Vertigo is the most common clinical syndrome, and with the aging of the population, the incidence of this syndrome is increasing and is receiving widespread attention from the medical community both at home and abroad.Smith (1993) reported that vertigo is the third most common symptom in outpatient clinics. It involves multiple disciplines and is experienced by the majority of people throughout their lives. According to statistics, vertigo accounts for 5% of outpatients in internal medicine and 15% of outpatients in otolaryngology. Elderly people living at home have vertigo 50-60% of the time, accounting for 81-91% of geriatric outpatient visits; among them, the incidence of vertigo in people over 65 years of age is 57% for women and 39% for men.
What is vertigo?
Vertigo is a general term for dizziness and lightheadedness. Vertigo is characterized by blurred vision, blurred vision and darkness, while dizziness is characterized by spinning vision or inability to stand up as if the sky is spinning.
Causes of vertigo
1, anemia elderly people who have dizziness, weakness and pale face should go to the hospital to check if they are anemic. Elderly people who do not pay attention to nutritional health care can easily suffer from anemia. In addition, anemia can be secondary to dyspepsia, peptic ulcer, gastrointestinal bleeding, and chronic inflammatory diseases in elderly patients.
2. High blood viscosity hyperlipidemia and thrombocythemia can cause high blood viscosity and slow blood flow, resulting in insufficient blood supply to the brain and easy fatigue, dizziness and weakness. Among the many causes of hyperlipidemia, the most important one is the unreasonable structure of the usual diet.
3, patients with atherosclerosis feel dizzy, and often have insomnia, tinnitus, emotional instability, forgetfulness, and numbness of the limbs. Cerebral arteriosclerosis makes the inner diameter of blood vessels smaller, and blood flow in the brain decreases, resulting in insufficient blood and oxygen supply to the brain, causing dizziness.
4. Cervical spondylosis often presents with neck tightness, limited flexibility, occasional pain, numbness and coldness of the fingers, and a feeling of heaviness. Cervical spine hyperplasia squeezes the vertebral artery in the neck, causing insufficient blood supply to the brain, which is the main cause of dizziness caused by this disease.
5, hypertension hypertension patients in addition to dizziness, often accompanied by head swelling, panic, irritability, tinnitus, insomnia and other discomforts.
6, heart disease early coronary heart disease, some people may feel headache, dizziness, weakness of the limbs, mental concentration is not easy, etc.. This is mainly due to atherosclerosis of the coronary arteries of the heart, which causes dizziness due to insufficient blood supply.
7, Meniere’s syndrome Meniere’s syndrome is an inner ear disease, and vertigo is the main manifestation of Meniere’s syndrome.
8.Blood diseases such as leukemia, pernicious anemia and blood hypercoagulable diseases can cause vertigo, which can be confirmed by blood system examination.
Classification of vertigo: true vertigo and pseudovertigo
(1) True vertigo (peripheral, vestibular peripheral): paroxysmal rotation, tilting and falling sensation of external objects or itself, with heavy symptoms, mostly accompanied by obvious nausea, vomiting and other vegetative symptoms, lasting for a short time, from tens of seconds to hours, rarely more than days or weeks. Because it is mostly seen in vestibular peripheral lesions.
(2) Pseudovertigo (central, cerebral): It is a sense of shaking instability of external objects or oneself, or swaying from side to side or back and forth, aggravated when gazing at moving objects, or in noisy environment. The symptoms are mild, accompanied by inconspicuous vegetative symptoms, and last for a long time, up to several months, mostly seen in brain and eye disorders.
Medical history and clinical signs and symptoms
1.The situation before the onset of vertigo
Are there any factors such as excessive smoking and drinking, mental and emotional instability, exertion and insomnia before the onset of vertigo?
2.Situation of vertigo attack
(1) Whether the attack occurs at night or in the morning, suddenly or slowly.
(2) First attack or repeated attacks;
(3) What kind of condition is the onset of vertigo, such as change of body position, neck twisting, or some special position;
(4) whether the form of vertigo is rotational or non-rotational;
(5) Whether the intensity is tolerable and whether the consciousness is clear;
(6) Whether the vertigo is reduced or increased when opening or closing the eyes, and whether the vertigo is increased by sound and light stimulation or changing the position.
3.Symptoms associated with vertigo
(1) Autonomic symptoms: change in blood pressure, sweating, pale face, diarrhea;
(2) Ear symptoms: deafness, tinnitus, stuffy ears;
(3) Eye symptoms: darkness in front of the eyes, double vision, blurred vision;
(4) Neck symptoms: pain in the neck or shoulder and arm, numbness in the upper limbs, and limited movement;
(5) Central nervous system symptoms: headache, impaired consciousness, sensorimotor disorders, speech or dysarthria, etc.
What tests should be done for vertigo?
Vestibular function tests.
(1) In-office or bedside vestibular function tests: including upright tilt test, in situ step test, neck twist test, etc;
(2)Nystagmus
(3)Nystagmography
(4)Balance posture chart
Hearing function examination.
Imaging examinations: cranial CT, MRI, etc. to clarify the presence of head occupancy, ischemic or hemorrhagic disorders.
Other medical examinations: blood pressure, electrocardiogram, biochemical examination, etc.
Various common systemic diseases with vertigo
1. Cerebrovascular vertigo: Sudden onset of severe rotational vertigo, which may be accompanied by nausea and vomiting, gradually reduced after 10-20 days, mostly accompanied by tinnitus and deafness, but with clear mind.
2.Brain tumor vertigo: Early on, mild vertigo is often seen, which can be a sense of swaying and instability, while rotational vertigo is rare, often with unilateral tinnitus and deafness, etc. With the development of lesion, signs of adjacent brain nerve damage can appear, such as numbness and sensory loss of the diseased side, peripheral facial palsy, etc.
3. Cervicogenic vertigo: It is manifested as various forms of vertigo, with dizziness, swaying, unsteadiness, floating sensation and other sensations. The vertigo is recurrent, and its occurrence is obviously related to sudden head rotation, i.e., it occurs mostly during neck movement, and sometimes presents variable vertigo when sitting up or lying down. The episodes are usually brief, ranging from a few seconds to a few minutes, but there are cases of longer duration. Pain in the neck or posterior occipital region may occur in the morning. Some patients may have symptoms of cervical nerve root compression, i.e. numbness and weakness in the arms, and involuntary falling of objects held. More than half of the patients may have tinnitus, and 62-84% of the patients have headache, which is mostly confined to the parieto-occipital region, often with episodes of throbbing pain.
4. Oculogenic vertigo: non-motor illusion vertigo, mainly manifested as a feeling of instability, aggravated by excessive use of eyes and reduced after resting with eyes closed. The vertigo lasts for a short period of time and is aggravated when the eyes are opened to look at external moving objects, and is relieved or disappears when the eyes are closed. It is often accompanied by blurred vision, loss of vision or diplopia. Visual acuity, fundus and ocular muscle function examination are often abnormal, and there is no abnormal performance of the nervous system.
5.Cardiovascular vertigo: vertigo caused by hypertension can be clearly diagnosed by blood pressure measurement. Carotid sinus syndrome can lead to episodes of vertigo or syncope. Most of the onset triggers are factors that suddenly cause pressure on the carotid artery, such as sharp neck turn, low head, tight collar, etc.
6.Endocrine vertigo: Hypoglycemic vertigo often occurs before hunger or eating and lasts for tens of minutes to one hour, and the symptoms are relieved or disappear after eating, often accompanied by fatigue, and the presence of hypoglycemia can be found when checking blood sugar during the attack. Thyroid dysfunction can also lead to vertigo, with clinical balance disorder as the main cause, and relevant examination of thyroid function can confirm the diagnosis.
7. Vertigo caused by blood diseases: leukemia, pernicious anemia and blood hypercoagulable diseases can cause vertigo, and the diagnosis can be confirmed by blood system examination.
8.Neurological vertigo: The patient’s symptoms are diverse, and the dizziness is mostly pseudo-vertigo, often accompanied by headache, head swelling, heaviness, or a variety of neurological manifestations such as insomnia, palpitation, tinnitus, anxiety, dreaminess, inattention, memory loss, etc. There is no sense of rotation of external objects or rotation or shaking of oneself. For women over 45 years old, attention should also be paid to differentiate it from menopausal syndrome.
Prevention and treatment of vertigo
Patients suffering from vertigo should be accompanied by family members when they go out to prevent accidents.
1. Cerebrovascular vertigo: Due to the increase of blood viscosity in summer and winter, various cerebrovascular accidents are likely to occur, leading to the occurrence of cerebrovascular vertigo. You should be careful to drink more water and not to change your position suddenly, such as getting up when you go to the toilet at night, which can easily cause cerebrovascular vertigo. Once it happens, you should go to the hospital as soon as possible, and after the diagnosis is confirmed, you can give appropriate vasodilator drugs, anti-platelet aggregation drugs (such as aspirin), anticoagulant drugs, etc.
2.Brain tumor vertigo: The onset of this kind of vertigo is slow and the initial symptoms are mild and not easy to detect. For mild vertigo that appears gradually, if it is accompanied by unilateral tinnitus, deafness and other symptoms of adjacent brain nerve damage, such as numbness and sensory loss on the side of the patient, peripheral facial palsy, etc., you should go to the hospital as soon as possible to get a clear diagnosis and early surgical treatment.
3. Cervicogenic vertigo: Pay attention to the usual work and study position, and move the neck appropriately after long hours of ambulatory work. The height of pillow should be appropriate, and the pillow should not be padded too high to cause the occurrence of cervicogenic vertigo. Treatment mostly adopts rehabilitation methods, such as cervical jaw pillow sling traction, Tuina manipulation treatment, acupuncture, etc. Serious cases need surgical treatment.
4.For vertigo caused by other diseases, such as endocrine vertigo, hypertensive vertigo and ophthalmogenic vertigo, the original disease should be treated actively, such as controlling blood pressure and treating ophthalmological diseases, and the vertigo can be relieved naturally based on the recovery of the original disease.
5.Neurofunctional vertigo: For vertigo caused by mental factors, firstly, the patient’s anxiety should be relieved, and anti-anxiety or antidepressant drugs can be given appropriately, but sedative drugs should be avoided for a long time to avoid increasing the tolerance and dependence of drugs.
Clinical manifestations of vertigo.
Meniere’s disease, which used to be called Meniere’s disease, is the most typical vertigo caused by inner ear disease, and its pathological change is endolymphatic fluid accumulation, the onset of which is more common in middle-aged people and less common in children under 10 years old, and the attacks gradually decrease after old age. The disease is characterized by recurrent vertigo with deafness, tinnitus and stuffy ears as the main symptoms, which can be accompanied by rehearing, nausea, vomiting, cold sweat, pale face and cold limbs; deafness is mostly unilateral, with hearing fluctuations at the early stage, which can return to normal, and about 15-20% of patients can have deafness spread to the opposite ear; tinnitus is more aggravated before the vertigo attack, and can disappear at the early stage with the relief of vertigo, but after repeated vertigo attacks Tinnitus can be persistent after repeated vertigo attacks. Vestibular function test temperature test is usually low or absent in the affected hemianopsia. Hearing test is sensorineural deafness, early typical is low frequency sensorineural deafness. If a cochlear electrogram is performed, a basally broadened negative phase and potential should be recorded in the typical case, with patients in the exacerbation phase -SP/AP ≥ 40%.
Vestibular neuronitis
Vestibular neuronitis This disease is a type of peripheral neuritis. The lesion occurs in the vestibular ganglion or in the centripetal portion of the vestibular pathway. There is a history of upper respiratory viral infection about two weeks before the disease. Vertigo symptoms may occur suddenly, last for days or months, and worsen with activity. Symptoms of the vegetative nervous system are generally slightly less severe than in Meniere’s disease. There are no hearing changes, i.e., no complaints of tinnitus or deafness. Most patients have complete remission of symptoms after two or three months, and only a few cases have recurrent attacks. On examination, spontaneous nystagmus toward the healthy side, hypoacusis or hemianopsia on the affected side is seen. There are no other symptoms of cranial nerve damage.
Sudden deafness with vertigo
Sudden deafness with vertigo is common in 30-50 year olds and may be caused by viral infection of the inner ear or vascular lesions or rupture of the window membrane. Patients have sudden onset of tinnitus and deafness on one side of the ear, and some of them have vertigo and vomiting, and the condition resembles Meniere’s disease, but the vertigo lasts longer and does not recur later. The hearing examination shows severe sensorineural deafness (more than 60 dB), and vestibular function may be impaired in cases with vertigo.
Labyrinthitis
In cases of acute or chronic purulent otitis media, the infection may spread to the inner ear vagus and lead to plasmacythematous or purulent vagalitis. In this case, in addition to ear leakage, the patient may experience tinnitus, vertigo, nausea, vomiting and hearing loss. When the disease progresses to septic labyrinthitis, not only is the vertigo severe and persistent, but also the hearing may decrease to total deafness, the spontaneous nystagmus may shift to the healthy side, and the vestibular function test on the affected side may disappear. In the event of the above, an ear mastoid x-ray should be taken, and preferably a CT scan of the temporal bone should be done to clarify the presence of mastoiditis, cholesteatoma, and vagal fistula. Viral labyrinthitis is mostly caused by herpes virus, mumps virus, and measles virus infections. Secondary to viral infection, patients present with vertigo, gait instability, marked nausea and vomiting, and mostly with severe deafness. Vestibular function tests are hypofunctional or absent on the affected side. The vertigo symptoms can gradually disappear completely after about 1 to 3 months due to normal vestibular function on the patient’s healthy side.
Labyrinthine vertigo
Labyrinthine concussion is mostly caused by head trauma and often coexists with concussion. The strong air wave impact after explosion can also cause inner ear labyrinthine concussion. After the trauma, patients experience vertigo, nausea, vomiting, and significant hearing loss in the injured ear. Some of these are seen on otologic examination along with tympanic membrane trauma, with rupture or bleeding of the tympanic membrane. Hearing threshold changes of varying degrees and nature, either unilateral or bilateral, may be seen on audiological examination, and in severe cases, total deafness may be seen, with some acoustic conductance audiometry suggesting damage to the auditory chain and low vestibular function on the affected side. When diagnosing patients with concussion, especially those with hearing impairment and vertigo complaints, it should be noted that vagal concussion may also be present.
Case review
Case 1.
Bai, male, 48 years old, address: Makeng village, Bai Shao town, Ruanhou county, Fujian province, China
Initial diagnosis: February 3, 2000
Complaint: 10 years ago, the patient suddenly felt vertigo, tinnitus, hearing loss, nausea and vomiting, pale face, panic and sweating, lying in bed with eyes closed, not daring to turn over, diagnosed by a hospital as inner ear vertigo, after taking glutamate and sedative drugs, the symptoms were slightly reduced, but for 10 years the attacks were frequent, once every 1-2 days, and work was affected.
Examination: The patient has no light texture, thin white fur, and a sunken and slippery pulse.
Diagnosis: Inner ear vertigo (Meniere’s syndrome)
Treatment: After one course of medicine, the symptoms were reduced from one attack in 1-2 days to one attack in 6 days, and another course of medicine was taken.
Commentary.
The exact cause of this disease is still unclear, but it is generally believed that it may be due to the spasm of the vagus artery caused by the dysfunction of the vegetative nerves and local hypoxia, resulting in excessive lymphatic production in the inner ear or impaired absorption, causing water accumulation in the vagus of the inner ear membrane. We believe that this disease belongs to the category of “vertigo”. In Su Wen, Zhi Zhen Yao Da Lun, there is a discussion on the causes of vertigo, such as “all winds and dizziness belong to the liver”. In Danxi Xinfa (Head Dizziness), phlegm is the main cause of dizziness, and there is the idea of “no dizziness without phlegm”, and the method of “treating phlegm first” is proposed. The patient’s dampness and phlegm are blocked, so that the clear yang does not rise and the cloudy yin does not descend, and when the qi is depressed and turns into fire, the liver yin is depleted and the wind yang rises and moves, dagger disturbing the clear space, so dizziness will occur.