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眩晕:六问法——良性阵发性位置性眩晕的自我诊断

2022-09-03 ANDs ANDs

良性阵发性位置性眩晕又称耳石症,是最常见的眩晕原因,耳石手法复位是治疗的有效手段。

良性阵发性位置性眩晕(BPPV)又称耳石症,是最常见的眩晕性疾病。

由于某些原因导致椭圆囊和球囊内正常附着的耳石脱落,并随着淋巴液流动进入半规管内,在体位变化时耳石的活动就会引起过度刺激,从而引起眩晕、恶心等症状。

50~60岁的中老年人是发病高峰群体。发病率10.7~64.0/10万人,每年复发率15%~18%,40个月复发率可达50%。

BPPV分为后半规管型、水平半规管型和上半规管型,其中后半规管型占60%~90%,其次是水平半规管型,而上半规管型罕见。

BPPV不经治疗可自发缓解,水平半规管型BPPV平均7 d缓解,后半规管型BPPV平均17 d缓解。

耳石手法复位是治疗BPPV的有效手段。单次耳石手法复位缓解率80%,多次复位治疗缓解率可达92%。

药物用于缓解严重的恶心呕吐症状。手术仅用于难治型患者。

近些年,临床医生对于BPPV的认识有了很大的进步。遗憾的是,目前,在神经科BPPV容易被误诊为“后循环缺血”,从而过度治疗;在耳鼻喉科还有医生认为眩晕常是脑部的问题而忽视该病专科治疗的重要性。而其他非专科的医生,还有人错误地认为眩晕是颈椎病的问题。BPPV正确的诊断和治疗,能够缓解患者的心理压力,减少不必要的住院,减少患者不必要的经济支出,减少医疗资源的浪费。

使用量表或问卷的形式可以使得BPPV的诊疗简便易行,这些问卷会帮助医生尽快明确BPPV诊断并做分型。Neurology杂志发表了韩国Ji-SooKim等人的研究,他们制作了一个供患者自己诊断的问卷,研究发现这个问卷对于BPPV敏感性87%,而特异性达到89.8%。

前三个问题用于排除因BPPV之外的其他疾病导致的头晕/眩晕的患者。当这3个问题中的任何一个回答“否”时,患有其他疾病的可能性更大,不必再回答剩下的问题。患者对前3个问题回答均为“是”,考虑为BPPV。

问题4用于区分水平半规管抑或后半规管的BPPV。当眩晕是由躺下或起床诱发,而不是躺着转头时诱发,考虑为后半规管或上半规管的BPPV。

问题5用以确定哪一侧受累。例如,向右侧转头时患者感到眩晕更严重,考虑为右侧后半规管BPPV或左侧上半规管BPPV;向左侧转头时感到眩晕更严重,则诊断为左侧后半规管BPPV或右侧上半规管BPPV。当躺着向一侧转头时,眩晕加重,则诊断为水平半规管BPPV。

如根据问题4确定是水平半规管BPPV的诊断,对问题5和6的回答用于确定患侧和亚型(向地性与背地性)。例如,当向右转头时眩晕更加严重,发作持续<1>1 min,则诊断为左侧背地性水平半规管BPPV,反之亦然。

对于亚型的判断,尽管神经科医生使用起来相对陌生,但这个问卷的价值在于前3个问题。这3个问题也可以用于医生对眩晕患者的问诊中,帮助我们判断是否存在BPPV。当然在临床实践中也要注意,单纯依赖临床表现有时难以区分中枢性前庭疾病和周围性前庭疾病,这时候就需要其他的辅助检查来帮助鉴别。

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