More than half of the patients attending neurology clinics complain of vertigo, and there are various kinds of vertigo: dizzy vertigo, spinning vertigo, light-headed vertigo ……
Vertigo is very common, but the treatment of vertigo is not simple at all, so what are the common misunderstandings of vertigo treatment?
Do not distinguish “real” vertigo from “fake” vertigo
1. First of all, there is no distinction between dizziness and vertigo.
Vertigo refers to the sensation of rotation or oscillation of oneself or the environment, which is a kind of motion hallucination; dizziness mainly manifests itself as a sense of instability, often accompanied by a sense of mental unclearness, that is, dizziness.
2. Secondly, vertigo is also divided into true and false.
”Pseudovertigo” is also called cerebral vertigo, which is mostly caused by the cortical centers of the balance triad (visual, proprioceptive and vestibular) or systemic diseases that affect the above cortical centers, and patients feel “dizzy” without a clear sense of rotation. “True vertigo” is caused by balance triad lesions, and there is a clear sense of rotation or body movement.
Inadequate history taking
Taking a medical history is the beginning of the doctor-patient relationship and the cornerstone of clinical treatment. Only by obtaining detailed medical history information can we make a successful localization and qualitative diagnosis.
The main points of outpatient vertigo consultation include
1. Precipitating factors.
Head position changes: BPPV, posterior cranial fossa tumor and migrainous vertigo, etc;
Menstruation-related or sleep deprivation: migrainous vertigo, etc;
Tile action: superior hemimelia and ectolymphatic fistula;
Standing position: postural hypotension, etc;
Object movement in visual field: bilateral vestibular disease.
2. Duration.
Seconds or tens of seconds: BPPV, vestibular paroxysms, variable pressure vertigo, cervical vertigo, epileptic vertigo and pre-syncope, etc;
Minutes: TIA, migrainous vertigo, vestibular paroxysm, epileptic vertigo, superior hemiplegic fissure, varicose vertigo, etc;
More than 20min: Meniere’s disease and migrainous vertigo;
Several days: Stroke, vestibular neuritis and migrainous vertigo, etc;
Persistent dizziness: bilateral vestibular hypofunction and psychiatric disorders.
3. concomitant symptoms.
Cerebral nerve or limb paralysis: posterior cranial fossa or skull base lesions;
Deafness, tinnitus or swelling: Meniere’s disease, auditory neuroma, sudden deafness, labyrinthitis, exolymphatic fistula, large vestibular aqueduct syndrome, vestibular paroxysm, otosclerosis and autoimmune inner ear disease;
Photophobia, headache or visual aura: migrainous vertigo.
4. Frequency of attacks.
Single or first: vestibular neuritis, brainstem or cerebellar stroke or demyelination, first-episode migrainous vertigo, first-episode Meniere’s disease, labyrinthitis, ectolymphatic fistula, and pharmacological.
Recurrent: BPPV, Meniere’s disease, TIA, migrainous vertigo, vestibular paroxysm, exolymphatic fistula, epileptic vertigo, autoimmune inner ear disease, auditory neuroma, otolithic dysfunction, unilateral hypoplastic vestibular insufficiency.
5. Prior medication history.
Carbamazepine – reversible cerebellar damage;
Long-term application of phenytoin sodium – cerebellar degeneration; long-term exposure to heavy metals such as mercury, lead and arsenic – damage to the cochlea, vestibular apparatus and cerebellum; organic solvents formaldehyde, xylene, styrene and trichloromethane – damage to the cerebellum.
Common ototoxic drugs: antibiotics such as aminoglycosides, vancomycin, viomycin and sulfonamides, antineoplastics such as cisplatin, chlorhexidine and vincristine, quinine, high-dose salicylates, diuretics such as tachykinuria and diuretic acid, some local anesthetics applied in the middle ear, such as lidocaine. Dimethylaminetetracycline damages only the vestibule, and the vestibular toxins of gentamicin and streptomycin are far more toxic than their cochlear toxicity.
Ignoring the importance of physical examination
Of course, we can’t blame the doctors for this, because we have a lot of people in China, and the amount of patients a doctor sees in an outpatient clinic in a day is equivalent to the amount of doctors abroad in a week (in terms of quantity). However, there are a few basic checkups that you should do in your mind.
1. Dix-Hallpike anisometropic nystagmus test.
The patient sits on the examination table, the examiner turns the patient’s head to the right 45°, keeping the above head position unchanged, while the position is rapidly changed to supine, with the head hanging backward outside the bed at 30° from the horizontal; in BPPV, transient vertigo and vertical rotational nystagmus appear after a few seconds of latency when the head is turned to the affected side.
2. Roll maneuver test.
The patient sits on the examination table, quickly takes the horizontal position, and does 90° barrel roll of the head and body to the left side, returns to the horizontal position, and then does 90° barrel roll to the right side; BPPV patients immediately experience severe rotational vertigo and horizontal nystagmus.
The above test should be used with caution or disabled for patients with severe heart disease, cervical spine disease and carotid artery stenosis.
3. Head Thrust Test
Hold the patient’s head with both hands and ask the patient to look at the examiner’s nose. The patient’s head is then turned rapidly to one side by about 20°, and the eye movements of the patient are noted. If the vestibular function is normal, the patient’s eyes will remain on the examined nose.
Over-reliance on medication
In fact, in the end, we find that not many patients with vertigo have a clear etiology and can be treated etiologically, except for immediate thrombolysis in acute vertebrobasilar ischemic stroke and manual repositioning of otoliths.
Of course, some anti-dizziness drugs are needed during vertigo attacks or in the acute phase, but is it really necessary to give intravenous drips for 14 days at the first sign of vertigo? This is actually a waste of medical resources.
Besides, anti-vertigo drugs should not be used for a long time, because they will inhibit the establishment of the central compensatory mechanism, and patients should have early vestibular rehabilitation.