Acute, vestibular symptoms in childhood are primarily caused by acute labyrinthitis (end organ dysfunction) or central nervous system diseases such as neoplasia involving the pons or cerebellar nuclei or infection manifested by pontine encephalitis. The evaluation, treatment, and prognosis of end organ versus central disease is so different that the ability to make a bedside, presumptive diagnosis provides an important advance. Both patients presented here had a central vestibulopathy. By paying particular attention to the character of the nystagmus and past pointing, the Romberg test, and the details of the vertiginous history, central disease was the presumptive diagnosis prior to invasive procedures. The neurophthalmological clues are reviewed to demonstrate their value in making more accurate diagnoses in children with acute vestibular dysfunction.

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