澳大利亞John Murtagh 全科病案研究(三十九)——突然出現(xiàn)的眩暈

John Murtagh (著)，楊 輝(譯)

作(譯)者單位:3165 澳大利亞維多利亞州，澳大利亞Monash大學(xué)

1 病史

馬莉·文斯頓，34 歲，前來看病的原因是突然出現(xiàn)“頭暈?zāi)垦！薄恼眍^上抬起頭來的時(shí)候，頭暈情況更加嚴(yán)重，并引起嚴(yán)重的惡心癥狀。每次起床都會(huì)跌倒和嘔吐。

2 其他病史

這是她第一次突然出現(xiàn)頭暈的情況。沒有耳鳴，也不影響聽力。病人視力正常，不過眼前有閃光的感覺。病人沒有其他的身體不適。她因上呼吸道疾病，服用小劑量的撲熱息痛。在這次患病前，病人一向感到身體健康。

3 身體檢查

病人看上去很蒼白和憂郁，最好是平躺著不動(dòng)。生命體征正常，體位變化不影響血壓。病人有輕度上呼吸道感染的癥狀。在每次眩暈襲來的時(shí)候，眼球振顫，平衡紊亂?？雌饋砺犃]有受到影響。

4 問題

4.1 問題1 (1)初步的診斷是什么? (2)怎樣區(qū)分兩種相似的病因?

4.2 問題2 主要的并發(fā)癥是什么，怎樣排除?

4.3 問題3 怎樣治療這種疾病?

4.4 問題4 預(yù)后怎么樣?

5 問題的答案

5.1 答案1 (1)初步診斷是前庭神經(jīng)元炎(vestibular neuronitis)，是第8 顱神經(jīng)前庭支的炎癥。(2)其他可能的診斷是內(nèi)耳炎(labyrinthitis)，是中耳迷路炎癥。

事實(shí)上，很難區(qū)分這兩種疾病，因?yàn)樗鼈冇型瑯拥牟《静≡?。比較簡(jiǎn)單的區(qū)別方法是:突然出現(xiàn)眩暈+惡心和嘔吐=前庭神經(jīng)元炎;同樣的癥狀+聽力受損±耳鳴=急性內(nèi)耳炎。

不過，我們通常采用前庭病(vestibulopathy)這個(gè)病名來涵蓋這兩種情況。另外也有人把這兩種情況統(tǒng)稱為前庭功能減退(vestibular failure)。

應(yīng)該考慮到前庭神經(jīng)的病毒感染，眩暈的癥狀至少要持續(xù)幾天，嚴(yán)重的情況需要住院治療。這種情況很像梅尼爾綜合征(Meniere's syndrome)，但前庭病很少有聽覺失衡的情況。

5.2 答案2 最需要排除的并發(fā)癥是中耳乳突化膿。

5.3 答案3 治療措施歸納如下: (1)臥床休息，平躺;(2)注視一個(gè)方向可以減輕癥狀;(3)用藥物減輕眩暈癥狀。

可以采用下列藥物:(1)丙氯拉嗪(馬來酸甲哌氯丙嗪)12.5 mg IM (癥狀嚴(yán)重時(shí))，或者25 mg 直腸給藥然后口服給藥。(2)普魯米近(異丙嗪)10 ～25 mg IM 或緩慢IV，然后口服，或者根據(jù)情況IM 和緩慢IV。(3)另外一種替代藥物是安定，它可以減少腦干對(duì)前庭刺激的反應(yīng)。5 ～10 mg IM (急性期)，然后5 mg 口服。有些專家認(rèn)為安定是最適合的藥物。(4)短期使用皮質(zhì)甾類藥物，通?？梢源龠M(jìn)病人恢復(fù)。比如用強(qiáng)的松龍9 d，藥量遞減。

5.4 問題4 前庭神經(jīng)元炎和急性內(nèi)耳炎都是自限性疾病，通常要持續(xù)5 ～7 d 或一周的時(shí)間。內(nèi)耳炎持續(xù)的時(shí)間可能略長(zhǎng)一些，如果在恢復(fù)期間有快速轉(zhuǎn)頭動(dòng)作，則可能引起一過性眩暈。

譯者注:梅尼爾綜合征:內(nèi)耳膜迷路積水中主要病理特征的一種內(nèi)耳疾病，常表現(xiàn)為發(fā)作性眩暈，波動(dòng)性聽力減退、耳鳴、眼球振顫。發(fā)作有間歇期，多為中年人，多為單耳發(fā)病。

自限性疾病:疾病有自己的“生命周期”，人體會(huì)通過自身的免疫系統(tǒng)來克服疾病的影響，在沒有醫(yī)學(xué)干預(yù)的情況下也可以自愈。對(duì)自限性疾病的另外一種解釋，是感染之后對(duì)再次感染具有獲得性免疫力。很多病毒感染疾病屬于自限性疾病。然而，自限性疾病不等于否定醫(yī)學(xué)干預(yù)的必要性，合理的藥物干預(yù)可以為病人緩解疼痛和不適，幫助病人增強(qiáng)體力和加強(qiáng)免疫力。在必要的情況下，也可以考慮住院治療。

(本文編輯:閆行敏)

1 History

Mary Weston，aged 34，presents because of the sudden onset of 'whirling and spinning' of her head. The feeling is worse if she lifts her head off the pillow，which also aggravates severe nausea. She cannot get out of bed without falling and vomiting.

2 Other history

This is the first attack of this vertigo of sudden onset. There is not tinnitus or hearing loss. A flickering feeling of eyes is present although the patient has normal vision. There are no other bodily sensations. She has taken paracetamol on small doses for a recent URTI. She had been feeling well prior to this illness.

3 Examination

The patient was pale and distressed and preferred to lie flat and still. Vital signs were normal and there was no postural drop with her blood pressure. She had signs of a mild upper respiratory tract infection. During an attack she had nystagmus and marked disturbance of balance. There appeared to be no hearing loss.

4 Question

4.1 Question 1 (1)What is the probability diagnosis?(2)How do you distinguish between the two similar causes of this condition?

4.2 Question 2 What important complications should be excluded?

4.3 Question 3 What is the treatment of this disorder?

4.4 Question 4 What is the prognosis?

5 Answer

5.1 Answer 1 (1)The probability diagnosis is vestibular neuronitis (inflammation of the 8th cranial nerve). (2)The other possible diagnosis is labyrinithis (inflammation of the labyrinth of the middle ear).

In fact it is very difficult to distinguish between the two conditions and they usually have the same viral aetiology.

A simplified system is as follows:Acute vertigo with nausea and vomiting = vestibular neuronitis;Same symptoms + hearing loss ± tinnitus=acute labyrinthitis.

However we use the general term of acute vestibulopathy to cover both conditions. Another term used is vestibular failure.

This is considered to be a viral infection of the vestibular nerve that causes a prolonged attack of vertigo that can last for several days and be severe enough to require admission to hospital. The attack is similar to Meniere's syndrome expect that there is no hearing disturbance.

5.2 Answer 2 The important complication to exclude is suppuration in the middle ear or mastoil cavity (mastoiditis).

5.3 Answer 3 The treatment can be summarised as follows:(1)Rest in bed，lying very still. (2)Gaze in the direction that eases symptoms. (3)Drugs to lessen vertigo.

The following drugs can be used: (1)Prochlorperazine(stemetil)12.5 mg IM (if severe)or 25 mg per rectum，followed by oral medication. (2)Promethazine 10 to 25 mg IM or slow IV then oral or by IM or slow IV necessary. (3)An alternative is diazepam (with decreases brainstem response to vestibular stimuli)5～10 mg IM for the acute attack then 5 mg (o)tds. Some experts claim that diazepam is best. (4)A short course of corticosteroids often promotes recovery，e. g. ，prednislone in tapering does over 9 days.

5.4 Answer 4 Both vestibular neuronitis and labyrintitis are self limiting disorders and usually settle over several days e. g. ，5 ～7 or weeks. Labyrinthitis usually lasts longer and during recovery rapid head movements may bring on transient vertigo.

【編者按】當(dāng)今人口老齡化和慢性病海嘯給各個(gè)國(guó)家和地區(qū)的衛(wèi)生服務(wù)系統(tǒng)帶來了巨大挑戰(zhàn)，首當(dāng)其沖的問題是衛(wèi)生服務(wù)提供系統(tǒng)怎樣響應(yīng)老齡化社區(qū)的健康服務(wù)需要。它促使衛(wèi)生政策和服務(wù)的研究者們向探索創(chuàng)新性的衛(wèi)生服務(wù)系統(tǒng)方向發(fā)展，初級(jí)衛(wèi)生保健和全科醫(yī)學(xué)位于這場(chǎng)新戰(zhàn)役的前沿陣地。“快樂生活俱樂部”是受國(guó)際商標(biāo)保護(hù)的慢性病管理項(xiàng)目，它源于澳大利亞的美好生活俱樂部，作為一種創(chuàng)新性的探索，它以動(dòng)機(jī)談話為主要干預(yù)措施，致力于把社區(qū)衛(wèi)生服務(wù)更進(jìn)一步地推向生物-心理-社會(huì)健康的服務(wù)模式。 “快樂生活俱樂部”項(xiàng)目系列報(bào)告均為澳大利亞Monash 大學(xué)Colette Browning 教授等的原創(chuàng)性研究論文，均系英文來稿，因《中國(guó)全科醫(yī)學(xué)》雜志的主要讀者群為以漢語(yǔ)為母語(yǔ)的人群，故全文以中文形式刊出。本期為系列報(bào)告之八，探討2 型糖尿病的共病及其對(duì)社區(qū)干預(yù)計(jì)劃和實(shí)施的意義。澳大利亞Monash 大學(xué)楊輝教授對(duì)本文進(jìn)行了翻譯，在此表示衷心的感謝。同時(shí)，為了方便廣大讀者查閱，英文來稿原文已上傳至中國(guó)全科醫(yī)生網(wǎng):www. chinagp. net，敬請(qǐng)關(guān)注。