International Journal of Pediatric Otorhinolaryngology 146 (2021) 110751 Contents lists available at ScienceDirect International Journal of Pediatric Otorhinolaryngology journal homepage: www.elsevier.com/locate/ijporl Vestibular disorders in children: A retrospective analysis of vestibular function test findings Ozlem Gedik-Soyuyuce a, *, Zeynep Gence-Gumus a, Alper Ozdilek b, Mehmet Ada c, Nazim Korkut d a Acibadem Maslak Hospital Audiology Department, Istanbul, Turkey Acibadem Mehmet Ali Aydinlar University ENT Department, Istanbul, Turkey Acibadem International Hospital ENT Department, Istanbul, Turkey d Acibadem Maslak Hospital ENT Department, Istanbul, Turkey b c A R T I C L E I N F O A B S T R A C T Keywords: Benign paroxysmal positional vertigo Hearing loss Migraine Pediatric Vertigo Vestibular function test Objective: This study was designed to describe the most common vestibular disorders in children and their associated findings on vestibular function testing. Method: Data from 203 children with a mean age of 11.16 ± 3.87 (range, 1–17) years were collected from among 3400 patients who underwent vestibular assessment at a vertigo center in a tertiary hospital over a 3-year period. A retrospective data analysis was performed for 203 children. Results: Vestibular disorders were diagnosed in 78.3% (n = 159) of 203 children among 3400 patients, which revealed a 3-year incidence of 4.67% in our study. Benign paroxysmal positional vertigo (BPPV) was the most common diagnosis in our group of children (49%; n = 100), which involved both primary BPPV, and secondary BPPV that was associated with other vestibular pathologies. Vestibular migraine (VM) was the second most common diagnosis (41%; n = 83) followed by benign paroxysmal vertigo of childhood (BPVC; 4.5%, n = 9), vestibular neuritis (VN; 4.5%, n = 9), and psychogenic vertigo (4.5%, n = 9). Our study showed that Meniere’s Disease (MD; 1.5%, n = 3) and central vertigo (1.5%, n = 3) were less commonly diagnosed in children. Per­ ilymphatic fistula (PLF) was diagnosed and surgically confirmed in only one child. Conclusion: BPPV and VM were the most common pediatric vestibular disorders in our study. Clinicians should be aware of the prevalence, signs, and symptoms of the most common vestibular disorders in children to enable diagnosis, treatment, and rehabilitation. Vestibular function testing with age-appropriate adaptations results in improved differential diagnosis, which guides medical treatment and rehabilitation. 1. Introduction Vertigo in children complicates the diagnosis of pediatric vestibular disorders, and its expression is unclear [1,2]. Vertigo and dizziness can manifest in children as migraine, neurologic disorders, intestinal disor­ ders, ophthalmological disorders, or vestibular pathologies [1]. Pediatric vertigo was first mentioned in the modern scientific liter­ ature by Harrison in 1962. Widespread newborn hearing screening programs have increased the awareness of pediatric vestibular disorders due to the coexistence of auditory and vestibular pathologies [3]. Two to three babies out of every 1000 born in the US annually have hearing deficits [4], and among them, 20%–70% have vestibular deficits [5]. The prevalence of balance and vestibular disorders in children is estimated to be between 0.45% and 5.3%, with a slightly higher prev­ alence in girls compared to boys, and this prevalence tends to increase with age [6,7]. The prevalence of vestibular impairments in the pedi­ atric population is difficult to evaluate precisely because the symptoms are non-specific and often misleading [1]. It also depends on the age Abbreviations: BPVC, benign paroxysmal vertigo of childhood; BPPV, benign paroxysmal positional vertigo; BPTI, benign paroxysmal torticollis of infancy; mCTSIB, modified clinical test of sensory integration and balance; MD, Meniere’s Disease; PLF, perilymphatic fistula; SCC, semicircular canal; SNHL, sensori-neural hearing loss; c/o VEMPs, cervical/ocular vestibular evoked myogenic potentials; VM, vestibular migraine; VN, vestibular neuritis; VRT, vestibular rehabilitation therapy. * Corresponding author. E-mail address: [email protected] (O. Gedik-Soyuyuce). https://doi.org/10.1016/j.ijporl.2021.110751 Received 17 December 2020; Received in revised form 7 March 2021; Accepted 26 April 2021 Available online 29 April 2021 0165-5876/© 2021 Elsevier B.V. All rights reserved. Downloaded for Anonymous User (n/a) at National Institute for Respiratory Diseases from ClinicalKey.com by Elsevier on July 30, 2021. For personal use only. No other uses without permission. Copyright ©2021. Elsevier Inc. All rights reserved. O. Gedik-Soyuyuce et al. International Journal of Pediatric Otorhinolaryngology 146 (2021) 110751 range of the patients tested and on the vestibular testing technologies that are available [1]. Moreover, the differential diagnosis of childhood vertigo differs from that of adults because several etiologies are unique to the pediatric population while the occurrences of other pathologies are rather different in children and adults [8]. Vestibular function is traditionally assessed in children by the pedi­ atrician using a well-documented series of postural reflexes [9]. These postural reflexes are quantified in the vestibulospinal stability test [10]. Vestibulo-ocular reflexes are evaluated in the Farmer’s [11] rotation test in which the neonate is rotated around the perimeter of a circle, inducing widening of the eyes and deviation in the direction of rotation. Modern tests of vestibular function include videonystagmography (VNG), static/dynamic posturography, cervical/ocular vestibular evoked myogenic potentials (c/o VEMPs), rotary chair, and video head impulse test. Making a differential diagnosis in a dizzy patient who is > 4 years old is often aided by VNG testing to provide a global assessment of peripheral and central vestibular function [12]. Caloric responses have been reported in children as young as 2 months of age [13]. However, caloric testing is not usually routine in pediatric vestibular testing until children are over 6–7 years of age [14]. Although few centers perform pediatric vestibular assessment, a diagnosis is still primarily based on history and physical examination. Vestibular assessment is valuable in children who have vertigo, dizzi­ ness, or imbalance because it is now known that the most common disorders that cause dizziness in children may manifest as abnormalities on quantitative balance function testing [15]. However, deciding which test to perform and the need for age-appropriate adaptations are critical due to the relatively short attention span of children. When vestibular testing is necessary in a child, not all tests are essential or appropriate for all children depending on their age [14]. We retrospectively analyzed the records from 203 children who underwent vestibular assessment at a vertigo center in a tertiary hospital over a 3-year period. during vertigo episodes were also evaluated when needed. All vestibular migraine (VM) diagnoses were confirmed after a pe­ diatric neurology consultation and all psychogenic vertigo diagnoses were confirmed after pediatric psychiatry and neurology consultations. The study was conducted under the ethical principles stated in the Declaration of Helsinki, and the objectives and protocol were approved by the Medical Research Ethics Committee of Acibadem University and Acibadem Healthcare Group with an approval number 2021-06/11. 3. Results Among 203 children who underwent vestibular assessment, 121 girls and 82 boys were identified, with a mean age of 11.16 ± 3.87 (range, 1–17) years. Vestibular disorders (Fig. 1) were diagnosed in 78.3% (n = 159) of 203 children among 3400 patients, which revealed a 3-year incidence of 4.67% in our study. Most children were external referrals from diverse specialists, and only 3.4% (n = 7) were referred from the emergency room with an acute onset of vertigo. The medical history of the children revealed that 61% (n = 124) had motion sickness, 56% (n = 114) had a family history of migraine, 1.5% (n = 3) had torticollis, 6.8% (n = 14) had hearing loss, 2.5% (n = 5) had tinnitus, and 2% (n = 4) had ear fullness. BPPV (Table 1) was the most common diagnosis in our group of children (49%; n = 100), which involved both primary BPPV, and sec­ ondary BPPV associated with VM (n = 50), BPVC (n = 3), and vestibular neuritis (VN; n = 5). Primary BPPV (BPPV without an underlying vestibular disorder) was diagnosed in 20.6% (n = 42) of all children. Pre-existing sensori-neural hearing loss was present in three children and pre-existing unilateral conductive hearing loss was present on the same side as BPPV in one child with juvenile otosclerosis. Otitis media on the same side as BPPV was present in two children. A history of concussion was present in three of 100 children. In children with BPPV, the posterior (77%; n = 77), lateral (15%; n = 15), and multiple (8%; n = 8) semicircular canals (SCC) were affected, but no anterior semi­ circular canal BPPV was observed. BPPV was unilateral in 82% (n = 82) and bilateral in 18% (n = 18) of children. BPPV recurrence over a 3-year period was 51% (n = 51). Forty-eight of the children who had recur­ rence were also diagnosed with definite VM, of whom two had a history of concussion and one had a previous VN attack on the same side as the BPPV. Transient positional nystagmus was recorded in all children. High frequency head shake nystagmus was present in nine children. Caloric testing was completed in six children, and all showed normal and symmetrical responses. Sway on an unstable surface with eyes closed was observed on modified clinical test of sensory integration and bal­ ance (mCTSIB) in 28 children. VM (Table 2) was the second most common diagnosis in 41% (n = 83) of all the children in this study. The patients were later grouped as definite, probable, or suspected VM based on The International 2. Materials and methods The medical records of 203 patients who were less than 18 years old were identified and included from among 3400 patients who underwent vestibular assessment at a vertigo center in a tertiary hospital over a 3year period. A retrospective data analysis was performed for 203 chil­ dren. Diagnosis was made based on history, physical examination, audiological and vestibular assessments, interdisciplinary consultations, and radiologic imaging when needed. Audiological assessments were completed using play audiometry/pure tone audiometry, acoustic immittance measures, and transient evoked otoacoustic emissions tests for most patients; the auditory brainstem response test was performed where indicated in younger or less cooperative children. All children underwent VNG testing (Micromedical Visual Eyes by Interacoustics, Assens, Denmark) using age-appropriate visual targets. Oculomotor and optokinetic tests, gaze-evoked nystagmus, spontaneous nystagmus, high frequency head-shake test, Dix–Hallpike Maneuver, supine roll test, and caloric test findings were evaluated. However, caloric testing was not a routine in our vestibular assessment battery. The child and the caregiver were carefully informed when caloric testing was needed. Caloric irri­ gations using air stimulation (Micromedical Air Fx, Assens, Denmark) were performed with parental permission and alertness was maintained by counting numbers, singing songs, or engaging in conversation. Postural control and balance were evaluated using a modified clinical test of sensory integration and balance (PhysioSensing’18 by Sensing Future Technologies, Coimbra, Portugal), which measures the static balance in sensory conditions including stable and unstable surfaces with eyes open and with eyes closed. Cervical vestibular evoked myogenic potentials (cVEMP) testing (Interacoustics Eclipse, Assens, Denmark) was performed when there was a history of torticollis and a suspicion of benign paroxysmal vertigo of childhood (BPVC). In addition to vestibular function testing, a caregiver’s self-recordings of their child Fig. 1. Distribution Of Diagnoses In 159 Children With Vestibular Disorders (n) BPPV (P&S), benign paroxysmal positional vertigo (primary & secondary); VM, vestibular migraine; BPVC, benign paroxysmal vertigo of childhood; VN, vestibular neuritis; MD, Meniere’s Disease; PLF, perilymphatic fistula. 2 Downloaded for Anonymous User (n/a) at National Institute for Respiratory Diseases from ClinicalKey.com by Elsevier on July 30, 2021. For personal use only. No other uses without permission. Copyright ©2021. Elsevier Inc. All rights reserved. O. Gedik-Soyuyuce et al. International Journal of Pediatric Otorhinolaryngology 146 (2021) 110751 Table 1 BPPV characteristics. BPPV CHARACTERISTICS (n = 100) Primary/Secondary Unilateral/Bilateral Affected SCC Recurrence (+) Primary Secondary Unilateral Bilateral P L M 42 58 82 18 77 15 8 51 BPPV, benign paroxysmal positional vertigo; SCC, semicircular canal; P, posterior; L, lateral; M, multiple. patients had psychogenic vertigo in our study. All children with phobic postural vertigo had a history of multiple BPPV attacks, but they were all asymptomatic by the time they were evaluated at our center. Despite the atypical postural instability pattern that conflicted with normal equi­ librium laws on mCTSIB that was observed in children with somatoform vertigo, all vestibular function test results were normal in the psycho­ genic vertigo group. MRI of the brain showed unremarkable results in all children. Meniere’s Disease (MD) was present in 1.5% (n = 3) of all children. Tinnitus was described by one child and ear fullness was described by two children. Low frequency sensori-neural hearing loss was present in all three children. Contralesional (away from the affected side of a lesion) spontaneous nystagmus in a vision-denied condition, and highfrequency head shake nystagmus were observed in all three children after 24 h following an episode. However, spontaneous nystagmus di­ rection was ipsilesional (on the same side as a lesion) during an episode in two children. Unilateral caloric weakness was present in two of the three children with MD. None of the children with MD developed sec­ ondary BPPV. Sway on an unstable surface with eyes closed was observed on mCTSIB in all children. MRI of the temporal bone showed unremarkable results in all children. Central vertigo was present in 1.5% (n = 3) of all children. Vertigi­ nous seizures were diagnosed by a pediatric neurologist and confirmed with EEG in two of the three children with central vertigo. One of the children with vertiginous seizures who had a previous diagnosis of Niemann–Pick Type C disease presented supranuclear gaze palsy, abnormal saccadic eye movements, and ataxia. The other child with vertiginous seizures presented gaze-evoked nystagmus. The third child with central vertigo who was diagnosed with acute bacterial meningitis secondary to suppurative labyrinthitis presented vertical downbeat spontaneous nystagmus and ataxia. Fall on a stable and unstable surface with eyes closed was observed on mCTSIB in children with ataxia. Perilymphatic fistula (PLF) was diagnosed and surgically confirmed by exploratory tympanotomy in only one child with a recent history of barotrauma. The child had a sudden profound sensori-neural hearing loss sloping to high frequencies. Ipsilesional spontaneous nystagmus was observed. The fistula test result was positive, and altering the pressure in the ear canal induced nystagmus. Fall on an unstable surface with eyes closed was observed on mCTSIB. Table 2 VM characteristics. VM CHARACTERISTICS (n = 83) N DEFINITE PROBABLE/SUSPECTED COEXISTING MOTION SICKNESS (+) FAMILY HISTORY OF MIGRAINE (+) NORMAL VESTIBULAR TEST RESULTS (+) SECONDARY BPPV (+) 48 35 82 74 28 50 VM: Vestibular Migraine. Classification of Headache Disorders criteria [16], as follows: 48 of these 83 children were diagnosed with definite VM, and the rest were in the follow-up period for probable/suspected VM. Motion sickness was re­ ported in 98% (n = 82) of patients, and a family history of migraine was reported in 89% (n = 74) of patients in the VM group. Tinnitus was reported by four children and ear fullness was reported by two children, but all children in the VM group had bilateral normal and symmetrical hearing. Transient positional nystagmus that was consistent with sec­ ondary BPPV was observed in 50 children, and this was the most com­ mon vestibular test finding in the VM group. Caloric testing was completed in 11 children, and all of them had normal and symmetrical responses. The other vestibular test findings that were observed were gaze-evoked nystagmus in two children, abnormal saccadic eye move­ ments in one child, horizontal spontaneous nystagmus in one child, and vertical downbeat spontaneous nystagmus in one child. Sway on an unstable surface with eyes closed was observed on mCTSIB in 32 chil­ dren. Normal vestibular test findings were found in 28 children. MRI of the brain showed unremarkable results in all children with VM. A migraine variant, BPVC, was present in 4.5% (n = 9) of the chil­ dren in our study. A family history of migraine was present in all nine patients, and an history of torticollis was present in three patients. Although no postural instability pattern was observed on mCTSIB be­ tween episodes, unilateral head tilt, and loss of balance were detected during BPVC episodes followed by pallor and lethargy in all nine chil­ dren. All patients with BPVC had abnormal unilateral cVEMPs on the same side as the lateral tilt during the episode. Transient positional nystagmus was recorded in three children between the BPVC episodes, and they were diagnosed with secondary BPPV. None of the children with BPVC underwent caloric testing. MRI of the brain showed unre­ markable results in all children with BPVC. VN was present in 4.5% (n = 9) of all children. Bilateral hearing was normal and symmetrical in all children. Spontaneous and high fre­ quency head shake nystagmus were the most common vestibular test findings that were observed in all nine children with VN. Caloric testing was completed in three children, all of whom had normal and sym­ metrical responses. High frequency head shake and caloric tests were performed following the resolution of acute vertigo attack. Transient positional nystagmus was recorded in five children with VN after the initial episode who were diagnosed with secondary BPPV. Sway on an unstable surface with eyes closed was observed on mCTSIB in all chil­ dren. MRI of the brain showed unremarkable results in all children with VN. Somatoform vertigo was present in 3% (n = 6) and phobic postural vertigo was present in 1.5% (n = 3), which revealed that 4.5% (n = 9) of 4. Discussion Many children who have vertigo, dizziness, or imbalance have trouble receiving a specific diagnosis. Although dizziness and vertigo are symptoms of diagnosis, these terms are still misused even by healthcare professionals as if the patient had a diagnosis. In addition, according to our clinical experience, dizziness and vertigo in children are usually treated by more than one specialist at a time, and there is no interdis­ ciplinary communication about different approaches and/or diagnoses that complicate the intervention. Most of the children in our study had already seen various specialists in addition to their pediatrician, and they had already had a MRI of the brain and laboratory test results, which were normal and available. Therefore, most of them had already been (mis)diagnosed with psychogenic vertigo. Although psychogenic vertigo in children is not rare both in our study (4.5%) and in the literature [6] (2.5%–14%), BPPV (49%) and VM (41%) were found to be 3 Downloaded for Anonymous User (n/a) at National Institute for Respiratory Diseases from ClinicalKey.com by Elsevier on July 30, 2021. For personal use only. No other uses without permission. Copyright ©2021. Elsevier Inc. All rights reserved. O. Gedik-Soyuyuce et al. International Journal of Pediatric Otorhinolaryngology 146 (2021) 110751 the most common diagnoses in our study. Vestibular pathologies in pediatric populations were reported in several studies, and an analysis of ten articles by Gioacchini et al. [2] comprised 724 subjects who showed an indication of BPVC (18.7%) and migraine-associated vertigo (17.6%) as the two main entities that were connected with vertigo and dizziness in children [2]. Although the high prevalence of VM is in agreement with the relevant literature [1,2,15,17, 18], BPPV in children has been reported to be rare in several studies [1, 15,18]. The variation in BPPV prevalence might reflect the differences in vestibular assessment techniques. We believe that the nystagmus anal­ ysis is the most important part of vestibular assessment. The type of nystagmus or even the absence of nystagmus in the presence of dizziness and imbalance aids in detecting the pathology. Based on our experience with the pediatric population, sufficient information for diagnosis is elicited most of the time with VNG testing. The most important goal in pediatric vestibular assessment might be to keep a child cooperative to allow completion of one entire test instead of trying to do as many different tests as possible. It is very difficult to detect nystagmus during examinations in a limited time, as indicated by Okumura et al. [19], because they successfully identified pathological nystagmus during paroxysmal vertigo in only two of the 68 children they evaluated. We believe that the higher rate of BPPV in our study was due to using VNG in the vestibular assessment of all children and also informing the care­ givers about the symptoms of probable development of BPPV secondary to other vestibular pathologies such as VM. In a population-based study about paroxysmal vertigo in children, vertigo was reported during headache attacks by 69% of patients with migraine [20]. Our study suggested that VM predisposed patients to recurrent BPPV attacks because 94% of the children who had recurrent BPPV were also diagnosed with VM. The new diagnostic criteria for VM are well estab­ lished, but they are mainly based on adult data [21]. Children and ad­ olescents, however, have a shorter medical history that can be used to establish a clinical diagnosis [21]. Normal vestibular test findings in 33.7% of the children with VM emphasize the importance of a comprehensive medical history in making a diagnosis because motion sickness (98%) and a family history of migraine (89%) were reported in our VM group, which indicates a high association. Migraine variant disorders of childhood include benign paroxysmal torticollis of infancy (BPTI) and BPVC, which occurs only in children aged 2–5 years [22]. The prevalence of BPVC in the literature is variable, ranging from 6% to 20%, which is probably because of the lack of a strict clinical definition and because of their rapid and spontaneous resolution (and the patients, thus, do not attend specialized clinics) [1]. All nine children (4.5%) who were diagnosed with BPVC in our study were under 4 years old. All of them had previous visits to several pediatric neurol­ ogists, and most of them had an initial diagnosis of probable epilepsy although they had multiple unremarkable EEG findings. The diagnosis of epilepsy is essentially clinical, and it relies on the description of the seizure that is provided by the patient and an eyewitness [23], which is similar to a BPVC diagnosis. As indicated in the literature [23], for a new onset seizure, if the MRI is normal or nonspecific, no further evaluation is required, and medical management was initiated in a similar manner in most children in our study before they were diagnosed with BPVC. Most of these children were referred to our clinic for further evaluation when treatment with traditional anticonvulsants failed. Epileptic vertigo and dizziness causing isolated vestibular symptoms were reported, but there is limited information about prevalence and clinical characteristics (e.g., accompanying symptoms, duration) that might help to distinguish it from nonepileptic causes [24]. Abnormal oculomotor function was observed on VNG in two children who were diagnosed with vertiginous seizures in our study, but we believe that the sensitivity of vestibular function testing is limited in its ability to detect epileptic vertigo. However, based on our experience, self-recordings by caregivers during the episodes and cVEMP testing are valuable in diagnosing BPVC. Most children who were referred from the emergency room were diagnosed with VN in our study. Our findings agree with those of Brodsky et al. [25], which showed that VN occurs in children at a similar rate as that in adults and that it should be considered in the differential diagnosis of pediatric patients with acute onset vertigo. VN was reported in 3.7% of patients by Brodsky et al. [25], which is similar to our find­ ings of 4.5%. MD is an uncommon cause of dizziness in children both in our study (1.5%) and in the literature (0.4%–2.6%) [26]. MD and VM attacks might both have similar symptoms, and they both typically last for hours. As indicated by Wiener-Vacher et al. [1], the recurrence of invalidating vertigo, which is associated with nausea and vomiting but without headache that lasts for several hours, will evoke a MD-like syndrome in the absence of any another cause. Audiological and vestibular assessments play an important role in the differential diag­ nosis because both our experience and other studies [1] indicate that tinnitus and mild hearing loss are rarely reported spontaneously by the child. Our experience suggested that MD was one of the conditions where caloric testing was most valuable because unilateral weakness was found in two-thirds of the children in our MD group. Care should be taken not to diagnose MD during an initial attack and to monitor the child regularly [1]. Hearing loss during initial episodes may recover spontaneously and the labile nature of the spontaneous nystagmus di­ rection in MD may fail to indicate the side of the unilateral peripheral hypofunction as in most of the other peripheral pathologies in which the fast phase of the spontaneous nystagmus beats toward the intact side. PLF has been a controversial topic in otolaryngology with many publications on its existence or on reliable diagnosis techniques [27]. Although PLF was diagnosed and surgically confirmed in only one child in our study, a child with a history of a recent event such as barotrauma that could cause a fistula, sudden sensori-neural hearing loss, and vestibular complaints should alert the clinicians to the possibility of PLF. Hearing-impaired children, including children with unilateral deaf­ ness [28], have a higher risk for vestibular dysfunction, which can affect their (motor) development due to the close anatomical relationship between the auditory and vestibular end organs [29]. Vestibular func­ tion testing is important in children with sensorineural hearing loss (SNHL) because it affects their rehabilitation plan [30]. Unfortunately, only three children with pre-existing sensori-neural hearing loss have been referred to our vertigo center in 3 years, which might indicate that vestibular dysfunction often goes unnoticed because vestibular assess­ ment in children with SNHL is still not the standard of care [29]. Many studies showed that children with SNHL have possible vestibular affection, which is related to the severity of cochlear pathology [30]. Previous studies showed that the children with SNHL showed worse balance performance compared to children with normal hearing who were in the same sex and age group [31], and those with severe and profound hearing loss and prematurity as an etiological factor demon­ strated the worst gait performance [32]. Abnormal vestibular responses that are associated with hearing loss were more frequently found in patients with cytomegalovirus infection, inner ear malformation, and genetic syndromes (e.g., Usher, CHARGE, Waardenburg, and Pendred) [1]. Therefore, children with SNHL, including young pediatric candi­ dates for unilateral or bilateral cochlear implantation who have not started to walk, should receive a vestibular assessment [33]. Vestibular function test results allow an improved differential diag­ nosis, which helps to determine the most effective treatment plan for children with vestibular disorders. Awareness of BPPV in pediatric pa­ tients may reduce delays in identification and successful treatment with repositioning maneuvers [34]. Most patients with BPTI experience complete resolution in early childhood and some progress to BPVC, while many patients with BPVC similarly progress to VM, which is referred to as “the vestibular march” [22]. Pediatric VM and migraine variant disorders in childhood can be successfully managed using migraine medications such as tricyclic antidepressants, topiramate, and cyproheptadine, as well as using a diet/lifestyle regimen with riboflavin and magnesium [35], although further study is needed to determine the relative efficacy of specific treatment regimens [36]. Dietary trigger 4 Downloaded for Anonymous User (n/a) at National Institute for Respiratory Diseases from ClinicalKey.com by Elsevier on July 30, 2021. For personal use only. No other uses without permission. Copyright ©2021. Elsevier Inc. All rights reserved. O. Gedik-Soyuyuce et al. International Journal of Pediatric Otorhinolaryngology 146 (2021) 110751 avoidance has shown efficacy in adult VM, but many common dietary migraine triggers (e.g., caffeine, aged cheese, and red wine) are less frequently consumed by children compared to adults, and a strict migraine diet might be difficult to maintain in children who are picky eaters [36]. The rate of spontaneous recovery is reported to be high in children <15 years old with VN, which suggests that medical therapy other than vestibular suppressants to control the acute attack may be unnecessary for younger children and that further study of the efficacy of oral corticosteroid treatment in adolescents, in particular, is needed [25]. Dietary restriction of sodium, as well as medications such as cen­ tral vestibular suppressants to control acute MD attacks, betahistine dihydrochloride, oral corticosteroids, and diuretics have historically been used to treat symptoms that are related to MD [37]. Because a diagnosed allergy has been reported in pediatric MD, restriction of al­ lergens and treatment of dysautonomia were also recommended [38]. Benefits of the migraine diet/lifestyle regimen with riboflavin and magnesium for pediatric MD were also reported, which suggested that there was substantial overlap between the symptoms of MD and migraine-related cochlear/vestibular disorders [35]. Intratympanic steroid treatment for MD is another option, but it may have practical limitations in the pediatric population [39]. To the best of our knowl­ edge, there is no study in the literature that has investigated the effec­ tiveness of surgical intervention for pediatric MD. Surgical management is recommended for PLF and superior semicircular canal dehiscence [37]. Professional psychological care is the management of choice for psychogenic vertigo [1]. Vestibular rehabilitation therapy (VRT) should also be considered in children with persistent vestibular symptoms [40]. There is promising evidence that VRT programs improve postural control, balance, and gait in children with SNHL [40], motion sensitivity [41], and concussion [42]. VRT has shown some symptom improvement in children with vestibular migraine, although these improvements were all related to imbalance that was assessed using an office examination or balance tests [36]. 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