Impaired/
inappropriate CNS
balance strategies
Impaired sensory
inputs
Fluctuating
vestibular activity
Disordered
perception of
stability
Poor eye/head
stabilisation
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Beyond the vestibule
The final balance
perception is not just the
ear but processing is a
central function. This
starts from the
vestibular nerve and is a
complex interplay
between the optical
system, the
proprioceptive system,
the motor system and
the cognitive centres
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Assessment of the vestibular system in children
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Significance
• Distinguish between central and peripheral causes of imbalance
• Formulation of effective management regimen including
compensation, adaptation and habituation protocols with
customised rehabilitation exercises
• Particle repositioning manoeuvres if necessary
• Exclusion/inclusion of vestibular pathology in solitary/
multifactorial conditions
• Remember the neurology and neurotology interface is far more
close than what you will find in the adult population
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Presentation of balance problems
• Obvious dizziness/vertigo/lightheadedness (+ 8y)
• Fright or pallor
• Clutching
• Bumping into things
• Clumsiness
• Sudden pole axing falls
• Periodic episodes of nausea or vomiting +/- migrainous features
• Delayed motor functions
• Loss of postural control
• Difficulty with ambulating in the dark
• Abnormal movements or behavior
• Difficulties in challenging movements (swimming, dancing)
• Oscillopsia
• Difficult to track challenging
visual targets
• Poor head eye coordination
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The clinical algorithm
History Examination
General examination
CVS
Neurological
Neuro-otological
Audiological Ocular Vestibular Central
QOL VAS; balance scale; questionnaires
VOR VS & VC
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The semicircular canals
• Nystagmus
• Head impulse test
• Provocation tests
• Head shake test
• Dynamic visual acuity
The otolith organs
• Head heave test
• Subjective visual vertical
• Ocular counter rolling
The vestibulo spinal/cervical
tests
• Romberg tests
• Unterberger and Fukuda
• Gait tests
• Lateral flexion
The CNS
• Non vestibular nystagmus
• Pursuits and saccades
• VOR cancel
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Investigations
• Video head impulse test – measures SCC
• Caloric test – measures LSCC
• Rotatory chair tests – measure LSCC
• Ocular counter roll, subjective visual vertical, off vertical
axis rotation – measure gravitational sensors
• Videonystagmography VNG – measures central and
vestibular functions
• Vestibular evoked myogenic potential (VEMP) –
measures gravitational sensors
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• Hearing assessment
• Imaging studies – HRCT for bony labyrinth, MRI for
membranous labyrinth
• Static and dynamic posturography
• Blood tests when indicated
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Paediatric vestibular disorders
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Aetiology O’Reilly 2007
(chair/calorics)
Vacher 2008
(chair/calorics)
Hamilton 2015
(vHIT)
Sommerfleck
2016 (vHIT)
Dasgupta
series 2017
(vHIT)
Peripheral
vestibular
29.5% 18% 40% 22% 20.3%
Migraine and
BPVC
24.2% 45% 24% 49% 18.5%
Traumatic
head injury
9.8% 10% 6% 6.8% 3.7%
Central 9.1% <5% 3% 2% 3.7%
Third window <1% <1% 6% <1% 26%
Genetic N/A N/A N/A N/A 12.9%
Idiopathic N/A N/A N/A N/A 12.9%
Others 26.4% 21% 21% 19.2% 5.7%
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A.I. duPont Hospital for Children, Wilmington, Delaware
Alder Hey Children’s Hospital, Liverpool
• Peripheral
vestibulopathy/third window
• Benign paroxysmal vertigo of
childhood
• Motor/developmental delay
• Traumatic brain injury
• CNS structural lesions
• Behavioural/psychogenic
• Idiopathic
• Movement
disorder/neurodegenerative
• Encephalopathy
• Vascular
• Peripheral neuropathy
• Oculomotor abnormality
Prevalence of 8 – 18%
between 1 to 15 years
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Congenital disorders
• Malformation
• Syndromic
• Non syndromic
Vestibular hypoplasia or aplasia or dysplasia
Enlarged vestibular aqueduct
Arnold Chiari malformation
CHARGE, BOR, Pendred, Usher, Alport, Alstorm,
JLN
DFNA9, DFNA12
DFNB2, DFNB4, DFNB12
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Otologic disorders
• Infective/ inflammatory – OME, CSOM, middle ear,
labyrinthitis, neuritis, meningitis
• Traumatic – head injury, perilymph fistula, iatrogenic
• Degenerative – Endolymphatic hydrops, BPPV
• Ototoxicity – Gentamycin, cisplatin, diuretics, antimalarials
• Third window disorders
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Neurological disorders
• Migraine and migraine variants (BPT, BPV,
hemiplegic, CV)
• Neoplastic and SOL – AN, meningioma, glioma,
ependymoma, cyst, Arnold Chiari
• Cerebellum and cerebellum ataxia syndromes
• Epilepsy
• CVAs
• Demyelinating disorders
• Hereditary sensory motor ataxias
• Hypoxic ischaemic encephalopathies
• Neurodegenerative conditions
• Post infective conditions – sepsis,
meningitis/encephelitis
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Cardiovascular disorders
• Long QT syndromes and orthostatic hypotension
Metabolic disorders
• Diabetis, electrolyte imbalances
Ocular abnormalities
• Refractive disorders, strabismus
Psychogenic disorders
• Anxiety disorders, panic attacks
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Management
• Diagnosis and explanation
• Investigation and treatment of primary cause
• Pharmacological intervention in acute spells, migraine, BPVC
• Particle repositioning in BPPV
• Customised vestibular rehabilitation exercises for recalibrating whole
system and promote compensation
• Sensory integration strategies
• Psychological intervention when appropriate
• Correction of visual problems
Very much MDT with audiovestibular physicians, paediatricians,
neurologists, ENT, oncologists, respiratory physicians, physiotherapists,
OT, psychiatrists, audiologists and play therapists
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Conclusions
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• Diagnosing balance disorders in children is
challenging, stimulating and rewarding as it is so
complex
• Awareness is very limited in paediatric general and
subspecialtes; in a recent survey even in balance
specialists, awareness is limited to 30% or less
• Often interpreted as a neurological problem and
typical journey includes ENT, community and general
paediatricians and neurologists
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• Intervention makes a significant difference in many
children’s and parents’ lives and recognition is crucial
• Is very much holistic and multidisciplinary – we are
essentially treating not just the balance disorder but the
child as a whole and indirectly the parents
• Medically inexplicable symptoms may be due to
vestibular disorder
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The Alder Hey paediatric vestibular medicine service is a
nationally and internationally recognised tertiary paediatric
balance service with facilities for advanced assessment
and rehabilitation of children with balance disorders
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Thank you