ABSTRACT
Objectives
To date, there are no clear guidelines in the literature on protocols for pediatric vestibular testing, and approaches may differ between teams. The objective of this study was to establish a consensus guideline for the minimum pediatric vestibular tests that should be conducted in both expert and non‐expert centers.
Methods
The leadership group identified 21 international experts in the pediatric vestibular field to participate. A modified Delphi process conducted over three rounds was employed to quantify consensus based on expert opinion. Consensus was considered achieved when over 80% of the participants agreed on a given proposition.
Results
For a non‐expert team wishing to develop a pediatric vestibular protocol and irrespective of the child's age, 17 respondents (81%) agreed that the minimal vestibular testing should include lateral canal vHIT with remote camera (and/or rotary chair) and bone conduction cervical VEMPs. The same tests were selected by 17 respondents (81%) for testing 1‐year‐old children with an expert team. For an expert team testing a 4‐year‐old child, 17 respondents (81%) agreed that the minimal testing should include vHIT in all canals, cervical and ocular VEMPs using bone or air conduction, and rotary chair. No consensus emerged for the testing of eight‐year‐old children.
Conclusion
This international consensus aims to help both expert and non‐expert teams conduct more comparable age‐dependent vestibular test protocols in children, fostering collaboration and establishing minimal standards for new teams. The key vestibular tests for children seem to be vHIT (and/or rotary chair) and cVEMP in bone conduction.
Level of Evidence
NA.
Keywords: children, cochlear implant, vertigo, vestibular testing
This study represents the first international consensus on vestibular testing in children. Twenty‐one international experts from nine countries provided guidelines on the recommended minimum test battery necessary to perform a pediatric vestibular assessment.
1. Introduction
Vestibular testing is a key part of the evaluation of young children presenting with gross motor delay, balance impairment, or other vestibular symptoms, particularly in the setting of concomitant sensorineural hearing loss (SNHL). In most cases, the clinical exam is sufficient for diagnosis, as in the case of vestibular migraine, which is the most common cause of vertigo in children [1]. However, in cases of inner ear malformations or profound SNHL, the prevalence of pediatric vestibulopathy increases substantially to between 30% and 70% [2, 3].
The evaluation of children with vestibular dysfunction can be challenging due to frequently limited subjective history, tolerance, and cooperation during the clinical evaluation. Achieving a reliable vestibular evaluation in young children requires well‐trained specialists and staff. In some cases, test sessions may need to be repeated depending on the child's stamina or cooperation. A recent French study [4] showed that despite the need to perform a vestibular assessment before cochlear implantation, national recommendations [5] were difficult to follow due to limited clinician expertise in testing young children. International recommendations on pediatric vestibular testing are very limited, although efforts are being made to make vestibular tests more user‐friendly [6, 7] and more conducive to screening at a local community level [8].
The present work aimed to reach a consensus on ideal vestibular test batteries in children with a twofold objective. First, we aimed to provide guidelines for expert teams who already have extensive expertise in testing children to promote data sharing and multicenter studies. Second, we aimed to advise teams who are not experts in this field on the recommended minimum test battery necessary to perform a clinically adequate pediatric vestibular assessment, even in younger children.
2. Materials and Methods
The mission of the International Pediatric Otolaryngology Group (IPOG) is to develop recommendations for the management of pediatric otolaryngological disorders and improve patient care. An international consensus committee was selected by a leadership group (FS, AC, JB, ID) and included experts in the pediatric vestibular field based on their clinical expertise, publications, and international presentations. A total of 21 panelists from nine countries (five each from France and the United States, two each from Belgium, Canada, and the United Kingdom, respectively, and one each from Chile, Malaysia, the Netherlands, Spain, and Sweden, respectively) participated in the consensus statement development group.
A modified Delphi process conducted over three rounds was employed to systematically quantify consensus based on expert opinions. During the first round, the 21 experts were invited to complete an online questionnaire focusing on all items that could be relevant for the consensus based on the literature and personal experience of the leadership group. Questions were asked in reference to both expert pediatric vestibular programs and non‐expert teams. Following panelists' responses, propositions were modified and new propositions were added before being sent out in a second round. In the third round, experts had to indicate if they agreed or disagreed with each item. Consensus was considered achieved when over 80% of participants agreed on a given proposition. This study did not require institutional review board approval, as no direct experimental or human study was performed.
3. Results
3.1. Characteristics of the Panelists
Fourteen (67%) respondents exclusively managed pediatric patients, while seven (33%) had a mixed adult/pediatric practice. Concerning pediatric cochlear implantation (CI), 10 (38%) respondents were from institutions that carried out between 50 to 150 pediatric CIs per year, nine (43%) were from institutions with less than 50 CIs per year, and two were from CI centers that did not carry out pediatric CI. All respondents were involved in a specialized pediatric vestibular clinic for the past two to more than 30 years (mean 11.5 ± 8.5 years).
Figure 1 summarizes the approximate number of patients undergoing vestibular assessments in the 21 centers and according to pediatric age. Most centers reported 20 to 40 pediatric vestibular consultations per month, but less than 10 per month for children under the age of 3.
FIGURE 1.
Number of children undergoing vestibular testing per month per center. Blue and orange, respectively, correspond to consultation dedicated to children under 3 and 18 years old. [Color figure can be viewed in the online issue, which is available at www.laryngoscope.com.]
Only 8 (38%) panelists regularly used quality of life questionnaires (the Pediatric Dizziness Handicap Inventory for Parents and Caregivers [9]) both for research purposes and clinical practice.
3.2. Consensus Statements
All of the panel members stressed that the vestibular assessment should begin with a general clinical exam. This assessment should include oculomotricity and neurologic assessments (including saccades), the head impulse test, the assessment of head postural control (specifically if the child has not yet learned to walk), and walking (if feasible).
Then, vestibular testing should be performed with regard to the center's experience (i.e., expert vs. non‐expert teams) and patient age. Panelists reached consensus in round three (81% of agreement) for the minimal equipment needed and the minimal assessment that should be done in non‐expert teams based on the child's age (Table 1). Concerning expert teams, panelists reached consensus on two statements: the recommended minimal assessment for a 1‐year‐old and four‐year‐old child. Notably, respondents stressed that it was essential to assess otolith function with VEMPs and semicircular canal function with either vHIT or rotary chair testing.
TABLE 1.
Consensus statements for minimal vestibular assessment.
| Statements | Agreements (%) |
|---|---|
For a non‐expert team wishing to develop a pediatric vestibular consultation, and whatever the child's age, the minimal equipment is:
|
81 |
For a non‐expert team wishing to develop a pediatric vestibular consultation and whatever the child's age, the minimal vestibular assessment should consist of:
|
81 |
For an expert team wishing to test 1‐year‐old children, the minimal vestibular assessment should consist of:
|
81 |
For an expert team wishing to test 4‐year‐old children, the minimal vestibular assessment should consist of:
|
81 |
Note: The ages given in the table are indicative and do not represent strict limits.
Abbreviations: AC: air conduction; BC: bone conduction; cVEMPs: cervical vestibular evoked myogenic potentials; oVEMPs: ocular vestibular evoked myogenic potentials; vHIT: video head impulse test.
The vestibular assessment for an 8‐year‐old child had the lowest agreement rate at 71.4% (Table 2). Even if all panelists agreed that in expert teams the vestibular assessment in older children should include the evaluation of semicircular canal, saccular, and utricular function, they did not find consensus on the specific tests to be performed. Respondents who did not support this testing (i.e., first statement in Table 2) suggested various alternative propositions such as adding the caloric test, removing the rotary test, performing VEMPs in bone conduction whatever the age, or using the subjective visual vertical test instead of oVEMPs.
TABLE 2.
Items that did not reach consensus.
| Statements | Agreements (%) |
|---|---|
For an expert team wishing to test 8‐year‐old children, the minimal vestibular assessment should consist of:
|
71.4 |
| Caloric tests in children have a low yield/clinical benefit and should not be performed systematically. They may be used in rare cases (mainly if no other vestibular test is feasible, or if hydrops is suspected) | 76.2 |
Note: The age given in the table is indicative and does not represent strict limits.
Finally, for expert and non‐expert teams, 20 panelists (95%) recommended testing in a precise order: (a) general clinical exam, (b) vHIT, rotary chair, and cVEMPs (in various orders), and (c) caloric testing (when indicated).
3.3. Age‐Related Feasibility and Frequency of Vestibular Testing in Expert Teams
The reported feasibility of each vestibular test depended on the child's age, and key trends emerged (reported in Figure 2). There were subtle differences between panelists for any given test; thus, these results only indicate an overall tendency, especially for non‐expert centers.
FIGURE 2.
Feasibility of vestibular tests according to age for the majority of panelists. This figure is not limiting, and tests may be feasible outside of these boundaries in certain conditions. AC: air conduction; cVEMPs: cervical vestibular evoked myogenic potentials; oVEMPs: ocular vestibular evoked myogenic potentials; vHIT: video head impulse test. [Color figure can be viewed in the online issue, which is available at www.laryngoscope.com.]
Semicircular canal function can be evaluated by three main vestibular tests (vHIT, rotary chair and caloric test) with variable ease of use, tolerance, and type of measurement. vHIT was declared feasible for a 1 year old by 15 (71.4%) panelists with a specific remote camera system that does not require goggles (e.g., the Inventis‐Synapsys device); goggles could be used after 4‐years‐of‐age, according to 15 (71.4%) respondents. Eleven panelists (52%) considered that before 2 years old, it was easier to evaluate only the lateral semicircular canals, and from the age of two onwards, all six semicircular canals should be assessed. The other panelists reported that they did not perform vHIT until 2 years old (n = 5) or only tested the lateral canals (n = 5) with VHIT and not the vertical canals. In order to obtain a reliable and interpretable vHIT, a minimum of 5 reproducible vHIT traces per canal would be needed according to 13 (62%) respondents, 10 according to 5 respondents (24%), and 3 according to 3 respondents (14%).
All the respondents agreed that the rotary chair could be feasible before one year of age with a camera technique; of which 14 (67%) preferred a mechanical stimulation with a sinusoidal test.
The caloric test was much debated among the panelists; 16 (76.2%) agreed that it had a low yield in pediatric vestibular testing and reported poor tolerance in children younger than 4–6 years old. The remaining five panelists declared that they performed caloric testing in addition to vHIT and cVEMPs, specifically when the latter were normal and there was a strong suspicion of a peripheral vestibular disorder. The preferred stimulation was water (n = 13), and most panelists (n = 14) began with cold irrigations regardless of the mode of use (water or air).
The panelists highlighted two main tests for the evaluation of otolith function: cervical and ocular VEMPs for saccular and utricular function, respectively. Twenty (95%) panelists considered cVEMPs to be feasible in children as young as 6 months of age by placing the child on his/her parents' lap with the head held by the examiner or the parents. Of these panelists, half (10/20) performed this test from the age of 3 months. Concerning oVEMPs, 12 (62%) panelists felt that they are feasible in children as young as 4 years old, and four panelists (19%) indicated that they are feasible in children as young as 1 year old if the child tolerated electrodes under the eyes. Of the remaining panelists, three said that oVEMPs were feasible for children over 8 years old, and two answered that they had no experience with this test.
Only five (24%) panelists frequently used a posturometry platform evaluation in children older than 8 years, with the following four conditions: “Open eyes stable platform, Open eyes unstable platform, Eyes closed stable platform, Eyes closed unstable platform.” The other panelists did not routinely perform posturometry.
Panelists were also asked about the frequency of use of each vestibular test in their current practice (Figure 3A) and the perceived discomfort children experience with each test (Figure 3B), whatever the child's age. On a scale of 0 (never) to 5 (always), the most commonly used vestibular test was cVEMPs (4.9 ± 0.2), closely followed by vHIT (4.6 ± 0.6). On a scale of 0 (not at all) to 10 (very important), the test perceived as the most uncomfortable was the caloric test (6.4 ± 2.0) while the discomfort of the other tests was below 3.5.
FIGURE 3.
(A) frequency of use and (B) perceived discomfort of vestibular tests in children according to the panelists' own daily practice. This figure reflects reality in the field and is not a recommendation on the use of each test. Means (“x” crosses), medians (black bold bar) and standard deviations for vestibular tests. Extremities of each box represent minimum and maximum. [Color figure can be viewed in the online issue, which is available at www.laryngoscope.com.]
3.4. Vestibular Testing in Cochlear Implant Candidates
Panelists were also asked about their vestibular assessment protocol for cochlear implant candidates. On a scale of 0 (never) to 5 (always), most panelists highlighted the necessity to perform vestibular testing before a unilateral or bilateral CI (4.1 ± 1.3). However, only 13 respondents (62%) took into account the result of the vestibular evaluation when choosing between simultaneous or sequential CI. In cases of a simultaneous CI, the necessity of performing a vestibular evaluation after the surgery was 4 ± 1.2. For a sequential bilateral CI, the recommendation for a vestibular assessment between both surgeries received an average rating of 4.4 ± 0.8.
4. Discussion
The present work was able to identify four consensus statements for vestibular testing in children. They considered the following key points: the feasibility of the vestibular tests according to the child's age and the practitioner's experience, the clinical relevance of these tests, and the perceived level of child tolerance.
The panelists all agreed that all vestibular test batteries should be preceded by an age‐appropriate history and physical exam. The first consensus highlighted that the minimal equipment needed to develop a pediatric vestibular testing program should be vHIT with remote camera (or rotary chair instead) and VEMPs to both evaluate the canal and saccular function, whatever the child's age (second consensus).
For the vestibular evaluation of a 1‐year‐old child performed by an expert team, 81% of the panel agreed that canal function should be assessed by rotary test or vHIT with a remote camera, focusing on the lateral canals, and saccular function by cVEMP testing (third consensus). The positive tolerance of these two tests by younger children appears to be a primary reason for the high level of agreement for this recommendation (intensity of discomfort out of 10 for vHIT and cVEMPs: respectively 2.2 and 3.1).
These consensus statements align with recent literature. Martens et al. developed a vestibular screening program in Belgium (Flanders) for all children with hearing loss. They explored the most appropriate vestibular screening tool for the youngest children: from the age of 6 months, and advised that cVEMPs allow for early detection of saccular dysfunction, which could impact a child's static and dynamic postural control. The use of cVEMPs often does not require purchasing new equipment, as they can be recorded with standard auditory brainstem response testing devices [8, 10]. Under 3 years old, the Belgian authors completed their vestibular screening by exploring the canal function with vHIT of the lateral canals and the rotary test [11]. From their point of view, the advantage of adding vHIT was to highlight an associated canal deficit, common in children with SNHL secondary to congenital cytomegalovirus (CMV) or inner ear anomalies (e.g., Mondini malformation, enlarged vestibular aqueduct).
There is conflicting evidence in the literature regarding the added value of the rotary test to assess the function of the lateral canal. Gerdsen et al. evaluated the sensitivity and the specificity of each vestibular test in a large cohort of hearing‐impaired children aged 0–8 years old [12]. They showed that vHIT combined with cVEMPs had the best diagnostic accuracy (i.e., 94%) to find a vestibular deficit as a first‐line test; and there was no benefit in adding a third test to improve the diagnostic accuracy. They recommended starting the vestibular evaluation with vHIT, regardless of the child's age. If vHIT results are normal but there is still suspicion of vestibular impairment, cVEMPs should then be performed. Another recent study demonstrated that the rotary test would be a valuable alternative to vHIT (a) when rapid head movements are poorly tolerated by children, and (b) to detect milder vestibular losses for the lateral canal [13]. The rotary test is also preferred in the United States and many other countries where the remote camera vHIT system is not yet available or approved by government regulatory bodies (e.g., the Food and Drug Administration in the United States).
Finally, the clinician's interpretation must take into account the limits of each test (e.g., the rotary test only evaluates the medium frequencies from 0.01 to 0.64 Hz with limited side specificity) and the child's age, as the maturation of each vestibular organ continues through adolescence [14, 15].
A fourth consensus was reached for the vestibular evaluation of a 4‐year‐old child by an expert team. In addition to obtaining vHIT of lateral canals and cVEMPs, the clinician should add the evaluation of the vertical canals with vHIT and utricular function via oVEMP testing. This recommendation is in line with the screening program of Martens et al. who suggested performing the same evaluation by 3 years old [8].
To make these recommendations possible in children, it is essential to adapt each vestibular test in duration and adapt them for younger children. The panelists of the DELPHI advised using a remote camera for vHIT until the age of four (e.g., the Inventis‐Synapsys device—Marseille, France) [16], where available. This system allows the child to keep their head free while recording the eye and head movements by a distant infra‐red camera. To ensure the reproducibility of the test, 80% of the panel suggested making 5–10 measurements per canal. This recommendation was also followed by Gerdsen et al. for children under 4 years of age; for the oldest, the authors performed up to 15 traces per canal [12]. Moreover, to avoid eye blinking and increase the attention of the child during vHIT, the examiner can replace a simple dot target (used for adults) with an animated and attractive target, such as a tablet or a toy [15].
The consensus group also recommended using a bone conduction stimulus for cVEMP testing in younger children, rather than air conduction, to avoid inaccurate results caused by middle‐ear effusion or by altered middle ear mechanics after CI. There is no strict age limit for bone conduction stimulation, but the panelists suggested it was possible to use an air conduction stimulus from the age of 4 years old when the prevalence of middle ear effusion decreases [8, 11, 17, 18]. The use of an animated and attractive target is also valuable for cVEMPs and oVEMPs to maintain sufficient muscle contraction of the neck or up‐gaze.
With the DELPHI method, the evaluation of an 8‐year‐old child did not reach consensus, and the most debated point was the use or not of the caloric test. Most panelists considered this test to be feasible from the age of six, which is supported by studies in the literature [6, 19]. But even if the caloric test is feasible, it did not seem to be frequently ordered by the panelists (mean 2.9 out of a 5‐scale) primarily due to poor patient tolerance (intensity of child discomfort perceived by the panel: 6.4 out of 10 compared to 2.2 for vHIT). Many authors have suggested that the caloric test should be considered in children in second intention if there was a high suspicion for vestibular impairment, despite normal data being found on initial vestibular testing with vHIT and VEMPs [8, 12], or in specific circumstances (e.g., before a cochlear implantation, follow‐up of a congenital CMV infection).
In practice, performing vestibular testing in very young children (less than 2‐years‐old) is particularly relevant in children with SNHL who are at higher risk for having associated vestibular deficits [7]. Although there is still considerable debate in the literature about the impact of CI surgery on vestibular function [20, 21, 22, 23, 24, 25], it seems also important to perform a minimal vestibular assessment prior to CI in children. Partial or complete vestibular impairments could lead to significant delays in early developmental milestones, such as head‐holding, sitting, and walking. In older children, vestibular impairments could have a negative impact on reading and writing skills due to impaired gaze stabilization, in addition to impacts on dynamic balance and motor coordination [26, 27, 28, 29]. The earlier the vestibular deficits are detected, the sooner rehabilitation can begin.
5. Conclusion
Based on a majority consensus survey of pediatric vestibular specialists, it is recommended that pediatric vestibular testing prioritize evaluation of the lateral semicircular canals (via the rotary chair test and/or vHIT) and the saccule (via cVEMPs), specifically in very young children or in non‐expert centers who may be limited in their access to resources. In an expert pediatric vestibular program accustomed to testing children, after 4 years of age, clinicians should test all canals and both saccular and utricular function with vHIT, the rotary chair test, cVEMPs, and oVEMPs. However, clinicians may try to perform these tests at an earlier age, when conditions allow. Utilization of standardized recommendations globally will enable more consistent and equitable clinical service delivery. It will also enable more researchers to share clinical data to improve our understanding of pediatric vestibular disorders and the impact of early identification of vestibular impairment in young children.
Conflicts of Interest
The authors declare no conflicts of interest.
Coudert A., Brodsky J. R., Dhooge I., et al., “International Pediatric Otolaryngology Group (IPOG) Consensus on Vestibular Testing in Children,” The Laryngoscope 135, no. 11 (2025): 4412–4418, 10.1002/lary.32261.
Funding: The authors received no specific funding for this work.
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