Do these 8 steps, and the diagnosis and treatment of dizziness/vertigo diseases can be easily achieved!

Dizziness/vertigo is one of the most common complaints of clinical patients.
Most people will experience this disease, involving neurology, otolaryngology, neurosurgery, orthopedics, ophthalmology, internal medicine and psychiatry and other disciplines, and dizziness The reasons are diverse and complex, and the current diagnosis and treatment of dizziness and vertigo is relatively confusing.
A series of diagnostic standards and consensus guidelines have been introduced at home and abroad , which also promotes the continuous development of the field of dizziness/vertigo diseases.
Therefore, when diagnosing dizziness/vertigo It needs to be carried out in a complete and orderly process, and cannot be overly dependent on auxiliary examinations.
It should have a more comprehensive dizziness/vertigo related knowledge, establish correct dizziness/vertigo diagnosis and treatment thinking, so as to improve the diagnostic accuracy rate and avoid misdiagnosis, missed diagnosis and mistreatment
.

While correctly identifying various dizziness/vertigo diseases, speed up the diagnosis and avoid delays in the treatment of serious diseases that cause dizziness

The diagnostic consensus can speed up the diagnosis while correctly identifying various dizziness/vertigo diseases, and avoid delays in the treatment of serious diseases that cause dizziness

1.
Basic knowledge of the anatomy and function of the vestibular system

1.
Basic knowledge of the anatomy and function of the vestibular system

The vestibular system can perceive and transmit the head position at rest and the head movement signals during movement, and upload these signals to the vestibular nucleus, spinal cord, cerebellum, autonomic nervous system, ocular motor nucleus and vestibular center through the vestibular peripheral pathway The cortex forms the perception of one's own stillness and movement, which is used to regulate eye movement and one's own posture, and produce high-level cognitive functions such as spatial memory and positioning in the vestibular center
.

The damage of the vestibular system's balanced information transmission pathway may lead to dizziness/vertigo.
Therefore, mastering and understanding the anatomy and function of the vestibular system's conduction pathway is beneficial to the diagnosis and treatment of dizziness/vertigo
.

2.
Understand the concept of dizziness/vertigo

2.
Understand the concept of dizziness/vertigo

At present, dizziness/vertigo adopts the symptom classification of 1972.
This classification method is more in line with clinical practical applications.
All patients who come to see the dizziness and dizziness clinic are regarded as a whole (dizziness), which mainly includes the following 4 types: ①vertigo : A movement illusion caused by spatial disorientation, which patients often describe as feelings of rotation, rollover, or toppling in themselves or in the external environment
.

② dizziness (lightheadedness): also known as dizziness, relatively vague concept, often refers to top-heavy, dizzy, drowsy head, body floating and so on

① Vertigo (vertigo): A movement illusion caused by spatial disorientation, which patients often describe as feelings of rotation, rollover, or toppling in themselves or in the external environment

3.

Peri vestibular vertigo refers to the vertigo caused by vestibular nerve ending receptors, vestibular nerve or vestibular ganglion disease, mainly including benign paroxysmal positional vertigo (BPPV), Meniere disease (MD), Vestibular neuritis (vestibular neuronitis, VN), sudden deafness with vertigo, vestibular paroxysm (vestibularparoxysmia, VP) and bilateral vestibular disease
.

Vestibular central vertigo refers to the vertigo caused by the ipsilateral and contralateral ascending paths involving the brainstem vestibular nucleus in the medulla oblongata of the pontine and its connection with the cerebellum, brainstem, thalamus and cortex.
It is seen in the central nervous system vascular , inflammatory, tumor or Neurodegenerative diseases, vestibular migraine (VM) also belong to this category, and rare causes include epileptic vertigo and paroxysmal ataxia
.

Vascular epilepsy

There is no clear definition of psychiatric dizziness.
It used to include postural phobic vertigo, visual vertigo and chronic subjective dizziness.
The 2015 International Classification of Vestibular Diseases referred to the three as persistent postural-perceptual dizziness.
perceptual dizziness, PPPD)
.

Associated systemic disease include dizziness common cause orthostatic hypotension, drug vertigo, motion sickness, anemia and low blood sugar and the like
.

Patients with dizziness of unknown etiology should be carefully followed up with medical history, detailed and comprehensive physical examination and necessary auxiliary examinations.

Hypoglycemia

4.
Detailed and complete medical history and key physical examination at the bedside

4.
Detailed and complete medical history and key physical examination at the bedside

Although many patients cannot accurately describe their own dizziness and dizziness characteristics and onset characteristics, and sometimes even inconsistent descriptions, the diagnosis of dizziness/vertigo disease is based on the "medical history is king", emphasizing that the patient's detailed history of dizziness and dizziness is the primary basis for preliminary diagnosis.
Diagnosis and differential diagnosis
.

Therefore, clinicians must first improve their ability to capture reliable and critical medical history information, pay attention to appropriately guiding patients during consultations, and be good at extracting key points that are helpful to diagnosis in an inaccurate medical history

Important physical examinations at the bedside include observation of spontaneous nystagmus, bedside head shaking test, and otolith position induction test
.

The spontaneous nystagmus of peripheral vestibular disease is generally slightly torsion horizontally, and the fast phase of nystagmus points to the side where the vestibular function is relatively enhanced, while the spontaneous nystagmus of non-horizontal torsion is generally a central source

5.
Reasonable and targeted auxiliary inspection

5.
Reasonable and targeted auxiliary inspection

Non-targeted auxiliary examinations are often the source of misdiagnosis of dizziness and vertigo diseases, especially the aging and non-specific changes found in the imaging examination of the head and cervical spine can easily mislead the clinic
.

If the cause of the patient's vertigo cannot be inferred from the medical history and physical examination, the auxiliary examination generally cannot provide more diagnostic clues

Interpretation

The targeted selection of reasonable and necessary auxiliary examinations to verify the diagnosis and identification of the initial positioning diagnosis and further qualitative diagnosis has a certain guiding effect, and can avoid the large-scale cause screening and the waste of medical resources
.

Screening

6.
Hierarchical diagnosis is an advanced diagnosis of dizziness and vertigo diseases

6.
Hierarchical diagnosis is an advanced diagnosis of dizziness and vertigo diseases

The stratified diagnosis introduced by the Barany Association is very helpful to the clinic.
It is divided into four levels: symptoms and signs, syndromes, diseases and potential causes.
The basis of stratified diagnosis is still the previous medical history and physical examination
.

Mainly according to the predisposing factors in the symptoms and signs, the duration and whether there are similar attacks in the past, it can be divided into positional vestibular syndrome, paroxysmal vestibular syndrome, acute vestibular syndrome and chronic vestibular syndrome
.
At the same time, it should be noted that many patients with systemic diseases such as hyperthyroidism, hypothyroidism, sleep apnea, Parkinson's disease, normal intracranial pressure hydrocephalus, etc.
often come to the doctor with chronic dizziness.
Although these patients have dizziness complaints, dizziness is not the patient’s The core symptoms, along with other clear non-vestibular symptoms or signs, can be diagnosed through auxiliary examinations or symptoms and signs.
Clinically, if these non-specific dizziness patients are included in the dizziness and vertigo disease spectrum, it is easy to cause generalization
.

7.
Comprehensive treatment is the key to improving the prognosis of patients with dizziness and vertigo

7.
Comprehensive treatment is the key to improving the prognosis of patients with dizziness and vertigo

Dizziness/vertigo patients may be accompanied by other vestibular diseases such as BPPV attacks after VN, even if the vestibular disease is relieved, and then chronic dizziness may also occur.
At the same time, many patients have underlying diseases that affect the prognosis.
Therefore, treatment should be emphasized on the cause and Comprehensive treatment of symptomatic, rehabilitation and psychology
.

Treatment of the cause: In the treatment of vertigo diseases, the treatment of the cause is fundamental.
Once the cause of some vertigo diseases is resolved, the symptoms of vertigo can disappear immediately, such as BPPV, PF, SSCD, etc.
, and for some vertigo diseases, treatment of the cause cannot make the symptoms of vertigo quickly.
Relief, but can speed up the recovery of vestibular function in patients such as VN
.
Therefore, for patients with BPPV, as long as there is no contraindication to reduction, manual reduction therapy should be given; while PCI patients, those within the thrombolytic time window and without contraindications should be given thrombolytic therapy; patients with VN should be given corticosteroids in the early stage Treatment; MD intermittent recommended step treatment; PF, SSCD patients after semicircular canal repair or tamponade surgery, the symptoms of vertigo can often be completely relieved; and VP patients who are ineffective against epilepsy drugs, microvascular decompression surgery can relieve vertigo in 75% of patients Discomfort
.
Patients with chronic dizziness with systemic diseases should be treated accordingly
.

Symptomatic treatment: mainly for the acute episode of vertigo.
In addition to the symptoms of vertigo, patients in the acute phase are often accompanied by obvious autonomic symptoms such as nausea, vomiting, palpitation, and sweating.
Symptomatic drug treatment can reduce the vestibular function of the contralateral side and cause both sides The degree of imbalance between vestibular functions is reduced, so it can reduce the dizziness and accompanying symptoms of patients.
The commonly used symptomatic drugs are as follows: antihistamine drugs such as phenagen and halohaining; GABA-enhancing drugs such as diazepam; Choline drugs such as 654-2, atropine; dopa blocker drugs such as chlorpromazine
.
When using the above symptomatic drugs, it must be emphasized: these drugs can inhibit the compensatory function of the vestibular center.
In principle, the use time should not exceed 3 days.
Long-term use of vestibular inhibitors can slow the recovery of vestibular function in patients
.

Rehabilitation treatment: Evidence-based medical evidence shows that vestibular rehabilitation benefits more than harm to patients with vestibular disease and vestibular dysfunction.
It can alleviate vestibular symptoms, promote the recovery of vestibular function, and further improve the patient’s balance function and daily activities.
, To reduce the risk of falls, suitable for acute, subacute, chronic unilateral and bilateral peripheral vestibular dysfunction peripheral vestibular disease and central vestibular disease
.
Some drugs that can improve the compensatory function of the vestibular center should also be used clinically, such as Betahistine and EGb761
.

Psychotherapy: In view of the fact that vertigo patients are prone to be accompanied by anxiety and depression as the main manifestation of psychiatric symptoms, there are also a considerable number of depression and anxiety patients who come to the vertigo outpatient clinic to promptly assess the patient’s psychological condition, and give corresponding cognitive behavioral therapy, and give SSRI Anti-anxiety and depression drugs represented by /SNRI can significantly improve the dizziness and discomfort of patients
.

8.
Learn new concepts and developments at home and abroad to continuously improve the level of diagnosis and treatment of dizziness/vertigo

8.
at home and abroad to learn new ideas, new progress continuously improve dizziness / vertigo diagnosis and treatment level clinics

Understanding the new concepts and new developments of vestibular-related diseases at home and abroad is conducive to grasping the development trend of the field of vertigo, quickly grasping these latest research results, and applying them to clinical practice in time
.

In short, on the basis of mastering the relevant anatomy and functions of the vestibular system, clinicians should accurately understand the concept of dizziness/vertigo, keep in mind its classification, disease spectrum and diagnostic criteria, and obtain it through detailed medical history collection, physical examination and targeted auxiliary examinations.
Complete and detailed clinical data can make a correct diagnosis of dizziness/vertigo only after rigorous and correct analysis and identification, which has a decisive effect on the correct treatment of patients and the improvement of prognosis
.

references

references

[1] Ju Yi, Zhao Xingquan.
Update dizziness/vertigo concept, clarify the diagnosis and treatment thinking [J].
Chinese Journal of General Practitioners, 2020, 019(003): 198-200.

[1] Ju Yi, Zhao Xingquan.
Update dizziness/vertigo concept, clarify the diagnosis and treatment thinking [J].
Chinese Journal of General Practitioners, 2020, 019(003): 198-200.

[2] Dizziness diagnosis process recommendations expert group, Li Yansheng, Wu Ziming.
Dizziness diagnosis process recommendations [J].
Chinese Journal of Internal Medicine, 2009, 48 (05): 435-437.

[2] Dizziness diagnosis process recommendations expert group, Li Yansheng, Wu Ziming.
Dizziness diagnosis process recommendations [J].
Chinese Journal of Internal Medicine, 2009, 48 (05): 435-437.

[3] Bhattacharyya N, Gubbels SP, Schwartz SR, et a1.
Clinical Practice Guideline: Benign Paroxysmal Positional Vertigo

[3] Bhattacharyya N, Gubbels SP, Schwartz SR, et a1.
Clinical Practice Guideline: Benign Paroxysmal Positional Vertigo

(Update)[J].
Otolaryngol Head Neck Surg, 2017, 156(3 Suppl): S1-S47.
DOI: 10.
1177/0194599816689667.

(Update)[J].
Otolaryngol Head Neck Surg, 2017, 156(3 Suppl): S1-S47.
DOI: 10.
1177/0194599816689667.

 

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