1/21/2020 Introduction to Vestibular Anatomy and Physiology Joshua - - PDF document

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Joshua Hu ppert, Au.D .

Assistant Professor and Pediatric Audiologist University Of Miami Ear Institute Cde Hea Pa (CHP) G.Paul Moore Symposium University of Florida February 6, 2020

Introduction to Vestibular Anatomy and Physiology

Disclosures

• Financial: Honorarium, travel, and lodging

provided by University of Florida

• Associations/Affiliations:

–University of Miami Ear Institute

Employer

–American Academy of Audiology (AAA)

Past-Chair-Outreach Counsel

Extension of Gratitude

• Anna Marie Jilla, AuD/PhD

–Co-creator/shared mind trust for presentation slides

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Learner Objectives

1. List and describe the 3 systems used for balance. 2. List and describe the 5 peripheral vestibular structures and which types and axes of movement for which they are most sensitive. 3. Explain how differences in the sensory structures of the semicircular canals and otolith organs work differently to activate the vestibular hair cells. 4. Describe how the central vestibular integrator is the “peacekeeper for balance. 5. Describe each of 3 vestibular reflexes (i.e., VOR, VCR, VSR) and their importance for maintaining balance.

Balance and Equilibrium

• 3 systems

– Proprioceptive – Visual – Vestibular

• Correct input from sensory modalities

Did you know? The vestibular organs of the inner ear are present by 7 weeks gestation!

Peripheral Vestibular Structures

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5 Structures Per Ear

• Semicircular canals (3)

– Angular acceleration

• Otolith organs (2)

– Li near/translational acceleration

• Mode of stimulation

– Change in acceleration, not movement

Want more? A&P V Dysfx Duke U Webinars

Semi-Circular Canals (SCC)

• Sensors for angular acceleration
• Three for each ear

– Lateral/Horizontal – Posterior – Anterior/Superior

Excitation toward kinocilium, inhibition away

Sem i-Circular Canals (SCC)

Axes of rotation

• Posterior

– Think Cartwheel

• Horizontal/lateral

– Think Pirouette

• Anterior/superior

– Think Somersault

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Sem i-Circular Canals (SCC)

Fluid-filled with endolymph (Hi K, Lo Na) kinocilium stereocilia

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Semi-Circular Canals (SCC)

• Nerve impulses

–Steady state –Excitation (toward kinocilium) –Inhibition (away from kinocilium)

• Coplanar pairs

kinocilium

Otolith Organs

• Sensors for linear/translational acceleration
• Two per ear

1. Saccule

• - vertical (think elevator)
• - up-down
• - stuck to the wall

2. Utricle

• - horizontal (think car)
• - forward-backward
• - on the floor

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Otolithic Membrane = Gelatinous matrix Otoliths *GRAVITATIONAL FORCES*

Oto = ear; Lith = stone

Central Vestibular Structures

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Vestibular Portions of CNVIII

• Superior Vestibular Nerve Branch

– Lateral SCC, Superior SCC, and Utricle

• Inferior Vestibular Nerve Branch

– Posterior SCC and Saccule

T e c a C Rad 12. I a ea.

• Specialized nerve fibers

– Ty pe I-irregular – Ty pe II-regular

• Inhibition & Excitation

– Ex citation up to 400 spikes/s – Inhibition (contra SCC) 0 spikes/s – Ew alds Laws

Central Integrator

• Primary afferent projections

– Communicate ipsilaterally and contralaterally to the cerebellum and vestibular nuclei in the medulla

• Secondary afferent projections

– Receive sensory information from the eyes, central visual system, and neck proprioceptive systems

• Vestibulo-cerebellum

– Informs postural responses – Guides movement – Mediates vestibular compensation after insult

Want more?

• Central Vestibular Pathways
• Vestibular Nerve Activity

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Central Integrator

Vestibulo-cerebellum (the “peacekeeper)

• Receives information from:

– Proprioceptive – Vi sual – Vestibular systems

• Informs eye movements
• Informs postural responses
• Guides movement

Vestibulo-Cerebellum Vestibular Reflexes

• Vestibulo-ocular reflex (VOR)

– Stabilizes vision during rotational head movement in various pl anes through utilization of extraocular muscles

• Vestibulo-spinal reflex (V SR)

– Makes automatic, postural adjustments to upright stance and stability of head and body during various conditions/activities

• Vestibulo-collic reflex (VCR)

– Stabilizes head during body movements (e.g., ambulation)

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Vestibular Reflex Orientation within Vestibulo-Cerebellum

Vestibul0-Ocular Reflex (VOR) Vestibulo-Colic Reflex (VCR) Vestibulo-Spinal Reflex (VSR)

Other Vestibular Reflexes to Consider

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Frequency, Velocity, and Acceleration. OH MY!

• Normal activities
• <1 to 20 Hz—frequency of head motion

(Das et al 1995; Crossman et al 1988)

• 550°/s—head velocity (time rate of change)
• 6000°/s2—head acceleration (time rate of change of velocity)
• The vestibular system is the only detector for this range

(Waespe & Henn 1987)

• VOR latency is only about 5-

7 ms (Huterer & Cullen 2002; Minor et al 1999)

Cognitive and Gross Motor Development from Birth to 5 Years

\

Joshua Hu ppert, Au.D .

Assistant Professor and P ediatr ic Aud iologist University Of Miami Ear Institu te C de H ea Pa (C HP ) G.Paul Moore Symp

• siu

m University of Florida February 6, 2020

Learner Objectives

• 1. Li st and describe the 4 primary domains of development
• 2. Identify age-appropriate milestones specific to cognition and

mov ement/physical development in children from birth to 5 y ears of age

• 3. Describe “red flags and what they indicate
• 4. Ex plain what steps may be recommended should parental

concerns for development arise and/or should red flags be i dentified

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Developmental Milestones

• Functional skills/age-specific tasks achievable within a certain

age range

• Achieved through play, active/passive learning, speaking, various

behaviors, and movement

• Mi l estones are met when a child is able to perform a task/set of

tasks independently

• Unachieved milestones can raise concerns about developmental

di sorders, underlying health conditions, or other factors that may negatively impact a childs development

Developmental Domains Social/Emotional

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Language/Communication Cognitive Movement/Physical

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CDC Developmental Milestone Checklist/App

https://www.cdc.gov/ncbddd/actearly/milestones-app.html

Quick Review: Vestibular Reflexes

• Vestibulo-ocular reflex (VOR)

– Stabilizes vision during rotational head movement in various pl anes through utilization of extraocular muscles

• Vestibulo-spinal reflex (VSR)

– Makes automatic, postural adjustments to upright stance and stability of head and body during various conditions/activities

• Vestibulo-collic reflex (VCR)

– Stabilizes head during body movements (e.g., ambulation)

• Pays attention to faces
• Begins to follow objects

with eyes and recognize faces from a distance

• Begins to act bored if

activity doesnt change

2 Months: Cognitive

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2 Months: Movement/Physical

• Holds head up and begins

to push up when lying prone

• Can make smooth

movements with extremities 2 Months: Typical/Atypical Side By Side Comparison

4 Months: Cognitive

• Lets you know if he/she is happy
• r sad
• Responds to affection
• Reaches for a toy with 1 hand
• Uses hands and feet together

(e.g., seeing a toy & reaching for it)

• Follows moving objects with eyes

from side to side

• Watches faces intently/closely
• Recognizes familiar

people/objects at a distance

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4 Months: Movement/Physical

• Hol ds head steady when

unsupported

• Pushes dow n on legs when

feet are on a firm surface

• May roll prone to supine
• Can hol d/shake a toy and

sw i ng at dangling toys

• Bri ngs hands to mouth
• Pushes up on elbows when

l y ing prone

4 Months: Typical/Atypical Side By Side Comparison

6 Months: Cognitive

• Looks around at nearby
• bjects
• Brings objects to mouth
• Shows curiosity about
• bjects and attempts to

retrieve objects out of reach

• Begins to pass objects

between hands

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6 Months: Movement/Physical

• Rol l s prone to supine and

supi ne to prone

• Begi ns to sit

i ndependently

• When standing, supports

w ei ght on legs and may bounce

• Rocks to and fro, at times,

crawling before moving forward

6 Months: Typical/Atypical Side By Side Comparison

9 Months: Cognitive

• Watches path of an object

as i t falls

• Looks for objects she/he

sees caretaker hide

• Pl ays peek-a-boo
• Transfers objects from one

hand to the other

• Pi cks up objects (e.g. food)

usi ng pincer grasp (thumb and i ndex finger)

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9 Months: Movement/Physical

• Stands while holding onto
• bject
• Begins to get into a sitting

position independently

• Sits independently
• Pulls to stand
• Crawls

A Baby at 9 Months 12 Months: Cognitive

• Explores in different ways (e.g.,

shaking, banging, throwing)

• Finds hidden things easily
• Begins to use items correctly

(e.g., brush, cup, etc.)

• Places and removes items in a

container

• Lets items go without help
• Pokes with index finger
• Follows simple directions
• Looks at the right picture or item

when its named

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12 Months: Movement/Physical

• Gets into a sitting position

independently

• Pulls to stand and then

walks while holding on to furniture

• May take a few steps

without holding on

• May stand alone

A Child at 12 Months 18 Months: Cognitive

• Know s w hat ordinary items

are for (e.g., spoon, phone, etc.)

• Poi nts to get attention
• Show s i nterest in a doll or

stuffed animal by pretending to feed it

• Scri bbles independently
• Can follow 1-step verbal

commands w ithout gestures (e.g., “sit down)

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18 Months: Movement/Physical

• Ambulates independently
• May walk up steps and

run

• Pulls toys/objects during

ambulation

• Can help undress
• Drinks from cup
• Eats with spoon

A Child at 18 Months 2 Years: Cognitive

• Finds items, even when hidden
• Begins to sort shapes/colors
• Completes sentences and rhymes

in familiar books

• Plays simple, make-believe games
• Builds towers of 4 or more blocks
• May begin to show hand

preference

• Follows 2-step instructions (e.g.,

“pick up your coat and hand it by the door)

• Names items in a picture book

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2 Years: Movement/Physical

• Stands on tip-toe
• Kicks a ball
• Begins to run
• Climbs onto and down from

furniture with minimal (if any assistance)

• Ascends/descends stairs

while holding onto railing

• Throws ball overhead
• Makes/copies straight

lines/circles

A Child at 2 Years 3 Years: Cognitive

• Can manipulate toys with movi

ng parts

• Plays make-believe with dolls,

animals, and people

• Can complete basic puzzles (i.e.,

3-4 pieces)

• Understands what “two means
• Copies circles with pencil/crayon
• Turns book pages 1-by-1
• Builds towers of 6 or more blocks

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3 Years: Movement/Physical

• Climbs well
• Runs easily
• Can pedal a tricycle
• Ascends/descends stairs

with proper weight transfer (i.e., one foot on each step)

• Can screw/unscrew lids

and turn door handles

A Child at 3 Years 4 Years: Cognitive

• Names some colors and numbers
• Understands idea of

sequencing/counting

• Begins to understand time
• Can recall parts of story
• Understands idea of same/different
• Can draw a person with 2-4 body

parts

• Can use scissors
• Starts to copy some capital letters
• Can play simple board/card games
• Can relay what he/she predicts might

happen next in a book

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4 Years: Movement/Physical

• Can hop and stand on 1

foot for up to 2 seconds

• Can catch a bounced ball

most of the time

• Pours, cuts, and mashes
• wn food

A Child at 4 Years 5 Years: Cognitive

• Can count 10 or more items
• Can draw person with at

l east 6 body parts

• Can w rite some letters

and/or numbers

• Can copy a triangle and
• ther geometric shapes
• Know s about items used

dai l y (e.g., food, money, etc.)

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5 Years: Movement/Physical

• Can stand on 1 foot for >10

seconds

• Hops and may be able to

ski p

• Can do a somersault
• Can use a fork, spoon, and

someti mes a knife

• Can use the restroom

i ndependently

• Sw i ngs and climbs

A Child at 5 Years Red Flags

• Behaviors/signs/delays

that signal a possible problem with development, supporting need for referral for more in-depth screening and/or diagnostic evaluation.

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Taking Action

• Refer to Pediatrician
• Provide contact/scheduling

information for state early intervention program

• Provide and/or direct

families to resources to better track/monitor milestones

• Perform screening yourself

Ages and Stages Questionnaire (ASQ-3)

• Validated developmental and emotional/social screening tool for

children birth to 5.5 years

• Takes 10-15 minutes for the family to complete and 5 minutes for

the clinician to score

• Draws on familys in-depth observation of the child to pinpoint

dev elopmental progress and catch any underlying delays

– Scores include “monitoring zone to help identify children that may be borderline and require routine follow-up/monitoring to track progress

• Av ailable in 6 languages (English, Spanish, Arabic, French,

Vi etnamese, and Chinese)

• Can be completed in clinic/waiting room, at home, or via phone

Ages and Stages Questionnaire (ASQ-3)

Sample Questionnaire

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Ages and Stages Questionnaire (ASQ-3)

Free Screening through Easter Seals

“…the first 5 years of life lay the foundation for a childs long-term well-being and

• v erall success.
• Easter Seals

Content Sources

• Center for Disease Control (CDC)
• Easter Seals
• Ages and Stages

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Reference Framework: A Woman Who Dared to Dream JCIH, EDHI, and NBHS: Acronyms-Oh My!

• Consequences of hearing loss:

– Delayed speech/languag e development

Increased risk for cognitive and academic delay and significant p sycho/social/emotion al con sequences

• Joint Committee on Infant Hearing (JCIH) endorses early detection of and intervention for

infants with hearing loss (EDHI) – Aimed to maximize speech/language and lit eracy development given increased aforementioned risks for delays as a result

• f underlying

hea ring loss

Ideal: Screened by 1 month, diagnosed by 3 months, an d received intervention by 6 month s (1-3-6)

• Newborn Hearing Screening (NBHS)

– Aimed to identify newborns who were likely to have hea ring loss and who require further evaluation to confirm

A a Re f NBHS

• ~96% of children born in the United States were screened for hearing loss

before 1 month of age (NIDCD, 2016)

• ~98% of children born in the United States received NBHS (NIDCD,

2018)

• Increased focus on early auditory development in children
• As a result of earlier intervention, impacts hearing loss would otherwise

cause are significantly reduced, allowing most children to excel on par with normal hearing peers

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Ad Deaded See: So, what about early identification of vestibular/balance dysfunction in cde

COCHLEA VESTIBUL AR APPARAT US:

Semicircular Canals and Otolith Organs

Development of the Vestibular/Balance System

• Sensate vestibular inputs by 5-6 months post-

gestation

• Functional at birth
• Cca Ped

– 1-2 years of age (Jamon, 2014; Wiener-Vacher, 2013)

• Reflexes reach peak development at 12 years of

age (Peterson et al., 2005) to facilitate the development

• f emerging motor skills and postural control (McCaslin,

2016).

Prevalence

• OReilly et al., 2010

– Retrospective review based on ICD-9 codes related to vestibu lar d isorders and associated CC

• 561,151 pediatric (birth to 18 years)

– Prevalence found to be less than 1%

• Li et al., 2016

– Retrospective review based on encou nters involving “d izziness across EN T Depar tments of 11 hospitals

• 11,000 pediatric patients (3-17 years)

– Prevalence found to be 5.3%

• Brodsky et al., 2019

– Cross-sectional analysis based on encoun ters involving complaints of “dizziness or “imbalan ce as indicated on the National Health Interview Su rvey in 2016

• 3.5 million pediatric patients (3-17 years)

– Prevalence found to be 5.6%

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A pplied Prevalence

• Li et al., 2016 and Brodsky et al., 2019

– Nationally-weighted prevalence of vestibular dysfunction in children-5-6%

• University of Miami Ear Institute-Childrens Hearing Program (UMEI-

CHP)

– ~4,000 children in 2018

~200 (5.3% of 4,000) of which likely had vestibular dysfunction

• Nicklaus Childrens Hospital (NCH)

– 10,600 inpatients, 211,800 outpatients, 288,000 throughout all satellites (510,400 in total) seen in 2017

~25,520 (5.3% of 510,400) of which likely had vestibular dysfunction

Risk Factors Associated with Vestibular Dysfunction in Children

• Sensory/Neural Hearing Loss (SNHL)
• Del ayed Gross Motor Mil estones
• Otitis Media with Effusion (OME)
• Migraine
• Head Trauma (Concussion and TBI)
• Cochleovestibular Anomalies and/or Syndromic

Etiologies

• Congenital and/or Acquired Infectious Diseases
• Vestibulotoxicity

Other Possible Indicators of Vestibular Dysfunction in Children

• Reading Deficits
• Math Deficits
• Poor Spatial/Body Awareness

– Clumsy/lack of coordination

• Anxiety/depression
• Poor Attention
• Acute or chronic headache/migraine
• Hyper/hyposensitivity

– Hyper/hypotonicity

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Birth History

– NICU

Sepsis r/o?

Medical History

– Torticollis in infancy/toddlerhood – Hx motion intolerance – Hx staring spells – Fam. hx imbalance/dizziness – Fam. hx headache/migraine – Recent vision examination

W/i last 6 months=ideal

Audiologic History

– Recent hearing evaluation

W/i last 6 months=ideal

Academic and Social History

– Delayed/slow learning – Academic strengths/weaknesses

Excels in/is most challenged by

– Behavioral concerns – Concerns for attention/focus – Sensory concerns

Avoiding/seeking/both

– Socialization concerns

Additional Considerations (RE: Case Hx)

A chievement of Dev elopmental Milestones

• 1. A cce cd baace ad/

development?

• 2. Has your child achieved the following gross motor

milestones at/prior to the age listed below?

Table I. Motor Milestone Benchmarks (McCaslin, 2016) Motor Milestone Benchmarks (McCaslin, 2016)

MILESTONE IN PLACE BY Response to Ti lt (Greater than 36 months) Should right within seconds Head Control 4 months of age Sitting Unassisted 9 months of age Walking 18 months of age

Achievement of Developmental Milestones Cont.

Per Janky et al, 2018, a diagnostic vestibular evaluation may be warranted for children with SNHL who:

• 1. PTA > 66 dBHL
• 2. Sit later than 7.25 months
• 3. Walk later than 14.5 months
• 4. Whose parents express concerns with gross motor development

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Wa We K

• Ocular motility
• Hi gh frequency head shake
• Fukuda step test
• Romberg
• Di x-Hallpike maneuver

Ne Cdea

• Head thrust/impulse test
• Si ngle leg stance
• Lay mans rotary chair
• DVA w/ Snellen eye chart
• Gans SOP Test/mCTSIB
• Physioball
• Subjective observation of gait
• 4 Mountains Test

Screening Measures for Bedside Evaluation

Head Thrust/Impulse Test Single Leg Stance

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Laa Ra Ca DVA with Snellen Eye Chart Gans SOP Test/mCTSIB

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Physioball Subjective Observation of Gait 4 Mountains Test

https://www .jove.com/video/54454/the-4-mountains-test-short-test- spatial-memory-with-high-sensitivity

1/21/2020 33

Ages and Stages Questionnaire (ASQ-3)

• Validated developmental and emotional/social screening tool for

children birth to 5.5 years

• Takes 10-15 minutes for the family to complete and 5 minutes for

the clinician to score

• Draws on familys in-depth observation of the child to pinpoint

dev elopmental progress and catch any underlying delays

– Scores include “monitoring zone to help identify children that may be borderline and require routine follow-up/monitoring to track progress

• Av ailable in 6 languages (English, Spanish, Arabic, French,

Vi etnamese, and Chinese)

• Can be completed in clinic/waiting room, at home, or via phone

Sample Questionnaire

Ages and Stages Questionnaire (ASQ-3) Ages and Stages Questionnaire (ASQ-3)

Free Screening through Easter Seals

1/21/2020 34

Take Aways

• Screenings are quick and easy to administer and interpret.
• Increases/enhances your level of service and value as a

provider.

• Screenings can be easily incorporated into standard hearing

ev aluation appointment slots (i.e., ami dst billable services).

AND…

Take Aways Cont.

Children with vestibular dysfunction cannot adequately navigate the world around them, much in the same way children with HL struggle to interact and engage with the world around them. Why i s this any less important?

Fu ture Aspirations…

• Development/growth of vestibular (and research) component within current/future

AuD Programs – Provoke interest, increased specialization, and provider scope of competency

• Identify/train current/prospective mentors within the field to facilitate expan

ding knowledge – Provide greater opportunity for us to contribute to our own evidence base

• Expand web of influence beyond the realms of audiology
• Increase public/provider awareness of vestibular dysfunction in children
• Joint Committee on Infant/Toddler Vestibular Development

– Hey, a boy can dream…

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Meae, Be

Vestibular Infant Screening-Flanders (VIS-Flanders) –Objective: Aims to implement and refine a vestibular screening protocol for all children diagnosed with neonatal hearing loss in Flanders, Belgium to limit the impact

• f vestibular dysfunction on motor, cognitive, and

physical development of hearing impaired children.

VIS-Flanders Protocol

Tools and Resources Parent and/or child self-report measures

–Pediatric Dizziness Handicap Inventory for Patient Caregivers (pDHI-PC) and/or the Dizziness Handicap Inventory (DHI) –Pediatric Vestibular Symptom Questionnaire (PVSQ) –Pediatric Visually-Induced Dizziness Questionnaire (PVID) –Questionnaire for Dizziness, Eye, and Balance Function for Children and Adolescents (Q-DEB)-Not yet available –Pediatric Vestibular Screening Tool (PVST)

1/21/2020 36

Remember Sara?

V estibular screening completed in March 2019 indicated the following:

–Refl exes mediating vestibular function are under- developed –Under-reactive vestibular system –Notable fall risk/increased propensity for head injury –Poor activation of vestibulo-limbic interactions

Sara 5 Months Later (August 2019) References

• Big elow, R.T., & Ag ra wa l, Y. (2015). Vestibula r inv
• lv

ement in cog nition: Visuospa tia l a bility , a ttention, ex ecutiv e function , a nd memory . J ournal of vestibular research : equilibrium & orientation, 25 2 , 7 3-89 .

• Brodsky

, J. R., Lipson, S., & Bha tta cha ry y a , N. (2019). Prev a lence of Pedia tric Dizziness a nd Imba la nce in the United Sta tes. Otolaryngology–Head and Neck Surgery, 0194599819887 37 . doi: 10.117 7 /0194599819887 3 7 5

• Ca sselbra nt ML, Villa rdo RJ , Ma ndel EM. Ba la nce a nd otitis media

with effusion. Int J Audiol 2008;47 :584 –89 .

• Ca sselbra nt ML, Furma n JM, Rubenstein E, Ma ndel EM. Effects of otitis media on the v

estibula r sy stem in children. Ann Otol Rh inol La ry ng ol 1995;104:620–24.

• Clemmens CS, Guidi J, Ca roff Ae

t a l. Unila tera l cochlea r nerv e deficiency in children. Otola ry ng ol Hea d Neck Surg 2013;149:318–25.

• Cushing SL. Vestibula r a nd Ba la nce Dy

sfunction in the Pedia tric Popula tion: A Primer for the Audiolog ist. Canad ian Audio logist: Striking the Right Bala

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a mes AL, Bla ser SL, Gordon KA. Vestibula r end -org a n a nd b a la nce deficits a fter mening itis a nd cochlea r impla nta tion in children correla te poorly with functiona l outcome. Otol Neurotol 2009;30:488–95.

• Cushing SL, Pa psin BC, Rutka JA, J

a mes AL, Gordon KA. Ev idence of v estibula r a nd ba la nce dy sfunction in children with profoun d sensorineura l hea ring loss using cochlea r impla nts. La ry ng oscope 2008;118:1814 –23.

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urnal of Otorhinol a ry ng olog y 7 4(6) (2008), 815 -825.

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estibula r a ssessment for infa nts. Audiology Today. J a n/Feb 2012: Vol 2 4 (1); 25 -30.

• Golz A, Netzer A, Ang el-Yeg er B, Westerma n ST, Gilbert LM, Joa chims HZ. Effects of middle ea r effusion on the v

estibula r sy stem in children. Otola ry ng ol Hea d Neck Surg 1998;119:695 –99.

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wma n CW. The dev elopment of the Dizziness Ha ndica p Inv entoJa mon M. (2014). The dev elopment of v estibula r sy stem a nd rela ted functions in ma mma ls: impa ct of g ra v ity . Frontiers in integrative neuroscience, 8, 11. doi:10.3389/fnint.2014.00011

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elopment of the Dizziness Ha ndica p Inv entory . Arch Otolaryngol Head Neck Surg. 1990;116(4):424–427 . doi:10.1001/a rchotol.1990.0187 0040046011

• Ja nky

KL, Thoma s ML, Hig h RR, Schmid KK, Og un OA. Predictiv e fa ctors for v estibula r loss in children with hea ring loss. Am J Audiology. 2018 Ma r; 27 : 137 -146.

• Ka g a K. Vestibula r compensa tion in infa nts a nd children with cong enita l a nd

a cquired v estibula r loss in both ea rs. Int. J. Pediatr. Otorhinolaryngol., 4 9 (1999), pp.215-224.

• Li CM, Hoffma n J J , Wa r BK, et a l. Epidemiolog

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• f dizziness a nd ba la nce problems in children in the United Sta tes: A popula ti on-ba

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References Cont.

• McCa slin DL. 20Q: Pedia tric v

estibula r disorders a nd the role of the a udiolog ist. AudiologyOnline, Article 17 145; 2016. Retriev ed from www.a udiolog y

• nline.com .
• McCa slin DL, Ja cobson GP, La mbert W, et a l. The dev

elopment of the Va nderbilt Pedia tric Dizziness Ha ndica p Inv entory for Pa tient Ca reg iv ers (DHI-PC). Int J Pedia tr Otorhinola ry ng ol 2015;7 9:1662–66.

• O'Reilly

R, Cushing SL, a nd Morlet T. Ma nua l of Pedia tric Ba la nce Disorders. Sa n Dieg o: Plura l Publishing ; 2013.

• OReilly

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Quantitative Vestibular Function Testing in Pediatric Populations

Joshua Hu ppert, Au.D .

Assistant Professor and Pediatric Audiologist University Of Miami Ear Institute Cde Hea Program (CHP) G.Paul Moore Symposium University of Florida February 6, 2020

Primary Source for This Lecture

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Reference Framework: A Man Who Dared to Dream

Objectives

1. Describe challenges to objective quality objective measures of vestibular function in children

• 2. List which tests of vestibular function are appropriate for children

based on their age

• 3. Describe modifications that can be made to each test to adequately

accommodate children

Challenges

• Equ ipment unavailable
• Lack of pediatric-sized goggles
• Lim ited attention-span/focus
• Lack of normative data
• Lack of provider knowledge/specialization in

pediatric vestibular assessment

• Lim ited awareness of prevalence of vestibular

dy sfunction in children

• Poor su bjective report from patient

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Complete Audio? Complete Vestibular Exam?

Cervical Vestibular-Evoked Myogenic Potential (cVEMP)

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Ocular Vestibular-Evoked Myogenic Potential (oVEMP) Pediatric Modifications for c/oVEMP

Test Procedure Characteri stic Modification Shorten testing time – Perform bilateral, simultaneous cVEMP and oVEMP – Use a bone conduction stimulus Increase attention span – Use interesting toys, stickers, or videos as distractors and targets Improve sustained muscle contraction cVEMP: – Rotate the head and stimulate rooting reflex for newborn s – Sit child on parent's lap or have him/her lie on a table with head turned toward a toy or video

• VEMP:

– Use of a sitting position with target (light bar or video adhered to the wall) elevated at ∼ 30 degrees – Use eye-closed testing for small children who cannot perform testing with eyes open Utilize EMG monitoring – Use an animated cartoon that plays when contraction level is met Improve electrode tolerance – Use one reference electrode (e.g., chin) – Put oVEMP active electrodes on aftercVEMP testing Improve safety for air-conduction VEMP – Present at 120 dB SPL if ear canal volume is ≤ 0.8 mL – Use a 750-Hz tone burst stimulus – Use an ascending threshold search approach – Use a bone-conduction stimulus

VEMP Administration

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Video Head Impulse Testing (vHIT) Pediatric Modifications for vHIT

Test Procedure Characteristic Modification Poor goggle fit secondary to small head size

• Insert foam block between band and

back of childs head to increase tension/tighten fit

• Consider remote video system for

children 3 months-3 years Increase attention span

• Use interesting toys, stickers, or videos

as distractors and targets and feel free to change frequently between impulses

vHIT Administration

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Rotational Vestibular Testing (RVT) Pediatric Modifications for RVT

Test Procedure Characteristic Modification Poor goggle fit secondary to small head size

• Insert foam block between band and back of

childs head to increase tension/tighten fit

• Consider remote video system for children 3

months-3 years Inability to sit independently

• May sit in parents lap, who may then assist

with maintaining head position/stability and/or google placement throughout rotation Child afraid of dark/enclosure Maintaining alertness/tasking

• Door may remain open if remote video system is

being utilized and/or if googles are light-tight

• Consider singing nursery rhymes/familiar

songs, allowing the child to talk about an interesting topic (e.g., dinosaurs), or have them name their favorite cartoon/Disney characters.

VRT Administration

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Caloric Irrigations Pediatric Modifications for Caloric Irrigations

Test Procedure Characteristic Modification Poor goggle fit secondary to small head size

• Insert foam block between band and back of

childs head to increase tension/tighten fit Fearful of testing/afraid of dark

• Reinforce/reassurance of safety from

clinician/parent

• Child may hold/squeeze clinician/parents hand

during irrigation/data collection Maintaining alertness/tasking Truncated test time

• Consider singing nursery rhymes/familiar

songs, allowing the child to talk about an interesting topic (e.g., dinosaurs), have them name their favorite cartoon/Disney characters, and/or ask them to take you through all the toys in their playroom/bedroom.

• Consider monothermal vs. bithermal irrigations
• Reduce irrigations from 30 sec to 15-20 sec

Caloric Administration

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Take Aways

• Ev aluation aim:

– To comprehensively assess functional output of the vestibular system across entire dynamic range of

• peration
• V estibular function testing by age:

– 0-2 years (RVT, cVEMP, and *vHIT) – 3-7 years (vHIT, c/oVEMP) – 8+ years (vHIT, *calorics, and c/oVEMP)

• More comprehensive the assessment, the better
• u r diagnostic power becomes.

THANK

Joshua.Huppert@med.miami.edu