The "2024 Academic Annual Meeting of the Vertigo Medicine Branch of the China Association for the Promotion of International Exchange in Health Care and the 5th China Vertigo Medicine Forum" was held in Zhuhai, Guangdong Province from May 10 to 12, sponsored by the Vertigo Medicine Branch of the China Association for the Promotion of International Exchange in Health Care and undertaken by Zhuhai Hospital of Integrated Traditional Chinese and Western Medicine and Union Hospital Affiliated to Tongji Medical College of Huazhong University of Science and Technology. This conference invited a number of experts from all over the country to conduct in-depth discussions on new concepts, new technologies and new products in the field of vertigo medicine, bringing a feast of academic gluttony with various forms and rich contents. At this conference, Professor Yu Lisheng from Peking University People's Hospital gave a wonderful report on the theme of "The Road to Vertigo Advancement".
The author of this article is the report team of the Yimaitong Vertigo Conference
Yimaitong collated the report, please do not reprint without authorization.
History of dizziness and stratification of the examination
➤ History in dizziness - history is king
Professor Yu Lisheng pointed out that in the process of dizziness diagnosis and treatment, the collection of medical history is very important. Attention should be paid to the following during the medical history:
- structured inquiries;
- Proper guidance and techniques;
- comprehensive and correct concepts and concepts of disease;
- Can distinguish 90% of non-rotational dizziness and 70%-80% of causes of dizziness;
- The vast majority of dizziness is not an emergency and requires adequate inquiry.
➤ Stratified diagnosis of dizziness
Figure Four-tier framework of the International Classification of Vestibular Disorders
The relationship between the different levels is as described above, such as the conceptual relationship between the "acute vestibular syndrome" (layer 2), the symptoms it contains (layer 1), the possible causes (layer 3-A) and its mechanistic basis (layer 3-B).
➤ Stratified consultation
Vestibular syndrome classification
According to the classification of syndrome clusters, it can be divided into acute vestibular syndrome, episodic vestibular syndrome, and chronic vestibular syndrome.
➤ Chronic vestibular constriction
Most of them are multi-etiology, common PPPD, central sensitization (including vestibular migraine), drug-induced, etc.
➤ Acute vestibular coax
The onset time is > 24 hours, and common diseases include vestibular neuritis, sudden deafness with vertigo, vestibular migraine, etc. It is important to rule out central lesions (solitary vertigo).
For vestibular syndrome, the differentiation of benign and malignant vertigo is the focus of the consultation, and the symptoms of dizziness and vertigo are the focus of the consultation.
diplopia, dysarthria, facial and limb sensory, motor disturbances, or ataxia suggest brainstem cerebellar lesions, and if the headache occurs transiently, it suggests vestibular migraine attack or posterior circulation TIA, and the persistence of these symptoms suggests possible posterior circulation infarction or hemorrhage; Slow, persistent facial and limb sensorimotor deficits or ataxia suggest craniocervical junction malformations or demyelinating disease; Symptoms and signs of cerebellar ataxia alone may be seen in hereditary or acquired ataxia.
➤ Episodic vestibular syndrome (EVS)
Recurrent, multiple seizures. Common diseases include vestibular migraine (VM), otolithiasis (BPPV), Meniere's disease, vestibular paroxysmal (VP), etc.
Key points: (1) Only a single position change is induced (such as when the lying position is changed to a sitting position, and the sitting position is changed to an upright position): consider orthostatic hypotension. (2) Turn your head in a standing position and consider vagus nerve overexcitation. (3) Atypical otolithiasis, vestibular migraine should be considered when the reduction effect is not good. Professor Yu Lisheng also pointed out that there is a difference in the way of dealing with problems between general outpatient clinics and specialist (special needs) outpatient clinics. Common diseases are given priority in general outpatient clinics, while rare or rare diseases and multi-etiological diseases need to be considered in specialist outpatient clinics because most of the common diseases have been excluded.
➤ The most common vertigo diseases: vestibular migraine (50%), BPPV (20%~30%), Meniere's disease (10%), vestibular paroxysmal (5%)
➤ Familiar peripheral vertigo: vestibular neuritis, sudden deafness with vertigo, middle ear cholesteatoma/chronic otitis media, large vestibular aqueduct syndrome, vestibular paroxysmal, superior semicircular canal fissure syndrome, various tumors such as acoustic neuroma, and ruptured window membrane
➤ Specific types of Meniere's disease: Lermoyez syndrome, Tumarkin otolithiasis crisis, delayed membranous labyrinth
➤ Systemic diseases associated with endolymphatic/homeostasis: immune diseases, hypothyroidism, hyperthyroidism, chronic adrenal insufficiency, diabetes, pituitary tumors, hematologic disorders
Classification and characteristics of vertigo
➤ Types of vertigo – distinguish between the presence and absence of directionality
- Peripheral vestibular lesions: rotational, elevator weightlessness, walking at an incline to one side.
- Central vestibular lesions: shaky instability, tilting of the side in uncertain direction, often with unsteady gait and a sense of loss of control.
- Non-vestibular lesions: dark eyes, leg weakness, drowsiness, double vision.
The stronger the sense of direction, the more severe the vertigo, and the greater the probability of peripheral vestibular lesions. However, it is sometimes difficult to distinguish between central-vestibular and non-vestibular lesions.
➤ Characteristics of the time of vertigo onset
- One minute: otolithiasis; Vestibular paroxysmals
- 5 minutes ~ 72 hours: Migraine (more than 5 attacks)
- 20 minutes ~ hours: Meniere's disease (more than 2 episodes)
- Days ~ weeks: vestibular migraine; vestibular neuritis, acute labyrinthine poisoning or trauma, labyrinthine; Isolated vertigo, etc
➤ Vertigo is accompanied by symptoms
- with impaired consciousness, other cranial nerve symptoms, and headache: neurology presentation
- With chest tightness and heartache: cardiology visit
- With glaucoma, diplopia, strabismus, visual anomaly: ophthalmologist visit
- Accompanied by ear symptoms and/or strong autonomic reactions (nausea, vomiting, cold sweats, desire to defecate, paleness) are mostly peripheral vestibular lesions: an otologist visit
➤ Vertigo triggers
- Head movements, diet, heat and cold, changes in body position, as well as systemic illness, trauma, noise, and stress in life.
- Drugs that can cause vertigo include digitalis, antiepileptic drugs, sedatives, aminoglycoside antibiotics, and some antihypertensive drugs.
Dizziness disease spectrum at different ages
➤ Vertigo in children: recurrent vestibulopathy, vestibular migraine, and vestibular paroxysmal are common, others include large vestibular aqueduct syndrome, vestibular neuritis, otolithiasis (unlikely)
➤ Vertigo in young people: vestibular migraine, Meniere's disease, sudden deafness with dizziness, vestibular neuritis, PPPD, psychopsychological dizziness, BPPV
➤ Vertigo/dizziness in the elderly: BPPV (most common), orthostatic hypotension, drug-related dizziness, bilateral vestibulopathy, central dizziness, Meniere's disease (requires careful diagnosis)
Hearing loss with tinnitus and vertigo
➤ Tinnitus and vertigo with hearing loss
Most peripheral auditory system lesions + vestibular system lesions will have hearing loss, tinnitus, and vertigo at the same time. Only the lesions with tinnitus and vertigo symptoms are mostly directed to the center (except for eighth cranial nerve compression syndrome), while the majority of vertigo is vestibular peripheral lesions (below the vestibular nucleus)
Common disorders of tinnitus and vertigo with hearing loss include Meniere's disease, vestibular migraine, sudden hearing loss, Hunter's syndrome, otosclerosis, cerebellar lesions, cerebellar angle tumors, large vestibular aqueduct syndrome, semicircular canal fissures, rupture of the round window membrane, and chronic purulent otitis media/middle ear cholesteatoma
➤ Tinnitus and vertigo without hearing loss
Common diseases include eighth cranial nerve compression syndrome, vestibular migraine, high intracranial pressure syndrome, intracranial tumors or malignant brain metastases, multiple sclerosis, and more
Clinical Practice Notes
➤ The same patient may have different causes
In comorbid cases, episodes of dizziness in the same patient at different points in time may be due to an unetiological cause; Different triggers can manifest in different ways; VM can be comorbid with MD; VMs can have both BPPV and CPPV
It is important to note that Meniere's disease and vestibular migraine have similar symptoms and can be difficult to distinguish in the early stages, but careful analysis still makes a difference, and an audiological examination is essential.
Table Difference Between Menieer Bin and Vestibular Migraine
➤ Seizure scene recovery is important
Two or more cephalic changes must be required to raise suspicion of otolithiasis. Only dizziness or dizziness when waking up should be followed up if there is dizziness when moving from sitting to standing position (consider orthostatic hypotension); dizziness when the head is lowered should be relieved by opening or closing the eyes; dizziness when turning the head, should be supplemented by asking whether the head is dizzy when turning the head when standing (consider autonomic dysfunction); Ask if you get dizzy when you stand up or if you feel dizzy after walking for a while (consider a heart function problem).
➤ Avoid simply speculating on the diagnosis based on test results
The results of vestibular function examination should be judged with caution, and the whole reflex arc should be paid attention to, rather than a single point, especially when the hot and cold water test is not elicited; C-VEMP: supravestibular nerve pathway; O-VEMP: Hypovestibular Nerve Pathway
➤ 慎重诊断前庭性偏头痛与PPPD
Professor Yu Lisheng emphasized that clinical symptoms are the main diagnostic criteria for such diseases, but it must be noted that other possible diagnoses need to be ruled out first.
A special report on the 2024 Academic Annual Meeting of the Vertigo Medicine Branch of the China Association for the Promotion of International Exchange in Health Care and the 5th China Vertigo Medicine Forum
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