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Vestibular

neuritis in

children

and

adolescents:

Clinical

features

and

recovery§

Jacob R. Brodsky a,b,*, Brandon A. Cusicka,b, Guangwei Zhoua,b

aDepartment of Otolaryngology and Communication Enhancement (J.R.B., B.A.C., GW.Z.), Boston Children’s Hospital, Boston, MA, USAbDepartment of Otology and Laryngology (J.R.B., GW.Z.), Harvard Medical School, Boston, MA, USA

1. Introduction

Vestibular neuritis (VN) is an acute inflammatory process

typically affecting the superior vestibular nerve that results in an

acute, unilateral, peripheral vestibular loss that preferentially

affects

the

utricle

and

the

anterior

and

lateral

semicircular

canals.

The initial clinical presentation is characterized by the sudden

onset of rotary vertigo, imbalance, and nausea, which generally

lasts for a few days. The specific etiology of VN remains

controversial,

though

an

association

with

herpes

simplex

virus

infection has been demonstrated [1–4]. The presentation, recovery,

and treatment of VN in adults have been well described [4–7]. A

high incidence of incomplete recovery (IR) has been described in

adults, which is associated with long term residual vestibular

symptoms and deficits after a case of VN [7]. Vestibular

rehabilitation

(VR)

and

oral

corticosteroids

have

both

been

shown

efficacy at reducing the risk of IR following VN in adults [8–10].

Epidemiological reports of pediatric vertigo generally report VN

to represent between 1 and 5% of cases of pediatric vertigo [11–15],

though

descriptions

of

the

clinical

features,

vestibular

test

findings,

and recovery course of VN in pediatric patients has been very

limited and have also excluded adolescents [16–18]. Children are

thought to recover from acute vestibular losses more efficiently

than

adults

[19], but

the

risk

of

IR

after

VN

across

the

pediatric

age

spectrum

is

still

unclear.

The

goal

of

this

study

was

to

describe

the

clinical features, vestibular test findings, and recovery course of

children and adolescents diagnosed with VN.

International Journal of Pediatric Otorhinolaryngology 83 (2016) 104–108

A R T I C L E I N F O

Article history:

Received

1

December

2015Accepted 23 January 2016

Available online 1 February 2016

Keywords:

Vestibular neuritis

Vestibular neuronitis, Pediatric dizziness,

Pediatric vestibular testing, Childhood

vertigo, Video head impulse test

A B S T R A C T

Objective:

Describe the clinical presentation and recovery of vestibular neuritis in children and

adolescents.Study design: Retrospective case series.

Setting: Pediatric tertiary care center.

Subjects and methods: Eleven patients diagnosed with vestibular neuritis were identified from a

database of 301 patients evaluated at our pediatric vestibular clinic from January 2012 through January

2015. Medical records were reviewed to determine clinical presentation, vestibular testing results,

treatment, and recovery. Incomplete recovery was defined as residual dizziness or imbalance at most

recent follow-up >30 days from symptom onset.

Results: Patients were 5–19 years old (mean 13.1 5.34) and included 6 boys and 5 girls. All presented

with

a sudden

rotational

vertigo,

imbalance,

and

nausea

for

an

average

of

10

dayswithout

other

associated

symptoms. Testing included rotary chair (8 of 9 abnormal), caloric (2 of 2 abnormal), video head impulse (5 of

8 abnormal), subjective visual vertical (4 of 8 abnormal), and cervical vestibular evoked myogenic potential

(0

of

6

abnormal)

tests.

All

patients

with

incomplete

recovery

(n =

4; 36%)

were 15 years old at symptom

onset. All patients with incomplete recovery that underwent vestibular rehabilitation (n = 2) initiated it 90

days

from

symptom

onset,

while

3

out

of

4

patients

with

complete

recovery

that

underwent

vestibular

rehabilitation

initiated

it 14 days

from

symptom

onset.

Two

patients

received

oral

steroids,

neither

of whom

had

incomplete

recovery.

Conclusion: Vestibularneuritis should be considered in pediatricpatients with vertigo andmay result in

longstanding symptoms, particularly in adolescents. The treatment of pediatric vestibular neuritis with

rehabilitation and steroids deserves further study.

2016 Elsevier Ireland Ltd. All rights reserved.

§ Presented at the American Academy of Otolaryngology—Head & Neck Surgery

Annual Meeting, Dallas, TX, U.S.A., September 27, 2015.

* Corresponding author at: Department of Otolaryngology and Communication

Enhancement, Boston Children’s Hospital, 300 Longwood Avenue, Boston, MA

02115, USA. Tel.: +1 781 216 2849; fax: +1 781 216 3155.

E-mail address: [email protected] (J.R. Brodsky).

Contents

lists

available

at

ScienceDirect

International Journal of Pediatric Otorhinolaryngology

jo urn al hom ep ag e: www.els evier .c om/locat e/ i jp o r l

http://dx.doi.org/10.1016/j.ijporl.2016.01.027

0165-5876/ 2016 Elsevier Ireland Ltd. All rights reserved.

http://dx.doi.org/10.1016/j.ijporl.2016.01.027http://dx.doi.org/10.1016/j.ijporl.2016.01.027http://dx.doi.org/10.1016/j.ijporl.2016.01.027http://dx.doi.org/10.1016/j.ijporl.2016.01.027http://dx.doi.org/10.1016/j.ijporl.2016.01.027http://dx.doi.org/10.1016/j.ijporl.2016.01.027http://dx.doi.org/10.1016/j.ijporl.2016.01.027http://dx.doi.org/10.1016/j.ijporl.2016.01.027http://dx.doi.org/10.1016/j.ijporl.2016.01.027http://dx.doi.org/10.1016/j.ijporl.2016.01.027http://dx.doi.org/10.1016/j.ijporl.2016.01.027http://dx.doi.org/10.1016/j.ijporl.2016.01.027http://dx.doi.org/10.1016/j.ijporl.2016.01.027http://dx.doi.org/10.1016/j.ijporl.2016.01.027http://dx.doi.org/10.1016/j.ijporl.2016.01.027mailto:[email protected]:[email protected]://www.sciencedirect.com/science/journal/01655876http://www.elsevier.com/locate/ijporlhttp://www.elsevier.com/locate/ijporlhttp://www.elsevier.com/locate/ijporlhttp://www.elsevier.com/locate/ijporlhttp://www.elsevier.com/locate/ijporlhttp://www.elsevier.com/locate/ijporlhttp://www.elsevier.com/locate/ijporlhttp://www.elsevier.com/locate/ijporlhttp://www.elsevier.com/locate/ijporlhttp://www.elsevier.com/locate/ijporlhttp://www.elsevier.com/locate/ijporlhttp://www.elsevier.com/locate/ijporlhttp://www.elsevier.com/locate/ijporlhttp://www.elsevier.com/locate/ijporlhttp://www.elsevier.com/locate/ijporlhttp://dx.doi.org/10.1016/j.ijporl.2016.01.027http://dx.doi.org/10.1016/j.ijporl.2016.01.027http://www.elsevier.com/locate/ijporlhttp://www.sciencedirect.com/science/journal/01655876mailto:[email protected]://dx.doi.org/10.1016/j.ijporl.2016.01.027http://crossmark.crossref.org/dialog/?doi=10.1016/j.ijporl.2016.01.027&domain=pdfhttp://crossmark.crossref.org/dialog/?doi=10.1016/j.ijporl.2016.01.027&domain=pdf


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2. Materials and methods

2.1. Patients

This retrospective study was approved by the Institutional

Review

Board

of

Boston

Children’s

Hospital.

We

retrospectively

reviewed

our

internal

database

of

all

patients

seen

at

the

Balance

and Vestibular Program clinic at Boston Children’s Hospital from

July 2012 to January 2015 to identify all patients 19 years of age

that

were

diagnosed

with

VN.

Clinical

presentation

consistent

with

VN

was

defined

as

a

single,

isolated

episode

of

acute

onset

rotary

vertigo and imbalance lasting several days followed by either

spontaneous complete symptom resolution or by a prolonged

period

of

general

disequilibrium

with

or

without

imbalance

lasting

for

several

days

afterward.

Vestibular

testing

results

consistent

with VN were defined by evidence of an acute, unilateral,

peripheral vestibular loss in the absence of hearing loss. The

electronic

medical

records

of

all

included

patients

were

reviewed

to

determine

clinical

presentation,

diagnostic

test

results,

and

treatment responses. Incomplete recovery (IR) was defined as the

presence of residual dizziness and/or imbalance symptoms at the

most

recent

follow-up

appointment

>30

days

from

symptom

onset.

All subjects had a normal otologic and neurologic examinationat the time of presentation with the exception of variable

combinations

of

the

following:

Presence

of

spontaneous

nystag-

mus,

abnormal

head

impulse

test,

abnormal

head

shake

maneuver,

abnormal Romberg test, abnormal Fukuda march test, and/or

positive findings on ipsilateral Dix-Hallpike maneuver. Patients

with

an

abnormal

Dix-Hallpike

maneuver

did

undergo

an

Epley

maneuver

on

the

affected

side

prior

to

undergoing

vestibular

testing. No subjects had a head injury immediately prior to onset of

symptoms.

2.2. Vestibular testing

All

patients

completed

a

variable

combination

of

objective

vestibular and balance tests. All testing was conducted in ourclinical vestibular laboratory at the Balance and Vestibular

Program at Boston Children’s Hospital by a licensed audiologist

(GWZ),

with

the

support

of

a

trained

assistant.

Testing

was

performed

at

the

time

of

initial

patient

presentation

to

our

clinic.

Sinusoidal harmonic rotary chair, videonystagmography (VNG),

static subjective visual vertical (SVV), and binaural, bithermal

water

caloric

tests

were

performed

using

Micromedical

equipment

(System

2000

and

VisualEyes

with

AquaStim;

Micromedical

Technologies, Chatham, Illinois). Computerized dynamic postur-

ography (CDP) was conducted with NeuroCom SMART EquiTest,

and

cervical

vestibular

evoked

myogenic

potential

testing

(cVEMP)

was

recorded

with

Bio-logic

Navigator

Pro

Evoked

Potential

system (Natus Medical Inc, San Carlos, California). Video head

impulse

testing

(VHIT)

was

performed

using

the

ICS

Impulsesystem

(GN

Otometrics,

Denmark).

The

majority

of

patients

underwent

rotary

chair

testing

instead

of

caloric

testing,

since

we prefer rotary chair testing for pediatric patients in our lab as it is

better tolerated. SVV testing was not administered to children 6

years

old

due

to

their

limited

ability

to

follow

the

instructions

adequately.

Balance and vestibular testing results were compared to

manufacturer-supplied age-specific norms, with the exception of

the

cVEMP,

SVV,

and

VHIT

tests,

which

were

compared

to

our

normative

pediatric

data

established

in

prior

studies

[20–22].

Rotary chair results were considered abnormal if gains for all

frequencies tested were below the age-adjusted normal range,

phase

leads

for

the

lowest

3

frequencies

tested

were

above

the

age-

adjusted

normal

range,

and

the

time

constant

was

less

than

12

s.

Caloric testing was considered abnormal if a reduced vestibular

response

of 20% was observed for the affected ear. VHIT testing

was considered abnormal if the vestibulo-ocular reflex gain was

30

days

from

symptom

onset.

All

patients

were

first

diagnosed

with

VN

upon

initial

presentation

to

our

clinic,

though

many

had

been

followed my multiple outside providers for their symptoms prior to

receiving the diagnosis. All 4 patients that were diagnosed with

concurrent BPPV also reported symptoms of worsening rotary vertigowith

the

affected

ear

down

when

supine

in

bed,

which

resolved

following an Epley repositioning maneuver in the clinic directed at

the affected ear. All patients had a normal audiogram. Testing results

are

outlined

in

Table

2.

IR

occurred

in

4

patients

(36%),

all

of

whom

were

>15

years

old

at

time

of

symptom

onset.

A

3

month

course

of

vestibular rehabilitation (VR) was completed by 6 patients immedi-

ately following their initial evaluation at our program. Three of the

patients

that

underwent

VR

initially

presented

to

us

within

14

days

of

symptom

onset,

and

none

of

these

3

patients

experienced

IR.

The

3

other patients that underwent VR initially presented to us at 54, 90,

and

180

days

after

symptom

onset,

respectively,

the

latter

2

of

which

continued

to

have

some

persistent

symptoms

even

after

completing

VR. Two patients received a course of oral prednisone starting at 6 and

7 days after symptom onset, respectively, neither of whom had IR,though

both

of

these

patients

also

underwent

VR.

4.

Discussion

Adult studies consistently demonstrate VN to be the third most

common cause of adult vertigo, making up approximately 7% of

adult

vertigo

cases

[4].

General

epidemiological

studies

of

pediatric

Table 1

Patient demographics.

Age, years

Mean SD (range) 13.1 5.34 (4–19)

Sex, n

Male 6

Female 5

Preceding URI

Yes 6

No 5

Secondary diagnoses, n

BPPV 4

Migraine 2

Epilepsy 1

BPPV, benign paroxysmal positioning vertigo; URI, upper

respiratory

tract

infection.

J.R. Brodsky et al. / International Journal of Pediatric Otorhinolaryngology 83 (2016) 104–108 105


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vertigo

describe

VN

as

representing

between

1

and

5%

of

cases

of

pediatric

vertigo

[11–15]. Our

study

found

VN

to

make

up

3.6%

of

cases of pediatric dizziness or vertigo at our program. These

patients were identified from a group of 301 pediatric patients at

our

program,

which

is

a

much

larger

group

than

that

described

in

the

above-mentioned

epidemiologic

studies

of

pediatric

vertigo,

with the exception of Wiener–Vacher’s 2008 study of 2000children with vertigo, which described a rate of VN of 5% of

pediatric

vertigo

cases

[11]. No

patients

in

our

study

initially

came

to

our

clinic

with

a

diagnosis

of

VN

made

prior

to

their

visit,

despite

the fact that patients initially presented to our clinic an average of

nearly 2 months after their symptoms began, and despite the fact

that

the

majority

of

patients

had

previously

been

evaluated

by

multiple

other

physicians.

This

may

have

resulted

from

a

lack

of

awareness of the existence of VN among pediatric healthcare

providers,

an

assumption

that

VN

does

not

occur

in

pediatric

patients,

or

a

lack

of

knowledge

about

how

to

clinically

assess

a

patient for VN. This supports the need for increased awareness of

the features, assessment, and management of VN among pediatric

healthcare

providers.

Vestibular

testing

results

were

all

consistent

with

a

partial,

unilateral, peripheral vestibular loss affecting only the function of organs supplied by the superior vestibular nerve. In adults VN has

been

shown

to

typically

affect

only

the

superior

vestibular

nerve

[5],

with

only

rare

cases

of

inferior

vestibular

nerve

involvement

being described [23]. In the current study normal posterior canal

function on all subjects that underwent VHIT (Fig. 1) and

consistently

normal

cVEMP

findings

indicate

the

absence

of

any

cases

with

objective

evidence

of

inferior

vestibular

nerve

involve-

ment. An association between VN and upper respiratory tract

Table 2

Vestibular testing results.

Patient Rotation Calorics (RVR) VHIT (canals affected) SVV (deviation) cVEMP

1 (+) Right (20%) (+) Right (2.58)

2 (+) (+) Left (LC) (–) (–)

3 (+) Right (23%) (+) Right (AC) (–)

4 (+) (–) (+) Right (3.18) (–)

5 (+) (–) (–)

6 (+) (+) Left (LC & AC)

7

(–)

(+)

Right

(AC)

(–)

(–)8 (+) (+) Right (2.08) (–)

9 (+) (+) Right (AC & LC) (+) Right (4.88) (–)

10 (+) (–)

11 (+)

(+), abnormal result; (–), normal result; RVR, reduced vestibular response; VHIT, video head impulse test; SVV, subjective visual vertical test; cVEMP, cervical vestibular

evoked myogenic potential test; LC, lateral canal; AC, anterior canal.

Fig. 1. Video head impulse test result in a patient with left vestibular neuritis demonstrating reduced vestibulo-ocular reflex gain (blue X’s, left column, first and second rows)

and the presence of overt corrective saccades (middle column, first and second rows) in the left anterior and lateral semicircular canals with sparing of the posterior canal,

representing

the

typical

isolated

involvement

of

the

superior

vestibular

nerve.

J.R. Brodsky et al. / International Journal of Pediatric Otorhinolaryngology 83 (2016) 104–108106


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