Four common misconceptions about the diagnosis and treatment of vertigo
More than half of the patients attending neurology clinics complain of vertigo, and there are various kinds of vertigo: dizzy, spinning, light-headed… 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 between “real and fake” vertigo
1. First of all, there is no distinction between dizziness and vertigo.
Vertigo refers to the sense of rotation or oscillation of oneself or the environment, which is a kind of motion illusion; 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-mentioned cortical centers. “True vertigo” is caused by a triad of balance 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 successfully make a localized and qualitative diagnosis.
The main points of outpatient vertigo consultation include.
1. Precipitating factors.
Head position change: 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 the visual field: bilateral vestibular disease.
2. Duration.
Several seconds or tens of seconds: BPPV, vestibular paroxysm, variable pressure vertigo, cervical vertigo, epileptic vertigo and pre-syncope, etc.;
Minutes: TIA, migrainous vertigo, vestibular paroxysm, epileptic vertigo, superior hemiplegic fissure, variable pressure 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. Accompanying 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 of migrainous vertigo, first episode of Meniere’s disease, labyrinthitis, exolymphatic 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 vestibular hypoplasia compensatory 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). But there are a few basic medical checkups that you should do in your mind.
1. Dix-Hallpike anamnesis test.
The patient sits on the examination table, and the examiner turns the patient’s head 45° to the right, 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 instruct 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 subject 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.