� 病人双脚并拢站立(或地板或海绵）
� 睁眼1min � 眼闭合1 min
� 倾倒或者向外踏步为阳性 � 前庭功能减弱
� 闭眼摇摆程度较大
� 本体或小脑病变
� 睁眼和闭眼的摇摆程度相同提示
体格检查
� 特殊检查
� 瘘管实验
� 耳屏施压 � 鼓气耳镜
� 正压或者负压
� Tullio现象
� 音叉 � 强声 (100 dB, 5 s)
Joseph Furman
背景
� 研究报道约30%的普通人群中有过中重度的头晕，其 中25%为眩晕
� 人群中头晕或眩晕的患病率为5-10%；年患病率为 5.2%，年发病率为1.5%
� 我国的研究报道10岁以上人群的眩晕总体患病率为 4.1%
� 65岁以上人群就医的首位原因，18%因头晕而活动减 少
周围性眩晕的快速诊断
戴春富 耳鼻喉科 复旦大学眼耳鼻喉科医院
In 70% of dizzy patients, diagnosis can be established based on a careful history inquiry and physical examination.
70%的眩晕病人可以通过细致的病史询问 和体格检查得到确诊。
•Neuhauser HK, von Brevern M, Radtke A, et al. Epidemiology of vestibular vertigo: a neurotologic survey of the general population. Neurology, 2005,65:898-904. •徐霞，行宽，邢光前等. 江苏省≥10 岁人群的眩晕流行病学调查研究.中华耳科学杂志，2006，4：250253.
� Volume 250ml 8l � Duration 30s 1m � Temerature 44/30 50/24
� Ice water test (fill ear with 2cc of ice water wait for 20s)
Caloric test
� Three different time intervals must be carefully analyzed
vestibular weakness
� Mann test: the patient stands heel to toe rather than with feet together
� Static posturography （静态姿势反应）
Dynamic balance test
� Dynamic posturography � Co-ordination function test:
(electronic nystagmus graph)
� Smooth pursuit (tracking) test:
� Tracking (velocity) gain
� Artifacts: anticipating target movements
� Brainstem or cerebellum lesion
� Mal de debarquement综合症
外周性前庭眩晕的伴随症状
� 伴随症状
� 听力减退 � 耳鸣 � 耳胀
� 随头位改变和闭合眼睛症 状有所改善提示眩晕为外 周性
体格检查
� 眼震
� 方向：快相 � I度：眼球位于快相时出现眼
震 � II度：眼球位于正中位时出
现眼震 � III度：眼球在所有方向均出
� Immediately before and after fixation (to detect fixation suppression)
Interpretation of caloric test
� Unilateral weakness (bular lesion involving the LSCC or its afferent pathways
体格检查
� Dix-Hallpike手法 � 操作
� 病人坐位 � 头偏转45度 � 病人快速躺下
体格检查
� Dix-Hallpike手法（R counter clockwise)
� 观察眼震
� 潜伏期 � 方向 � 持续时间 � 疲劳
� 眩晕诱发
R postBPPV linked.mpg
Romberg检查
眩晕感的描述
� 持续时间
� BPPV, MD, vestibular neuritis
� 强度
� 突发的、旋转性的眩晕 � 伴有恶心和呕吐
� 频率
� 单发性 � 复发性
外周性前庭眩晕的诱因
� 诱发因素
� 位置的改变 � 声音诱发 � 中耳压力或颅内压力改变 � 伴随偏头痛(畏光，怕声） � 月经相关 � 应激，抑郁 � 旅行后
� Place patients in the standard caloric position (supine with head flexed forward 30°, place LSC in the vertical plance).
� Warm irrigation cause excitatory response � Cold irrigation cause inhibitory response. � Nystagmus follows COWS principle
� Peak velocity � Accuracy � Latency (abnormality >300ms)
� Artifacts: anticipating target movement (latency <200ms)
� Brainstem, or cerebellum lesion
ENG(VNG)
ENG(VNG)
(electronic nystagmus graph, Vedio nystagmus graph)
� Optokinetic nystagmus
� Record eye movements as the patient watches a series of visual images moving first to the right then to the left in the horizontal plane
现眼震 � Frenzel 眼镜
� 放大图像 � 减少凝视抑制
甩头实验
� 头前倾30C， � 两眼注视检查者鼻尖
� 快速向左或右转动患者头部（10-20°）
� 敏感性为75% � 特异性为85% � 频率范围为0.1-6Hz
� 甩头实验主要测试半规管的功能
�
病人
正常对照
Head
Eye
体格检查
� 甩头实验(head impulse test, Halmagyi test) 向损伤侧移动较为困难.
� 上半规管（裂）
体格检查
� Fukuda走步试验
� 病人原地踏步一分钟 � 双臂摆动 � 双眼闭合
� 观察最后向外侧旋转的角度
体格检查
� 机制
� 大多数前庭功能正常的人向一侧旋转角度不 超过45度
� 前庭功能失代偿的患者向患侧偏向大于45度
Static balance test
� Romberg test: useful in patients with an acute unilateral labyrinthine lesion
� Is present without fixation and its intensity is less than a threshold (6 °/s in ENG and 4 °/s in VNG)-normal
� For vertical nystagmus:
� Is present with fixation-central � Is present without fixation and its intensity is less than a
� Valsalva 按压鼻孔 � Valsalva 关闭声门
体格检查
� 机制Mechanisms
� 迷路和中耳及中颅窝之间存在 异常的通路存在
� 卵圆窗（瘘管，蹬骨底板过度运 动）
� 圆窗（外淋巴瘘）
体格检查
� 机制
� 眼震的方向和兴奋的半规管相关
� 外侧半规管(瘘管)
体格检查
� 机制
� 眼震的方向和兴奋的半规管相 关
� First 10-15 s before the onset of irrigation (to detect spontaneous nystagmus)
� After 60-90 s of irrigation (to detect the peak of caloric response) (SPV-slow phase velocity)
� Can be caused by disease that effect the labyrinth, the vestibular nerve or the blood supply to those sites
threshold (7 °/s in VNG) –normal
� Lesion in central nerve system
实验室检查
� Caloric实验
� Basic assumption of caloric test is that both ears receive equal stimulation
� Patient asked to stand with feet together and eyes closed