Vertigo occurs when the vestibular-vestibular system and/or its related systems are abnormally stimulated. As such excitation spreads in the brainstem, it involves other neural structures and causes nausea, vomiting, pallor, sweating, and deficiency. Therefore, the principles of treatment should be.
(1) Identify and treat the primary disease as much as possible;
(2) Apply drugs that reduce the excitability of these systems, such as aminophylline and benadryl, and other sedative and antiemetic drugs;
③Disrupt the inner ear vagus;
(iv) Selective application of anticholinergic drugs, adrenergic drugs, or antihistamines.
Many diseases can cause vertigo, and vertigo can have many concomitant symptoms, so treatment should be analyzed on a case-by-case basis. Here, we will introduce some treatment measures that may have commonality with Meniere’s syndrome as an example.
(i) Diphenhydramine (Dramamine, Dimenhydrinate) can reduce the stimulation of the vagus, 25mg each time, 2-3 times a day.
(ii) 2% lidocaine 2 to 3ml diluted in 20% glucose 20ml and injected intravenously. Women use 2ml, men use 3ml, which is roughly equivalent to 1mg/kg. there may be ear blockage and head confusion at the time of injection, but it usually disappears after lying down for about 5min. It is quite effective for vertigo, nystagmus, nausea, vomiting, etc.
(C) Sulpiride is a pro-psychotic drug. It acts on vestibular neurons and synapses of the brainstem reticular formation. Probably by raising the vestibular perceptual threshold, while its impulses issued to the reticular formation or higher centers are reduced; therefore, it is effective in both peripheral and central vertigo. It is usually administered 25mg 3 times a day. It has been used to treat 127 cases of traumatic vertigo with good results; and it is more effective in patients with normal or increased vestibular response than in those with low vestibular response. No significant side effects were found.
(iv) Innovar is a 50:1 combination of the pro-psychotic haloperidol and the anesthetic fentanyl. It has been reported to be indicated for refractory vertigo and to relieve the signs and symptoms in many patients with peripheral vertigo. It has a complete, transient inhibitory effect on the vestibule. It is administered intravenously, not more than 2ml at a time, and the nystagmus usually disappears within 1-10min after intravenous injection. The effect on peripheral vertigo is good and long-lasting (>170min), while the effect on central vertigo is poor and short-lived (shorter than 90min). Side effects are uncommon, mainly syncope and fatigue, which may be accompanied by short periods of sleep; no side effects such as respiratory depression, bradycardia and extrapyramidal system have been observed. Some people advocate that it should be injected slowly intravenously, and it is best to prepare for assisted breathing beforehand.
(E) Methotrexate has antispasmodic and antiemetic effects. It can effectively treat nausea and vomiting associated with various diseases through peripheral (reduction of afferent impulses from the stomach and duodenum to the vomiting center) and central (inhibition of the vomiting center) effects.
It has been reported to be ineffective in Meniere’s syndrome and vomiting with inadequate vertebrobasilar artery supply; conversely, it has also been reported to be effective in the treatment of vagal vertigo in large numbers.
(vi) Adrenal corticosteroids During the acute phase of Meniere’s syndrome, β-flumethasone 2-3 mg can be given in 3-4 doses. After the acute phase, it can be reduced by 1mg every 3-5 days. during the reduction of adrenal corticosteroids, to prevent its rebound, add licorice tablets, 6 tablets, 3 times a day. In cases of hypertension and diabetes mellitus where adrenocorticosteroids cannot be used, other anti-edema drugs such as vincristine may be used.
(G) Sodium bicarbonate intravenous drip 5% or 7% sodium bicarbonate 20-50ml intravenously, once every other day, 10 times for a course. Although there is no significant inhibitory effect on nystagmus, it can reduce the clinical manifestations of nausea, vomiting and other plant nerve involvement. With 200-500ml intravenous drip, the effect is better.
(H) Anticholinergic drugs It is one of the most effective anti-vertigo agents. It has the function of blocking acetylcholine centrally and peripherally and decreasing the tension of parasympathetic nerves. It acts to stop dizziness by bringing a new balance of sympathetic and parasympathetic tone. Scopolamine has the strongest anti-vertigo effect with less side effects, and a single dose of 0.6mg is appropriate.
(ix) Sympathomimetic drugs Dextroamphetamine is an effective anti-vertigo agent. The effect is moderate and lasts for about 6 h. There is irritability when applied alone, and side effects such as increased blood pressure and accelerated heart rate can be seen with continued application. However, when combined with other anti-dizziness drugs, it can complement each other’s strengths and offset the side effects to enhance its anti-dizziness effect. Generally, it is most appropriate to combine dexamphetamine 10mg and scopolamine 0.6mg; it can also be combined with fenugreek.
(X) Antihistamines Some people think that this is the standard symptomatic drug for the treatment of vertigo. Its anti-dizziness mechanism may be through competitive binding with “receptor sites” in the effector cells, so that such receptors do not respond to histamine; or through the antagonistic effect on acetylcholine in the central and peripheral nervous system. The effect starts after 1h of oral administration and gradually decreases in 4-6h. These drugs have side effects of sedation. They may have teratogenic effects when used in pregnant women within the third trimester of pregnancy. However, the combination of amphetamine and scopolamine has no such side effects and can be used in early pregnancy. In the treatment of vertigo, the following three groups of drugs are useful: (1) vinblastine group: multiplying dizziness and benadryl; (2) piperazine group: Cycline, chlorpheniramine, chlorphenbutazine; (3) phenothiazine group: finasteride, fenadine, trifluoperazine.
(xi) Surgical treatment is suitable for those who are still ineffective after more than 2 years of drug treatment, mainly for peripheral vertigo, such as Meniere’s syndrome.
Peripheral vertigo, or otogenic vertigo, is one of the common clinical diseases in otorhinolaryngology. With the progress of society, the improvement of people’s living standard and the acceleration of work and life rhythm, the influence of vertigo on people’s life becomes more and more important. There are various diseases that cause otogenic vertigo, such as Ménière’s disease, vestibular neuronitis, positional vertigo, vaginitis and so on. Most peripheral vertigo such as Ménière’s disease can be improved with medication and other adjunctive treatments, but 10% of them are difficult to cure with medication and other conservative treatments and require surgical intervention. Surgery plays an important role in the treatment of refractory peripheral vertigo.
There are various surgical procedures for refractory peripheral vertigo, and they can be divided into three categories according to their impact on cochlear and vestibular functions.
I. Destructive surgery; this type of surgery achieves vertigo control by completely eliminating vestibular and cochlear functions, of which vagotomy is the representative.
Semi-destructive surgery; this type of surgery usually eliminates the vestibular function without destroying the cochlear function, and vestibular neurectomy is the representative surgery.
Third, function-preserving surgery, such as posterior semicircular canal obstruction surgery for refractory positional vertigo. The corresponding surgery is chosen according to the patient’s specific situation. The following surgical procedures for peripheral vertigo have been performed in the Department of Otolaryngology of Shanghai Sixth People’s Hospital.
Endolymphatic sac decompression
Endolymphatic mastoid shunt
Ear canal pathway vagotomy
mastoid pathway vagotomy
Semicircular canal obstruction
Posterior labyrinthine vestibular neurectomy
Labyrinthine pathway vestibular neurectomy
Posterior ethmoid sinus vestibular neurectomy
Vestibular neurotomy of the middle cranial fossa
Among them, the recent development of the semicircular canal obstruction technique for positional vertigo and Meniere’s disease that failed conservative treatment based on extensive animal testing and anatomical training of the temporal bone is a new breakthrough in the field of vestibular surgery and inner ear surgery.