Routine Vestibular Function Assessment in Children With Congenital CMV: Are We Ready?

Congenital cytomegalovirus (cCMV) is a leading non-genetic cause of sensorineural hearing loss (SNHL) and an important neurodevelopmental delay.1,2 Vestibular hypofunction can result in gross motor delay, hypotonia, postural instability, lack spatial awareness. physiotherapy safety advice may be indicated. Studies have shown vestibular impairment to common children with cCMV, both those with, without, loss.3 Routine screening for, appropriate management of, all has been recommended NICE-accredited guidelines issued by the British Association Audiovestibular Physicians.4 One author5 that cCMV without SNHL tested for dysfunction. However, how when test function does not form part standard guidance UK.Shutterstock/ Robert Kneschke. Hearing loss, balance, genetics.Figure 1: Usage balance tests used assess cCMV. genetics.Table Clinician-perceived barriers assessment genetics.The majority referrals clinics are made audiovestibular physicians pediatricians. We therefore invited pediatricians audiology take national survey, record current practice UK. MATERIALS & METHODS An electronic survey requesting details services assessments was designed trialed four physicians. It subsequently revised their feedback sent 100 members Paediatricians Audiology 25 Physicians (BAAP) pediatric practice, via email completion over three weeks June 2019. No patient identifiable data requested. Survey questions found appendix 1. RESULTS Twenty-one clinicians responded. This approximately half relevant clinics, as 25/50 BAAP trained pediatrics minority had training. 19/21 reported assessing system cCMV: 16/19 carried out clinical SNHL, 11/19 also normal hearing. The most time carry at diagnosis (42.1 %) or if symptoms were (36.8%); however, ages. frequently general demonstrated figure 1 included Romberg test, gait assessment, hopping, tandem gait, one-leg stance. Farmer's head thrust which specifically function, (see Fig. 1). clinician commented he would avoid testing jumping severely disabled child it might safe. Sixteen access quantitative tests. Tests commonly videonystagmography (4/16), video impulse (vHIT) (3/16), cervical evoked myogenic potentials (cVEMP) (3/16). Two ocular (oVEMP), rotation testing, bithermal caloric tests, mastoid vibration. Rates referral varied between 0-100% Of 13 who referred patients 10 (77%) seen cases confirmed diagnosing presenting primarily imbalance, rather than loss. When asked comment on CMV dysfunction, nearly 80% respondents said they refer dysfunction physiotherapy, 63% give regarding activities promote balance/function. respondent make situational counseling, psychological full medical screen detecting factors decompensation. Another mentioned “customized vestibular/sensory rehabilitation, and, where appropriate, psychologist input stress management” strategy Several identified: being well enough, priority, training, awareness, facilities, clinic (Table Clinicians need more specialized across UK, reports one service recently decommissioned. DISCUSSION common,3 even SNHL.6 whilst awareness cCMV-related grown, there its impact dedicated UK to. In this 75% responding regularly assessed yet timing investigations from clinician. number including time, resources. acknowledged severe impairments able tolerate some indicated evaluate function. Whilst medicine higher specialist remains lesser known field. estimated 50 consultant physicians, working setting, whereas little formal training audiology. There only handful equipment diagnose Some such VEMPs, employ departments already have, relatively inexpensive, vibrators, Frenzel goggles, vHITs. These comparatively tolerated could widely increase testing. (used up age 6 weeks) any fixate target) bedside require no additional easy learn. They tool difficulties and/or delay milestones guide limited small sample size. Conclusions cannot drawn about prevalence cases. possible field experience likely respond, mean smaller proportion survey. itself, despite deafness, under diagnosed, diagnosed will ability retrospectively retrieval stored newborn dried blood spots essential individuals outside period worthy consideration future investigation disorders. first capture views practices shortage Given recent evidence commonest sequelae case expertise area, advise management, growing. Including simple should considered, particularly early milestones, informs therapy provision advice. Moreover, given inclusion outcome measure randomized controlled treatment trials. demonstrates variation coupled NICE-approved guidelines4 recommending assessments, Teissier5 suggesting reinforces argument greater nationally.