peds vestib eval - 8/18/2008 Welcome! to this...

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Unformatted text preview: 8/18/2008 Welcome! to this AudiologyOnline Live Expert e-Seminar Pediatric Vestibular Evaluation Presenter: Maureen Valente, Ph.D. Director of Audiology Studies Program in Audiology and Communication Sciences Washington University School of Medicine If you need assistance, please call AO at 800 753 2160 or submit a question using the Question Pod - please include phone number. Moderator: Paul Dybala, Ph.D. - AudiologyOnline Earning CEUs 1) 2) Must be logged in for full time requirement Must pass short multiple-choice test • Post-event email within 24 hours with instructions ( • Click on the “Start e-Learning Here!” button on the AO home page and login • Must pass test within 7 days of today • You must pass exam within 2 attempts to receive CEU credit Introduction Vestibular Assessment in Children Maureen Valente, Ph.D. Director of Audiology Studies Program in Audiology and Communication Sciences Washington University School of Medicine Audiology Online Course Presented on August 20, 2008 Importance Importance cannot be overestimated Comorbid Comorbid existence w/ other disorders: SNHL SNHL Childhood Childhood BPV Syndromes Syndromes Migraine Migraine OME OME Ophthalmologic Ophthalmologic Disorder Temporal Temporal Bone Fractures Literature Review: Two Major Bodies Occupational Occupational Therapy and Physical Therapy Motor Motor Delay Dyslexia Dyslexia Learning Disability Learning Disability Autism Autism Audiology Audiology and Otolaryngology Children Children demonstrating hearing impairment Children Children demonstrating normal hearing Introduction Introduction There There is a paucity of clinical work and research Early Early identification is important, as it is with hearing impairment with hearing impairment Understanding Understanding of vestibular system development is crucial Attain Attain child normative data Adapt Adapt adult techniques for children 1 8/18/2008 Literature Review: Nystagmic Response Maturation Eviatar Eviatar et al 1974, 1978 PerPer-rotary studies revealed that premature infants “caught up” by 9 mos. Oth Other researchers: varying results in measuring the VOR Van Van der Laan and Oosterveld (1974) found low nystagmic beat frequency and larger amplitudes Nystagmic Response Maturation AndrieuAndrieu-Guitrancourt et al (1981): beat frequency increases and maximum eye speed decreases with maturation Ornitz et al (1979): stronger amplitude Ornitz and velocity in one month olds versus 11 year olds Mulch Mulch and Peterman (1979): more intense response in middle to late middle age of adulthood Nystagmic Response Maturation Donat Donat et al (1980): VOR goes through several stages of maturation Healthy Healthy response several months after full term Fife Fife et al (2000): Absence of VOR by 10 months should be considered abnormal Krejcova Krejcova et al (1975): Differences between adult and child caloric response Children Children exhibited higher frequency of beats Kenyon Kenyon (1988) and Levens (1988): Consider differences when interpreting clinical results Additional Balance Disorders in Children Acute Acute spontaneous vertigo Head Head trauma Perilymph Perilymph fistula Neuronitis Neuronitis or labyrinthitis Recurrent Recurrent episodes Meniere’s Meniere’s MigraineMigraine-associated Seizure, Seizure, periodic ataxia or anxiety Additional Balance Disorders in Children Disequilibrium Disequilibrium and Ataxia Bilaterally Bilaterally hypoactive systems Otitis Otitis media Motion Motion sickness CNS CNS lesions MedicationMedication-induced Psychiatric Psychiatric Ocular Ocular Important Aspects of History Clumsy Clumsy Nausea Nausea Fear Fear Hearing Hearing loss Aural Aural fullness Carsickness Carsickness Falling Falling down Pressure Pressure change Postural control Vomiting Merry go round Tinnitus Visual disturbance Seizures Loud noises 2 8/18/2008 Medical/Physical Exam Oculomotor Oculomotor testing Spontaneous Spontaneous Gaze Gaze DixDix-Hallpike Head Head thrust Head Head shake Dynamic Dynamic visual acuity Standing Standing balance poses: posture and gait Test Techniques: VOG/EOG There There are many challenges in performing standard VOG with children! These These especially involve the darkened environment positional testing and environment, positional testing and bithermal bithermal caloric irrigation Landmark Landmark work of Cyr and colleagues at BTNRH in 1980s: rotary chair became a viable option for VOR assessment EOG/VOG: Adapting for Children A dizziness questionnaire is crucial for children dizziness Many Many studies are also within the OT literature related to disorders and dx Calibration: Calibration: cartoon characters on light bar Calming Calming fears within darkened room Parent/caregiver present i Electrodes Electrodes may be difficult PediatricPediatric-sized goggles exist for VOG/VNG Adapting VOG Techniques Oculomotor Oculomotor testing: Saccades: Saccades: can use animal characters although children will automatically follow lights and stripes lights and stripes OKN: OKN: Same as above; filling of visual field is important Tracking: Tracking: Same testing adaptation as described above Adaptation of VOG Techniques Spontaneous Spontaneous Nystagmus: Tasking with familiar nursery rhymes/children’s songs Gaze: Gaze: See previous suggestions re: cartoon characters cartoon characters May May need to vary because of habituation Also Also verify with your own observation Positioning Positioning and positionals may be more difficult, depending upon child Adaptation of VOG Techniques Hearing Hearing impaired children: may need written signs if they can read (EO, EC) Children Children may be tasked via sign language Bithermal Bithermal Caloric Irrigation is the gold standard, of course. This This is also the most challenging Air Air may be preferred, as may cool temp Tasking Tasking as before; may only be able to perform two irrigations Discussion Discussion of other VOG adaptations for children 3 8/18/2008 Rotary Chair (RC) This This has gained importance with children A milder and “more fun” stimulus milder Darkened Darkened enclosure may resemble spaceship hi Tasking Tasking with familiar nursery rhymes/songs It’s It’s important to observe the VOR on the tv screen Rotary Chair (RC) May May approach a screening rather than diagnostic Most Most common subtests are SHA and Step Velocity May May only be able to perform a few frequencies of SHA Gain, Gain, Phase and Symmetry Measures attained Normative Normative data used for children RC Measures Gain: A measure of reflex strength; eye velocity/head velocity Phase: timing relationship between head movement and reflex eye movement; compensatory eye movements may lead or lag the lead or lag the head movement Asymmetry: slow component eye velocity of right versus left Step Velocity: Time in seconds for nystagmus to decay to 37% of its original strength (Time constant) Upon full acceleration (per-rotary) (perUpon stopping (post-rotary) (post- Rotary Chair (RC) Gain Gain measures are oftentimes different than with adults, at least at some frequencies (Valente, 2007) The same may be found with regard to The same may be found with regard to phase phase (Valente, 2007) Head Head stabilization is a crucial factor Important Important to test several frequencies: may see hypoactivity at one and not another Younger 10 8 6 4 2 0.72 0 (0.1) Older 9.5 7.5 6.3 Younger 10 8 6.2 6 4 2 0.8 (0.1) Older 6.8 4.9 5.1 5.4 0.71 (0.1) (7.5) (4.6) (5.4) (5.6) 0.77 (0.1) (9.5) (3.4) (3.9) (5.3) 0 Gain (unlabelled) Symmetry (%) Phase (degrees) Gain (unlabelled) Symmetry (%) Phase (degrees) Means and SDs (in parentheses) for RC measures at .08 Hz: ANOVA revealed no significant differences between the two groups of children. Means and SDs (in parentheses) for RC measures at .5 Hz: ANOVA revealed no significant differences between the two groups of children. 4 8/18/2008 Comparisons of Pediatric Results and Adult Normative Data .08 Hz Gain Younger Older Adult .72 .71 .5 - .65 Asymmetry 5.41 4.83 -15 – +15 .50 Hz Phase 9.45 6.28 -13 - +3 Pearson Correlation Coefficients TestTest-retest reliability for .08 and .5 Hz .08 Hz Gain 1-2 1Gain 1-3 1Asymmetry 1-2 1Asymmetry 1-3 1Phase 1-2 1Phase 1-3 1- .893* .783* .315 .372 .696* .501* Younger Older Adult .80 .77 .5 - .89 6.21 4.86 -5.2 - +15 5.10 6.76 -15 - +15 .50 Hz .591* ** p < .05 * p < .01 .408** .722* .284 .312 .007 a. Onea. One-sample t-tests: significantly higher gain for children than adults at .08 Hz (p< .05). tb. A significant phase lead at .08 Hz was seen for children when compared with adult normative data (p<.01). Rotary Chair (RC) Child Child may sit on parent lap May May need to open door between subtests Step Step Velocity may be performed, but is challenging challenging Time Time constants may be important measures but are difficult to attain, due to head stabilization More More research needed on other subtests Other Other modifications/issues with children CDP CDP Studies Studies have also been seen in the PT literature Smallest Smallest harness used Children oftentimes feel this is “ride-like” Children oftentimes feel this is ride Must Must determine height beforehand since this determines magnitude of MCT translations Allaying Allaying of fears and reinforcement, as always Brief Literature Review DiFabio DiFabio and Foudriat (1996): Even a child as young as 3 years may be tested Performance Performance increases as he ages Hirabayashi Hirabayashi and Iwasaki (1995): somatosensory system matures by 3-4 years Visual Visual system: 15 years Vestibular Vestibular system: last to mature and many children have not reached maturity by 15 years Shimizu Shimizu et al (1994): CDP pediatric and adult performance differed greatly (6 – 13 years) Brief Literature Review Cyr Cyr and colleagues felt CDP should be performed: History History of imbalance “Clumsiness “Clumsiness” Clumsiness Neurological Neurological impairment Suspected Suspected organic disease Rine Rine et al (2000): Subjects of 3-7 years; 3SOT provides useful measures of systems and their maturation 5 8/18/2008 CDP SOT SOT and MCT are most common subtests Sensors Sensors not equipped for children under 40 pounds (Neurocom) (Neurocom) Consider conditions trials apiece Consider 6 conditions, 3 trials apiece May May not be able to perform all 3 trials, due to attention span This This is important, though, for reliability Could Could possibly begin w/ more difficult conditions CDP Valente Valente (2007): CDP performance on 4-6 year 4olds reduced compared to older children and adults CDP CDP performance on 9-11 year olds reduced 9compared to adults compared to adults No No MCT norms existed prior MCT: MCT: Calm fears Learning Learning curve seen Quick Quick and efficient w/ children (takes 10 minutes) Younger 100 Older * 90.5 *86.9 * 88.9 82.1 77.2 80 74.8 60 Comparisons Comparisons of Pediatric SOT Conditions with Adult Normative Data Cond 1 Cond 2 Cond 3 Cond 4 Cond 5 Cond 6 Comp * p < .01 * 71.4 46.1 * 69.4 * 53.9 * 55.8 51 31.1 31.5 Younger 82.1 51.0 Older 69.4 Adult 70.0 90.5 94.0 77.2 86.9 92.0 74.8 88.9 91.5 46.1 71.4 82.5 31.1 53.9 69.2 31.5 55.8 67.2 40 20 0 One sample t-tests: tYounger versus Adult: Significant age effects on all 6 Conditions (p<.001) Adult: Cond 1 Cond 2 Cond 3 Cond 4 Cond 5 Cond 6 Comp SOT means showing age effects for Conditions 1-6: ANOVA results revealed that younger children achieved significantly lower scores than older children on all conditions. Older versus Adult: Significant age effects on all 6 Conditions Adult: (p<.01 for Conditions 1 and 2, <.05 for Conditions 3-6) 3- Younger 16 14 12 10 8 6 4 2 0 (4.5) (2.8) (3.7) (4.3) Older 13.6 14.6 CDP ** p < .05 ** 13.5 11.4 14.3 12.3 13 15.3 (3.6) (3.9) (3.5) (3.5) CCW Mov CCW Stop CW Mov CW Stop Means and SDs (in parentheses) for SV Time Constants: ANOVA revealed a significant age effect for the “CW Stop” TC. All pediatric TC means were within the adult normative range of 5 – 25 seconds. MCT: MCT: Very few significant differences between children and adults Is Is the 200 msec. “cut off” still appropriate with children? Case Case studies with hearing impaired children revealed abnormalities (variable) More More research is needed related to these and other subtests Differential Differential dx with disorders; results to expect with childhood syndromes Referral Referral to pediatric CDP articles Other Other pediatric adaptations 6 8/18/2008 Motor Control Test (MCT) Small F Med. F Lg. F Small B Med. B Lg. B VEMP VEMP Kelsch Kelsch et al (2006): Children from 3-11 years (2006): Found Found shorter latency on initial peak VEMP VEMP is well tolerated Sheykholeslami Sheykholeslami et al (2005): 12 normal (2005): neonates and 12 with clinical findings neonates and 12 with clinical findings Morphology Morphology similar to that of adults; shorter latency of N peak and amplitude variability Valente (2007): Valente (2007): VEMP is a viable technique with children Shorter Shorter latencies as compared to adults (4-6 (4 year olds and 9-11 year olds; P1 and N1) P1 N1 Younger 156.2 Older Adult 146.0 147.6 140.8 143 139.0** 129.0 135 133.3 133.7 129.1 131.2 124 129.8** 120.2 117 ANOVA ANOVA revealed significant differences between pediatric groups: LF and LB (p<.05). OneOne-sample t-tests: tYounger vs. Adult: Significant age effects seen with backward translations (p<.001). Adult: Older vs. Adult: Significant age effects seen with medium backward (p<.001). Adult: Older children performed significantly better with large forward (p<.05). Younger Older Adult 30 25 20 15 13.3 13.9 10 5 0 (1.5) (2.0) (2.5) (1.7) (1.9) (2.2) (1.7) (2.2) (2.9) (2.3) (2.9) (2.9) Younger Older Adult 70 25.2 65.6 47.2 39.1 49.9 43.9 22.8 18.8 19.8 16 15.6 16.5 18.3 22.7 23.4 60 50 40 36.8 30 20 10 7.7 8.3 6.7 (22.3(32.5)(12.5) ) (4.7) (4.5) (2.7) (29.5)(43.7) (25.0) 9.6 10.5 7.4 (6.3) (6.5) (3.7) P1 Click N1 Click P1 Tone N1 Tone 0 Raw CL Norm CL Raw TB Norm TB Adaptation of VEMP Technique Electrodes Electrodes utilized: call them a sticker and then they’ll receive a “more fun” sticker afterwards Child Child focused upon wall mounted cartoon character to maintain neck contraction Sometimes Sometimes difficult to maintain this pose Pediatric Pediatric inserts used May May be able to use 64 sweeps instead of 128 Bilateral Bilateral tracings may be more efficient Replicate Replicate tracings Adaptation of VEMP Techniques May May wish to have parent present This This seems to be more intimidating than RC or CDP Robust Robust waveforms seen at 500 Hz May not be necessary to test additional May not be necessary to test additional frequencies, frequencies, especially if a screening Amplitude Amplitude variable Ways Ways needed to control for level of neck contraction Be Be aware of intensity level with regard to small ear canal 7 8/18/2008 Adaptation of VEMP Techniques Other Other issues related to VEMP Is Is quick, efficient and non-invasive nonResearch Research is needed related to latencies and maturational effects of age More More research is needed related to BC VEMP, stimuli used, procedures, findings with various disorders and syndromes Implications for Future Research Vestibular Vestibular testing with children is an important area that is sometimes overlooked More teamwork is needed w/ other More disciplines Additional Additional adaptation of techniques for younger children Test Test findings that we may see with disorders and syndromes Case Studies with HearingHearingImpaired Children 1. How might vestibular function of hearing-impaired children hearingbest be evaluated? Are the assessment tools described in the current study efficiently used with this population? 2. What are the effects of hearing impairment upon measures comprising the vestibular evaluation battery: RC, CDP and VEMP? It is hypothesized that hearing status effects will be seen when comparing with newly-acquired pediatric norms: newlyRC gain, phase and SV time constants CDP conditions: SOT and MCT Case Study Subjects ●Bilateral SNHL of at least a moderate degree ●Congenital or acquired loss ●Current users of hearing aids or CI ●Children utilizing total communication were excluded ●Four children recruited within younger age group: two could not adapt to tasks required ●Seven children recruited within older age group Methods ●Same vestibular test battery: RC, CDP and VEMP ●Free of middle ear disease via tympanometry ●Provided with auditory and visual cues for all instructions ●Same patient preparation procedure ●Tasked appropriately during RC testing ●Most recent audiogram provided by parent Case Study #1 #1 ●6-11 year old female ●Etiology unknown ●Acquired versus congenital status unknown ●CI in right ear for several years ●No measurable response in right ear at limits of equipment ●Profound loss at 250 and 500 Hz with NR at higher frequencies in left ear 8 8/18/2008 Vestibular Evaluation Summary RC: Immeasurably low gain seen at .08 Hz with no nystagmus noted in response to rotation Phase and asymmetry measures could not be attained .50 Hz: Gain of .76, Asymmetry of 7 and Phase of 4 No nystagmus noted in response to Step Velocity testing; test results were non-interpretable non- Case Study #1: VEMP Results No VEMP response could be attained for the right ear for either click or toneburst stimuli. Left P1 N1 P1P1- N1 CL 13 13.1 2 1 .1 21 5.76 TB TB 15.9 21.1 5.41 Summary of Case #1 ●Unsure and disoriented when visual cues removed ●Falls and lowered scores seen on CDP when relying upon vestibular input Case Study #2 ●9-11 year old female ●Etiology of hearing-impairment is meningitis hearingin early infancy ●RC: NR at lowest frequency and SV at lowest frequency and SV ●Profound SNHL bilaterally ●No VEMP for right, implanted ear ●Successful user of binaural behind-the-ear behind-thehearing aids since early infancy RC: Vestibular Evaluation Results: Case Study #2 Gain .76 .80 Asymmetry 4 1 Phase 4 2 VEMP Results: Case Study #2 R CL L CL R TB L TB P1 12.7 12.5 17.5 14.5 N1 17.9 18.5 25.3 20.3 P1P1-N1 6.16 10.83 4.14 5.71 .08 Hz .50 Hz SV: CW: TC of 12 sec. and 13 sec. CCW: TC of 8 sec. and 12 sec. CDP: Wide variability with conditions 4-6 4Nausea and pallor noted post-testing post- Summary: RC and VEMP essentially within normal limits. Difficulty seen on CDP conditions where the child relied on vestibular input alone. Each child is unique and should be evaluated independently. 9 8/18/2008 Case Study #3 ●10-4 year old female 10●Etiology of congenital hearing impairment is unknown ●Profound SNHL bilaterally, with no responses seen at limits of equipment VEMP Results: Case Study #3 P1 N1 R CL 13.3 20.3 R TB 14.9 22.7 NR seen for left ear P1P1-N1 1.68 3.09 ●CI in right ear for several years ●RC: Exceptionally low gain at .08 Hz (.14) and .50 Hz (.17). ●NR to Step Velocity testing Summary: RC: RC: low gain measures at both frequencies CDP: CDP: falls seen with use of vestibular input alone VEMP: VEMP: appeared WNL for RE but absent for the LE The right is the implanted ear and this emphasizes importance of evaluation pre- and post-implantation whenever possible. prepost- Conclusions HearingHearing-impaired children may be successfully evaluated with the test battery described and pediatric normative data are crucial. RC: a. several test frequencies b. observe nystagmus b. observe nystagmus c. many exhibited hypoactivity Conclusions (cont.) VEMP: This is a feasible and valuable procedure, used to provide information about saccular function. Each of the 9 subjects exhibited some type of difficulty with one or more subtests of the entire battery. Stresses importance of: Adapting techniques for children Child normative data Testing children with SNHL: hearing aid users and CI recipients CDP: a. assessment of functional balance b. many exhibited difficulty when relying upon vestibular input alone A Suggested Vestibular Evaluation Battery for Children RC: Directions for Future Research ●Thorough pediatric questionnaire ●Methodologies for younger children ●Relationships with various disorders ●CDP: sensors for <40 pounds ●RC: additional test frequencies test frequencies enhanced head stabilization methods Two frequencies (lower and higher) and SV measures Gain seemed to be the most reliable parameter CDP: All three trials necessary; two possible for older children under conditions #4-6 hild #4 VEMP: Only one stimulus ●VEMP: other stimuli threshold measures additional age effects bonebone-conducted VEMP monitoring of tonic EMG activity Repeat tracings 64 sweeps 500 Hz: more robust amplitudes 10 8/18/2008 Directions for Future Research ●Enhanced team approach toward evaluation and remediation ●Continued adaptation of adult techniques for children ●Continued focus toward early identification In Closing: Children may be evaluated and many should be evaluated. Just as we strive toward early identification of hearing loss, we should also strive for early identification of vestibular disorders. The sooner identified, the sooner remediation may begin when and if warranted. 11 ...
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This note was uploaded on 04/11/2010 for the course AUD 831 taught by Professor Drlisakoch during the Spring '10 term at A.T. Still University.

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