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AUD fall 2019 vestib > Pediatrics > Flashcards

Pediatrics Flashcards

1
Q

what develops first, the vestibular system or auditory system?

A

vestibular system

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2
Q

when are the semicircular canals developed by

A

7 weeks gestation

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3
Q

when are the cristae and maculae developed by

A

12-14 weeks gestation

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4
Q

when is the cochlea developed

A

mid term of gestation

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5
Q

when does the vestibular system myelinate

A

around 16 weeks gestation

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6
Q

when is the auditory system myelinated

A

around 20-24 weeks gestation

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7
Q

when is the vestibulo-ocular reflex present

A

24 weeks gestation

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8
Q

when is the peripheral vestibular system anatomically developed fully

A

at birth

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9
Q

VOR as an infant

A

physiologically is similar to that of an adult, but does have maturational effects
—VOR can be evaluated by rotary chair at birth

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10
Q

when do saccades and smooth pursuit develop

A

4-6 months

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11
Q

when do OPK/ONK fully develop

A

age 4

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12
Q

incidence of vestibular problems in children

A
  • limited data on incidence as it is thought to be rare
  • data often found in retrospective reviews of data
  • review of records of 724 kids:
  • –27.82% migraine
  • –15.68% BPPV
  • –9.81% vestibular neuritis
  • –14% head trauma
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13
Q

development of the vestibular system (when is it fully developed)

A

*anatomically the vestibular system is fully developed at birth, however, maturation is needed for balance to be consistently maintained. this will occur around 12-15 years of age

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14
Q

the VOR purpose and maturation

A
  • purpose= to maintain a steady vision during head movement and to keep the visual target on the fovea
  • will reach full maturity by 6-12 months of age
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15
Q

vestibulo-colic reflex purpose (VCR)

A
  • stabilize the head during body movement
  • –same reflex that is used in cVEMP testing
  • a baby with inability to hold their head up may be indicative of a significant vestibular pathology
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16
Q

vestibulo-spinal reflex (VSR) purpose and age of development

A
  • goal is to stabilize the body for postural control
  • this system is not fully developed until 12-15 years of age
  • the sensory organization test (SOT) with CDP will evaluate this reflex
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17
Q

gross motor in kids with HL

A
  • higher incidence of gross motor delay
  • incidence increased when cognitive delay is noted as well
  • compared to peers will show delays in:
  • –holding up upright
  • –sitting
  • –standing
  • –walking
  • –crawling
18
Q

typical norms for gross motor

A
  • sititng= 6-8 months
  • standing= 10-11 months
  • walking=10-12 months
  • while each child is different this is a guide to appropriate gross motor development
19
Q

gross motor norms for children with vestibular loss

A
  • sitting= 8-18 months
  • standing= 9-20 months
  • walking= 12-33 months
  • –huge range in milestones for these kids because it depends on onset and severity of the vestibular loss
20
Q

strategy changes with development

A
  • strategy for integrating visual, proprioceptive, and vestibular info changes as we mature
  • children tend to be more dominant on vision in their early years
  • –because vestib system isnt fully developed yet
  • by age 14-15 the utilization of vision is more adult like but the vestibular system is still maturing
  • the use of all 3 systems starts to be utilized around 10-15 yrs, but around 7-8 children begin the process
21
Q

vestibular eval of children

A
  • under age 5 need to plan the eval because the next test you acquire may be your last
  • older children can often be tested like adults
  • do not be afraid to take longer tan 1 session to test
  • may even want to let parents know they can expect to take longer than one visit
  • **do not let them leave on a bad note
22
Q

things to ask during history and see during clinical presentation

A
  • are symptoms episodic or persistent?
  • do symptoms seem to represent a sensation of movement of the child’s environment or of the child within the environment?
  • if episodic how long are the episodes?
  • history of childhood diseases since birth, prenatal disorders, postpartum disorders?
  • any know or suspected hearing loss?
  • often ask parent but let pt tell you stuff too, because they may have told the parent something but the parent brushed it off
  • –also helps rapport
23
Q

direct office exam of an infant at the start of independent walking

A
  • head thrust
  • -sticker on forehead or nose and baby on parents lap
  • pursuit tracking
  • –large sticker on finger
  • –younger than 4 months may not be able to perform
  • saccade testing
  • –use 2 finger puppets or 2 different stickers
  • –have 1 pop up and disappear, alternating between the 2
  • –parents may need to gently hold the head/chin
  • optokinetic testing
  • –under 4 months may not be able to perform
  • –use cloth with repeating stickers that can be drawn across the visual field
  • –lack of OPK is not necessarily indicative of problem, may be developmental
  • rotary chair (non-diagnostic)
  • –oscillating office chair back and forth with child on parent’s lap
  • –child needs to look at examiner and not environment
24
Q

direct office exam of a child walking independently (18 months+)

A
  • all methods used with younger children can still be used, however variations would be used
  • –smaller objects to focus on
  • –rotary chair would be performed on diagnostic piece of equipment
  • children over 6 should be testing similar to adults, however adult norms cannot be used
  • add office exam of SOT utilizing 4 conditions
  • –standing on firm surface with and without vision
  • –standing on a compliant surface with and without vision
  • —-if a child will not keep their eyes closed use a blindfold
25
Q

what is the purpose of laboratory testing children?

A
  • determine the pathophysiology of dizziness complaints
  • the etiology of hearing loss
  • the underlying cause of gross motor developmental delay
26
Q

rotary chair with children

A
  • only tests horizontal canal
  • does not provide ear specific info
  • is a good test of the horizontal canal when unable to achieve accurate caloric responses due to tubes, atresia, middle ear fluid, etc
  • tolerated well y children, can sit by themselves or on parents’ lap, usually 4 months of age or older
  • taking can be done with conversation, counting, spelling, singing nursery rhymes, etc
  • rotary chair outcomes are similar to adults, in the normal population a high gain result may be seen and should not be considered abnormal
  • if abnormal findings are found in a kid <6 months, it is recommended they are repeated when they are older to evaluate of a true disorder
27
Q

postural control assessment of children

A
  • sensory organization test (SOT)
  • children must weigh 30 lbs to put enough weight on the platform to record sway
  • normative data for 3+ years is available
  • composite scores improve with age
  • conditions 1-3 can mimic adults
  • remaining conditions 4-6 will see greater sway util 12-15 yrs of age
  • can be used to detect balance dysfunction but also to monitor various disorders
28
Q

pursuit testing with children

A
  • can be tested as young as 2 months of age
  • however, smooth pursuit gains are significantly lower and more variable with children as compared to adults
  • normal smooth pursuit should be present by 5 year of age
29
Q

random saccade testing of children

A
  • saccade latency decreases with age while velocity remains stable
  • maturation of saccades is thought to be complete by age 12
30
Q

OKN up to age 7

A
  • the target should take up to 90% of the visual field
  • OKN is thought to reach maturity by age 7
  • those kids under age 7 will have low gain values
  • some equipment has the ability to switch to cartoon characters
  • –if not you cant just tell them to watch and tell me when you see ____
  • –similar to telling adult to look for the pink light
  • –let the eyes natural reflex work without too much instruction
31
Q

hallpike and roll tests children

A
  • BPPV is rare in children but it can occur especially after head trauma
  • BPPV has been reported in children as young as 3
  • testing and treatment of BPPV is the same as adults
32
Q

gaze and postural testing children

A
  • test as you would with adults with the exception of your target, again using stickers or cartoon characters
  • findings are interpreted the same for adults and children
33
Q

VEMPS: cervical and ocular in children

A
  • cVEMP:
  • –evaluated the saccule and inferior vestibular nerve
  • –ipsilateral ressponse
  • –has been measured in infants as young as 1-4 weeks at 95-100dBHL
  • –morphology is similar to adult but latencies are shorter in younger children and prolong with age
  • –greater variability in peak to peak amplitude
  • oVEMP:
  • –evaluated the utricle and superior portion of the vestibular nerve
  • –contra respose
  • –do not appear to be reliable until 4 yrs of age
  • –no significant difference in latency or amplitude to date; more research is needed
34
Q

pros of VEMPS in children

A
  • quick to administer

* great to use in peds because dizzy symptoms to no have to be induced to get results unlike calorics

35
Q

cons of VEMPS in children

A
  • difficult to get children to hold muscle contraction or eye position for very long
  • stimulation rates that induce a response can be harmful to a small pediatric ear when considered safe in the adult ear canal
36
Q

caloric irrigation in children

A
  • interpretation of calorics is identical to adult standards
  • caloric responses have been reported in children as young as 2 months of age with complete maturation by 6-12 months
  • calibration may be a concern if you cant tell them to look at the dot
  • children may be fearful of the stimulation
  • –they are already concerned about otoscopy, now add air or water
  • if you do get a stimulation they become dizzy and may refuse further irrigations
  • consider monothermal (warm because stronger responses)
  • praise and encourage (and bribe)
37
Q

Video head impulse testing in children (vHIT)

A
  • just as with adults, looking for overall gain, and corrective saccades (overt and covert)
  • no reports on vHIT in children as of right now
  • getting child to fixate on target is difficult
38
Q

disorders in utero (CMV)

A
  • cytomegalovirus (CMV)
  • congenital infection which is the leading cause of hearing loss in children, resulting in progressive and fluctuation sensorineural HL
  • 40,000 children with CMV born each year
  • vestib loss is common in CMV, SSCs and saccule may be affected
  • –dont have research about utricle yet
  • –60% children with CMV have abnormal calorics (33% have absent cVEMPs)
39
Q

more in utero disorders

A
  • rubella
  • –variable vestib loss, HL also associated
  • usher syndrome
  • –autosomal recessive genetic condition
  • –SNHL and retinitus pigmentosa
  • waardenburg
  • –HL, while forelock, and heterochromia iridium
  • –1 in 40000 affected
  • –77% of these kids have vestib loss
  • auditory neuropathy
  • –breakdown of vestib info transmission
  • –cVEMP absent often and caloric responses are variable
  • GJB2 connexin 26 mutations
  • –absent cVEMP and variable calorics, unilateral to bilateral
40
Q

acquired disorders in children

A
  • meningitis
  • –doesnt always cause vestib loss but can and can also be variable
  • –known to delay motor milestones
  • –expect poor balance
  • ototoxicity
  • –when vestib system is affected it is often widespread, otolith and SCCs
  • measles and mumps
  • –both are virus that is highly contagious
  • –vaccination has greatly reduced the concern
  • what is the concern most recently? anti-vaccers

AUD fall 2019 vestib (16 decks)

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