Pediatric emergency medicine trisk 0548 0548
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its efferents or afferents. Diagnosis is confirmed by MRI and lumbar puncture.
Paroxysmal torticollis of infancy consists of spells of head tilt associated with
nausea, emesis, pallor, agitation, and ataxia. Episodes are brief and self-limited
and may recur for months or years. The cause is unclear, although some authors
see it as a prelude to benign paroxysmal vertigo. Perilymphatic fistula is an
abnormal communication between the labyrinth and the middle ear, with leakage
of perilymphatic fluid through the defect. It may be congenital or acquired by
trauma, infection, or surgery. The diagnosis may be suspected when vertigo and
acute hearing loss is provoked by sneezing or coughing, actions that can increase
perilymphatic drainage. Diagnosis is confirmed by middle ear exploration.
Benign paroxysmal positional vertigo (BPPV) is rare in children, but has been
reported in the literature in a patient as young as 3 years old. Patients typically
complain of vertigo with changes in head position, especially upon waking in the
morning and sitting up in bed. Episodes usually last less than 1 minute. Finally,
vertigo may be associated with diabetes mellitus and chronic renal failure.
EVALUATION AND DECISION
Differentiation of True Vertigo and Pseudovertigo
Evaluation of children with dizziness begins by distinguishing between those with
true vertigo and those with pseudovertigo ( Tables 24.1 and 24.3 ). True vertigo is
always associated with a subjective sense of rotation of the environment relative
to the patient or of the patient relative to the environment. All vertigo is made
worse by moving the head, and acute attacks are usually accompanied by
nystagmus.
True Vertigo
History and Physical Examination
Once true vertigo ( Fig. 24.1 ) is identified, its severity, time course, and pattern
must be established. In general, the most severe attacks of vertigo have peripheral
causes, whereas central causes tend to be more recurrent, chronic, and
progressive. Sudden onset of sustained vertigo suggests central or peripheral
trauma, infection, stroke, or ingestion. Recurrent episodic attacks suggest
seizures, migraine, or benign paroxysmal vertigo. More persistent episodes
suggest brainstem or cerebellar mass lesions.
Recurrent, transient, altered mental status suggests seizure or basilar migraine.
Episodes of prior head injury suggest concussion syndromes. Recent upper
respiratory tract infections may suggest vestibular neuronitis. History of ototoxic
