In the neurology clinic, more than half of the patients complained of dizziness, and it was a variety of dizziness, the patients were old, middle-aged and young people; there were more forms, including dizzy dizziness, spinning dizziness, light-headed dizziness; and the doctors’ diagnosis seemed to show a certain pattern: elderly patients – cerebral blood supply deficiency, middle-aged patients – cervical spondylosis, women – Meniere’s syndrome. .
Yes, vertigo is very common, it is a simple clinical symptom, but the treatment of vertigo is not simple at all, so what are the common misunderstandings of vertigo treatment?
I. Do not distinguish “real” vertigo from “fake” vertigo
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 hallucination; dizziness mainly manifests itself as a sense of instability, often accompanied by a sense of mental unclearness, that is, dizziness.
Secondly, vertigo is also divided into true and false. “Pseudovertigo, also known as cerebral vertigo, is mostly caused by the cortical centers of the balance triad (visual, proprioceptive, vestibular) or systemic diseases that affect the above cortical centers, and the patient feels “dizzy” without a clear sense of rotation; for example Pseudovertigo” can be caused by hypertension, fever, anemia, etc. “True vertigo” is caused by balance triad lesions, and there is a clear sense of rotation or body movement.
Inadequate history taking
Taking medical history is the beginning of doctor-patient relationship and the cornerstone of clinical treatment. Only by obtaining detailed medical history information can we successfully make 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 motion: superior hemimelia and ectolymphatic fistula; standing position: postural hypotension, etc.; object motion in the visual field: bilateral vestibular disease.
2.Duration.
Several seconds or tens of seconds: BPPV, vestibular paroxysm, varicose vertigo, cervical vertigo, epileptic vertigo and pre-syncope, etc.; several minutes: TIA, migrainous vertigo, vestibular paroxysm, epileptic vertigo, superior semicircular fissure, varicose vertigo, etc.; 20min
More than 20 min: Meniere’s disease and migrainous vertigo; several days: stroke, vestibular neuritis and migrainous vertigo; 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 ear 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, 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, trichloromethane – damage to the cerebellum.
Common ototoxic drugs: antibiotics such as aminoglycosides, vancomycin, viomycin and sulfonamides, antineoplastic drugs 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.
III. Ignoring the importance of physical examination
Of course, we can’t blame the doctor for this, because we have a lot of people in China, and the amount of patients a doctor sees in a day at an outpatient clinic is equivalent to the amount of doctors abroad in a week (in terms of quantity), and there is no time for consultation, let alone physical examination. But there are a few basic medical checkups that you should do in your mind.
1. Dix-Hallpike dislocation nystagmus test.
The patient sits on the examination table, and the examiner turns the patient’s head 45° to the right, keeping the above-mentioned 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.Rollmaneuver roll test.
The patient sits on the examination table, quickly takes the flat position, and does 90° barrel roll of the head and body to the left side, returns to the flat position, and then does 90° barrel roll to the right side; those with BPPV immediately experience severe rotational vertigo and horizontal nystagmus.
The above test is used with caution or disabled for patients with severe heart disease, cervical spondylosis and carotid stenosis.
3.HeadThrustTest
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 degrees, 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.
Fourth, over-reliance on drug treatment
In fact, in the end, we will find that not many patients with vertigo have a clear etiology and can be treated etiologically, no more than immediate thrombolysis for acute vertebrobasilar ischemic stroke and manual repositioning for otoliths, etc. Most patients are treated symptomatically, i.e., anti-dizziness, anti-emetic, anti-anxiety and depression, etc.
Of course, some anti-dizziness drugs need to be applied symptomatically during vertigo attacks or in the acute stage, but is it really necessary to give intravenous drips and drops for 14 days as soon as they come? This is actually a waste of medical resources. Moreover, anti-vertigo drugs should not be applied for a long time, as they will inhibit the establishment of central compensatory mechanism, and patients should have early vestibular rehabilitation training; in addition, the Epley otolith restoration method and Semontmaneuver tube stone restoration method for BPPV should be really applied in the clinic.