Vertigo is a common clinical symptom, and many people have experienced vertigo in their lifetime. True vertigo is a dysfunctional phenomenon caused by lesions or other factors stimulating the interconnected pathways of the vagus, vestibular nerve, vestibular nucleus or central nucleus in the inner ear. According to statistics, vertigo accounts for about 5% of internal medicine patients, 15% of ENT patients, and 81%-91% of geriatric outpatients; vertigo is mostly seen in adults, especially in the elderly, but vertigo in children is not uncommon. Vertigo is closely related to the function of the vestibular system (for the anatomy and physiology of the vestibular system, please see the special section of this project), and the role of the vestibular system is crucial in the management of the body’s balance function. This section introduces the diagnosis, differential diagnosis and treatment principles of vertigo.
I. Diagnosis of vertigo
1. Medical history: vertigo is an abnormality of self-perception, often feeling movement in the outside world and in oneself, or tumbling, rotating or lifting in heavy cases, or shaking or unstable in light cases, to objectively grasp the symptoms of vertigo, it is necessary to take a detailed medical history, and the following points should be noted in the process of inquiry.
(1) Nature of vertigo: whether vertigo is the main symptom of onset. (1) The nature of vertigo: whether vertigo is the main symptom of vertigo, and to identify the true vertigo (Vertigo), such as “the house is spinning”, “the wall is going to fall down”, “I am going to fall down”, etc., and to exclude dizziness, black eyes, dull head, syncope, etc. The sensation of general dizziness such as dizziness, fainting, etc. Terminal vertigo is heavy, episodic and short-lasting, often accompanied by tinnitus and deafness. The degree of vertigo can be roughly divided into three levels: dizziness can still move and hold itself as the first level; lying still with eyes closed and moving head can cause motion sensation in oneself and the environment as the second level; there is also intense motion sensation and accompanied by vegetative symptoms as the third level.
(2) Temporal variation of vertigo: the duration of vertigo attack is very helpful for differential diagnosis. Vestibular terminal lesions are mostly episodic vertigo, with sudden onset, lasting from a few seconds to ten minutes, as transient vertigo, often with recurrent attacks, and the symptoms can be completely relieved in between attacks, such as Meniere’s disease. Central disorders tend to be slow in onset and longer in duration, and balance disorders are not easily compensated for, and the symptoms are not easily relieved completely.
(3) Triggering factors of vertigo: Triggering factors are mostly seen in mental and physical overwork. In children, vertigo is mostly seen in children who are precocious, neurotic and have high self-esteem with excellent intellectual development. We should inquire in detail if there is any history of infection, fever, trauma, medication, mental stress, depression or overexcitement before the attack. In elderly people, vertigo can be a very important “alarm signal” for stroke because it is mostly caused by cardiovascular disease and is prone to brainstem and cerebellar infarction or insufficient blood supply when suffering from hypertension and arteriosclerosis.
(4) Whether the vertigo attack is accompanied by balance dysfunction: Generally, when there are only vertigo symptoms, it is mostly otogenic vertigo, which is a vestibular end lesion. When there is only balance disorder but no vertigo, it is mostly vestibular central lesion. The presence of both is usually a lesion of both the vestibular endings and the vestibular center.
(5) Whether vertigo is accompanied by hearing impairment: The inner ear is closely related to the hearing and balance functions, and symptoms often appear simultaneously or sequentially. Otogenic vertigo is the first in the incidence of vertigo and is mostly accompanied by deafness and tinnitus. Early on, tinnitus and deafness can fluctuate with vertigo attacks, but over time tinnitus and deafness can cause permanent damage. Young children often do not complain, so attention should be given to ask parents carefully ……
(6) Whether there are other neurological symptoms: whether there is clarity of mind during vertigo attack, whether there are small movements such as twitching of eyes, corners of mouth and limbs, which is an important basis for differentiation from epilepsy.
(7) Any family history of vertigo, motion sickness, Meniere’s disease, etc. have obvious family history.
2. Examination: Because of the close organic connection between the vestibular vestibular system, the visual system and the proprioceptive system of the trunk of the limbs, which maintain the body balance, it is extremely important to examine the balance function to understand the status of vestibular function and to help localize the lesion. (For more details on the examination of the vestibular system, please refer to the topics of this project)
(1) General balance function examination: with the help of the upper and lower extremity deep and shallow proprioceptive system response, using the upright reflex, oblique phenomenon observation. It can be used by the general population and children who can walk independently at the age of 3. Commonly used examination methods are: static balance test and dynamic balance test.
(2) Coordination test: test cerebellar function, such as finger-nose test, finger-nose-finger test, finger-to-finger movement, alternating movement, etc. to understand whether there is a cerebellar lesion causing balance disorder.
(3) Oculomotor examination: use a finger or toy to move the eyeball 50 cm away from the eye, at the level of the eyebrow, and move the eyeball 30o in the direction of up, down, left and right, observe the eye gaze and movement and record them. The examination items are.
(4) Ear examination: The ear should be routinely examined, paying attention to the morphology of the tympanic membrane for any abnormalities. Cerumen embolism and foreign body blockage in the external ear canal can stimulate the vagus nerve branches in the external ear canal and cause dizziness. Suppurative otitis media can cause vertigo secondary to vaginitis, cholesteatoma, or vagal fistula formation, which can stimulate the vestibular receptors in the semicircular canal. A fistula test should be performed if necessary. In recent years, it has been reported in the literature that vertigo is induced in children with exudative otitis media due to the stimulation of fluid in the middle ear cavity.
(5) Hearing examination: The vestibule and the cochlea are closely related to each other, and vertigo is often accompanied by symptoms of the cochlea. These tests are safe, reliable and painless, and the data obtained can be used to objectively analyze whether there are pathological changes in the auditory pathway from the middle ear, cochlear hair cells, auditory nerve to the nucleus of the auditory nerve at all levels of the brainstem, providing an important basis for disease diagnosis. Children and adults can further do suprathreshold audiometry or cochlear electrogram. These tests can help identify whether there is a cochlear or postcochlear lesion.
(6) Complete systemic examination: All patients with complaints of vertigo should have a complete physical examination if possible. Cardiac, pulmonary and vascular disorders such as hypotension, hypertension, arteriosclerosis, cervical spondylosis, syncope, anemia, hypoglycemia, intestinal ascariasis, chronic diseases of the gastrointestinal system, electrolyte disorders and endocrine disorders can induce vertigo. Refractive error and congenital nystagmus can cause vertigo. The neurological system should be examined, such as corneal reflex, facial muscle movement, facial sensation, walking gait and ataxia signs. In cerebellar lesions, there may be a duck gait and tremors during finger-nose or heel-shin tests. If vertigo does not improve after treatment, brainstem or posterior cranial fossa lesions should be considered, especially tumors in the fourth ventricle, and further necessary tests should be done.
(7) Others: For patients with combined otitis media, mastoid X-ray, horizontal and coronal scans of temporal bone CT should be taken. If intracranial occupying lesions are suspected, skull base, cranial lateral and internal auditory tract X-rays should be taken, and CT scan and MRI of temporal bone and brain should be done if necessary. Biochemical, blood, stool, cerebrospinal fluid and other routine examinations should be done according to the condition.
II. Differential diagnosis of vertigo
After the presence of vertigo is confirmed, the localization of the lesion should be further considered for diagnosis. Terminal vertigo is the most common form of vertigo.
Terminal vertigo is caused by vestibular end disorder and is mostly accompanied by vegetative symptoms such as nausea, vomiting, cold sweat and facial pallor. The attacks are short-lived, mostly transient and easily recurrent. It is often accompanied by hearing impairment with deafness and tinnitus. It is not accompanied by impaired consciousness. Spontaneous nystagmus is horizontal or mixed, without verticality, and the amplitude can change, and the nystagmus can subside or disappear after a few hours or days. Spontaneous tilting and static upright tests tend to tilt in the direction of the slow phase of nystagmus. Head position induced nystagmus is mostly fatiguing. Temperature-evoked nystagmus mostly has hemianopsia and may have a dominant bias in the same direction as spontaneous nystagmus.
Central vertigo is caused by disorders of the vestibular center. The vertigo is usually mild, the symptoms last longer, and is mostly not accompanied by hearing impairment. Most vertigo levels are inconsistent with balance disturbances. Nystagmus can be a single type of vertical nystagmus, and nystagmus can mostly persist for a long time with constant intensity, and usually the direction of nystagmus does not coincide with the direction of the lesion. Spontaneous tilting and static upright test tilting directions do not coincide. Temperature-induced nystagmus is mostly without hemianopsia, and the dominant bias does not exactly coincide with the affected side. In addition, the attacks may be accompanied by impaired consciousness and some may be seen with other cranial nerve damage, such as diplopia, facial nerve palsy, dysphagia, etc.
Some of the common types of vertigo are as follows.
1. 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 common in middle-aged people and rare 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 may be accompanied by rehearing, nausea, vomiting, cold sweat, pale face and cold limbs. 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 done, a basal widening negative phase and potential should be recorded in typical cases, and patients in the attack phase -SP/AP ≥ 40%.
2. 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 tract 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.
3. Sudden deafness with vertigo: It is common in 30 to 50 years old and may be caused by viral infection of the inner ear or vascular lesions or window membrane rupture. Patients have sudden onset of tinnitus and deafness on one side, and some of them have vertigo and vomiting. The condition resembles Meniere’s disease, but the vertigo lasts longer and there are no recurrent attacks later. The hearing examination shows severe sensorineural deafness (more than 60dB), and vestibular function may be impaired in those with vertigo.
4. Labyrinthitis: In acute or chronic purulent otitis media, the infection may spread to the inner ear labyrinth and plasmacytic or purulent labyrinthitis may occur, which may be accompanied by tinnitus, vertigo, nausea, vomiting and hearing loss in addition to ear leakage. 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 the normal vestibular function of the patient’s healthy side.
5. Vagal concussion: It is mostly caused by head trauma and often coexists with concussion, because the strong air wave impact after explosion can also cause inner ear vagal 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 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 can be present at the same time.
6. Vestibular system drug intoxication: mostly after the use of aminoglycoside antibiotics such as streptomycin, gentamicin, kanamycin, or quinine, salicylates, or phenytoinamide overdose, can cause inner ear intoxication. The symptoms of vestibular toxicity usually appear a few days or weeks after drug administration, manifesting as dizziness, staggering gait, unstable standing and walking difficulties in children who used to walk, and difficulty in walking in adults who feel no roots under their feet, especially at night, and vertigo is not obvious when sitting or lying in bed, but worsens when moving, and some people have tinnitus and deafness, and symptoms of cochlear toxicity can appear simultaneously with or later than vestibular toxicity. If vestibular tract drug intoxication occurs in children, the prognosis is generally good because children are still developing and have a strong compensatory capacity, and walking difficulties can be significantly improved and symptoms eliminated after a few weeks. Relative to the elderly, the higher the age, the slower the recovery.
7, motion sickness: commonly known as “motion sickness”, “seasickness”, “airsickness” and so on. It is more common in school-age children, more females than males. The symptoms are dizziness, nausea, vomiting, cold sweat, pallor, etc. when riding in a car, boat, airplane or rotating toys, due to the acceleration stimulation of the movement is not adapted. Most of them are caused by riding in small recumbent cars, which may be related to factors such as fast speed and closure of the car. About half of the patients have a positive family history. Hearing is normal on examination, and vestibular function may be more sensitive or hypoactive. The pathogenesis of motion sickness is not fully understood, and the severity of symptoms varies for each patient. Generally, the degree of motion sickness can be reduced or eliminated by several gradual trainings in car riding.
8. Positional vertigo: Unlike the above mentioned Ménière’s disease, positional vertigo means that the attack of vertigo is not spontaneous but induced, i.e., vertigo occurs only in one or several specific head positions.
Peripheral vestibular vertigo is called benign episodic positional vertigo. It is most likely due to trauma, vascular disease, infection, etc., which causes otolithic lesions and deposits of degenerated otoliths and cells in the posterior semicircular canal, causing an increase in density, which leads to the deflection of the roof of the canal when the head position is changed and induces vertigo. The clinical manifestation is a transient vertigo that occurs only when the head is in a certain position and rarely lasts more than 30 seconds without tinnitus and deafness. The vertigo and rotational nystagmus appear after a few seconds of latency when the head position is taken, and the response decreases or does not recur when the experiment is repeated, but can be induced again at intervals. Vestibular function is mostly normal.
Central nystagmus is seen in posterior cranial fossa disorders, and the nystagmus is long-lasting when the head position is evoked, mostly vertical, without latency and fatigue.
9.Phytokinetic disorder: Mostly seen in middle-aged women, more sensitive and agitated nerves or introverted people are prone to develop. Before the disease, there can be mental stimulation, sudden onset of vertigo, external rotation, afraid to open the eyes, usually accompanied by nausea, cold sweat, pale face and other symptoms, and return to normal after the attack. Hearing and vestibular function tests are normal.
10.Benign paroxysmal vertigo in young children: This disease was first reported by Basser’s in 1964. It is characterized by a single episode of vertigo with no signs of hearing changes. It occurs mostly in children aged 1-4 years, both sexes. The onset of vertigo is sudden, mostly without any obvious cause, and the attacks are brief, rarely lasting more than a few minutes, accompanied by pallor, cold sweat, vomiting, and fear of movement. After remission, activities are normal. The seizures are irregular and can be intermittent for a few days to several months, with normal intervals between seizures. The child’s general examination is normal, hearing is normal, temperature tests of the vestibule may have unilateral or bilateral moderate or complete hemianopsia, and the EEG and CT scan of the head are normal. A positive family history can often be traced and the disease has a good prognosis.
11, congenital enlarged vestibular aqueduct syndrome: since Valvassori first reported in 1978, it is now very common in China. This disease is mostly found in childhood, children with poor hearing since childhood, with speech disorders, hearing in both ears can be asymmetrical, often due to head trauma, colds and other triggers and hearing fluctuations, some children have a typical history of vertigo attacks, the onset is very similar to Ménière’s disease, vertigo attacks are often followed by hearing loss, repeated hearing fluctuations, can cause severe hearing damage is difficult to recover. The diagnosis of the disease is based on the enlarged vestibular aqueduct on CT examination of the temporal bone, and sometimes it may be accompanied by congenital malformation of the vestibule and hemianopia or cochlea. The child may have a positive family history, and siblings are prone to the same onset.
12. Vestibular epilepsy: vertigo can be the aura of epilepsy, sudden seizure with loss of consciousness, transient memory loss, hallucinations or hallucinations, and inability to describe the sensations during the seizure after the seizure. Most of the patients have normal hearing and vestibular function, and the EEG may have abnormal patterns. Most of them have a history of birth injury or head trauma, and some of them have positive family history.
13.Cervical vertigo: vertigo caused by organic or functional changes of cervical spine and related soft tissues (joint capsule, ligaments, etc.). Common organic damage of cervical spine and soft tissue lesions in the neck, such as cervical spondylosis, circumoccipital deformity, neck trauma, cervical ribs, cervical muscle injury, joint cyst, disc protrusion, anterior oblique muscle compression, ligament injury, etc., stimulate cervical sympathetic nerve to cause spasm of vertebral artery, etc. Vertigo mostly occurs when the neck is turned, usually without cochlear symptoms, and may be accompanied by neck and occipital pain, deep pressure pain beside the cervical vertebrae, numbness and weakness in the arm.
14. vertigo of central nervous system lesions: vertigo is often associated with central system diseases. meningitis in children aged 1 to 3 years often starts with very sudden instability, and irregular dancing-like asynchronous nystagmus appears a week later. About 3/4 of brain tumors have vestibular dysfunction and should be highly alarming.
Tumors of the pontocerebellar horn of the cerebellum (including auditory neuroma) mostly start with symptoms of tinnitus and deafness, and vertigo is mostly shaking sensation with balance disorder. When the tumor grows up, it may invade VII, IX, X and D. cranial nerve pairs, and the corresponding symptoms will appear. The corneal reflex is blunted or disappeared, and the nystagmus is mostly horizontal spontaneous nystagmus, mostly to the affected side. In the early stages of hearing loss, only the affected side of the hearing threshold is increased, and the stapedius muscle acoustic reflex has a positive half-life on acoustic conductance audiometry. The brainstem auditory response is extremely valuable in diagnosis, mostly showing increased threshold, prolonged interwave interval and prolonged wave latency. In larger tumors, only wave I can be recorded, and later waves disappear, and in more severe cases, no waveform can be recorded or even waves to the contralateral side. Vestibular function examination is low in the early stage and disappears in the late stage. Nystagmography may record central damage, and visual tracking may appear to have significant abnormalities. Larger tumors result in increased intracranial pressure and optic papillary edema. Radiographs, CT and MRI of the temporal bone may show enlargement of the internal auditory canal and thinning or destruction of the bone wall. Cerebrospinal fluid assay has increased amount of protein.
The tumors near the fourth ventricle are mostly associated with vertigo symptoms. CT and MRI examinations can clarify the diagnosis.
Treatment of vertigo
After the diagnosis is made by comprehensive examination and analysis, active treatment should be given to control or reduce the symptoms and seizure; strengthen the functional exercises to promote the recovery and compensation of vestibular function; if necessary, surgical treatment should be performed.
1, mainly to control the symptoms: acute vertigo attack with nausea, vomiting, the patient is very painful, should be given sedatives, appropriate use of drugs to reduce the excitability of the central nervous system; vitamin B6, B1, C, glutamate; anticholinergic drugs, such as belladonna, 654-2, multiplying dizzying, Min make Lang, Feisaile (phencyclidine) and traditional Chinese medicine vertigo Ning, etc.. In case of severe vomiting, intramuscular injection of Emol or Methotrexate can be given. If vertigo is serious and you cannot eat, inject 5% sodium bicarbonate and 50% glucose intravenously, and pay attention to maintaining water and electrolyte balance and rest in bed. Adults can also use drugs to improve microcirculation in the inner ear, such as geranium, salvia, and ginkgo biloba preparations.
Acupuncture and Chinese herbal medicine can be used in conjunction. Acupuncture points such as Neiguan, Hegu, Foot Sanli, Renzhong, Fengchi and Quchi can be used. Chinese herbs can be used in the formulations of Salvia miltiorrhiza, Huang Jing, Wu Wei Zi, Ge Ge Gen, Prince’s ginseng, Fructus Lycii, Radix et Rhizoma Polygonati, Yam, Shen Qu, Raw malt, Fried Citrus Aurantium, Patchouli, Semen, Ze Di, Fried Betel nut, etc. For children, it is mainly for tonicity, nourishing Yin, diuresis and antiemetic.
2.Functional exercises: It is extremely beneficial for patients with vertigo to perform functional exercises, especially for plant nerve dysfunction, drug-induced vertigo, etc. Practicing taijiquan, massage, gymnastics and proper head exercises can be effective. People with motion sickness can gradually start from a short distance ride in a car, slow rotation chair, turning in place, etc., repeatedly take that transportation several times, gradually increase the amount of activity, to be persistent, the symptoms can be significantly reduced. If the training is combined with self-relaxation and biofeedback training, the effect will be better.
3, remove the cause: otitis media with cholesteatoma and vagus fistula and other comorbidities, should be surgically removed from the lesion or be repaired. If intracranial tumors are clearly diagnosed and localized, those with suitable indications should have the tumors removed surgically. If vertigo is induced by intestinal ascariasis, anemia, refractive error, etc., it should be corrected for the cause.
4.Relief of mental concern: Recurrent attacks of vertigo can make patients and their families very nervous. Doctors should be kind and give necessary comfort. Patients should have sufficient sleep, regular life, comfortable environment and less greasy and easy to digest diet, especially in the hot summer. Some people who are too nervous should be given a small amount of sedative.
IV. Summary
Vertigo is commonly seen in pediatrics, otology, ophthalmology and neurology. We should do a comprehensive examination and give active treatment to these patients, and most of them can get a good prognosis.