三维眼震图及临床应用北大核心CSCD

前庭功能测评是眩晕类疾病诊疗康复的关键环节,眼震分析是前庭功能测评的主要途径。前庭性眼震主要是三对半规管系统损伤后的综合权重,可呈水平、扭转、斜向等方向特征。与传统检测技术相比,三维视频眼震视图技术(three-dimensional videonystagmograph,3D-VNG)可将眼震或眼球运动分解为水平、垂直、扭转三个分量,为解析眼震的病理生理特征及临床眩晕类疾病诊疗提供更客观支持。本综述介绍了眼震检查的发展、3DVNG试验方法及临床意义。并结合良性位置性阵发性眩晕(BPPV)和前庭神经炎(VN)的生理病理特征,进一步阐述3D-VNG技术在BPPV、VN等疾病诊断中的作用。从3D-VNG对眼震综合向量的分解溯源,以眼震分量角度为眩晕类疾病精准诊疗提供帮助。     

红外摄像眼震镜对良性阵发性位置性眼震的观察

良性阵发性位置性眩晕(benign paroxysmal positional veal-go，BPPV)作为最常见的外周性旋转性眩晕，其典型的病理改变是变性脱落的耳石坠入后半规管作用于壶腹嵴所致。而变位性试验是诊断BPPV的常规检查手段，变位性眼震的类型和方向对BPPV的定位诊断有重要意义。本文利用红外摄像眼震镜(videonystagmoscope，VNS)，在变位性眼震试验中对42例怀疑为BPPV患者进行实时检测，并在头位变位疗法中动态观察眼震变化，以评价VNS在BPPV的诊断和疗效观察方面的临床价值。     

非典型良性阵发性位置性眩晕的诊断难点

眩晕是机体空间定向能力障碍所产生的运动性或位置性错觉，其常见原因不仅是前庭外周性病变，也可能与中枢神经系统和其他全身系统性疾病及眼科疾病有关，因为前庭系统还通过传导束与小脑、脊髓、植物神经系统、动眼系统有着广泛的联系。当前庭系统本身与中枢传导通路相关联的任何部位受到病理或生理性刺激，均可能导致双侧的传人神经冲动不对称而出现平衡失调：同样，与平衡相关联的传出系统以及负责调控锥体系和椎体外系的脑干网状结构和小脑部位的病变也可能引发眩晕。眼震是临床上各种前庭反应中最明显和最重要的体征之一，前庭系统异常所引发的眼震经由前庭动眼反射弧来完成，称为前庭性眼震，     

视频眼震电图对突发性聋伴眩晕患者前庭功能的诊断价值分析

目的探讨视频眼震电图对突发性聋伴眩晕患者前庭功能的诊断价值。方法将2013年2月~2017年12月收纳的500例突聋患者作为研究对象,根据是否合并眩晕分为眩晕组（180例）和非眩晕组（320例）,所有患者入院后进行纯音听力测试、视频眼震电图（videonystagmograph,VNG）检测等,比较眩晕组和非眩晕组患者纯音测听和视频眼震电图检测结果,同时统计患者平坦型、全聋型、低频型、中频型、高频型的听力曲线例数及冷热试验的前庭功能评价结果,并比较组间差异。患者根据视频眼震电图和相关检测结果进行对应治疗,统计两组患者的治疗效果。结果①眩晕组患者的前庭功能正常比例（48.9%）显著低于非眩晕组（83.8%）（P＜0.05）;听力学结果显示听力损失严重者比例（67.2%）显著高于非眩晕组（28.1%）,轻度患者比例（8.3%）明显低于非眩晕组（40.0%）（P均＜0.05）;②患者的听力曲线主要有平坦型108例,其中前庭功能异常15例（13.9%）;全聋型78例,其中前庭功能异常34例;低频型100例,其中前庭功能异常28例（28.0%）;中频型94例,其中前庭功能异常25例（26.6%）;高频型120例,其中前庭功能异常42例（35.0%）。表明全聋型曲线前庭功能异常率显著高于其他类型听力曲线患者,冷热试验结果表明前庭功能异常的主要表现为半规管轻瘫;③两组患者临床疗效其中眩晕组患者显效率26.7%（48/180）、有效率28.9%（52/180）及总有效率55.6%（100/180）明显低于非眩晕组的38.1%（122/320）、45.6%（146/320）及83.7%（268/320）（P均＜0.05）。结论突发性聋伴眩晕患者前庭功能受到明显损伤,采用视频眼震电图进行前庭功能检测对突发性聋伴眩晕患者的病情评估、诊断、治疗具有重要指导意义,值得临床借鉴。     

外周性眩晕眼震电图的三维分析

眼震电图的监测和记录是诊断外周性眩晕程度和预后的基础，可判断外周前庭器官的病变部位。应用已开展的计算机影像识别技术检查外周性前庭疾病病人眼震电图的三维分析。全部梅尼埃病人的记录显示眼球运动有二种成分，名为水平性和旋转性，其方向朝向右和逆时针方向。前庭神经炎的大多数病人自发性眼球震颤则有3种成分，水平性和垂直性眼震朝向病变对侧和上方，旋转性眼震的方向随水平眼震而定，当水平眼震朝向左侧时，其为逆时针方向；水平眼震向右时，则为顺时针方向。而梅尼埃病动物模型的颈骨组织学检查证实内淋巴水肿病变发生于全迷路…     

伴有先天性眼球震颤的眩晕症患者VNG特点分析:2例报道

目的探讨伴有先天性眼震的眩晕症患者通过眼震视图诊断前庭功能的可行性。方法通过VNG记录知觉缺陷型先天性眼震及运动缺陷型先天性眼震患者自发性眼震、静态位置性眼震、变位性眼震,扫视试验、视动性眼震、平稳跟踪试验、温度试验及其固视抑制试验,分析其VNG各测试项目特点。结果 1对于方向及慢相角速度恒定的先天性眼震,其扫视试验及平稳跟踪试验结果为:扫视及跟踪曲线与视靶曲线吻合良好,仅在扫视及跟踪曲线上叠加恒定的细小眼震波,向低视力侧扫视时欠冲,0.4Hz平稳跟踪试验可见Ⅲ型曲线;2对于恒定的水平型先天眼震(CN),温度试验及其固视抑制可不受干扰;3CN对BPPV的测试结果干扰较大,曲线杂乱无法分析。结论先天性眼震非VNG检查的绝对禁忌症,对于方向及慢相角速度恒定的水平型CN,扫视试验、平滑跟踪、温度试验及其固视抑制依然可用于对眩晕症病变部位的诊断。     

蜗窗膜入路人工耳蜗植入术

目的　探讨以持续性眩晕为表现的良性阵发性位置性眩晕（benign paroxysmal positional vertigo,BPPV）患者的诊治。方法　回顾性分析2例以持续性眩晕为表现的BPPV患者的临床资料。结果　此2例患者在坐位及平躺位见方向向患侧的水平自发持续性眼震,甩头试验健侧阳性,平卧侧头试验双侧均诱发出水平离地性眼震,平躺后头部向患侧连续转360°时分别出现2个眼震消失点和2个眼震最强点,给予手法复位后患者眩晕症状缓解。结论　水平半规管BPPV患者偶可表现为持续性眩晕发作,其病因为壶腹嵴帽耳石症,临床表现与耳石重力因素和水平半规管空间位置相关。     

以持续性眩晕为表现的水平半规管良性阵发性位置性眩晕的诊治

目的　探讨以持续性眩晕为表现的良性阵发性位置性眩晕（benign paroxysmal positional vertigo,BPPV）患者的诊治。方法　回顾性分析2例以持续性眩晕为表现的BPPV患者的临床资料。结果　此2例患者在坐位及平躺位见方向向患侧的水平自发持续性眼震,甩头试验健侧阳性,平卧侧头试验双侧均诱发出水平离地性眼震,平躺后头部向患侧连续转360°时分别出现2个眼震消失点和2个眼震最强点,给予手法复位后患者眩晕症状缓解。结论　水平半规管BPPV患者偶可表现为持续性眩晕发作,其病因为壶腹嵴帽耳石症,临床表现与耳石重力因素和水平半规管空间位置相关。     

李氏复位法治疗水平离地性眼震BPPV的短期疗效

目的探究李氏复位法对水平离地性眼震良性阵发性位置性眩晕(BPPV)复位治疗的近期疗效。方法回顾性分析2014年5月~2016年7月确诊的43例向地性眼震水平半规管BPPV患者和30例离地性眼震水平半规管BP-PV患者的临床资料,两组均采用李氏手法复位治疗,将每次门诊治疗计算为1个周期,每个周期进行2次相同复位法治疗,中间间隔5至10分钟,3天后及1周后复查,分析两组患者治疗后的临床效果。结果 3天及1周的向地眼震患者复位有效率分别为83.7%和95.3%,离地性眼震患者的有效率分别为90.0%和96.7%两组之间差异无统计学意义(P>0.05)。结论李氏复位法对治疗离地性眼震HC-BPPV同样能取得良好的治疗效果,且操作简便,过程迅速,可在临床应用。     

眼源性前庭诱发肌源性电位

眼性前庭诱发肌源性电位(ocular vestibular evoked myogenic potential,oVEMP)是起源于椭圆囊的能够客观反映前庭-眼反射通路完整性一种无创电生理检查,是一项新的前庭功能检查技术,与眼震电图和颈性前庭诱发肌源性电位用于眩晕相关疾病诊断及鉴别诊断,全面评价前庭系统的功能状态。     

Video-oculography findings in patients with otosclerosis.

OBJECTIVE: To evaluate the existence of vestibular irritation with video-oculography before and after stapes surgery and to examine whether there would be signs of specific end-organ irritation. STUDY DESIGN: A prospective study of preoperative and postoperative nystagmus, vertigo, and hearing thresholds. SETTING: University hospital, tertiary referral center. PATIENTS: Thirty-three patients (mean age, 47 yr) with otosclerosis. INTERVENTION: Stapedotomy/stapedectomy with laser or microdrill. MAIN OUTCOME MEASURES: Spontaneous, gaze-evoked, and head-shaking nystagmus was measured preoperatively and approximately 1 week, 1 month, and 3 months after the operation. Three dimensions of nystagmus were identified and their slow-phase velocities were calculated. RESULTS: Spontaneous horizontal nystagmus was found preoperatively in 18% (slow-phase velocities, 1.3-3.3 deg/s) and postoperatively in 11 to 19% of the patients (slow-phase velocities, 1.3-3.8 deg/s). Head-shaking nystagmus was not detected preoperatively. After the operation, 11 to 15% of the patients had head-shaking nystagmus (slow-phase velocities, 6.6-17.8 deg/s), but this prevalence did not differ statistically significantly from the preoperative level (p = 0.18). Vertical nystagmus was found equally pre- and postoperatively. Torsional nystagmus was not found. One week after the operation, nine patients (27%) had some sensation of vertigo, but it lasted over 1 month in only one patient. We found no significant correlation with vertigo and the types of nystagmus. CONCLUSION: Nystagmus with a low slow-phase velocity can occur in patients with otosclerosis. However, according to the video-oculographic findings and subjective symptoms, significant vestibular dysfunction seems to be rare and temporary after stapes surgery.     

鼓膜穿孔眩晕者的冷热气试验结果分析

目的：分析冷热气刺激下鼓膜穿孔患者的试验结果特点,探讨鼓膜穿孔者冷热气试验的可行性。方法：慢性中耳炎鼓膜穿孔伴眩晕的患者43例（49耳）,行双耳冷热气试验,观测眼震特点、慢相角速度（SPV）和眼震不对称比（UW）。结果：穿孔耳冷热气刺激诱发眼震呈现4种类型：①增强型：穿孔耳诱发性眼震SPV增强并超过正常范围,或强于非穿孔耳、UW＞15％者15例（17耳）;②“正常型”：穿孔、非穿孔耳眼震SPV均在正常范围,UW〈15％者7例;③减弱型：穿孔耳眼震SPV弱于非穿孔耳,UW〉15％者9例;④反向型：非穿孔耳冷热气刺激眼震正常,穿孔耳热气刺激眼震反向者12例（14耳）。反向型眼震均出现在近期慢性中耳炎复发、鼓膜穿孔且有渗出或潮湿者;其余类型均为慢性中耳炎静止期患者。结论：对于穿孔耳,冷热气成为强刺激,半规管功能正常时诱发的眼震强于非穿孔耳;穿孔耳半规管功能不同程度减弱时,诱发眼震可为正常或减弱反应;活动期的中耳炎患者,穿孔耳热气刺激可转化为冷刺激效应,诱发出反向眼震;冷热气试验可用于鼓膜穿孔伴眩晕患者的前庭功能评定。     

Vibration induced nystagmus in normal subjects and in patients with dizziness. A videonystagmography study

OBJECTIVE: To analyze the incidence and characteristics of vibration-induced nystagmus in normal subjects and in patients with vertigo. STUDY DESIGN AND SETTING: This is a prospective analysis of the effect of vibration on several points of the skull in 38 normal subjects, 10 patients who had undergone labyrinthectomy and 125 consecutive patients with dizziness referred to a tertiary care center. Nystagmus was documented and its corresponding slow phase velocity measured with a videonystagmography system. RESULTS: In 81.6% of normal subjects and 80.8% of all patients, nystagmus could be provoked by stimulation of at least one of the points on the skull to which the vibrator was applied. In normals, however, no subject had nystagmus greater than 2.8 degrees s-1 whereas 35.2% of patients did. CONCLUSION/SIGNIFICANCE: The value of the slow-phase velocity of vibration-induced nystagmus can be used to identify a sizeable proportion of patients with a vestibular disorders. Vibration-induced nystagmus is a frequent sign in patients with dizziness and can provide complimentary information about vestibular system function.     

Delayed endolymphatic hydrops. Special emphasis on nystagmus associated with episodes and contribution of chemical labyrinthectomy

ObjectivesThe main objective was to describe spontaneous nystagmus characteristics during an episode of delayed endolymphatic hydrops (DEH), including an initial vertical upbeating nystagmus in one patient. The secondary objective was to highlight the contribution of chemical labyrinthectomy.MethodsEpisodic vertigo after a prolonged period of time of sensorineural hearing loss (profound or total) in one ear characterized ipsilateral DEH and was associated with the development of hearing loss in the opposite ear in contralateral DEH.ResultsTen patients met the criteria for DEH: 7 ipsilateral and 3 contralateral. Three (all ipsilateral DEH) were examined during a vertigo episode. Two patients had a typical horizontal-torsional nystagmus beating contralaterally to the hearing loss. One patient showed atypic initial vertical upbeating nystagmus with a slight torsional component, which secondarily became horizontal-torsional beating contralaterally to the hearing loss. Four patients had disabling vertigo with unilateral total deafness (ipsilateral DEH), successfully treated by 1-3 transtympanic gentamycin (Gentalline^®) injections.ConclusionNystagmus direction during vertigo episodes varies, and may initially present as vertical upbeating nystagmus, which, to our knowledge, has not been previously reported in DEH or Menière's disease. This nystagmus might reflect an inhibition of the superior semicircular canal (on the hearing-impaired side), suggesting incipient hydrops in this canal. Chemical labyrinthectomy is a simple and effective procedure in unilateral DEH, especially as the patient often suffers from total deafness.     

Subjective benign paroxysmal positional vertigo in patients with osteoporosis or migraine

IntroductionSubjective benign paroxysmal positional vertigo is a form of benign paroxysmal positional vertigo in which during the diagnostic positional maneuvers patients only present vertigo symptoms with no nystagmus.ObjectiveTo study the characteristics of subjects with subjective benign paroxysmal positional vertigo.MethodsProspective multicenter case-control study. All patients presenting with vertigo in the Dix-Hallpike test that presented to the participating hospitals were included. The patients were separated into two groups depending on whether nystagmus was present or not. An Epley Maneuver of the affected side was performed. In the follow-up visit, patients were checked to see if nystagmus and vertigo were present. Both groups of patients were compared to assess the success rate of the Epley maneuver and also to compare the presence of 19 variables.Results259 patients were recruited, of which 64 belonged to the subjective group. Nystagmus was eliminated in 67.2% of the patients with benign paroxysmal positional vertigo. 89.1% of the patients with subjective benign paroxysmal positional vertigo remained unaffected by nystagmus, thus showing a significant difference (p = 0.001). Osteoporosis and migraine were the variables which reached the closest to the significance level. In those patients who were taking vestibular suppressors, the percentage of subjective benign paroxysmal positional vertigo was not significantly higher.ConclusionsSubjective benign paroxysmal positional vertigo should be treated using the Epley maneuver. More studies are needed to establish a relationship between osteoporosis, migraine and subjective benign paroxysmal positional vertigo. The use of vestibular suppressants does not affect the detection of nystagmus.     

Benign Paroxysmal Positional Vertigo without nystagmus: diagnosis and treatment

Nystagmus tests to diagnose BPPV are still relevant in the clinical evaluation of BPPV. However, in everyday practice, there are cases of vertigo caused by head movements, which do not follow this sign in the Dix-Hallpike maneuver and the turn test.AimTo characterize BPPV without nystagmus and treatment for it.Materials and methodsA non-systematic review of diagnosis and treatment of benign paroxysmal positional vertigo (BPPV) without nystagmus in the PubMed, SciELO, Cochrane, BIREME, LILACS and MEDLINE databases in the years between 2001 and 2009.ResultsWe found nine papers dealing with BPPV without nystagmus, whose diagnoses were based solely on clinical history and physical examination. The treatment of BPPV without nystagmus was made by Epley maneuvers, Sémont, modified releasing for posterior semicircular canal and Brandt-Daroff exercises.ConclusionFrom 50% to 97.1% of the patients with BPPV without nystagmus had symptom remission, while patients with BPPV with nystagmus with symptom remission ranged from 76% to 100%. These differences may not be significant, which points to the need for more studies on BPPV without nystagmus.     

Prospective study of positional nystagmus in 100 consecutive patients

OBJECTIVES: The purpose of this study was to investigate the various diagnoses of patients who present with positional nystagmus. METHODS: Positional maneuvers were systematically performed in the plane of the posterior canal (PC; Dix-Hallpike maneuver) and the horizontal canal (HC; patients were rolled to either side in a supine position) on 490 consecutive patients essentially referred for vertigo and/or gait unsteadiness. RESULTS: One hundred patients (20%) presented positional nystagmus. This nystagmus had a peripheral origin in 83 patients, including 80 patients with benign paroxysmal positional vertigo (BPPV). In BPPV, the PC was involved in 61 patients, the HC in 18 patients (geotropic horizontal nystagmus in 11 and ageotropic in 7; changing from geotropic to ageotropic or the reverse in 4 patients), and both the PC and HC in 1 patient. There was evidence of central positional nystagmus in 12 patients, including positional downbeat nystagmus during the Dix-Hallpike maneuver in 7 patients with various neurologic disorders, and ageotropic horizontal nystagmus during the HC maneuver in 2 patients with, respectively, cerebellar ischemia and definite migrainous vertigo. The peripheral or central origin of the positional nystagmus could not be ascertained in 5 patients, including 1 patient with probable migrainous vertigo and another with possible anterior canal BPPV. CONCLUSIONS: A rotatory-upbeat nystagmus in the context of PC BPPV, a horizontal nystagmus, whether geotropic or ageotropic, due to HC BPPV, and a positional downbeat nystagmus related to various central disorders are the 3 most common types of positional nystagmus. Geotropic horizontal positional nystagmus and, most certainly, horizontal positional nystagmus changing from geotropic to ageotropic or the reverse point to HC BPPV. In contrast, an ageotropic horizontal positional nystagmus that is not changing (from ageotropic to geotropic) may indicate a central lesion.     

Neuro-otological manifestations as presentacion of type I Chiari malformation

The type I Chiari malformation consists of an caudal descent of the cerebellar tonsils through the foramen magno towards the spinal cervical channel. The usual clinical presentation are occipital headaches and cervical pain, as well as some otoneurological symptoms. Among them are common dizziness and crisis of central positional vertigo in which down beating nystagmus can be observed. We present our experience with three cases presenting with neurotological manifestations in which MRI showed a type I Chiari malformation. Case 1: a patient of 24 years that had frequent instability, and common crisis ofpositional vertigo. It was possible to see the presence of positional down-beating nystagmus, of central characteristics, that improved after neurosurgical treatment. Case 2: patient of 11 years who suffered from occasional headaches, dizziness and positional vertigo, without severe handicap, and did not need surgery. Case 3: lady of 63 years who had common episodes of vertigo with head tilt, and unsteadiness during walks. Due to the coexistence of hydrocephalus and syringomyelia, surgery was indicated. A revision is done on otoneurological presentation of type I Chiari malformation, especially as differential diagnosis on central positional vertigo.     

Benign paroxysmal positional vertigo

Benign paroxysmal positional vertigo (BPPV) is characterized by positional vertigo (brief attacks of rotatory vertigo triggered by head position changes in the direction of gravity) and is the most common peripheral cause of vertigo. There are two types of BPPV pathophysiology: canalolithiasis and cupulolithiasis. In canalolithiasis, otoconial debris is detached from the otolithic membrane and floats freely within the endolymph of the canal. In cupulolithiasis, the otoconial debris released from the otolithic membrane settles on the cupula of the semicircular canal and the specific gravity of the cupula is increased. Consensus has been reached regarding three subtypes of BPPV: posterior-canal-type BPPV (canalolithiasis), lateral-canal-type BPPV (canalolithiasis) and lateral-canal-type BPPV (cupulolithiasis). In the interview-based medical examination of BPPV, questions regarding the characteristics of vertigo, triggered movement of vertigo, duration of vertigo and cochlear symptoms during vertigo attacks are important for the diagnosis of BPPV. The Dix–Hallpike test is a positioning nystagmus test used for diagnosis of posterior-canal-type BPPV. The head roll test is a positional nystagmus test used for diagnosis of lateral-canal-type BPPV. When the Dix–Hallpike test is repeated, positional nystagmus and the feeling of vertigo typically become weaker. This phenomenon is called BPPV fatigue. The effect of BPPV fatigue typically disappears within 30 min, at which point the Dix–Hallpike test again induces clear positional nystagmus even though BPPV fatigue had previously caused the positional nystagmus to disappear. For the treatment of BPPV, sequential head movements of patients can cause the otoconial debris in the semicircular canal to move to the utricle. This series of head movements is called the canalith repositioning procedure (CRP). The appropriate type of CRP depends on the semicircular canal in which the otoconial debris is located. The CRP for posterior-canal-type BPPV is called the Epley maneuver, and the CRP for lateral-canal-type BPPV is called the Gufoni maneuver. Including a time interval between each head position in the Epley maneuver reduces the immediate effect of the maneuver. This finding can inform the development of methods for reducing the effort exerted by doctors and the discomfort experienced by patients with posterior-canal-type BPPV during the Epley maneuver.     

Eye movements induced by lateral tilt and testing of otolithic function

In the last few years, we have studied ocular reflexes caused by tilting stimulations in test subjects placed in an upright sitting position on a chair apparatus which tilts continuously. In healthy persons, a weak nystagmus can be observed, and involves a nystagmus of minor amplitude and showing a small number of beats. The actual incidence of nystagmus in the younger group was minimal, but it tended to increase with age. This occurrence is considered to be due to age-related degeneration of the otolithic organ. Patients with vertigo and/or dizziness clearly develop nystagmus. These responses are classified as follows: type I is of fixed direction; type II is of changed direction; and type III is a combination of the first and second types. Among the peripheral vestibular disorders, particularly involving those patients with benign paroxysmal positional vertigo, a nystagmus of changed direction was found. This type was rarely seen in patients with other vestibular disorders, but was a common occurrence in healthy individuals who readily experienced motion sickness. These observations have led us to conclude that patients with benign paroxysmal positional vertigo have definite reactions which are similar to those of individuals with motion sickness, and that such depends on the susceptibility of the otolithic organs.