Pediatric Vestibular Assessment: A Guide for Clinicians

Aug 29, 2025

Why Pediatric Vestibular Assessment Matters

Pediatric vestibular assessment is an often-overlooked area in clinical practice. Yet research shows that nearly 50% of children with hearing loss have some degree of vestibular dysfunction (Cushing et al., 2013; Verbecque et al., 2017). Risk is higher in children with:

Severe hearing loss (>66 dB)
Structural inner ear anomalies (e.g., enlarged vestibular aqueduct)
Congenital cytomegalovirus
Usher syndrome type 1
Meningitis or temporal bone fracture
Ototoxic medication exposure

Undetected vestibular loss in children can lead to gross motor delays, poor postural control, academic challenges, and limited participation in sports or play. Early pediatric vestibular testing allows timely intervention and better developmental outcomes.

Given this, here are some tools you can use to screen for vestibular impairments with the pediatric population.

Pediatric Vestibular Testing: Age-Appropriate Options

The American Academy of Audiology Clinical Consensus Statement (2024) outlines vestibular function tests by age group.

Test	0–2 years	3–7 years	8+ years
Bedside Tests
Identification of nystagmus (spontaneous & evoked)	✔	✔	✔
Head impulse test (HIT)	✔	✔	✔
Dynamic visual acuity (DVA)		✔	✔
Tandem stance/walk		✔	✔
Romberg		✔	✔
Modified Clinical Test of Sensory Integration of Balance (mCTSIB)		✔	✔
Single-leg stance		✔	✔
Laboratory Tests
Head shake nystagmus	10+ months	✔	✔
Skull vibration induced nystagmus	10+ months	✔	✔
Positional		4+ years	✔
Oculomotor		4+ years	✔
Rotary chair	✔	✔	✔
Video head impulse test (vHIT)	✔	✔	✔
Caloric testing		5+ years	✔
Cervical VEMP (cVEMP)	✔	✔	✔
Ocular VEMP (oVEMP)	(may attempt)	✔	✔

Bedside Pediatric Vestibular Tests and Adaptations

1. Identification of Nystagmus

Pediatric adaptation: Use flashing toys, parent-assisted head stabilization, dim lighting or Frenzel goggles.
Interpretation: Peripheral loss = horizontal nystagmus opposite lesion; vertical/torsional or non-suppressible nystagmus = possible central cause.

2. Head Impulse Test (HIT / vHIT)

Pediatric adaptation: Toys or stickers as fixation points, short unpredictable impulses (~15°).
Key indicator: Catch-up saccades suggest impaired VOR.

3. Dynamic Visual Acuity (DVA)

Adaptation: Pocket Sloan or LEA symbols, ~16-inch viewing, head moved at 2 Hz.
Indicator: ≥2-line drop from static acuity = VOR deficit.

4. Postrotary Nystagmus

Adaptation: Swivel chair rotation for 30 seconds, eyes closed.
Indicator: Absence of postrotary nystagmus when tested in both directions suggests bilateral vestibular loss. If postrotary nystagmus on one side decays before 15 seconds in room light and 24 seconds with visual fixation removed, predictive of vestibular loss.

Laboratory-Based Pediatric Vestibular Tests

Vestibular Evoked Myogenic Potentials (VEMPs)

cVEMP: Tests saccule/inferior vestibular nerve; feasible from newborn age.
oVEMP: Tests utricle/superior vestibular nerve; reliable from age 4.
Pediatric adaptation: Fun targets for gaze, parent lap positioning, EMG monitoring adjustments.

Pediatric Balance Norms for Clinical Screening

Tandem Stance Norms (sec, eyes open/closed)

4–5 yrs: >7 / 4
6–7 yrs: >13 / 6
8–9 yrs: >51 / 12
10–11 yrs: >68 / 17
≥12 yrs: >120 / 18

Single-Leg Stance Norms (sec, eyes open/closed)

30–36 mo: 1–2
4 yrs: 5
5 yrs: 10 / <5
7 yrs: 15 / 5
9 yrs: 30 / 15
≥11 yrs: ≥30 / 30

Functional Outcome Measures for Pediatric Vestibular Patients

Measure	Best For	Notes
Pediatric Dizziness Handicap Inventory (DHI-PC)	Ages 5–12	Quantify subjective handicap of dizziness
Pediatric Vestibular Symptom Questionnaire (PVSQ)	Ages 6–17	Quantify subjective vestibular symptom (ie, dizziness, unsteadiness) severity in children
Pediatric Visual Induced Dizziness Questionnaire (PVID)	Ages 6–17	Quantify the presence and severity of visually induced dizziness
Ages and Stages Gross Motor (ASQ)	Birth to 5 yrs	Monitoring milestone progress for children

Why Every Clinic Should Be Ready for Pediatric Vestibular Evaluation

Even if you do not routinely see children, knowing pediatric vestibular assessment options lets you:

Screen at-risk children (especially with hearing loss)
Select age-appropriate bedside or lab tests
Make timely referrals to pediatric audiology, ENT, or neurology

Pediatric vestibular testing is not just about dizziness, it’s about safeguarding a child’s motor development, school performance, and quality of life.

References:

Cushing SL, Gordon KA, Rutka JA, James AL, Papsin BC. Vestibular end-organ dysfunction in children with sensorineural hearing loss and cochlear implants: an expanded cohort and etiologic assessment. Otol Neurotol. 2013 Apr;34(3):422-8. doi: 10.1097/MAO.0b013e31827b4ba0. PMID: 23370550.

Lavender V, Janky K, Bachmann K, Caine M, Castiglione M, Zhou G. American Academy of Audiology Clinical Consensus Statement: Assessment of Vestibular Function in the Pediatric Population. J Am Acad Audiol. 2025 Jul 7. doi: 10.3766/jaaa.24250301. Epub ahead of print. PMID: 40619806.

Verbecque E, Marijnissen T, De Belder N, Boudewyns A, Van Rompaey V, Van de Heyning P, Van Hoecke H.Vestibular (dys)function in children with hearing loss: A systematic review. International Journal of Audiology. 2017;56(6):361–381. doi:10.1080/14992027.2017.1294858