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Authors: Ling Xia, Wu Yuexia, Zhao Tongtong, Zhao Guiping, Wang Chaoxia, Yang Xu
Unit: Department of Neurology, Peking University First Hospital, Department of Neurology, Peking University School of Aerospace Clinical Medicine
Vertigo/vestibular disease has a high incidence, complex etiology, and multidisciplinary knowledge.
As an interdisciplinary discipline, the diagnosis and treatment of vertigo/vestibular disease is increasingly of interest to multidisciplinary physicians and researchers
.
With the deepening of clinical diagnosis and treatment, how to further promote the rapid development of vertigo/vestibular medicine in clinical diagnosis and treatment is imminent! In order to further promote the exchange and dissemination of vertigo expertise in China In collaboration with multidisciplinary experts from the Vertigo/Vestibular Medicine Branch of the Chinese Geriatric Society, Yimaitong launched a special column on the theme of "Vertigo Time", hoping to provide students across the country with more exciting clinical knowledge points for learning
.
In the second phase, Dr.
Ling Xia from the Department of Neurology of Peking University First Hospital was invited to share the content of "Bedside Examination for Dizzy/Vertigo Patients".
1.
Common dizziness/vertigo disease damaged parts
Clinically, common damaged sites of dizziness/vertigo disease are mainly found in the five sites of ABCDE (see figure below) in the vestibular pathway, including the labyrinth (including semicircular canal, elliptical sac, and balloon), vestibular nerve, brainstem, cerebellum, thalamus, and vestibular cortex
.
In addition, medical conditions such as anemia, arrhythmias, heart failure, hypotension, drug poisoning, uremia, and asthma need to be considered
.
II.
Diagnostic process of vertigo/vestibular disease: medical history collection (2022 version)
Clinically, in the face of dizziness/vertigo patients, a detailed medical history should be collected first, and the relevant medical history collection can be found in "Vertigo Time · Issue 1 | History of patients with vertigo/vestibular disease"
.
The etiology of dizziness is more complex than the chief complaint of vertigo in the vestibular system, because in addition to vestibular access injury, dizziness is also seen in some medical conditions, so bedside examination also requires complete medical examination
.
Bedside examination of patients with dizziness/vertigo mainly includes internal medical examination, neuroophthalmology, otology, ophthalmology, eye, head, posture, gait, and position tests
.
3.
Bedside examination
Brachial artery blood pressure, lying blood pressure, cardiac examination
, and some other medical examinations.
➤ Vital signs: blood pressure, pulse, heart rate, body temperature - the most basic and important! Especially in patients with dizziness, such as acute cardiopulmonary events;
➤ Bilateral brachial artery blood pressure: The systolic blood pressure difference between bilateral brachial arteries is usually at least 15 mmHg
.
Simultaneous palpation of bilateral radial pulses usually reveals a decrease and delay in the amplitude of the affected pulse, and a bruit on auscultation of the vertebral-subclavian artery suggests subclavian artery stealing syndrome;
➤Lying down blood pressure: systolic blood pressure after standing decreased by > 20mmHg compared with the flat lying position, or diastolic blood pressure decreased by >10mmHg, or systolic blood pressure < 90mmHg, which is orthostatic hypotension, and it is necessary to pay attention to factors such as druggability;
➤ Cardiac examination: patients with transient episodic dizziness, presyncope or history of syncope, pay attention to the possibility of cardiogenic dizziness, need to auscultate heart sounds, pay attention to abnormal P2 hyperactivity to exclude pulmonary embolism, and whether there is a systolic murmur to exclude left ventricular outflow tract infarction;
➤ Other internal medicine
examinations.
.
(3) Bedside examination based on vestibulo-ophthalmo/retinophthalmotic pathway
With the development of new technologies and the deepening of dizziness/vertigo research, some new bedside examination methods for dizziness/vertigo have been derived, including spontaneous nystagmus and nystagmus-like eye movement, head position/eye position examination, eye movement examination (gaze test, saccade test, stable tracking test), shaking head test, head shake test, position test and posture gait examination
.
Eye position examination: binocular consistency first of all, eye position examination, mainly check the consistency of both eyes, including horizontal and vertical consistency, if inconsistency can be seen in congenital strabismus, oculomotor nucleus, oculomotor nerve, extraocular muscle paralysis, otolith/vertical semicircular canal oculomotor pathway injury (reverse deviation of the eye).
。 Ocular position examination methods include examination of nine eye positions, corneal photoreflection (Hirschberg test), alternating occlusion test, masking-depatching test, Maddox rod test and red slide test
.
(1) The examination of the nine eye positions first looks directly ahead, then gazes to the left, right, up, and down, and then gazes towards the upper left, lower left, upper right, and lower right
.
Examination of nine positions can observe whether the movement of both eyes is conjugated, so as to preliminarily determine whether the patient has ophthalmoplegia, strabismus, and whether there is nystagmus and changes
in nystagmus intensity in each position.
(2) Corneal photoreflection method determines whether the patient has dominant strabismus
by observing the photogenic points of the pupils of both eyes.
The light source is 33cm away from the patient's pupil, left eye esotropia, left ocular exotropia, left eye upper strabismus,
left eye hypostrabismus
(3) occlusion test/occlusion-de-occlusion test
Monocular occlusion test: is a test for overt strabismus by covering one eye for 1-2 seconds and then observing the movement of the other eye
.
If the left eye moves from inside to outside while covering the right eye, this indicates the presence of esotropia; If the left eye moves from the outside inward, this indicates exotropia; If moving downwards indicates the presence of upward strabismus; Upward movement indicates the presence of hypostrabismus
.
Masking-demasking test: Covering the patient's eye for more than a few seconds to separate the fusion, then quickly removing the occlusion, and observing the movement of the patient's covered eye when demasking, mainly used to check for recessive strabismus
.
(4) Alternating covering test Alternate covering test: repeatedly cover both eyes alternately, stay in each eye for a few seconds, separate the fusion function of both eyes, and observe the direction of
movement when the non-covered eye gazes again.
Overt and recessive strabismus can be examined horizontally and vertically, and is currently the most commonly used ocular examination in patients with vertigo
.
Reverse eye deviation in HINTS examination is examined by alternating occlusion tests, which mainly check for vertical separation of both eyes, and a positive eye deviation often indicates a central lesion
.
It should be noted that many normal people will have slight horizontal strabismus, such as horizontal exotropia or esotropia, which is not eye deviation
.
One study found that some patients with peripheral vestibular lesions also had this reverse deviation of the eyeball, with an incidence of about 24%, but the angle of deviation was very small
.
Studies have concluded that when the deviation angle is greater than 3.
3°, the specificity of central diagnosis is high, but its sensitivity is not high, because many patients with central injury do not have reverse deviation of the eyeball, and only about one-third of patients with acute unilateral brainstem infarction have reverse deviation of the
eyeball.
(5) Maddox rod test and red slide test Maddox rod test: cover one eye with a monocular Markovian rod, such as covering the left eye, the left eye sees a vertical/horizontal straight line, and the right eye sees a point of light, Strabismus is judged by asking the patient about the relationship between the light spots and straight lines observed by the left and right eyes
.
Red slide test: cover the right eye, the right eye sees red light, while the left eye sees white light, white light and red light if they coincide represents normal, if the two are separated, vertical separation represents vertical strabismus, horizontal separation represents horizontal strabismus
.
2.
Ocular tilt reaction Ocular tilt reaction (OTR): It is an important sign of
static tension imbalance in the vertical semicircular canal and otolith gravity conduction pathway.
These include head tilt, eye deflection, eye torsion, and subjective visual vertical line abnormalities
.
➢ Head tilt (HT): The head tilts
to one side.
It is easy to observe clinically and easy to be ignored
by clinicians.
It is important to note that head tilt can occur in scoliosis, torticollis, pelvic scoliosis, or pelvic muscle abnormalities in the neck
, in addition to abnormalities in the OTR pathway.
➢ skew deviation (SD): Both eyes are separated vertically, with one eye higher
than the opposite eye.
Its main detection methods include corneal photoreflection method, alternating occlusion test, Markovian rod or red slide test, etc.
, mainly to see the separation of
the eyes in the vertical direction.
➢ Ocular torsion (OT): internal rotation of one eye is elevated and external rotation of the other side is reduced, and the two eyes are different in height and not at the same level (the negative film shows that the papillae on both sides are not at the same level).
Eye torsion can be detected by ophthalmoscope or bedside fundus photography, or indirectly
by binocular markovic.
➢ Subjective visual vertical (SVV) abnormality: Due to the damage of the OTR pathway, the vertical lines of the two eyes are deflected, and SVV cannot be accurately perceived, which is the most sensitive indicator
of the OTR quadruple.
The barrel measurement method and the computerized SVV based on VR eyemask can perform point-of-care detection
of subjective visual vertical lines.
It has been suggested that injuries to the peripheral vestibule, medulla oblongata, and inferior pontine cause the OTR to be ipsilateral, while the OTR is biased to the healthy side and the midbrain above the midbrain is biased in the upper and midbrain regions after the chiasmatic injury
.
➤Identification of ophthalmic/nerve paralytic strabismus and otolith gravity pathway (OTR) abnormalities When OTR abnormalities are suspected, it is necessary to distinguish them from vertical strabismus caused by ophthalmoplegia, which can be distinguished in the following ways: (1) upright supine test : Because the canolith gravity pathway is abnormal, the degree of eye torsion in the sitting and supine positions will change, that is, the degree of torsion in the supine position is reduced by more than 50% compared with the sitting position, while the degree of torsion of ophthalmoplegia is basically unchanged
.
(2) The direction of the torsion of the high eye: It can be identified by observing the torsion direction of the high eye, that is, when the OTR is abnormal, The high eye is internally rotated, while the high eye is externally rotated in superior oblique paralysis
.
(3) Red slide dip examination, red slide test under the nine eye position, by comparing the degree of strabismus in each position to judge extraocular muscle or ocular nerve palsy and OTR nerve abnormalities
.
Because the degree of strabismus is greatest when gazing in the direction of ophthalmic muscle contraction in simple extraocular muscle paralysis, the degree of strabismus is greatest when gazing in the direction of ophthalmic contraction; ocular deviation caused by OTR abnormalities is manifested as synergistic ocular deviation, that is, the degree of strabismus is the same
when looking at different eye positions.
Left eye trochlear nerve palsy
OTR abnormality
References and image sources: Past recommendations:Vertigo time · Issue 1 | History of patients with vertigo/vestibular disease
