In the initial investigation of the diagnosis of dizziness and vertigo, the most used terms are “cervical dizziness”, “cervical vertigo”, “cerebral blood supply deficiency” or ” Insufficient blood supply to the basilar artery”. Even patients themselves, like most physicians, give themselves the diagnosis of cervical dizziness/vertigo (thought to be related to cervical spondylosis) or insufficient cerebral blood supply to the vertebral basilar artery (mistakenly thought to be arterial compression). This is precisely due to the inability of some physicians to correctly understand the concept of dizziness or vertigo and the lack of careful differentiation and determination of the etiology. Therefore, it is especially important for clinicians to correctly understand the concept of dizziness and vertigo, to understand the characteristics of common diseases related to the syndrome, and to correctly diagnose them in their daily clinical work. The author introduces the correct concept of dizziness and the characteristics of common dizziness and vertigo diseases, combining the progress of dizziness diagnosis and treatment abroad and his own clinical practice experience, for the reference of relevant clinicians in practice to avoid blind selection of examination means and drug treatment.
I. Epidemiological characteristics of dizziness and problems in diagnosis
Dizziness and vertigo are almost one of the most common clinical conditions with high incidence and prevalence, and are the main syndromes seen in outpatient clinics of internal medicine, neurology and otorhinolaryngology, as well as one of the main conditions in emergency departments. An annual National Health Service survey study in the United States showed that approximately 19.6% of people over the age of 65 had dizziness and balance disorders. This is comparable to data from another community-based and population-based survey in the United States and the United Kingdom (21%-29% prevalence). A Dutch survey of dizziness in all age groups showed an annual incidence of 4.7 per 1,000. The vast majority of dizziness is episodic, with less than 5% being persistent. The frequency of dizziness episodes varies across studies. In a community-based study of dizziness, 51% of people had monthly episodes, 14% had weekly episodes, and 35% had daily episodes.
Despite the high incidence of dizziness, the diagnosis of dizziness by some clinicians is often “confusing” and “arbitrary”. The term “confusion” refers to the fact that some dizziness can be difficult to diagnose due to poor presentation or lack of experience on the part of the patient; the term “casual” refers to the fact that physicians are more casual about diagnosing dizziness or vertigo of “unclear etiology”. The so-called “casual” refers to the fact that physicians give the diagnosis of “cerebral insufficiency of blood supply” or “cervical dizziness” to dizziness or vertigo of which the cause is “unclear”, or simply use the word “dizziness” to make a symptomatological diagnosis, instead of conducting in-depth diagnostic analysis of dizziness and vertigo. The diagnosis of dizziness and vertigo should be analyzed and considered in depth.
For example, when a patient presents with dizziness or vertigo during head movement, the diagnosis often differs from one specialist to another, and some doctors often make a one-sided diagnosis based on their own opinion or from the perspective of their discipline. Some doctors consider cervical dizziness or cervical vertigo simply based on the presence of osteophytes and narrowing of the spinal space as shown by cervical spine X-ray; some diagnose arterial stenosis or spasm as a result of cerebral blood supply deficiency when they see the rapid blood flow in a certain artery as indicated by transcranial Doppler ultrasound; some directly diagnose Meniere’s disease or vestibular peripheral vertigo based on simple vertigo; and some doctors generalize the diagnosis by “deficiency”. “Some of them directly diagnose Meniere’s disease or vestibular peripheral vertigo based on simple vertigo. As a result, the same patient is diagnosed differently and given different treatment and medication as if he or she was “blinded by an elephant”, but with little effect, and some of them even get worse. Therefore, it is necessary to clarify the concept and diagnostic ideas of dizziness and vertigo.
II. Correctly grasp the concept of dizziness
In 2009, Bisdorff et al Mo proposed a new classification of vestibular disorders. This new classification classifies vestibular symptoms into vertigo, dizziness (narrowly defined as non-vertigo dizziness), visual vestibular symptoms, and postural symptoms. Moreover, this classification has not been widely used because the more detailed classification associated with each symptom is very complicated and actually not particularly suitable for clinical operation.
Broadly speaking, in 2010 Post and DickersonHl classified the concept of dizziness (dizziness) into the following four categories of conditions from a clinically practical perspective: dizziness (1ightheadedness), vertigo (vertigo), balance instability (disquilibrium), and presyncope (presyncope). This classification is very simple and easy to grasp for the diagnosis and treatment of dizziness. These symptoms occur when the patient is conscious. In other words, syncope and epilepsy that occur during loss of consciousness are not included. Thus, we understand that dizziness is a broad concept and that vertigo and dizziness are only a part of it.
Dizziness is a paroxysmal or persistent feeling of lack of clarity in the brain, dizziness and dullness, head swelling, and a feeling of tightness in the head. High blood pressure and mental factors often cause dizziness. Dizziness may sometimes be a physiological process, not necessarily a pathological mechanism, such as lack of sleep, fatigue, long overnight shifts, etc., which can be corrected if adjusted at the right time. Dizziness is a symptom of illusion of motion of the patient’s subject to the static surrounding objects or his own position, which is mostly a pathological phenomenon. It is often manifested as a sense of rotation of visual objects or rotation of oneself, but it can also have a sense of swaying instability, undulating waves and falling. In general, patients are afraid to open their eyes during vertigo, often accompanied by nausea, and in severe cases, autonomic symptoms such as vomiting, excessive sweating, blood pressure fluctuations, etc. Some of them may be accompanied by nystagmus, ataxia and other neurological localization signs. The pre-syncope state refers to the signs of chest tightness, palpitations, dizziness, blackness, and weakness that occur before syncope. If upright hypotension occurs, the presyncope state is likely to occur. Unstable balance refers to dizziness symptoms with unstable standing or movement disorders in action.
Therefore, patients who present to the clinic with dizziness should be distinguished as to whether they are dizzy and, if so, what type. Of course, for the individual patient, symptoms of dizziness can occur alone, simultaneously, or sequentially with symptoms of dizziness, vertigo, or unsteadiness of balance.
Common diseases of dizziness and their symptom characteristics
Dizziness is generally divided into two categories: non-vestibular dizziness and vestibular dizziness. Non-vestibular system disease dizziness is mainly caused by medical system diseases [such as cardiovascular diseases (high and low blood pressure, arrhythmia), blood diseases (anemia, erythrocytosis), endocrine diseases], environmental changes and excessive activities (high temperature, heat stroke, prolonged standing, overwork, etc.), post-traumatic head injury syndrome, visual fatigue and ocular myopathy (such as myasthenia gravis, glaucoma, etc.), inflammation of the five senses (oral cavity, paranasal sinusitis), upper respiratory tract infections and drug effects or drug poisoning, peripheral nerve diseases, etc. In addition, it also includes psychogenic dizziness, such as depressive and anxiety states, mild mania, etc. These dizziness are not an involvement of the vestibular system per se. Most of them are dominated by dizziness, unstable balance, and pre-syncopal states.
Vestibular system disorders are subdivided into central and peripheral dizziness. The main peripheral vestibular disorders include benign paroxysmal positional vertigo (BPPV), Meniere’s disease, vestibular neuronitis, labyrinthitis, and lymphangioleptic leakage. Central vestibular system disease dizziness includes inadequate blood supply to the basilar artery, posterior circulation ischemia, cerebral hemorrhage, brain tumor, encephalitis or demyelinating disease, and vertiginous epilepsy. Others have both central vestibular involvement and peripheral vestibular involvement, such as migrainous vertigo (i.e. migraine isotonicity), which may have central symptoms such as visual field defects and transient blurred consciousness, and a few may have unilateral hemiplegia on peripheral vestibular examination.
According to the latest domestic and international literature, the common causes of dizziness are BPPV, migrainous vertigo, psychogenic dizziness, non-vestibular system disease dizziness, posterior circulation ischemia or stroke. While conditions like Meniere’s disease, vestibular neuronitis or other central nervous system disorders (demyelination, tumors, inflammation) are among the less common dizziness conditions, cervical dizziness is increasingly less mentioned abroad unless it is due to cervical hyperflexion and extension injury or neck trauma.
BPPV, also known as otolithology, is a condition in which the otoliths in the ellipsoidal sac of the vestibular organ in the ear, which is responsible for balance, are dislodged and fall into the hula-hoop-like semicircular canal, which is connected to the otoliths, because there is a potbelly ridge in the semicircular canal that senses balance, and the collision of the otoliths when the position changes produces dizziness. Therefore, the clinical characteristics of vertigo are as follows: (1) vertigo attacks when the head position changes: it can be triggered when getting up, lying in bed, lifting or turning the head, and patients often “sigh at the bed” and “can’t look back”; (2) the time of vertigo attacks for each head position change is measured in seconds, mostly within 10 (2) the duration of each vertigo attack is measured in seconds, mostly within 10 s, so the vertigo is “instantaneous”; (3) the attack is vertigo, but the dizziness can still be felt for a short time after the attack; (4) the vertigo symptoms are self-improving and can recur; (5) there is no hearing loss or tinnitus, and there are no brainstem symptoms such as diplopia or walking instability; (6) the treatment mainly adopts otolithic manipulation to reset.
Migrainous vertigo, also known as vestibular migraine, is actually migraine equilibrium. The clinical characteristics are: (1) the disease usually occurs in women; (2) it occurs in all age groups, mostly in middle-aged and old people; (3) the clinical manifestations are mainly dizziness or vertigo, some have obvious migraine, a few have no migraine or headache symptoms; (4) the dizziness may be aggravated when the head position changes, but there is no directionality; (5) there may or may not be aura symptoms; (6) the vertigo attacks are mostly accompanied by nausea and vomiting, and after vomiting (6) The symptoms are relieved by nausea and vomiting, and after vomiting, there are obvious signs such as fear of sound, fear of light, preference for silence and irritability; (7) There may be blurred vision, and a few patients may have very brief blurred consciousness; (8) The attacks are often recurrent, with different frequencies, some once in several years, some once in several weeks or days, and the frequency is variable; (9) The symptoms last for 2~3 h (short tens of seconds, long hours or 2~3 d), usually after quiet rest or sleep (next day). or after sleep (the next day), the symptoms improve. Some people feel better after receiving infusion for 3~4 hours during the attack, but in fact, the improvement is mostly a natural process, not the effect of drugs; (10) most of them have but a few have no history of migraine, some have migraine manifestation when they are young, and with the increase of age, only the symptoms of dizziness or vertigo appear, and no more headache, the transformation of headache and vertigo form should be mastered; (11) vestibular function examination: it can be normal or unilateral hemiplegia with mild paralysis. The incidence is reported in the literature as 8.1%~23.8%, and most of them can be basically recovered with time and treatment; (12) Treatment: proceed according to the principles of migraine treatment, symptomatic pain relief or with sedative drugs, and appropriate rest.
Studies on the etiology of dizziness and vertigo have found that the etiology of long-term, chronic persistent dizziness or vertigo is mainly related to mental disorders, such as depression, anxiety, panic, obsessive-compulsive or somatization disorders, which can account for about 20% of dizziness. Staab and Ruckenstein suggest that 60% of unexplained persistent dizziness is due to primary or secondary anxiety disorders. 4.6% of patients with vertigo are suffering from psychogenic dizziness. In this issue, a detailed analysis of the clinical symptoms and treatment of 208 patients with psychogenic dizziness in our hospital was conducted. For the first time, psychiatrists guided us to classify psychogenic dizziness into three types for easy operation in practice, which provides a valuable empirical reference for the treatment of such patients.
Dizziness is also one of the first symptoms of posterior circulation ischemia, and the diagnosis of inadequate blood supply to the vertebrobasilar artery was commonly used in the past, but the concept of posterior circulation ischemia includes both transient ischemic attack and cerebral infarction, and is therefore more suitable for clinical application than inadequate blood supply to the vertebrobasilar artery. In some cases, posterior circulation ischemia starts with only vertigo without other symptoms, and sometimes detailed MRI examinations (including DWI image position) do not even reveal infarct manifestations, but brainstem infarction, even involving respiration with impaired consciousness, soon occurs, and one must be careful of this occurrence. For the diagnosis of posterior circulation ischemia, it is necessary to have the etiology of its occurrence, such as the history of smoking, the history of “three highs” (hypertension, hyperglycemia and hyperlipidemia), and to be able to confirm the formation of atherosclerotic plaques, rather than emphasizing the presence of cervical spondylosis.
The diagnosis of Ménière’s disease should be noted when the patient presents with vertigo, tinnitus, deafness (after multiple episodes), and a feeling of fullness in the ear. When patients experience vertigo to sharp sounds or under self-exertion, the occurrence of superior hemimegaplasia should be noted. The diagnosis of vestibular neuronitis should be noted when the patient has more vertigo, forced head (lateral) position, clear tilting to one side during physical examination standing, and finger-nose test with deviation to the affected side without other symptoms of auditory involvement. In the elderly population, special attention should be paid to the problem of dizziness caused by combined medications, such as antihypertensive drugs and prostate therapy drugs; attention should also be paid to the differentiation of dizziness caused by malnutrition, anemia, vitamin deficiency and hypothyroidism.
Fourth, familiar with the diagnostic ideas of dizziness
In clinical practice, it is very important for patients with dizziness to be diagnosed quickly, and a clear and simple diagnostic idea of dizziness can enable clinicians to quickly determine the cause of dizziness in their busy daily work. The author has summarized a diagnostic flow chart from the analysis of dizziness symptoms in clinical practice old J. Many clinicians use it and think it is easy to use and can be used as a reference. In addition, clinical practice should focus on the combination of basic examination and meticulous physical examination. For example, if blood pressure is measured, some dizziness is actually caused by long-term hypertension; sometimes dizziness occurs after long hours of reading, but it is actually a glaucoma problem, and it is not difficult to make a preliminary judgment as long as the rapid increase in intraocular pressure is induced by reading.
In conclusion, dizziness is a common clinical symptom, a seemingly “simple” but indeed “uncomplicated” diagnosis. The common causes are BPPV, migraine dizziness or vertigo, cardiac dizziness, and posterior circulation ischemia. Vestibular neuronitis, Meniere’s disease or cervical dizziness are rare causes, especially cervical dizziness. Patients with possible posterior circulation ischemia must be on high alert and should be seen immediately to avoid regret. For dizziness, it is necessary for the relevant specialists to continuously master the characteristics of their different disorders in practice and improve the diagnosis and differential diagnosis; at the same time, internal medicine and neurology doctors should also learn the technique of BPPV manipulation and repositioning to relieve the pain of these patients who first come to you, and to bring back the pain with a wonderful hand.