Disorders and Syndromes in Children with Vestibular Impairment

In this video Darren Whelan, International Clinical Trainer at Interacoustics Academy speaks about the risk factors for vestibular impairment in children. You can read the full transcript below.

Introduction

In this next short talk, we're going to take a very quick overview of the risk factors, some disorders and syndromes that we may see in our pediatric patients presenting into clinic for assessment of hearing, where we should consider vestibular or balance disorders.

Central disorders of balance

To give an overview of some of the central disorders of balance. So again, we're talking a lot in these trends of pediatrics around hearing and rightly so. However, amongst those with some hearing dysfunction, we may also see patients who are presenting with disruption to balance or motor commands that may have a central origin. So having a little bit of insight into that is always useful.

Now, developmental coordination disorders certainly may present, and it would be useful for us to know if there is any vestibular or ear-related contribution to that. Certainly, head trauma, post-concussive syndromes. And again, we think of concussion as something where it's been a fairly major or traumatic injury to the head. And actually, quite minor head concussions can have a significant disruption to balance and balance coordination.

Childhood migraine is relatively common and something that children often do go out of. There is obviously the risk of familial migraine also. However, these can present with some balance disruption as children are not the most reliable at describing dizziness.

Vascular conditions can also affect both the central systems to such an extent that the balance coordination can be impaired or disrupted. And neurological conditions as well. Epilepsy should also be considered because that may also present with some balance disruption.

Syncope, typically in the slightly older child, we certainly see postural hypertension when they stand up too quickly and become quite lightheaded and imbalanced. And not forgetting demyelinating diseases such as multiple sclerosis.

There are quite a few articles that look at the prevalence associated with vestibular disorders in children, so there's always good reviews for us to dip into to have a look at a little bit more insight into things that potentially can show up in a pediatric clinic.

Peripheral disorders of balance

Now, focusing a little bit more on peripheral disorders of balance. So obviously the trend that we're looking at this week has been associated with hearing and following a child through hearing investigation. And so, we want to consider the role then of the ear in relation to the peripheral vestibular system and balance.

So, within the literature associated with hearing, and as we've been discussing, sensorineural hearing loss can also be very much a red flag for potential vestibular dysfunction. There's an interesting article, a very detailed article [1] by Melissa Hazen and Sharon Cushing from Toronto in Canada, looking at the implications of concurrent vestibular dysfunction in pediatric hearing loss.

And interestingly, we'll talk a little bit more about this when we consider the consequences of a vestibular impairment in a child. But again, some of the data that we see within this does give us an indication of some red flags that we may want to then look out for when we're in our pediatric clinic.

Red flags for infant vestibular impairment

So, to summarize some of the potential red flags for infant vestibular impairment that we may see in our pediatric audiology clinic, and we can group those into a high, medium and low risk. Again, this is not an inclusive list. It's just to give some indications of the types of disorders that may fit under those categories.

So, things that we might consider at high risk of having vestibular impairment alongside the hearing loss are any inner ear abnormalities, so cochlear-vestibular abnormalities, either congenital or acquired early in life, syndromes such as Wartenberg’s, Klipple-Feil, Pendred, or Usher.

Conditions such as meningitis, where we can have changes around the inner ear structure or damage to any of the inner ear organs, ototoxicity, or anything around birth that has placed the cochlea at risk. Anything that's placed the cochlea or the inner ear structures at risk can implicate the vestibular and organ at the same time, and often that is possibly the bit that we may overlook when we're concentrating solely on the hearing things at medium risk.

So, congenital CMV and changes around the vascular structures in the inner ear being vulnerable, and then other viral infections that can place that structure also at some degree of vulnerability.

We mustn't forget that children with chronic ear infections or otitis media can also have disruptions going into the vestibular end organ.

More of a lower risk for vestibular involvement, but as we mentioned a bit earlier, there are neurological disorders and conditions, particularly things like cerebral palsy or hydrocephalus. Posterior faucet brain tumors can have some involvement as well around balance.

Mitochondrial disorders and autoimmune disorders, again, are relatively rare in children, but still will present into our pediatric clinics. And these can also have changes for both end organs, both the inner ear structures from the cochlear perspective and from the vestibular perspective.

Well, that gives us a very quick overview of some of the conditions to then consider where we may be at a higher risk of vestibular involvement when seeing children who have hearing changes in relation to some of those conditions. So, we'll pause at this point and then we'll get ourselves ready to consider how we can then best assess these patients.

References

[1] Hazen, M., & Cushing, S. L. (2021). Vestibular Evaluation and Management of Children with Sensorineural Hearing Loss. Otolaryngologic clinics of North America, 54(6), 1241–1251.