Correct understanding of the concept of dizziness and vertigo, understanding the characteristics of common diseases related to the syndrome, and correct diagnosis are especially important for clinicians in their daily clinical work. The author introduces the correct concept of dizziness and the characteristics of common dizziness and vertigo disorders, taking into account the progress of dizziness diagnosis and treatment abroad and his own clinical practice experience, for the reference of relevant clinicians in their practice and to avoid blind selection of examination means and drug treatment.
In the initial investigation of the diagnosis of dizziness and vertigo, the most frequently used terms are “cervical dizziness”, “cervical vertigo”, “cerebral insufficiency of blood supply” or ” Insufficient blood supply to the basilar artery”. Even patients themselves, like most physicians, give themselves the diagnosis of cervical dizziness/vertigo (thought to be related to cervical spondylosis) or inadequate cerebral blood supply to the basilar artery (mistakenly thought to be arterial compression). This is precisely due to the inability of some physicians to correctly understand the concept of dizziness or vertigo and the lack of careful differentiation and determination of the etiology. Therefore, it is especially important for clinicians to correctly understand the concept of dizziness and vertigo, to understand the characteristics of the common diseases related to the syndrome, and to correctly diagnose them in their daily clinical work. The author introduces the correct concept of dizziness and the characteristics of common dizziness and vertigo diseases, combining the progress of dizziness diagnosis and treatment abroad and his own clinical practice experience, for the reference of relevant clinicians in practice to avoid blind selection of examination means and drug treatment.
I. Epidemiological characteristics of dizziness and problems in diagnosis
Dizziness and vertigo are almost one of the most common clinical conditions with high incidence and prevalence, and are the main syndromes seen in outpatient clinics of internal medicine, neurology and otorhinolaryngology, as well as one of the main conditions in emergency departments. An annual National Health Service survey study in the United States showed that approximately 19.6% of people over the age of 65 had dizziness and balance disorders. This is comparable to data from another community-based and population-based survey in the United States and the United Kingdom (21%-29% prevalence). A Dutch survey of dizziness in all age groups showed an annual incidence of 4.7 per 1,000. The vast majority of dizziness is episodic and less than 5% is persistent. The frequency of dizziness episodes varies across studies. In a community-based study of dizziness, 51% of people had monthly episodes, 14% had weekly episodes, and 35% had daily episodes.
Despite the high incidence of dizziness, the diagnosis of dizziness by some clinicians is often “confusing” and “arbitrary”. The term “confusion” refers to the fact that some dizziness can be difficult to diagnose due to poor presentation or lack of experience on the part of the patient; the term “casual” refers to the fact that physicians are more casual about diagnosing dizziness or vertigo of “unclear etiology”. The so-called “casual” refers to the fact that physicians give the diagnosis of “cerebral insufficiency of blood supply” or “cervical dizziness” to dizziness or vertigo of which the cause is “unclear”, or simply use the word “dizziness” to make a symptomatological diagnosis, instead of conducting in-depth diagnostic analysis of dizziness and vertigo. The diagnosis of dizziness and vertigo should be analyzed and considered in depth.
For example, when a patient presents with dizziness or vertigo during head movement, the diagnosis often differs from one specialist to another, and some doctors often make a one-sided diagnosis based on their own opinion or from the perspective of their discipline. Some doctors consider cervical dizziness or cervical vertigo simply based on the presence of osteophytes and narrowing of the spinal space as shown by cervical spine X-ray; some diagnose arterial stenosis or spasm as a result of cerebral blood supply deficiency when they see the rapid blood flow in a certain artery as indicated by transcranial Doppler ultrasound; some directly diagnose Meniere’s disease or vestibular peripheral vertigo based on simple vertigo; and some doctors generalize the diagnosis by “deficiency”. “Some of them directly diagnose Meniere’s disease or vestibular peripheral vertigo based on simple vertigo. As a result, the same patient is diagnosed differently and given different treatment and medication as if he or she was “blinded by an elephant”, but with little effect, and some of them even get worse. Therefore, it is necessary to clarify the concept and diagnostic ideas of dizziness and vertigo.
II. Correctly grasp the concept of dizziness
A new classification of vestibular disorders was proposed in 2009. This new classification classifies vestibular symptoms into vertigo, dizziness (non-vertigo dizziness in a narrow sense), visual vestibular symptoms, and postural symptoms. Moreover, this classification has not been widely used because the more detailed classification associated with each symptom is very complicated and actually not particularly suitable for clinical operation.
Broadly speaking, in 2010, dizziness was classified from a clinically practical perspective into the following four categories of conditions: dizziness, vertigo, balance instability, and presyncopal states. This classification is very simple and easy to grasp for the diagnosis and management of dizziness. These symptoms occur when the patient is conscious. In other words, syncope, epilepsy, and other disorders that occur during loss of consciousness are not included. Thus, we understand that dizziness is a broad concept and that vertigo and dizziness are only a part of it.
Dizziness is a paroxysmal or persistent feeling of lack of clarity in the brain, dizziness and dullness, head swelling, and a feeling of tightness in the head. High blood pressure and mental factors often cause dizziness. Dizziness may sometimes be a physiological process, not necessarily a pathological mechanism, such as lack of sleep, fatigue, long overnight shifts, etc., which can be corrected if adjusted at the right time. Dizziness is a symptom of illusion of motion of the patient’s subject to the static surrounding objects or his own position, which is mostly a pathological phenomenon. It is often manifested as a sense of rotation of visual objects or rotation of oneself, but it can also have a sense of swaying instability, undulating waves and falling. In general, patients are afraid to open their eyes during vertigo, often accompanied by nausea, and in severe cases, autonomic symptoms such as vomiting, excessive sweating, blood pressure fluctuations, etc. Some may be accompanied by nystagmus, ataxia, and other neurological localization signs. The pre-syncope state refers to the chest tightness, palpitations, dizziness, blackness, and weakness that occur before syncope. If upright hypotension occurs, the presyncope state is likely to occur. Unstable balance refers to dizziness symptoms with unstable standing or movement disorders in action.
Therefore, patients who present to the clinic with dizziness should be distinguished as to whether they are dizzy and, if so, what type. Of course, for the individual patient, symptoms of dizziness can occur alone, simultaneously, or sequentially with symptoms of dizziness, vertigo, or unsteadiness of balance.
Common diseases of dizziness and their symptom characteristics
Dizziness is generally divided into two categories: non-vestibular dizziness and vestibular dizziness. Non-vestibular system disease dizziness is mainly caused by medical system diseases [such as cardiovascular diseases (high and low blood pressure, arrhythmia), blood diseases (anemia, erythrocytosis), endocrine diseases], environmental changes and excessive activities (high temperature, heat stroke, prolonged standing, overwork, etc.), post-traumatic head injury syndrome, visual fatigue and ocular myopathy (such as myasthenia gravis, glaucoma, etc.), inflammation of the five senses (oral cavity, paranasal sinusitis), upper respiratory tract infections and drug effects or drug poisoning, peripheral nerve diseases, etc. In addition, it also includes psychogenic dizziness, such as depressive and anxiety states, mild mania, etc. These dizziness are not an involvement of the vestibular system per se. Most of them are dominated by dizziness, unstable balance, and pre-syncopal states.
Vestibular system disorders are subdivided into central and peripheral dizziness. Peripheral vestibular system disorders include benign paroxysmal positional vertigo, Meniere’s disease, vestibular neuronitis, labyrinthitis, and lymphangiolemmal leakage. Central vestibular system disease dizziness includes inadequate blood supply to the basilar artery, posterior circulation ischemia, cerebral hemorrhage, brain tumor, encephalitis or demyelinating disease, and vertiginous epilepsy. Others have both central vestibular involvement and peripheral vestibular involvement, such as migrainous vertigo (i.e. migraine isotonicity), which may have central symptoms such as visual field loss and transient blurred consciousness, and a few may have unilateral hemiplegia on peripheral vestibular examination.
According to the latest domestic and international literature, the common causes of dizziness are BPPV, migrainous vertigo, psychogenic dizziness, non-vestibular system disease dizziness, posterior circulation ischemia or stroke. While conditions like Meniere’s disease, vestibular neuronitis or other central nervous system disorders (demyelination, tumors, inflammation) are among the less common dizziness conditions, cervical dizziness is increasingly less mentioned abroad unless it is due to cervical hyperflexion and extension injury or neck trauma.
BPPV, also known as otolithosis, is a condition in which the otolith in the otic capsule of the vestibular organ in the ear, which is responsible for balance, is dislodged and falls into the hula hoop-like semicircular canal, which is connected to it. Therefore, its clinical characteristics are as follows
1. Vertigo can occur when the head position changes: it can be triggered when getting up, lying in bed, lifting or turning the head, and patients often “sigh at the bed” or “can’t look back”;
2. The duration of vertigo attack with each change of head position is measured in seconds, mostly within 10s, so the vertigo is “instantaneous”;
3. The vertigo is dizzy during the attack, but the dizziness can still be felt for a short time after the attack;
4. This kind of vertigo has self-improvement, but it can also recur;
5.It is not accompanied by hearing loss, tinnitus and brainstem symptoms such as double vision and unstable walking;
6.The treatment mainly adopts otolithic manipulation.
Migrainous vertigo, also known as vestibular migraine, is actually migraine equilibrium. Clinical features are.
1. The disease is more likely to occur in women;
2. It occurs in all age groups, with the middle-aged and the elderly being the most common;
3. The clinical manifestation is mainly dizziness or vertigo, some have obvious migraine, and a few have no migraine or headache symptoms;
4.Dizziness may increase when the head position changes, but there is no directionality;
5.May or may not have aura symptoms;
6.The attack of vertigo is mostly accompanied by nausea and vomiting, and the symptoms are relieved after vomiting, and there are obvious manifestations such as fear of sound, fear of light, preference for silence and irritability;
7. There may be blurred vision, and a few patients may have very short-lived blurred consciousness;
8, the disease is often recurrent, the frequency varies, some years 1 time, some weeks or days 1 time, sparse and variable;
9. The symptoms last mostly within 2-3 h (short tens of seconds, long hours or 2-3 d), and generally improve after quiet rest or sleep (the next day). Some people feel better after receiving infusion for 3-4 hours during the attack, but the improvement is actually a natural process, not the effect of drugs;
10.Most of them have a history of migraine but a few do not. Some of them have migraine when they are young, but with age, they only have dizziness or vertigo symptoms and no longer have headache, so it is important to master the transformation of headache and vertigo;
11. Vestibular function examination: It can be normal or unilateral hemiplegia with mild paralysis, the incidence of which is reported in the literature as 8.1%-23.8%, and most of them can basically recover with time and treatment;
12.Treatment: According to the principles of migraine treatment, symptomatic pain relief or with sedative drugs, and appropriate rest.
Studies on the etiology of dizziness and vertigo have found that the etiology of long-term, chronic persistent dizziness or vertigo is mainly related to mental disorders, such as depression, anxiety, panic, obsessive-compulsive or somatization disorders, which can account for about 20% of such dizziness. Sixty percent of unexplained persistent dizziness is due to primary or secondary anxiety disorders. 4.6% of patients with vertigo are suffering from psychogenic dizziness. In this issue, we analyzed the clinical symptoms and treatment of 208 patients with psychogenic dizziness in our hospital in detail, and for the first time, under the guidance of psychiatrists, we divided psychogenic dizziness into three types for easy operation in practice, which provides valuable empirical reference for the diagnosis and treatment of such patients.
Dizziness is also one of the first symptoms of posterior circulation ischemia, and the diagnosis of inadequate blood supply to the vertebrobasilar artery was commonly used in the past, but the concept of posterior circulation ischemia includes both transient ischemic attack and cerebral infarction, and is therefore more suitable for clinical application than inadequate blood supply to the vertebrobasilar artery. In some cases, posterior circulation ischemia starts with only vertigo without other symptoms, and sometimes detailed MRI examinations (including DWI image position) do not even reveal infarct manifestations, but brainstem infarction, even involving respiration with impaired consciousness, soon occurs, and one must be careful of this occurrence. For the diagnosis of posterior circulation ischemia, it is necessary to have the etiology of its occurrence, such as the history of smoking, the history of “three highs” (hypertension, hyperglycemia and hyperlipidemia), and to be able to confirm the formation of atherosclerotic plaques, rather than emphasizing the presence of cervical spondylosis.
The diagnosis of Ménière’s disease should be noted when the patient presents with vertigo, tinnitus, deafness (after multiple episodes), and a feeling of fullness in the ear. When patients experience vertigo to sharp sounds or under self-exertion, the occurrence of superior hemimegaplasia should be noted. The diagnosis of vestibular neuronitis should be noted when the patient has more vertigo, forced head (lateral) position, clear tilting to one side during physical examination standing, and finger-nose test with deviation to the affected side without other symptoms of auditory involvement. In the elderly population, special attention should be paid to the problem of dizziness caused by combined medications, such as antihypertensive drugs, prostate therapy drugs, etc.; attention should also be paid to the differentiation of dizziness caused by malnutrition, anemia, vitamin deficiency and hypothyroidism.
Fourth, familiar with the diagnostic ideas of dizziness
In clinical practice, it is very important for patients with dizziness to be diagnosed quickly, and a clear and simple diagnostic idea of dizziness can enable clinicians to quickly determine the cause of dizziness in their busy daily work. The author has summarized a diagnostic flowchart for the analysis of dizziness symptoms in clinical practice, which many clinicians have used and found easy to follow and can be used for reference. In addition, clinical practice should focus on the combination of basic examination and detailed physical examination. For example, if blood pressure is measured, some dizziness is actually caused by long-term hypertension; sometimes dizziness occurs after long hours of reading, but it is actually a problem of glaucoma, and it is not difficult to make a preliminary judgment as long as reading induces a rapid increase in intraocular pressure.
In conclusion, dizziness is a common clinical symptom, a seemingly “simple” but indeed “uncomplicated” diagnosis. The common causes are BPPV, migraine dizziness or vertigo, cardiac dizziness, and posterior circulation ischemia. Vestibular neuronitis, Meniere’s disease or cervical dizziness are rare causes, especially cervical dizziness. Patients with possible posterior circulation ischemia must be on high alert and should be seen immediately to avoid regret. For dizziness, it is necessary for the relevant specialists to continuously master the characteristics of their different disorders in practice to improve the diagnosis and differential diagnosis; at the same time, internal medicine and neurology doctors should also learn the technique of BPPV manipulation and repositioning to relieve the pain of these patients who first come to you, and to bring back the pain with a wonderful hand.