BPV of Childhood with torticollis in 20 month-old: Evaluated with VEMP and
Behavioral Protocols

The most common cause of dizziness (35%) in children is one of the six categories of migraine (IHC, 2004). Vestibular Evoked Myogenic Potentials (VEMP) is an ideal protocol when evaluating vestibular function in infants and young children (Gans R., 2012). VEMP has been extensively reported in the Neurology-migraine literature
(Liao LJ. and Young YH. ,2004). In addition to the VEMP, behavioral testing along with Motor Milestones should be included in a comprehensive pediatric vestibular assessment (Gans R., 2013).
Case History: Referred by pediatric ENT. Audiologic testing and EEG all reported unremarkable. Parents report episodes beginning at one-month of age, occurring as recently as the prior week. They range in duration, minutes up to hours, but have been decreasing in frequency and severity. Symptoms include: emesis, observation of nystagmus, imbalance, staggering with falls and torticollis, followed by fatigue. Mother and maternal grandmother have life-long report of migraine. Older female sibling (age 13 years) has migraine correlating with menses. Although the torticollis resolves after the episodes, there is an apparent residual 5-degree left lateral tilt. Likewise, parents report the child clearly staggers to the left and the observed torticollis is strongly left-sided, as much as 45 degrees.

Protocols and findings:
1.) Immittance WNL (tympanogram and reflexes prior to VEMP)
2.) VEMP-Right WNL, Left-Absent 3.) Behavioral – CTSIB WNL, Righting reflexes WNL

Recommendations: The child’s familial history, symptoms including the torticollis and absent left VEMP suggest a BPV of Childhood. Unremarkable ENT and EEG results further support this. Referral to pediatric Neurology for management is forthcoming. Parents were grateful to learn BPVC can be managed and is typically outgrown by 4-6 years of age.

References:
Gans, R. (2013) “Evaluation and Management of Vestibular Function in Infants and Children with Hearing Loss”, In Madell, J. and Flexer, C. (Eds.) Pediatric Audiology: Diagnosis, Technology, and Management, 2nd Edition, Thieme Medical Publishers, New York
Gans, R. (2012) “Equilibrium- Vestibular Assessment for Infants” Audiology Today (pp. 25-31), American Academy of Audiology, Jan-Feb 2012
Lih-Jen Liao and Young, Yi-Ho, “Vestibular Evoked Myogenic Potentials in Basilar Artery Migraine”, Laryngoscope 114: July, 2004
International Classification of Headache Disorders, 2nd Edition, Cephalgia, Volume 24, Supplement, 2004