Pediatric emergency medicine trisk 0551 0551
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puncture is indicated in cases of suspected meningitis or encephalitis, but imaging
may be required to rule out obstructive hydrocephalus from a posterior fossa mass
if there are cerebellar signs.
Radiologic imaging of the central nervous system, preferably by MRI for
adequate visualization of the posterior fossa and brainstem, is indicated in cases
of chronic and recurrent vertigo to exclude mass lesions. Children with vertigo
and an underlying bleeding diathesis or a predisposition toward ischemic stroke
(i.e., sickle cell disease) may also need an emergent cranial CT or MRI.
Posttraumatic vertigo, especially when accompanied by hearing loss or facial
nerve paralysis, is best assessed by CT that includes adequate images of the
temporal bone.
Some children with true vertigo will require referral for more extensive testing.
An EEG is indicated when vertigo accompanies loss of consciousness or other
manifestations of a seizure. Audiometry is indicated when vertigo accompanies
otalgia, hearing loss, or tinnitus. Specialized testing for nystagmus, including
electronystagmography, which measures eye movements at rest and at extremes
of gaze, can separate central from peripheral vestibular disorders. It may be
combined with caloric and positional testing.
MANAGEMENT
Most causes of vertigo remit spontaneously without therapy, but specific
disorders require treatment. Suppurative labyrinthitis, for example, is treated with
antibiotics if a bacterial etiology is suspected. An erosive cholesteatoma requires
surgical removal. Anticonvulsants may diminish vestibular and vestibulogenic
seizures. Motion sickness may respond to simple behavioral changes (e.g.,
encouraging children to look out the window).
Subspecialist consultation is indicated in certain situations. Neurosurgical
evaluation after trauma may be indicated in cases of suspected basilar skull
fracture. Suspected perilymphatic fistula, cholesteatoma, traumatic rupture of
tympanic membrane, or complicated otitis media may merit otorhinolaryngologic
evaluation. Neurologists may be helpful in cases of suspected seizure or migraine.
