What kind of positional dizziness/vertigo does the 13 patient "portraits" tell you might not be otolithiasis?

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Mr.
Chen Ganggang, combined with actual clinical cases and diagnosis and treatment experience, analyzes the key points of vertigo disease knowledge in simple language, which is very popular among clinicians! In order to facilitate everyone to read past articles (you can read "Hao's Strategy · Season 1", you can scan the QR code below), this year, we will continue to push the content of ""Halo' Strategy · Season 2" to learn from everyone.
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Review ""Dizziness" Strategy Season 1", for more information, scan the QR code below↓↓↓ Positional dizziness/vertigo is a common clinical complaint of patients, and patients often show dizziness in certain special positions/ Vertigo, with or without positional nystagmus
.

These common positions include: lying down, getting up, turning over, turning your head, looking up, bowing your head,
etc.

First, we state our opinion: Positional dizziness/vertigo does not equal otolithiasis
.

Although benign paroxysmal positional vertigo (BPPV) in international literature and guidelines refers specifically to otolithiasis, in fact, as the disease patterns of positional vertigo diseases are constantly being revealed, more and more international and domestic scholars suggest Expand the concept of benign paroxysmal positional vertigo and become "peripheral positional vertigo and dizziness" (PPVD)
.

Controversial syndromes are included, including anterior semicircular canal calculi, posterior ridge cap calculi, multisemicircular canal calculi, suspected diagnosis, and light ridge cap
.

In addition, vestibular migraine, central paroxysmal positional vertigo (CPPV), postural hypotension, vestibular paroxysmal syndrome, postural phobia dizziness, etc.
may all manifest as positional dizziness/vertigo
.

So what kind of positional dizziness/vertigo may be otolithiasis, and what kind of positional dizziness/vertigo may not be otolithiasis? Next, the author will describe this kind of "patient portrait" based on literature study and personal clinical experience (reminder: it may cover up to about 80% of common clinical situations, and cannot include 100% of clinical phenomena): 01 The patient has a recent positional Dizziness/vertigo episodes, no past history
.

For example, it began to appear half a month ago, and the body position is obviously related, and the time is less than 1 minute, which is in line with the three-character characteristics of otolithiasis "short, moving, and bed"
.

At this time, there is a high probability that it may be otolithiasis
.

Note: This type of patient must be asked if there is any postural dizziness in the past two days.
If so, there is a high probability that the positional test is positive.
If not, the patient may have recovered by itself, but the residual dizziness is causing trouble
.

02 The patient has a recent history of positional dizziness/vertigo episodes
.

Past history: ① There were 1-2 similar positional seizures several years ago, but the time was irregular, and there was no chief complaint of "once a year"
.

At this time, there is a high probability that it may be otolithiasis
.

② The patient has had repeated episodes of positional vertigo, which occurred almost every year for several years (> 3 or more episodes).
At this time, the high probability may not be otolithiasis, but more likely vestibular migraine or benign recurrent dizziness
.

③ However, it should be noted that vestibular migraine or benign recurrent dizziness can be combined/secondary to otolithiasis
.

03 The patient had repeated attacks for several years, with only one positional dizziness/vertigo each time
.

Patients often present with a few minutes of dizziness in the middle of the night and no episodes in the morning, but such episodes may have occurred several times in the past few years
.

At this time, there is a high probability that it is not otolithiasis
.

04 The patient only had positional dizziness/vertigo when he turned his head, lowered his head, and raised his head
.

Most likely it is not otolithiasis
.

05 The patient had a history of only one cluster-like episode of positional vertigo, and was unable to lie on one side for a long time after that
.

Such patients will complain of a positional dizziness several months or years ago that lasts for days to weeks, after which the vertigo disappears and becomes dizziness in a specific position (most commonly described as being unable to lie on the left or right side).
Recumbent), without nausea, persisting for months to years, with marked anxiety
.

At this time, there is a high probability that it is not otolithiasis, and I often like to call it "Phobic Postural Dizziness" (PPD)
.

The patient was actually "scared" by the previous otolithiasis attack, so even though the otolith has been reset or digested and absorbed, he still has obvious psychological barriers and dare not turn to the attack position
.

The treatment of such patients is not actually based on reset or drug treatment, but the most effective habituation treatment, that is, the patient is encouraged to do repeated lying down-up movements toward the attack position every day, 20-30 times a day for 7-14 days , most patients recover
.

Anti-anxiety and depressive drugs can be added if necessary
.

Of course, the premise still needs to exclude central diseases
.

06 The patient had only transient dizziness/vertigo when getting up in the supine position, but no symptoms when lying down
.

At this time, there is a high probability that it may not be otolithiasis.
① If there is persistent dizziness when standing and walking, no nausea, and >3 months, PPPD should be excluded
.

②If there are transient syncope, amaurosis and other symptoms, problems such as orthostatic hypotension should be excluded
.

07 Patient complained of a transient intracranial sound before the first onset of positional vertigo
.

Otolithiasis is likely to be considered
.

In 08, the patient first developed persistent severe vertigo, and after several days to several weeks, he developed positional vertigo
.

High probability to consider secondary otolithiasis
.

Secondary otolithiasis is more common in clinic.
For example, patients with dizziness in the past can be considered as vestibular neuritis, sudden deafness with vertigo, Hunt syndrome, vestibular migraine, Meniere's disease, PPPD and other diseases.
The performance of vertigo should be excluded by position test
.

09 Although positional nystagmus is typical, repeated reductions for 7-10 days are ineffective
.

At this time, the high probability may not be otolithiasis, and the scope of examination should be expanded to exclude central diseases
.

Note: It must be a patient who has repeatedly come to the hospital for more than 3-5 times of reduction, has used various methods, or has been repeatedly reset at home every day and is still ineffective
.

10 Patients not only had positional vertigo, but also had seizures in a resting state
.

Most likely not otolithiasis
.

Note: ①> 5-10 seizures per day, only a few seconds each time, there is a high probability that it may be vestibular paroxysm
.

② Attacks several times a day for a few minutes each time, with a high probability of vestibular migraine or benign recurrent vertigo
.

The Roll Test of 11 patients showed light crest cap
.

The high probability may be vestibular migraine/benign recurrent dizziness/sudden deafness,
etc.

In 12 patients, multiple nystagmus was induced by multiple positions, and various resets were ineffective
.

Most likely it is not otolithiasis
.

13 Patients with positional vertigo/nystagmus with severe walking instability and/or other central nervous system symptoms and signs
.

Most likely it is not otolithiasis
.

A comprehensive neurological examination is required to exclude central diseases such as CPPV
.

 So how should we quickly screen patients with otolithiasis? The latest research results published by the author's team in the "Chinese Journal of Otolaryngology Head and Neck Surgery" suggest that when the outpatients ask these 7 questions, and all the questions answer "yes", they are highly suspected of otolithiasis
.

Note: BPPV Simple Screening Questionnaire: 1.
Does dizziness or vertigo appear/aggravate when lying down, getting up, moving head quickly, or turning over in bed? Or after a head blow? (Meet one item) 2.
Do you feel dizzy or dizzy? 3.
Is the duration of each dizziness or vertigo < 5 minutes? 4.
Have you had no similar episodes of vertigo before (months/years ago)? 5.
Do you feel like the world is spinning when you walk or turn your head normally? 6.
Is it not accompanied by ear stuffiness and hearing loss during vertigo? 7.
Do you have irregular episodes of dizziness or vertigo? Note: For more detailed questionnaire research process and statistical indicators, please pay attention to the recently published "Chinese Journal of Otolaryngology Head and Neck Surgery"
.

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