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Клиническое обследование пациента с головокружением
Пальчун В.Т., Гусева А.Л., Левина Ю.В. Клиническое обследование пациента с головокружением. Consilium Medicum. 2015; 17 (2): 12–17. DOI: 10.26442/2075-1753_2015.2.12-17
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Palchun V.T., Guseva A.L., Levina Yu.V. Clinical bedside evaluation of dizzy patients. Consilium Medicum. 2015; 17 (2): 12–17. DOI: 10.26442/2075-1753_2015.2.12-17
Материалы доступны только для специалистов сферы здравоохранения. Авторизуйтесь или зарегистрируйтесь.
Аннотация
Первичное клиническое обследование пациента с головокружением проводится в короткие сроки, не требует специального оборудования и позволяет быстро и с большой вероятностью выявить предположительную причину вестибулярных нарушений, что необходимо для определения последующего алгоритма обследования и лечения. В статье представлены пробы из арсенала отоневролога, которые, по мнению авторов, достаточны для первичной диагностики, наиболее просты в исполнении, не требуют больших временных затрат и сложного оборудования, иначе говоря, доступны врачу любой специальности при обследовании пациента с головокружением в условиях амбулаторного приема. Подробно рассматриваются методики проведения и оценка таких тестов, как исследование спонтанного нистагма при взгляде прямо и отведении взора, саккады, плавное слежение, оптокинез, тест поворота головы, динамическая острота зрения, тест встряхивания головы, позиционные тесты на доброкачественное пароксизмальное позиционное головокружение, проба Ромберга, тест Унтербергера, указательные тесты и др.
Ключевые слова: головокружение, глазодвигательные пробы, нистагм, статокоординаторные пробы, вестибулярная дисфункция.
Ключевые слова: головокружение, глазодвигательные пробы, нистагм, статокоординаторные пробы, вестибулярная дисфункция.
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Primary clinical examination of the patient with dizziness conducted in a short time does not require special equipment and can quickly reveal the supposed cause of vestibular disorders, which is necessary to determine the subsequent examination and treatment algorithm. The article presents a sample of the methods used in otoneurologist practice, which, according to the authors, are sufficient for initial diagnosis, and being the simplest in execution, do not require time-consuming and complex equipment, in other words, are available for any specialty physician during the examination of the patient with dizziness in the conditions of outpatient visits. The detailed review of the methodology and evaluation of such tests as the study of spontaneous nystagmus when looking straight and abduction sight, saccades, smooth pursuit, optokinetic test of the head rotation, dynamic visual acuity, head shaking test, the positional tests for benign paroxysmal positional vertigo, Romberg test, Unterberger test, demonstrative tests and others.
Key words: dizziness, oculomotor tests, nystagmus, static coordination test, vestibular dysfunction.
Key words: dizziness, oculomotor tests, nystagmus, static coordination test, vestibular dysfunction.
Полный текст
Список литературы
1. Кунельская Н.Л., Лучихин Л.А., Гусева А.Л. и др. Чувствительность, специфичность и прогностическая значимость статокоординаторных и статокинетических тестов в обследовании пациента с головокружением. Омск. науч. вестн. 2014; 2 (134): 84–7. / Kunel'skaia N.L., Luchikhin L.A., Guseva A.L. i dr. Chuvstvitel'nost', spetsifichnost' i prognosticheskaia znachimost' statokoordinatornykh i statokineticheskikh testov v obsledovanii patsienta s golovokruzheniem. Omsk. nauch. vestn. 2014; 2 (134): 84–7. [in Russian]
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3. Curthoys I.S. Generation of the quick phase of horizontal vestibular nystagmus. Exp Brain Res 2002; 143 (4): 397–405.
4. Brandt T, Strupp M. General vestibular testing. Clin Neurophysiol 2005; 116 (2): 406–26.
5. Herr RD, Zun L, Mattews JJ. A directed approach to the dizzy patient. Ann Emerg Med 1989; 18: 664–72.
6. Frenzel H. Practical methods of a systematic study of otorhinolaryngology. Munch Med Wochenschr 1956; 98: 972–5.
7. Bronstein A. Oxford Textbook of Vertigo and Imbalance. Barcelona: Oxford University Press, 2013.
9. Lemos J, Eggenberger E. Saccadic intrusions: review and update. Curr Opin Neurol 2013; 26 (1): 59–66.
10. Phillipou A, Rossell SL, Castle DJ et al. Square wave jerks and anxiety as distinctive biomarkers for anorexia nervosa. Invest Ophthalmol Vis Sci 2014; 55 (12): 8366–70.
11. Alexander G. Die Ohrenkrankheitenim Kindesalter. In: Schlossmann A (ed) Handbuch der Kinderheilkunde. Leipzig: Verlag von F.C.W.Vogel, 1912.
12. Strupp M, Hufner K, Sandmann R et al. Central oculomotor disturbances and nystagmus: a window into the brainstem and cerebellum. Dtsch Arztebl Int 2011; 108: 197–204.
13. Marti S, Straumann D, Glasauer S. The origin of downbeat nystagmus: an asymmetry in the distribution of on-directions of vertical gaze-velocity purkinje cells. Ann N Y Acad Sci. 2005; 1039: 548–53.
14. Brandt T, Dieterich M, Strupp M. Vertigo and dizziness-common complaints. London: Springer, 2013.
15. Kanegaonkar R, Tysome J. Dizziness and Vertigo: An Introduction and Practical Guide. FL: CRC Press, 2014.
16. Willard A, Lueck CJ. Ocular motor disorders. Curr Opin Neurol 2014; 27 (1): 75–82.
17. Versino M, Hurko O, Zee DS. Disorders of binocular control of eye movements in patients with cerebellar dysfunction. Brain 1996; 119 (Pt 6): 1933–50.
18. Yee RD, Purvin VA. Acquired ocular motor apraxia after aortic surgery. Trans Am Ophthalmol Soc 2007; 105: 152–8; discussion 158–9.
19. Ohtsuka K, Enoki T. Transcranial magnetic stimulation over the posterior cerebellum during smooth pursuit eye movements in man. Brain 1998; 121 (Pt 3): 429–35.
20. Antoniades CA, Kennard C. Ocular motor abnormalities in neurodegenerative disorders. Eye (Lond). 2015; 29 (2): 200–7.
21. Weber KP, Aw ST, Todd MJ et al. Head impulse test in unilateral vestibular loss: vestibulo-ocular reflex and catch-up saccades. Neurology 2008; 70 (6): 454–63.
22. Walker MF, Zee DS. Cerebellar disease alters the axis of the high-acceleration vestibuloocular reflex. J Neurophysiol 2005; 94 (5): 3417–29.
23. Longridge NS, Mallinson AI. The dynamic illegible E-test. A technique for assessing the vestibulo-ocular reflex. Acta Otolaryngol 1987; 103 (3–4): 273–9.
24. Vital D, Hegemann SC, Straumann D et al. A new dynamic visual acuity test to assess peripheral vestibular function. Arch Otolaryngol Head Neck Surg 2010; 136 (7): 686–91.
25. Hain TC, Fetter M, Zee DS. Head-shaking nystagmus in patients with unilateral peripheral vestibular lesions. Am J Otolaryngol 1987; 8 (1): 36–47.
26. Minagar A, Sheremata WA, Tusa RJ. Perverted head-shaking nystagmus: a possible mechanism. Neurology 2001; 57 (5): 887–9.
27. Пальчун В.Т., Кунельская Н.Л., Ротермель Е.В. Диагностика и лечение доброкачественного пароксизмального позиционного головокружения. Вестн. оториноларингологии. 2007; 1: 4–7. / Pal'chun V.T., Kunel'skaia N.L., Rotermel' E.V. Diagnostika i lechenie dobrokachestvennogo paroksizmal'nogo pozitsionnogo golovokruzheniia. Vestn. otorinolaringologii. 2007; 1: 4–7. [in Russian]
28. Мельников О.А., Замерград М.В. Доброкачественное позиционное головокружение. Лечащий врач. 2000; 1: 19–21. / Mel'nikov O.A., Zamergrad M.V. Dobrokachestvennoe pozitsionnoe golovokruzhenie. Lechashchii vrach. 2000; 1: 19–21. [in Russian]
29. Dix MR, Hallpike CS. The pathology, symptomatology and diagnosis of certain common disorders of the vestibular system. Ann Otol Rhinol Laryngol 1952; 61 (4): 987–1016.
30. Pagnini P, Nuti D, Vannucchi P. Benign paroxysmal vertigo of the horizontal canal. ORL J Otorhinolaryngol Relat Spec 1989; 51 (3): 161–70.
31. McClure JA. Horizontal canal BPV. J Otolaryngol 1985; 14 (1): 30–5.
32. Lempert T, Brandt T, Dieterich M, Huppert D. How to identify psychogenic disorders of stance and gait. A video study in 37 patients. J Neurol 1991; 238 (3): 140–6.
33. Пальчун В.Т., Магомедов М.М., Лучихин Л.А. Оториноларингология. М.: ГЭОТАР-Медиа, 2008. / Pal'chun V.T., Magomedov M.M., Luchikhin L.A. Otorinolaringologiia. M.: GEOTAR-Media, 2008. [in Russian]
34. Никифоров А.С., Гусев Е.И. Общая неврология. М.: ГЭОТАР-Медиа, 2007. / Nikiforov A.S., Gusev E.I. Obshchaia nevrologiia. M.: GEOTAR-Media, 2007. [in Russian]
35. Cohen HS, Sangi-Haghpeykar H, Ricci NA et al. Utility of Stepping, Walking, and Head Impulses for Screening Patients for Vestibular Impairments. Otolaryngol Head Neck Surg 2014; 151 (1): 131–6.
2. Leigh RJ, Zee DS. The Neurology of Eye Movements. London: Oxford University Press, 2006.
3. Curthoys I.S. Generation of the quick phase of horizontal vestibular nystagmus. Exp Brain Res 2002; 143 (4): 397–405.
4. Brandt T, Strupp M. General vestibular testing. Clin Neurophysiol 2005; 116 (2): 406–26.
5. Herr RD, Zun L, Mattews JJ. A directed approach to the dizzy patient. Ann Emerg Med 1989; 18: 664–72.
6. Frenzel H. Practical methods of a systematic study of otorhinolaryngology. Munch Med Wochenschr 1956; 98: 972–5.
7. Bronstein A. Oxford Textbook of Vertigo and Imbalance. Barcelona: Oxford University Press, 2013.
9. Lemos J, Eggenberger E. Saccadic intrusions: review and update. Curr Opin Neurol 2013; 26 (1): 59–66.
10. Phillipou A, Rossell SL, Castle DJ et al. Square wave jerks and anxiety as distinctive biomarkers for anorexia nervosa. Invest Ophthalmol Vis Sci 2014; 55 (12): 8366–70.
11. Alexander G. Die Ohrenkrankheitenim Kindesalter. In: Schlossmann A (ed) Handbuch der Kinderheilkunde. Leipzig: Verlag von F.C.W.Vogel, 1912.
12. Strupp M, Hufner K, Sandmann R et al. Central oculomotor disturbances and nystagmus: a window into the brainstem and cerebellum. Dtsch Arztebl Int 2011; 108: 197–204.
13. Marti S, Straumann D, Glasauer S. The origin of downbeat nystagmus: an asymmetry in the distribution of on-directions of vertical gaze-velocity purkinje cells. Ann N Y Acad Sci. 2005; 1039: 548–53.
14. Brandt T, Dieterich M, Strupp M. Vertigo and dizziness-common complaints. London: Springer, 2013.
15. Kanegaonkar R, Tysome J. Dizziness and Vertigo: An Introduction and Practical Guide. FL: CRC Press, 2014.
16. Willard A, Lueck CJ. Ocular motor disorders. Curr Opin Neurol 2014; 27 (1): 75–82.
17. Versino M, Hurko O, Zee DS. Disorders of binocular control of eye movements in patients with cerebellar dysfunction. Brain 1996; 119 (Pt 6): 1933–50.
18. Yee RD, Purvin VA. Acquired ocular motor apraxia after aortic surgery. Trans Am Ophthalmol Soc 2007; 105: 152–8; discussion 158–9.
19. Ohtsuka K, Enoki T. Transcranial magnetic stimulation over the posterior cerebellum during smooth pursuit eye movements in man. Brain 1998; 121 (Pt 3): 429–35.
20. Antoniades CA, Kennard C. Ocular motor abnormalities in neurodegenerative disorders. Eye (Lond). 2015; 29 (2): 200–7.
21. Weber KP, Aw ST, Todd MJ et al. Head impulse test in unilateral vestibular loss: vestibulo-ocular reflex and catch-up saccades. Neurology 2008; 70 (6): 454–63.
22. Walker MF, Zee DS. Cerebellar disease alters the axis of the high-acceleration vestibuloocular reflex. J Neurophysiol 2005; 94 (5): 3417–29.
23. Longridge NS, Mallinson AI. The dynamic illegible E-test. A technique for assessing the vestibulo-ocular reflex. Acta Otolaryngol 1987; 103 (3–4): 273–9.
24. Vital D, Hegemann SC, Straumann D et al. A new dynamic visual acuity test to assess peripheral vestibular function. Arch Otolaryngol Head Neck Surg 2010; 136 (7): 686–91.
25. Hain TC, Fetter M, Zee DS. Head-shaking nystagmus in patients with unilateral peripheral vestibular lesions. Am J Otolaryngol 1987; 8 (1): 36–47.
26. Minagar A, Sheremata WA, Tusa RJ. Perverted head-shaking nystagmus: a possible mechanism. Neurology 2001; 57 (5): 887–9.
27. Пальчун В.Т., Кунельская Н.Л., Ротермель Е.В. Диагностика и лечение доброкачественного пароксизмального позиционного головокружения. Вестн. оториноларингологии. 2007; 1: 4–7. / Pal'chun V.T., Kunel'skaia N.L., Rotermel' E.V. Diagnostika i lechenie dobrokachestvennogo paroksizmal'nogo pozitsionnogo golovokruzheniia. Vestn. otorinolaringologii. 2007; 1: 4–7. [in Russian]
28. Мельников О.А., Замерград М.В. Доброкачественное позиционное головокружение. Лечащий врач. 2000; 1: 19–21. / Mel'nikov O.A., Zamergrad M.V. Dobrokachestvennoe pozitsionnoe golovokruzhenie. Lechashchii vrach. 2000; 1: 19–21. [in Russian]
29. Dix MR, Hallpike CS. The pathology, symptomatology and diagnosis of certain common disorders of the vestibular system. Ann Otol Rhinol Laryngol 1952; 61 (4): 987–1016.
30. Pagnini P, Nuti D, Vannucchi P. Benign paroxysmal vertigo of the horizontal canal. ORL J Otorhinolaryngol Relat Spec 1989; 51 (3): 161–70.
31. McClure JA. Horizontal canal BPV. J Otolaryngol 1985; 14 (1): 30–5.
32. Lempert T, Brandt T, Dieterich M, Huppert D. How to identify psychogenic disorders of stance and gait. A video study in 37 patients. J Neurol 1991; 238 (3): 140–6.
33. Пальчун В.Т., Магомедов М.М., Лучихин Л.А. Оториноларингология. М.: ГЭОТАР-Медиа, 2008. / Pal'chun V.T., Magomedov M.M., Luchikhin L.A. Otorinolaringologiia. M.: GEOTAR-Media, 2008. [in Russian]
34. Никифоров А.С., Гусев Е.И. Общая неврология. М.: ГЭОТАР-Медиа, 2007. / Nikiforov A.S., Gusev E.I. Obshchaia nevrologiia. M.: GEOTAR-Media, 2007. [in Russian]
35. Cohen HS, Sangi-Haghpeykar H, Ricci NA et al. Utility of Stepping, Walking, and Head Impulses for Screening Patients for Vestibular Impairments. Otolaryngol Head Neck Surg 2014; 151 (1): 131–6.
________________________________________________
1. Kunel'skaia N.L., Luchikhin L.A., Guseva A.L. i dr. Chuvstvitel'nost', spetsifichnost' i prognosticheskaia znachimost' statokoordinatornykh i statokineticheskikh testov v obsledovanii patsienta s golovokruzheniem. Omsk. nauch. vestn. 2014; 2 (134): 84–7. [in Russian]
2. Leigh RJ, Zee DS. The Neurology of Eye Movements. London: Oxford University Press, 2006.
3. Curthoys I.S. Generation of the quick phase of horizontal vestibular nystagmus. Exp Brain Res 2002; 143 (4): 397–405.
4. Brandt T, Strupp M. General vestibular testing. Clin Neurophysiol 2005; 116 (2): 406–26.
5. Herr RD, Zun L, Mattews JJ. A directed approach to the dizzy patient. Ann Emerg Med 1989; 18: 664–72.
6. Frenzel H. Practical methods of a systematic study of otorhinolaryngology. Munch Med Wochenschr 1956; 98: 972–5.
7. Bronstein A. Oxford Textbook of Vertigo and Imbalance. Barcelona: Oxford University Press, 2013.
9. Lemos J, Eggenberger E. Saccadic intrusions: review and update. Curr Opin Neurol 2013; 26 (1): 59–66.
10. Phillipou A, Rossell SL, Castle DJ et al. Square wave jerks and anxiety as distinctive biomarkers for anorexia nervosa. Invest Ophthalmol Vis Sci 2014; 55 (12): 8366–70.
11. Alexander G. Die Ohrenkrankheitenim Kindesalter. In: Schlossmann A (ed) Handbuch der Kinderheilkunde. Leipzig: Verlag von F.C.W.Vogel, 1912.
12. Strupp M, Hufner K, Sandmann R et al. Central oculomotor disturbances and nystagmus: a window into the brainstem and cerebellum. Dtsch Arztebl Int 2011; 108: 197–204.
13. Marti S, Straumann D, Glasauer S. The origin of downbeat nystagmus: an asymmetry in the distribution of on-directions of vertical gaze-velocity purkinje cells. Ann N Y Acad Sci. 2005; 1039: 548–53.
14. Brandt T, Dieterich M, Strupp M. Vertigo and dizziness-common complaints. London: Springer, 2013.
15. Kanegaonkar R, Tysome J. Dizziness and Vertigo: An Introduction and Practical Guide. FL: CRC Press, 2014.
16. Willard A, Lueck CJ. Ocular motor disorders. Curr Opin Neurol 2014; 27 (1): 75–82.
17. Versino M, Hurko O, Zee DS. Disorders of binocular control of eye movements in patients with cerebellar dysfunction. Brain 1996; 119 (Pt 6): 1933–50.
18. Yee RD, Purvin VA. Acquired ocular motor apraxia after aortic surgery. Trans Am Ophthalmol Soc 2007; 105: 152–8; discussion 158–9.
19. Ohtsuka K, Enoki T. Transcranial magnetic stimulation over the posterior cerebellum during smooth pursuit eye movements in man. Brain 1998; 121 (Pt 3): 429–35.
20. Antoniades CA, Kennard C. Ocular motor abnormalities in neurodegenerative disorders. Eye (Lond). 2015; 29 (2): 200–7.
21. Weber KP, Aw ST, Todd MJ et al. Head impulse test in unilateral vestibular loss: vestibulo-ocular reflex and catch-up saccades. Neurology 2008; 70 (6): 454–63.
22. Walker MF, Zee DS. Cerebellar disease alters the axis of the high-acceleration vestibuloocular reflex. J Neurophysiol 2005; 94 (5): 3417–29.
23. Longridge NS, Mallinson AI. The dynamic illegible E-test. A technique for assessing the vestibulo-ocular reflex. Acta Otolaryngol 1987; 103 (3–4): 273–9.
24. Vital D, Hegemann SC, Straumann D et al. A new dynamic visual acuity test to assess peripheral vestibular function. Arch Otolaryngol Head Neck Surg 2010; 136 (7): 686–91.
25. Hain TC, Fetter M, Zee DS. Head-shaking nystagmus in patients with unilateral peripheral vestibular lesions. Am J Otolaryngol 1987; 8 (1): 36–47.
26. Minagar A, Sheremata WA, Tusa RJ. Perverted head-shaking nystagmus: a possible mechanism. Neurology 2001; 57 (5): 887–9.
27. Pal'chun V.T., Kunel'skaia N.L., Rotermel' E.V. Diagnostika i lechenie dobrokachestvennogo paroksizmal'nogo pozitsionnogo golovokruzheniia. Vestn. otorinolaringologii. 2007; 1: 4–7. [in Russian]
28. Mel'nikov O.A., Zamergrad M.V. Dobrokachestvennoe pozitsionnoe golovokruzhenie. Lechashchii vrach. 2000; 1: 19–21. [in Russian]
29. Dix MR, Hallpike CS. The pathology, symptomatology and diagnosis of certain common disorders of the vestibular system. Ann Otol Rhinol Laryngol 1952; 61 (4): 987–1016.
30. Pagnini P, Nuti D, Vannucchi P. Benign paroxysmal vertigo of the horizontal canal. ORL J Otorhinolaryngol Relat Spec 1989; 51 (3): 161–70.
31. McClure JA. Horizontal canal BPV. J Otolaryngol 1985; 14 (1): 30–5.
32. Lempert T, Brandt T, Dieterich M, Huppert D. How to identify psychogenic disorders of stance and gait. A video study in 37 patients. J Neurol 1991; 238 (3): 140–6.
33. Pal'chun V.T., Magomedov M.M., Luchikhin L.A. Otorinolaringologiia. M.: GEOTAR-Media, 2008. [in Russian]
34. Nikiforov A.S., Gusev E.I. Obshchaia nevrologiia. M.: GEOTAR-Media, 2007. [in Russian]
35. Cohen HS, Sangi-Haghpeykar H, Ricci NA et al. Utility of Stepping, Walking, and Head Impulses for Screening Patients for Vestibular Impairments. Otolaryngol Head Neck Surg 2014; 151 (1): 131–6.
Авторы
В.Т.Пальчун*, А.Л.Гусева, Ю.В.Левина
ГБОУ ВПО Российский национальный исследовательский медицинский университет им. Н.И.Пирогова Минздрава России. 117997, Россия, Москва, ул. Островитянова, д. 1
*lorrsmu@mail.ru
ГБОУ ВПО Российский национальный исследовательский медицинский университет им. Н.И.Пирогова Минздрава России. 117997, Россия, Москва, ул. Островитянова, д. 1
*lorrsmu@mail.ru
________________________________________________
V.T.Palchun*, A.L.Guseva, Yu.V.Levina
N.I.Pirogov Russian National Research Medical University of the Ministry of Health of the Russian Federation. 117997, Russian Federation, Moscow, ul. Ostrovitianova, d. 1
*lorrsmu@mail.ru
N.I.Pirogov Russian National Research Medical University of the Ministry of Health of the Russian Federation. 117997, Russian Federation, Moscow, ul. Ostrovitianova, d. 1
*lorrsmu@mail.ru
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