Vertigo is a kinetic or positional illusion that occurs due to the body’s impaired spatial orientation and is multidisciplinary in nature. The vast majority of people experience this disorder throughout their lives. According to statistics, vertigo accounts for 5% of outpatients in internal medicine and 15% of outpatients in otolaryngology. Vertigo can be divided into true vertigo and pseudovertigo. True vertigo is caused by diseases of the eye, proprioception or vestibular system, with a distinct sensation of external objects or self rotation. Pseudovertigo is mostly caused by systemic diseases, such as cardiovascular disease, cerebrovascular disease, anemia, uremia, drug intoxication, endocrine disease and neurosis, etc. Almost all of them have symptoms of dizziness of varying severity, and patients feel “floating” without a clear sense of rotation. Shen Xiaoming, Department of Encephalopathy, The First Affiliated Hospital of Henan College of Traditional Chinese Medicine
I. Clinical manifestations
1. Peripheral vertigo
Vertigo caused by lesions in the vestibule or vestibular part of the inner ear or the extracranial segment of the vestibular nerve (in the internal auditory canal) is peripheral vertigo, including acute vaginitis and Meniere’s disease. The characteristics of vertigo are as follows: ①Vertigo is intense rotational, short-lasting, and can be aggravated by change of head position or body position. (2) Nystagmus: nystagmus coexists with vertigo attack, mostly horizontal or horizontal plus rotational nystagmus. Usually there is no vertical nystagmus, the amplitude can be changed, and the nystagmus may subside or disappear after a few hours or days, and it is more obvious when gazing to the healthy side. Head position induced nystagmus is mostly fatigue, and temperature induced nystagmus is mostly seen in hemianopia. (iii) Balance disorders: mostly rotational or up-and-down swaying motion sensation, unstable standing, spontaneous tilting, static upright test mostly tilting in the direction of the slow phase of nystagmus. ④Autonomic symptoms: such as nausea, vomiting, sweating and pallor, etc. ⑤ It is often accompanied by tinnitus and hearing impairment without brain function damage.
2. Central vertigo
It refers to vertigo caused by lesions in the vestibular nucleus, brainstem, cerebellum and temporal lobe of the brain. Features: (1) The degree of vertigo is relatively light, long lasting, rotational or motion to one side, which can be relieved by closing the eyes, not related to head or body position change. (2) The nystagmus is coarse and can be a single vertical nystagmus and/or horizontal or rotational type, and can persist for a long time with constant intensity. The direction of nystagmus is inconsistent with the side of the lesion, and the direction of spontaneous tilting and static upright test tilting is inconsistent. (iii) Balance disturbance: It is manifested as rotational or to one side motion sensation and unstable standing. Most of the vertigo and balance disturbance are inconsistent in degree. ④Autonomic symptoms are less obvious than peripheral ones. ⑤No hemianopia, hearing impairment, etc. ⑥It may be accompanied by brain function damage, such as cerebral nerve damage, extraocular muscle palsy, facial and tongue palsy, ball palsy, limb paralysis, high cranial pressure, etc.
3. Encephalogenic dizziness is seen as a result of cerebral arteriosclerosis (such as basilar arteriosclerosis) or cervical osteoarthrosis causing cerebral blood circulation disorders, or the resulting transient cerebral blood supply deficiency. The clinical features are dizziness, sleep disturbance, memory loss, parieto-occipital headache, light palsy, speech disturbance, emotional agitation, etc. The disease generally develops slowly, and such dizziness is characterized by easy appearance or aggravation during postural changes.
4. Cardiogenic dizziness can be seen in acute cardiogenic cerebral hypoperfusion syndrome, which is acute cerebral ischemia caused by cardiac arrest, paroxysmal tachycardia, paroxysmal atrial fibrillation, ventricular fibrillation, which can manifest dizziness, blurred vision, stomach discomfort, syncope, etc.
5. Vaso-inhibitory dizziness, often promoted by emotional stress, pain, fear, bleeding, sultry weather, fatigue, cavitation, insomnia, etc. Patients often have dizziness, vertigo, nausea, epigastric discomfort, pallor, cold sweat and other plant nervous disorders. Their blood pressure drops and pulse is weak. Vasodepressive dizziness is most often seen in young women who are frail. Orthostatic hypotension refers to dizziness, blurred vision, weakness of the legs, vertigo, and even syncope when standing, often accompanied by no sweating and urinary and fecal disorders.
6. Drug poisoning dizziness, with streptomycin, neomycin, kanamycin, gentamicin and other poisoning as the most common. In addition to dizziness, patients also have vertigo and sensorineural deafness due to cochlear nerve damage. Chronic lead poisoning is mostly manifested as neurasthenia syndrome (with dizziness, headache, insomnia, forgetfulness, weakness and dreaminess as the main symptoms), and also hypothermia, loss of appetite, etc.
7. Other: functional hypoglycemia can also cause dizziness, panic, weakness, tremor when fasting or exertion, sometimes convulsions, loss of consciousness, etc. When emotionally stressed or hyperventilating, respiratory alkalosis can occur due to the increase of carbon dioxide excretion, and brain cells are deprived of oxygen, causing dizziness and weakness, and the patient feels numb and cold on the face and hands and feet, and occasionally has a sense of trance.
II. Common vertigo disorders
1. Otoliths
It is the most common in clinical practice and is mostly seen in otorhinolaryngology. It starts suddenly with persistent vertigo, which is relieved in a few days and turns into episodic vertigo. However, vertigo occurs when the head is in a certain position and can last for tens of seconds, and it can be reduced or disappeared when the head is turned or reversed. Significant nystagmus can be seen, and the duration of its vertigo varies greatly, and most of it resolves itself or disappears within a few hours or days after the onset.
2. Meniere’s disease
The clinical manifestations are intermittent recurrent attacks of vertigo, with intervals ranging from days, months to years. The vertigo is often sudden and starts at the most severe level, intensifies with head movements and eye opening, and is often accompanied by tilting, panic due to a sense of intense rotation and movement, accompanied by tinnitus, deafness, nausea, vomiting, pallor, slow pulse, decreased blood pressure, and nystagmus. The duration of each attack varies from a few minutes to several hours, with some attacks lasting for several days. After each episode, fatigue and sleepiness are present. Balance and hearing return to normal during the interval. The vertigo decreases with the increase of deafness on the affected side after several episodes, and disappears when the deafness progresses to complete deafness.
3. Ischemic lesions of the VBA system of the vertebral basilar artery
Nystagmus is present without other neurological symptoms and signs. According to the clinical manifestations, they are classified as follows: ① Transient ischemic attacks The attacks are indefinite and may occur several times in a day or once in several days, and usually resolve or disappear in a few minutes to half an hour. In mild cases, there is only vertigo and instability, but in severe cases, frequent attacks progress to complete vagal stroke. (2) Progressive stroke medium The vertigo, tinnitus and deafness continue to progress and worsen after the onset of stroke, reaching a peak after a few days. (3) Complete stroke: Vertigo, instability, tinnitus, and deafness peak a few hours after onset, and nystagmus is apparent. The symptoms may gradually decrease after a few weeks. Dizziness is often associated with hearing impairment.
There are other lesions that can also cause vertigo, all of which fall under the category of vertigo, such as cerebellar hemorrhage, neck lesions, intracranial tumors, craniocerebral trauma, drug or poison poisoning, inflammatory demyelinating diseases, etc.
4. Six major causes of dizziness in the elderly
(1) Anemia elderly people who have dizziness, weakness and pale face should go to the hospital to check if they are anemic. In a healthy state, the amount of hematopoietic tissue present in the body of the elderly as well as the quality and quantity of hematopoiesis has declined, and the aging of the red blood cells themselves makes their utilization of iron much less than before. Therefore, the elderly are prone to anemia if they do not pay attention to nutritional care. In addition, anemia can be secondary to dyspepsia, peptic ulcer, gastrointestinal bleeding, and chronic inflammatory diseases in elderly patients.
(2) High blood viscosity, hyperlipidemia and thrombocytosis can increase blood viscosity and slow blood flow, resulting in insufficient blood supply to the brain and symptoms such as easy fatigue, dizziness and weakness. There are many causes of hyperlipidemia, the most important one is the unreasonable diet structure, patients eat a lot of high-fat and cholesterol food, and do not like to exercise. At present, the incidence of this type of disease has a rising trend.
(3) Patients with cerebral arteriosclerosis feel dizzy, and often suffer from insomnia, tinnitus, emotional instability, forgetfulness, and numbness of the limbs. Cerebral arteriosclerosis makes the internal diameter of cerebral blood vessels smaller, and blood flow in the brain decreases, resulting in insufficient blood and oxygen supply to the brain, causing dizziness.
(4) Cervical spondylosis Often the neck is tight, flexibility is limited, there is occasional pain, numbness and coldness of the fingers, and there is a feeling of heaviness. Cervical spine hyperplasia squeezes the vertebral artery in the neck, causing insufficient blood supply to the brain, which is the main cause of dizziness in this disease.
(5) Hypertension In addition to dizziness, hypertensive patients are often accompanied by discomfort such as head swelling, panic, irritability, tinnitus, and insomnia.
(6) Early stage of heart disease coronary heart disease, the symptoms are still mild, some people may not have chest tightness, palpitations, shortness of breath and other significant discomfort, only feel headache, dizziness, weakness of the limbs, mental concentration, tinnitus or forgetfulness, etc.. The main reason for dizziness at this time is atherosclerosis of the coronary arteries of the heart, which makes the lumen thinner and narrower, causing ischemia and lack of oxygen to the heart. And insufficient blood supply to the heart can cause insufficient blood supply and cause dizziness.
IV. Examination
1. Otologic examination
External auditory canal examination, vestibular function examination, nystagmography, hearing examination VEP/BAEP, etc.
2. Neurological examination
Examination of parts related to the vestibular system, star tracing test, deviated finger test, visual acuity and fundus examination.
3. Examination of vertigo caused by other medical disorders
It is more important to do a comprehensive physical examination, such as blood pressure and pulse test, if possible.
4. Imaging and electrophysiology related examinations
Head CT, CTA, brain MRI, DSA, TCD, ECG, EEG, etc.
5. Blood laboratory tests
Routine blood tests, biochemical tests.
V. Treatment
Vertigo is not a disease, but a combination of certain diseases. The diseases causing vertigo involve many clinical departments, including otolaryngology, ophthalmology, orthopedics and internal medicine. The main treatments are as follows.
1. Etiological treatment
(1) Vertigo with reversible damage to vestibular function This category has a better prognosis, such as benign paroxysmal positional vertigo and plagiocephaly. Once the cause is removed, vertigo disappears and vestibular function can be restored.
(2) Irreversible vertigo with one-time damage of vestibular function, such as septic vaginitis, sudden deafness, vestibular neuronitis, etc. Although the cause is removed, the vagus or vestibular function is completely destroyed and vestibular function cannot be restored, so it is necessary to rely on the vestibular center to compensate for the elimination of vertigo.
(3) Vestibular function fluctuating damage or irreversible damage of difficult to treat causes, such as arteriosclerosis or hypertension, cervical spondylosis, etc., are poorly treated. Surgical treatment is feasible if conservative treatment is ineffective.
2. Symptomatic treatment
(1) Conservative treatment during vertigo attack Choose the most comfortable position, avoid sound and light stimulation, and relieve the mind.
(2) Vestibular nerve sedatives: promethazine (finasteride), diazepam (Valium), etc.
(3) Anti-vomiting agents Atropine, scopolamine.
(4) diuretic and dehydration drugs tachyphylaxis, mannitol, etc.
(5) Vasodilators Ginkgo biloba extract, salvia, chuanxiongzin, etc.
(6) Hormones Prednisone, dexamethasone.
(7) Vitamins Vitamin C, vitamin E.
(8) Oxygen inhalation Generally treated with hyperbaric oxygen or 5% carbon dioxide mixed oxygen inhalation.
3. Chinese medicine treatment
(1) Etiology and pathology
(1) Emotional and moral injury with Yang in the body, combined with excessive anger and irritation, causes hyperactivity of liver yang and Yang rising and wind moving, resulting in vertigo; or long-term depression and irritation, causing depletion of liver yin, hyperactivity of liver yang and Yang rising and wind moving, disturbing the clear air, resulting in vertigo.
(2) Injury to the spleen and stomach due to poor diet, weakness of the spleen and stomach, lack of source of Qi and blood biochemistry, loss of nourishment of the clear orifices and dizziness; or alcoholism, fatty and sweet, hunger and fatigue, injury to the spleen and stomach, loss of health and transportation, resulting in failure of water and grain to transform essence, gathering dampness and phlegm, blockage of phlegm and dampness, failure to lower the cloudy yin, resulting in dizziness.
③ Trauma, surgery, head trauma or post-surgery, stagnation of qi and blood stasis, paralysis and obstruction of the clear orifices, resulting in vertigo.
If the kidney essence is not sufficient due to congenital deficiency, or if the kidney is deficient in old age, or if the kidney is injured by prolonged illness, or if the room is overworked, the kidney essence is deficient and cannot produce marrow, and the brain is the sea of marrow. Or kidney yin deficiency, liver loss of nourishment, resulting in liver yin deficiency, yin does not control yang, liver yang hyperactivity, dizziness. Vertigo can occur after a prolonged illness or blood loss, when the deficiency is not restored, or after excessive labor and fatigue, when the qi and blood are deficient, when the qi is deficient, the clear yang does not spread, and when the blood is deficient, the brain loses its nourishment.
It is caused by deficiency of qi and blood, deficiency of kidney essence, resulting in emptiness of the brain marrow and loss of nourishment of the clear orifices, or hyperactivity of liver and yang, phlegm and fire, or stasis of blood blocking the orifices, which disturb the clear orifices and cause vertigo. The pathology of vertigo is mostly deficiency, so Zhang Jinyue said “deficiency is the most common cause of vertigo”, such as deficiency of liver and kidney yin, internal movement of liver wind, deficiency of qi and blood, loss of nourishment of clear orifices, deficiency of kidney essence, and loss of brain marrow. The actual evidence of vertigo is mostly caused by phlegm and turbidity obstruction, abnormal lifting and lowering, phlegm and fire reversal, upward violation of the clear orifices, stasis of blood, and paralysis of the clear orifices. During the pathogenesis of vertigo, various etiological factors can interact with each other and transform each other to form a mixture of deficiency and reality; or yin damage and yang, and yin and yang deficiency. Liver wind and phlegm fire can disturb the clear orifices, and further development can block the clear orifices and meridians, resulting in stroke; or sudden reversal of qi, temporary closure of the clear orifices or loss of nourishment, resulting in vertigo.
(2) Treatment principles
The principle of treatment for vertigo is to nourish the deficiency while dipping the actual, and to adjust yin and yang. For deficiency, deficiency of kidney essence and deficiency of qi and blood are most common. In case of deficiency of essence, it is recommended to fill essence and promote marrow, nourish liver and kidney; in case of deficiency of qi and blood, it is recommended to benefit qi and nourish blood and tonify spleen and kidney.
(3) Treatment by evidence
(1) Hyperactivity of liver and yang
Symptoms: dizziness and tinnitus, headache and swelling, aggravated by exertion and anger, numbness and trembling of the limbs, insomnia and dreaminess, impatience and irritability, red tongue with yellow fur and string pulse.
Treatment: Calming the liver and submerging Yang, nourishing the liver and kidney.
Remedy: Tianma and Hooked Vine Drink.
②Liver fire on inflammation
Symptoms: dizziness and pain, more intense, red eyes and bitter mouth, chest and hypochondriacal pain, irritability, little sleep and dreams, yellow urine, dry stool, red tongue with yellow fur and string pulse.
Treatment: Clearing the liver and diarrhea of fire, clearing dampness and heat.
Remedy: Gentian and liver diarrhea soup.
(3) Upward clouding of phlegm
Symptoms: vertigo, head heavy like a cloud, spinning vision, chest tightness, vomiting and salivation, little food and sleep, white and greasy coating, smooth pulse.
Treatment: Drying dampness and dispelling phlegm, strengthening the spleen and harmonizing the stomach.
Remedy: Radix et Rhizoma Atractylodis Macrocephalae and Rhizoma Tenax.
Blood stasis blocking the orifices
Symptoms: vertigo and headache, with amnesia, insomnia, palpitation, mental discomfort, tinnitus and deafness, purple face and lips, stasis or petechiae on the tongue, and astringent or fine pulse.
Treatment: Invigorate blood circulation, resolve blood stasis, and clear the orifices and activate the channels.
Direction: Promoting blood circulation and activating blood circulation.
⑤ Deficiency of Qi and Blood
Symptoms: dizziness and dizziness, aggravated by movement and exacerbated by exertion, white face, unglamorous claws and nails, fatigue, palpitations and sleeplessness, poor appetite, loose stools, pale tongue with thin white coating and weak pulse.
Treatment: Nourishing Qi and Blood, tonifying the spleen and stomach.
Remedy: Gui Shen Tang.
(6) Yin deficiency of liver and kidney
Symptoms: persistent dizziness, diminished vision, dry eyes, forgetfulness, dry mouth, tinnitus, fatigue, lumbago, weakness, seminal emission, red tongue with thin coating, thin pulse.
Treatment: Nourish the liver and kidney, nourish Yin and fill essence.
Remedy: Zuo Gui Wan.
(4) Traditional Chinese medicine massage treatment
Tui Na massage therapy for dizziness to strengthen the massage areas: cerebellum, ears, inner ear vagus.
① Cerebellum (reflex zones are crossed).
How to treat dizziness
The middle of the two horizontal lines of the thumbs of both feet is the cerebellar reflex zone, just adjacent to the neck. Massage direction should be pressed from the outside to the inside direction and then pressed from the inside to the outside.
② brain (reflex zones have crossed).
Bit both feet thumbs throughout the toe belly are. Massage direction is from the top down massage.
③ trigeminal nerve (reflex zones have crossed).
Bit both feet thumbs outside of the bone edge below the muscle. Massage direction is from the bottom to the top massage.
④ frontal sinus (reflex zones have crossed).
At the end of the five toes of both feet, just below the toenail. Massage direction is from the bottom to the top massage.
⑤ inner ear vagus.
Located at the back of the feet, below the little toe, at the edge of the first bone of the palm of the foot, when touched, there are particles slightly convex feeling. Find the slightly convex small particles, press the hand and then rub at a fixed point.
(6) Ears (reflex zones are crossed).
In the soles of the feet of the four, five toes and the palms of the feet intersect below the muscles. Massage from top to bottom after clasping, massage inward.
4. Other treatments
The causes of vertigo are complex and involve a wide range of disciplines, but some vertigo disorders (such as benign paroxysmal positional vertigo) can be treated by repositioning to achieve healing and good therapeutic results. Surgical treatment of vertigo diseases must have clear localization diagnosis and indications.
VI. Prevention
Because vertigo symptoms involve many disciplines and many diseases, it is difficult to prevent the disease. Often, the onset of vertigo has no aura, and some of the triggers are still uncertain, such as peripheral vertigo vestibular neuritis, 30% of which have a history of pre-cold, and it is presumed that viral infection is a factor in its development. However, most colds do not necessarily cause vestibular neuritis, so there are no good interventions in the pre-onset period. MRI and DSA should be examined early for central vertigo to help the diagnosis and treatment of related diseases. Prevention can be done in the following ways.
1. actively participate in physical exercise. Those who have poor physical fitness can improve their physical quality, and those who are fat can enhance the operation of qi and blood and accelerate the excretion of water, dampness and phlegm.
2. Diet should be vegetarian and easy to digest. It is inappropriate to consume tobacco, alcohol, strong tea, coffee, leeks, chili peppers, garlic and other stimulating foods.
3. Winter melon, radish, taro, mushroom, ground chestnut, adzuki bean and rice kernel have the function of resolving phlegm and water-dampness, which can be chosen as auxiliary treatment.
4. Do not drink too much water and pay attention to the intake of allogeneic proteins, such as fish, shrimp, eggs, crab, milk, etc.
5. Bed rest is recommended during the attack period to prevent injuries from rising and falling. Reduce head rotation.
6. The bedroom should be dimly lit and the environment should be quiet.
7. Keep your mood relaxed and prevent excessive emotions (joy, anger, worry, thought, sadness, fear, and fright).