Balance and Vestibular Program

Benign paroxysmal positional vertigo (BPPV) causes recurring, brief episodes of vertigo, meaning a child feels a sensation that the world around her is spinning.

These episodes, typically lasting a few seconds to minutes, are usually prompted by lying down, rolling over in bed, turning the head, or similar movements. BPPV results from displacement of crystals called otoliths in the balance organs of the inner ear. These crystals normally rest on a jelly-like structure called the macula. A minor head injury can cause the crystals to dislodge from the macula and move around the inner ear.

Turning the head can also cause the dislodged crystals to stimulate another part of the inner ear called the posterior semicircular canal. This results in a sensation of vertigo.

How Boston Children’s Hospital approaches BPPV

We diagnose BPPV with a test called the Dix-Hallpike maneuver. For this test, your child’s doctor will move her quickly from a sitting position to a lying-down position while she wears special glasses capable of detecting subtle eye movements that are typical of the disorder.

BPPV usually resolves on its own after a few weeks, even without treatment. It can also be successfully treated with the Epley maneuver. In this maneuver, the doctor moves the child into a series of positions, attempting to move the displaced crystals in the inner ear back into their proper position.

Benign paroxysmal vertigo of childhood (BPVC) typically affects children starting at age 4 or younger. It is characterized by recurring episodes of vertigo (sensation that one’s surroundings are spinning) that last from seconds to minutes at a time.

Additional symptoms include:

• Abnormal eye movements (nystagmus)
• Ear ringing (tinnitus)
• Nausea
• Vomiting
• Sweating

During the attacks, there is no loss of consciousness, and a complete recovery usually follows an attack.

How Boston Children’s Hospital approaches BPVC

We diagnose BPVC by a series of criteria, based on a child’s symptoms and a number of other important factors in their medical and family background.

There is no specific test for BPVC, but many tests may be needed to rule out other causes of dizziness before your child is diagnosed with BPVC. These tests may include a hearing test and balance tests, which can be done right here at our Balance and Vestibular Program, as well as imaging tests, such as an MRI.

BPVC episodes are typically infrequent and brief, so the disorder does not typically require treatment. However, evaluation of children with suspected BPVC is important to rule out dangerous and/or potentially treatable causes of dizziness.

Labyrinthitis is an irritation or infection of the inner ear, which may follow an upper respiratory tract infection. Labyrinthitis usually causes a relatively sudden onset of hearing loss in one ear, along with symptoms of severe dizziness or vertigo (sensation that one’s surroundings are spinning). The vertigo usually lasts for several days, then gradually improves. The hearing loss may or may not improve.

Vestibular neuronitis is an irritation or infection of the nerve that connects the balance organs of the inner ear with the brain. It is very similar to labyrinthitis, but does not affect hearing.

How Boston Children’s Hospital approaches labyrinthitis and vestibular neuronitis

We diagnose labyrinthitis and vestibular neuronitis by the combination of an onset of symptoms that fit the typical course of one of these disorders, as well as a series of tests that evaluate hearing and vestibular/balance function.

The most useful tests are called rotational chair testing and caloric testing. The hearing test, as well as all of the vestibular/balance tests, can be done right here at our Balance and Vestibular Program.

The initial severe vertigo from labyrinthitis and vestibular neuronitis can be treated with medications, such as meclizine. If the damage from the labyrinthitis and vestibular neuronitis becomes permanent, then treatment usually centers around “retaining” the normal balance organs on the other side of the head to fill the role of the damaged balance organs.

This process can be helped by exercises that are done under the supervision of a specially trained physical therapist.

Ménière's Disease is an inner ear disorder. Its classic symptoms include:

• Episodes of dizziness and vertigo (the sensation that one’s surroundings are spinning)
• Unilateral (on one side) hearing loss
• Increased tinnitus (ringing in the ears) and a sense of “fullness” in the ear on the affected side

These vertigo episodes can often be severe and incapacitating, and the hearing loss may eventually progress into permanent deafness.

Ménière's Disease results from endolymphatic hydrops, an abnormal swelling of certain structures of the inner ear. However, the exact cause of the swelling is not entirely clear.

Although Ménière's disease is often seen in the adult population, children can also be affected by this debilitating inner ear disorder.

How Boston Children’s Hospital approaches Ménière's disease

We diagnose Ménière's disease with a series of criteria based on your child’s symptoms:

• Hearing evaluation and vestibular tests can be useful to reveal the affected side.
• Electrophysiological testing, such as electrocochleography (ECochG) and/or cochlear hydrops analysis masking procedure (CHAMP), may be very helpful in diagnosis.

All of these tests can be done right here at our Balance and Vestibular Program.

• The dizziness and vertigo caused by Ménière's disease can often be treated by a low-salt diet, and occasionally with a medication called a diuretic (“water pill”), both of which help to minimize the swelling in the inner ear that causes symptoms.
• Injection of gentamycin or a steroid through the eardrum can also provide relief of symptoms.
• When the dizziness is severe and cannot be controlled with diet and medications, surgery may be needed. A number of different surgical procedures are available to control the dizziness associated with Ménière's disease, though these are rarely performed in children unless absolutely necessary.

Many medications and heavy medal exposures can cause ototoxicity (temporary or permanent injury to the structures of the inner ear). This can result in hearing loss, dizziness, and imbalance typically affects children starting at age 4 or younger. It is characterized by recurring episodes of vertigo (sensation that one’s surroundings are spinning) that last from seconds to minutes at a time.

Other medications that may have ototoxic effects include:

• Loop diuretics, such as furosemide and ethacrynic acid
• Chemotherapy agents, such as cisplatin, carboplatin, vincristine, etc.

Toxic exposures to lead and mercury can also cause ototoxicity.

The symptoms of ototoxicity in children include:

• Hearing loss
• Dizziness or imbalance
• Tinnitus (ringing in the ears)

How Boston Children’s Hospital approaches ototoxicity

Ototoxicity is usually suspected when a child develops hearing loss or dizziness/imbalance either during or soon after treatment with a medication that is known to be ototoxic. Ototoxicity from heavy metals, such as lead or mercury, may be much more difficult to detect and may require special blood tests to check for abnormal levels of these metals in your child’s bloodstream.

A hearing test is required to evaluate hearing from ototoxicity. Sometimes, your doctor may want your child to undergo multiple hearing tests during a long-term treatment with a known ototoxic medication to monitor for development of hearing loss, even if your child is not yet experiencing a sensation of hearing loss or imbalance.

Vestibular and balance tests may also be needed to see if vestibular function is affected and to rule out other causes of dizziness and hearing loss before your child is diagnosed with ototoxicity. These test can be done right here at the Balance and Vestibular Program.

The main treatment for ototoxicity is to stop the administration of the offending medication. The effects of some ototoxic medications, such as aspirin and diuretics, on hearing and balance are temporary, while the effects of others, such as the aminoglycosides, can be permanent.

Patients with permanent balance problems and longstanding dizziness from ototoxicity may benefit from vestibular rehabilitation therapy, in which a specially trained physical therapist will help the child with exercises to “retain” his balance organs.

A concussion is a mild form of traumatic brain injury (TBI), usually occurring after a blow to the head from an accident, such as a car crash, a fall, or a sports injury.

In addition to headache and dizziness, post-concussion symptoms may also include:

• Fatigue
• Irritability
• Anxiety
• Insomnia
• Loss of concentration
• Noise and light sensitivity

Post-concussion syndrome is typically diagnosed when these symptoms persist for greater than three months after the injury, though the criteria for diagnosing the syndrome vary.

How Boston Children’s Hospital approaches post-concussion syndrome

Post-concussion syndrome is diagnosed by a series of criteria based on a child’s symptoms, the relationship of their symptoms to the specific traumatic event, and by exclusion of other medical causes of their symptoms.

Many tests may be needed to rule out other causes of dizziness and headache before your child is diagnosed with post-concussion syndrome. These tests may include vestibular and balance tests, which can be done right here at the Balance and Vestibular Program, as well as imaging tests, such as an MRI.

There is no specific treatment or cure for post-concussion syndrome, although many children may benefit from cognitive behavioral therapy that can be implemented by a psychologist.

Children with persistent dizziness or imbalance from concussion may require vestibular rehabilitation, which is supervised by a specially trained clinician (e.g. physical therapist) and involves exercises that are designed to “retain” the balance system.

Superior semicircular canal dehiscence (SSCD) is a recently discovered disorder. SSCD occurs when one of the balance organs of the inner ear, the superior semicircular canal, develops an abnormal communication with the inside of the child’s skull.

While the classic symptom of SSCD is dizziness/vertigo in response to loud noises or pressure changes in the middle ear; other, more unusual symptoms may include:

• Changes in hearing
• A heightened ability to hear one’s own bodily movements (such as footsteps, eye movements, and brushing hair)

How Boston Children’s Hospital approaches SSCD

• SSCD is diagnosed with a special type of imaging study called a computed tomography (CT) scan.
• The diagnosis of SSCD also usually requires a special kind of test called a vestibular evoked myogenic potential test (VEMP), in which a sticky pad is placed on the child’s neck and sounds are played through an earphone in his ears. The sticky pad is connected to a computer that detects small movements of the neck muscles in response to the sounds.
• A hearing test is also a part of the evaluation for SSCD.
• Often, a series of other balance tests may be required to rule out other causes of dizziness.

All of the balance tests, as well as the VEMP test and the hearing test, can be done right here at our Balance and Vestibular Program.

While SSCD in adults is usually managed surgically, it is treated much more conservatively in children:

• The hearing loss from SSCD in children can be effectively managed with specially programmed hearing aids.
• The dizziness from SSCD is usually fairly well tolerated, and may improve naturally over time.

If it does not, then surgery may be necessary. Surgery may be done through the ear canal or through an incision behind the ear.

Vestibular migraine, also known as migrainous vertigo or migraine-associated vertigo, is the most common cause of dizziness and vertigo in children. Migraine headaches, often localized to the frontal or peri-orbital region, may precede, follow, or occur simultaneously with dizziness/vertigo.

Many patients with vestibular migraine see flickering or vibrating lights just before a dizziness episode or headache begins. This is referred to as visual aura. Also, they may become very sensitive to light or loud sounds when they are experiencing a dizziness episode or headache.

How Boston Children’s Hospital approaches vestibular migraine

Vestibular migraine is diagnosed by a series of criteria based on a child’s symptoms and a number of other important factors in their medical and family background.

Although there is no specific test for vestibular migraine, many tests may be needed to rule out other causes of dizziness and headache before your child is diagnosed with vestibular migraine. These tests may include a hearing test and vestibular/balance tests, such as an MRI.

We can help identify triggers (e.g. certain food) to avoid the symptoms. We will prescribe medications, if necessary, to treat vestibular migraine.