案例报告的档案

ISSN：2637-3793

案例报告

急性外围眩晕的案例：使用提示考试指导诊断检查

Gerard Thong¹和Paula Casserly^2*

¹爱尔兰都柏林2
²爱尔兰都柏林2号阿德莱德路的皇家维多利亚眼睛和耳朵医院ENT顾问

*通讯地址：Ms. Paula Casserly, ENT Consultant, Royal Victoria Eye and Ear Hospital, Adelaide Road, Dublin 2, Ireland, Tel: 00353 (87) 4185069; Email: paulacasserly@hotmail.com

日期：提交：2018年10月12日;得到正式认可的：2019年3月7日；发布：2019年3月8日

如何引用本文：Thong G, Casserly P. A Case of Acute Peripheral Vertigo: Using the HINTS Exam to guide diagnostic workup. Arch Case Rep. 2019; 3: 001-004. DOI:10.29328/journal.acr.1001011

版权许可证：©2019 Thong G等。这是根据Creativ金博宝app体育e Commons归因许可分发的开放访问文章，该文章允许在任何媒介中不受限制地使用，分发和复制，前提是适当地引用了原始作品。

A 39-year-old female was referred emergently to the ENT service with a week-long history of disabling vertigo and imbalance. This was constant in nature and associated with severe nausea, gait instability, and nystagmus, compatible with acute vestibular syndrome. She had a history of a right canal wall up mastoidectomy nine years previously for cholesteatoma.

鼓膜膜和外听管（EAC）双侧检查正常。有水平的自发性和凝视线stagmus，左侧是快速相位。这是遵守亚历山大定律的第二级nystagmus，在朝着缓慢的阶段望去时没有改变方向。头突变测试显示右侧的异常前庭反射（VOR）。备用盖测试没有偏斜的偏差。患者无法独立行走，Romberg测试呈阳性。

紧急执行CT颞骨和大脑。这表明右乳突中有充气的中耳的较大软组织密度。横向半圆形管和面神经的水平段侵蚀（图1）。Tegmen鼓膜也有明显的侵蚀和与中颅中窝的通信（图2）。进行了麻醉（EUA）的检查，并在后EAC中明显缺陷。粘膜切开在这种缺陷上证实了角蛋白与居民胆汁脱瘤一致。

A right modified radical mastoidectomy (MRM) was performed which revealed extensive cholesteatoma, most likely arising from the posterior canal wall, filling the mastoid bowl and antrum eroding the tegmen tympani and bony horizontal semi-circular canal. The defects were repaired intra-operatively and post-operatively the hearing was preserved. Her vertigo and nystagmus gradually improved in the early post-operative period and she underwent intensive vestibular rehabilitation.

The rates of recurrent or residual cholesteatoma range from 5-70% with a multiplicity of factors affecting recidivism. Cholesteatoma is largely a clinical diagnosis which generally presents with a discharging ear and keratin visible in a retraction pocket or perforation. Our patient had a normal appearing middle ear but the severity of her symptoms, history of previous ear surgery and clinical signs pointing to a lesion in the her right semi-circular canal, meant we had a very high index of suspicion for active disease her right labyrinth.

眩晕和头晕是初级保健和急诊科（ED）的常见症状，对很大一部分人口的影响很大。

眩晕是一种虚假或失真的自我运动感，头晕是没有眩晕的空间取向。这两个术语都指多种病因和病原体[1]。

The vast majority of primary care patients with vertigo have benign paroxysmal positional vertigo (BPPV), acute vestibular neuritis, vestibular migraine, or Ménière’s disease [2]. However, consideration should be given to potentially life-threatening disorders as a cause of acute vertigo.

据估计，头晕占所有急诊科（ED）访问的4％，其中3-5％是中风患者。这些中风中有35％被遗漏了，而有运动症状的人中有4％[3]。

区分良性与更险恶或潜在的威胁生命的头晕对前线医生尤其重要。

与传统上认为头晕或眩晕通常与脑血管疾病中的其他神经系统症状和症状有关，眩晕和失衡是椎骨骨质症中最常见的症状[4][5,6]。

There no single diagnostic tool for most disorders causing dizziness. The diagnosis is largely based on a constellation of clinical features obtained with careful history taking and bedside examinations [7]. CT scans have low sensitivity for acute infarction particularly in the posterior fossa and false-negative MRI can occur with acute vertebrobasilar stroke in first 24-48 hrs [8]. Consequently, bedside predictors are essential to distinguish peripheral from central vestibulopathies.

Kattah et al., described a three-step physical exam, the HINTS exam, which can differentiate between peripheral causes of vertigo and stroke with a sensitivity of 100%, and a specificity of 96%. HINTS stands for Head Impulse test, Nystagmus and Test of Skew [8].

Head impulse test is performed by sitting face to face with the patient. Patients head is held in the examiners hands and the patient focuses on the examiners nose. The head is moved quickly about 10-15 degrees to one side. In a patient with normal vestibular function, the VOR results in movement of the eyes opposite to the head movement - essentially the eyes stay fixed on the nose throughout. Impairment of the VOR is noted when the eyes move off target and a voluntary saccade is observed bringing the patients eyes back to target after the head movement.

外围前庭病通常与特征性的，主要的眼球震颤相关，当患者朝着眼球震颤快速相位的方向时，它仅在一个方向上跳动并增加强度。纯粹的垂直或纯扭转的眼球震颤几乎总是由于中心病理。急性眩晕呈现的大多数笔触具有主要水平载体的黑眼形。与周围眩晕的区别在于偏心凝视方向的变化[8]。

最后，偏斜的测试是后窝病理学的标志。它是通过备用眼罩测试进行的。在再次面对面的同时，检查员要求患者直视前方，同时一次遮住患者的眼睛之一。如果异常，遮盖的眼睛会向下偏下，并且发现时会使矫正扫视向上。

该病例强调了先前乳突手术患者的急性眩晕的重要差异诊断，即使在正常的鼓膜膜检查的情况下也是如此。在累犯胆瘤的存在下，眩晕是侵略性或晚期疾病的指标，需要紧急评估。其次，对于那些在初级保健或急诊医学的人来说，提示检查是急性眩晕的患者易于记住且宝贵的三叶草工具。