Once in a while, one sees a book title that prompts the thought ‘Brilliant, why didn't I think of that?’ This one struck me, not because the rebel colonies continue to misspell words like paediatric, but because this book is something different. It covers a topic overlooked in so many training programmes. I can imagine the candidate's face in our ENT exit exam, the FRCS, if faced, in the paediatric viva, with the scenario of a child complaining of imbalance.
The format is traditional, starting with the relevant anatomy and physiology. ‘Structures are smaller, but work the same as adults’ might be the obvious reaction, but neither is true of course! The physiology chapter is great on maturation, something our own Guy Kenyon has worked on and reviewed over the years (I should have got him to review this, as the expert, now I think about it). The book works through the developmental reflexes present at birth, and the early years' development. Yes, I suppose I did know about the Moro and tonic neck reflexes, head righting and Doll's eye response, but the parachute reaction? I found it fascinating to see how maturation continues into the teenage years. As a father of three sons, I always imagined their attacks of unsteadiness to be related to their social activities. Reading of the sex differences in maturation of the teenage vestibular system also explains much of what one sees on a Saturday night in Middlesbrough.
Every chapter closes with self-assessment questions, and I found these quite encouraging. I was actually learning a lot as I worked through the book. There is a DVD showing how children of all ages are put through their paces in the investigation of their neurotologic system. Martin Bailey, the knave who accused me of never reading such books, tells me that at Great Ormond St the children love exercises like the rotatory chair. The problem is more with the parents holding their offspring on their laps, who emerge as white as a sheet!
Chapter three opens with the sentence ‘Children typically do not complain about vestibular dysfunction or vertigo’. At first, this seems to negate the whole purpose of the book, but no, it is actually profound. There is a very good summary of expected motor skills at different ages, which would be invaluable in any paediatric ENT lecture. The tips about modifying testing for children even include suggestions on how to talk to them, for example during caloric testing. I did not know VEMPs could be detected at two months of age. Posturography and gait analysis are very well explained, and the text would be as useful in adult work.
The third section deals with what can go wrong, with some very good case studies. There is obviously coverage of the expected peripheral disorders, then vestibular migraine, CNS abnormalities and seizure disorders. Of course, movement disorders can present as unsteadiness, and there is a daunting list of dystonias, which would be familiar only to my little mate Maurice Hawthorne (who would add several of his own). Then come the neurodegenerative disorders and those eponymous ataxias, with the comment ‘This review has presented only a few of the many …’ etc.
This book is highly recommended. If you flick through the contents you will be struck by the breadth of the subject. If stuck for a lecture at short notice, paediatric balance disorders is a great topic (which I have already worked on, since reading this).
