2015年12月27日 星期日
2010年10月17日 星期日
衛教:耳石脫落
參考來源:http://www.tchain.com/otoneurology/disorders/bppv/bppv.html
BENIGN PAROXYSMAL POSITIONAL VERTIGO
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Causes 
BPPV is a common cause of dizziness. About 20% of all dizziness is due to BPPV. The older you are, the more likely it is that your dizziness is due to BPPV, as about 50% of all dizziness in older people is due to BPPV. In a recent study, 9% of a group of urban dwelling elders were found to have undiagnosed BPPV (Oghalai, J. S., et al., 2000).
The symptoms of BPPV include dizziness or vertigo, lightheadedness, imbalance, and nausea. Activities which bring on symptoms will vary among persons, but symptoms are almost always precipitated by a change of position of the head with respect to gravity. Getting out of bed or rolling over in bed are common "problem" motions . Because people with BPPV often feel dizzy and unsteady when they tip their heads back to look up, sometimes BPPV is called "top shelf vertigo." Women with BPPV may find that the use of shampoo bowls in beauty parlors brings on symptoms. An intermittent pattern is common. BPPV may be present for a few weeks, then stop, then come back again.
WHAT CAUSES BPPV?
The most common cause of BPPV in people under age 50 is head injury . There is also an association with migraine (Ishiyama et al, 2000). In older people, the most common cause is degeneration of the vestibular system of the inner ear. BPPV becomes much more common with advancing age (Froeling et al, 1991). In half of all cases, BPPV is called "idiopathic," which means it occurs for no known reason. Viruses affecting the ear such as those causing vestibular neuritis , minor strokes such as those involving anterior inferior cerebellar artery (AICA) syndrome", and Meniere's disease are significant but unusual causes. Occasionally BPPV follows surgery, where the cause is felt to be a combination of a prolonged period of supine positioning, or ear trauma when the surgery is to the inner ear (Atacan et al 2001). Other causes of positional symptoms are discussed here.
What doesn't cause BPPV ?
Gacek has suggested that BPPV is due to recurrent neuritis of the inferior vestibular nerve (Gacek and Gacek, 2002). We think that this is highly unlikely as BPPV is very well explained by mechanical consequences of loose debris within the inner ear, and not at all consistent with the usual picture of vestibular neuritis. BPPV is also not caused by psychological distress, and it is not a side effect of medication.
HOW IS THE DIAGNOSIS OF BPPV MADE?
Your physician can make the diagnosis based on your history, findings on physical examination, and the results of vestibular and auditory tests. Often, the diagnosis can be made with history and physical examination. Most other conditions that have positional dizziness get worse on standing rather than lying down (e.g. orthostatic hypotension). Electronystagmography (ENG) testing may be needed to look for the characteristic nystagmus (jumping of the eyes). It has been claimed that BPPV accompanied by unilateral lateral canal paralysis is suggestive of a vascular etiology (Kim et al, 1999). For diagnosis of BPPV with laboratory tests, it is important to have the ENG test done by a laboratory that can measure vertical eye movements. A magnetic resonance imaging (MRI) scan will be performed if a stroke or brain tumor is suspected. A rotatory chair test may be used for difficult diagnostic problems. It is possible but rather uncommon to have BPPV in both ears (bilateral BPPV).
There are some rare conditions that have symptoms that resemble BPPV. Patients with certain types of central vertigo such as the spinocerebellar ataxias may have "bed spins" and prefer to sleep propped up in bed (Jen et al, 1998). These conditions can generally be detected on a careful neurological examination and also are generally accompanied by a family history of other persons with similar symptoms.
HOW MIGHT BPPV AFFECT MY LIFE?
Certain modifications in your daily activities may be necessary to cope with your dizziness. Use two or more pillows at night. Avoid sleeping on the "bad" side. In the morning, get up slowly and sit on the edge of the bed for a minute. Avoid bending down to pick up things, and extending the head, such as to get something out of a cabinet. Be careful when at the dentist's office, the beauty parlor when lying back having ones hair washed, when participating in sports activities and when you are lying flat on your back.
HOW IS BPPV TREATED?
BPPV has often been described as "self-limiting" because symptoms often subside or disappear within six months of onset. Symptoms tend to wax and wane. Motion sickness medications are sometimes helpful in controlling the nausea associated with BPPV but are otherwise rarely beneficial. However, various kinds of physical maneuvers and exercises have proved effective. Three varieties of conservative treatment, which involve exercises, and a treatment that involves surgery are described in the next sections.
OFFICE TREATMENT OF BPPV: The Epley and Semont Maneuvers
The maneuvers, named after their inventors, are both intended to move debris or "ear rocks" out of the sensitive part of the ear (posterior canal) to a less sensitive location. Each maneuver takes about 15 minutes to complete. The Semont maneuver (also called the "liberatory" maneuver) involves a procedure whereby the patient is rapidly moved from lying on one side to lying on the other. It is a brisk maneuver that is not currently favored in the United States.
The Epley maneuver is also called the particle repositioning, canalith repositioning procedure, and modified liberatory maneuver. It is illustrated in figure 2. Click here for an animation. It involves sequential movement of the head into four positions, staying in each position for roughly 30 seconds. The recurrence rate for BPPV after these maneuvers is about 30 percent at one year, and in some instances a second treatment may be necessary. While some authors advocate use of vibration in the Epley maneuver, we have not found this useful in a study of our patients (Hain et al, 2000). Some authors also suggest leaving out some of the positions in the Epley maneuver, especially position 'D'. We suggest that you avoid therapy using this methodology.
After either of these maneuvers, you should be prepared to follow the instructions below, which are aimed at reducing the chance that debris might fall back into the sensitive back part of the ear.
INSTRUCTIONS FOR PATIENTS AFTER OFFICE TREATMENTS (Epley or Semont maneuvers)
1. Wait for 10 minutes after the maneuver is performed before going home. This is to avoid "quick spins," or brief bursts of vertigo as debris repositions itself immediately after the maneuver. Don't drive yourself home.
3. For at least one week, avoid provoking head positions that might bring BPPV on again.
- Use two pillows when you sleep.
- Avoid sleeping on the "bad" side.
- Don't turn your head far up or far down.
Be careful to avoid head-extended position, in which you are lying on your back, especially with your head turned towards the affected side. This means be cautious at the beauty parlor, dentist's office, and while undergoing minor surgery. Try to stay as upright as possible. Exercises for low-back pain should be stopped for a week. No "sit-ups" should be done for at least one week and no "crawl" swimming. (Breast stroke is OK.) Also avoid far head-forward positions such as might occur in certain exercises (i.e. touching the toes). Do not start doing the Brandt-Daroff exercises immediately or 2 days after the Epley or Semont maneuver, unless specifically instructed otherwise by your health care provider.
4. At one week after treatment, put yourself in the position that usually makes you dizzy. Position yourself cautiously and under conditions in which you can't fall or hurt yourself. Let your doctor know how you did.
Comment: Massoud and Ireland (1996) stated that post-treatment instructions were not necessary. While we respect these authors, at this writing (2002), we still feel it best to follow the procedure recommended by Epley.
WHAT IF THE MANEUVERS DON'T WORK?
These maneuvers are effective in about 80% of patients with BPPV (Herdman et al, 1993). If you are among the other 20 percent, your doctor may wish you to proceed with the Brandt-Daroff exercises, as described below. If a maneuver works but symptoms recur or the response is only partial (about 40% of the time according to Smouha, 1997), another trial of the maneuver might be advised. The "habituation" exercises are also sometimes useful in the situation where all other maneuvers (Epley, Semont, Brandt-Daroff) have been tried -- in essence these consist of a more intense and prolonged series of positional exercises. When all maneuvers have been tried, the diagnosis is clear, and symptoms are still intolerable, surgical management (posterior canal plugging) may be offered.
BPPV often recurs. About 1/3 of patients have a recurrence in the first year after treatment, and by five years, about half of all patients have a recurrence (Hain et al, 2000; Nunez et al; 2000). If BPPV recurs, in our practice we usually retreat with one of the maneuvers above, and then follow this with a once/day set of the Brandt-Daroff exercises.
In some persons, the positional vertigo can be eliminated but imbalance persists. In these persons it may be reasonable to undertake a course of generic vestibular rehabilitation, as they may still need to compensate for a changed utricular mass or a component of persistent vertigo caused by cupulolithiasis. Fujino et al (1994) reported conventional rehab has some efficacy, even without specific maneuvers.
HOME TREATMENT OF BPPV:
BRANDT-DAROFF EXERCISES
The Brandt-Daroff Exercises are a method of treating BPPV, usually used when the office treatment fails. They succeed in 95% of cases but are more arduous than the office treatments. These exercises are performed in three sets per day for two weeks. In each set, one performs the maneuver as shown five times.
1 repetition = maneuver done to each side in turn (takes 2 minutes)
| Suggested Schedule for Brandt-Daroff exercises | ||
| Time | Exercise | Duration |
| Morning | 5 repetitions | 10 minutes |
| Noon | 5 repetitions | 10 minutes |
| Evening | 5 repetitions | 10 minutes |
Start sitting upright (position 1). Then move into the side-lying position (position 2), with the head angled upward about halfway. An easy way to remember this is to imagine someone standing about 6 feet in front of you, and just keep looking at their head at all times. Stay in the side-lying position for 30 seconds, or until the dizziness subsides if this is longer, then go back to the sitting position (position 3). Stay there for 30 seconds, and then go to the opposite side (position 4) and follow the same routine..
These exercises should be performed for two weeks, three times per day, or for three weeks, twice per day. This adds up to 52 sets in total. In most persons, complete relief from symptoms is obtained after 30 sets, or about 10 days. In approximately 30 percent of patients, BPPV will recur within one year. If BPPV recurs, you may wish to add one 10-minute exercise to your daily routine (Amin et al, 1999). The Brandt-Daroff exercises as well as the Semont and Epley maneuvers are compared in an article by Brandt (1994), listed in the reference section.
 |
| Home Epley (for the left ear). |
HOME EPLEY MANEUVER
The Epley and/or Semont maneuvers as described above can be done at home (Radke et al, 1999; Furman and Hain, 2004). We often recommend the home-Epley to our patients who have a clear diagnosis. This procedure seems to be even more effective than the in-office procedure, perhaps because it is repeated every night for a week.
The method (for the left side) is performed as shown on the figure to the right. One stays in each of the supine (lying down) positions for 30 seconds, and in the sitting upright position (top) for 1 minute. Thus, once cycle takes 2 1/2 minutes. Typically 3 cycles are performed just prior to going to sleep. It is best to do them at night rather than in the morning or midday, as if one becomes dizzy following the exercises, then it can resolve while one is sleeping. The mirror image of this procedure is used for the right ear.
There are several problems with the "do it yourself" method. If the diagnosis of BPPV has not been confirmed, one may be attempting to treat another condition (such as a brain tumor or stroke) with positional exercises -- this is unlikely to be successful and may delay proper treatment. A second problem is that the home-Epley requires knowledge of the "bad" side. Sometimes this can be tricky to establish. Complications such as conversion to another canal (see below) can occur during the Epley maneuver, which are better handled in a doctor's office than at home. Finally, occasionally during the Epley maneuver neurological symptoms are provoked due to compression of the vertebral arteries. In our opinion, it is safer to have the first Epley performed in a doctors office where appropriate action can be taken in this eventuality.
SURGICAL TREATMENT OF BPPV
If the exercises described above are ineffective in controlling symptoms, symptoms have persisted for a year or longer, and the diagnosis is very clear, a surgical procedure called "posterior canal plugging" may be recommended. Canal plugging blocks most of the posterior canal's function without affecting the functions of the other canals or parts of the ear. This procedure poses a small risk to hearing, but is effective in about 90% of individuals who have had no response to any other treatment. Only about 1 percent of our BPPV patients eventually have this procedure done. Surgery should not be considered until all three maneuvers/exercises (Epley, Semont, and Brandt-Daroff) have been attempted and failed. See the article by Parnes (1990, 1996) in the references for more information.
There are several alternative surgeries. Dr Gacek (Syracuse, New York) has written extensively about singular nerve section. Dr. Anthony (Houston, Texas), advocates laser assisted posterior canal plugging. It seems to us that these procedures, which require unusual amounts of surgical skill, have little advantage over a canal plugging procedure. Of course, it is always advisable when planning surgery to select a surgeon who has had as wide an experience as possible.Complications are rare (Rizvi and Gauthier, 2002)
There are several surgical procedures that we feel are inadvisable for the individual with intractable BPPV. Vestibular nerve section, while effective, eliminates more of the normal vestibular system than is necessary. Labyrinthectomy and sacculotomy are also both generally inappropriate because of reduction or loss of hearing expected with these procedures.
ATYPICAL BPPV
Lateral Canal BPPV, Anterior Canal BPPV, Cupulolithiasis, Vestibulolithiasis, Multicanal patterns
There are several rarer variants of BPPV which may occur spontaneously as well as after the Brandt-Daroff maneuvers or Epley/Semont maneuvers. They are mainly thought to be caused by migration of otoconial debris into canals other than the posterior canal, the anterior or lateral canal. There is presently no data reported as to the frequency and extent of these syndromes following treatment procedures. It is the author's estimate that they occur in roughly 5% of Epley maneuvers and about 10% of the time after the Brandt-Daroff exercises. In nearly all instances, with the exception of cupulolithiasis, these variants of BPPV following maneuvers resolve within a week without any special treatment, but when they do not, there are procedures available to treat them.
In clinical practice, atypical BPPV arising spontaneously is first treated with maneuvers as is typical BPPV, and the special treatments as outlined below are entered into only after treatment failure. When atypical BPPV follows the Epley, Semont or Brandt-Daroff maneuvers, specific exercises are generally begun as soon as the diagnosis is ascertained. In patients in whom the exercise treatment of atypical BPPV fails, especially in situations where onset is spontaneous, additional diagnostic testing such as MRI scanning may be indicated. The reason for this is to look for other types of positional vertigo.
Lateral canal BPPV is the most common atypical BPPV variant, accounting for about 3-9 percent of cases (Korres et al, 2002). Most cases are seen as a consequence of an Epley maneuver. It is diagnosed by a horizontal nystagmus that changes direction according to the ear that is down. More detail about lateral canal BPPV as well as an illustration of a home exercise can be found here.
Anterior canal BPPV is also rare, and a recent study suggested that it accounts for about 2% of cases of BPPV (Korres et al, 2002). It is diagnosed by a positional nystagmus with components of downbeating and torsional movement on taking up the Dix-Hallpike position, or a nystagmus that is upbeating and torsional when sitting up from the Dix-Hallpike. There are a number of different suggestions in the literature about the direction of the torsional quick phase in anterior canal BPPV. In our view, the nystagmus during the Dix-Hallpike to one side is most likely due to excitation of the anterior canal on the opposite side. This should cause downbeating nystagmus as well as torsional nystagmus with a quick-phase towards the disturbed ear. Thus the direction of the torsional component during the down-phase of the Dix-Hallpike tells you which is the bad ear. Anterior canal BPPV can be provoked from the opposite ear to the side of the Dix-Hallpike maneuver -- in other words, if you get dizzy to the right side, the problem ear might be the left. Some authors have suggested that because the anterior canals are oriented so that parts are near the saggital plane, anterior canal BPPV can be provoked with a Dix-Hallpike maneuver to either side as well as in the "head hanging" position (Bertholon et al, 2002). The upbeating nystagmus on sitting may be very persistent as the debris settles on the cupula of the anterior canal. Anterior canal BPPV is probably rare because the anterior canal is normally the highest part of the ear. Debris would naturally tend to fall out of the posterior half of the anterior canal. From the geometry of the ear, it would seem likely that anterior canal BPPV might occasionally result as a complication of the Epley maneuver.
Debris might also be temporarily located in the common crus area, which is the shared canal between the anterior and posterior canal. Should debris be present in the common cruse, one would expect a purely torsional nystagmus. During the down phase of the Dix-Hallpike, the torsional nystagmus should beat away from the bad ear. During the up phase of the Dix-Hallpike, the torsional nystagmus should beat towards the bad ear.
Cupulolithiasis is a condition in which debris is stuck to the cupula of a semicircular canal, rather than being loose within the canal. Cupulolithiasis is not a treatment complication, but rather is part of the spectrum of BPPV. The mechanistic hypothesis is based on pathological findings of deposits on the cupula made by Schuknecht and Ruby in three patients who had BPPV during their lives (Schuknecht 1969; Schuknecht et al. 1973). Moriarty and colleagues found similar deposits in 28% of 566 temporal bones (Moriarty et al. 1992). Schuknecht pointed out that cupulolithiasis hypothesis fails to explain the usual characteristic latency and burst pattern of BPPV nystagmus as well as remissions (Schuknecht et al. 1973). Rather, cupulolithiasis should result in a constant nystagmus. This pattern is sometimes seen (Smouha et al. 1995). Cupulolithiasis might theoretically occur in any canal -- horizontal, anterior or vertical, each of which might have it's own pattern of positional nystagmus. Some authors hold that both the cupulolithiasis and canalithiasis hypotheses may be correct (Brandt et al. 1994). If cupulolithiasis is suspected, it seems logical to treat with either the Epley with vibration, or alternatively, use the Semont maneuver. There are no studies of cupulolithiasis to indicate which strategy is the most effective.
Vestibulolithiasis is a hypothetical condition in which debris is present on the vestibule-side of the cupula, rather than being on the canal side. For this theory, there is loose debris, close to but unattached to the cupula of the posterior canal, possibly in the vestibule or short arm of the semicircular canal. Pathologic studies of BPPV have found roughly equal amounts of fixed debris on either side of the cupula (Moriarty et al. 1992), suggesting that loose debris might also be found on either side. For the vestibulolithiasis mechanism, when the head is moved, stones or other debris might shift from vestibule to ampulla, or within the ampulla, impacting the cupula. This mechanism would be expected to resemble cupulolithiasis, having a persistent nystagmus, but with intermittency because the debris is movable. Very little data is available as to the frequency of this pattern, and no data is available regarding treatment.
Multicanal patterns. If debris can get into one canal, why shouldn't it be able to get into more than one ? It is common to find small amounts of horizontal nystagmus or contralateral downbeating nystagmus in a person with classic posterior canal BPPV. While other explanations are possible, the most likely one is that there is debris in multiple canals.
WHERE ARE BPPV EVALUATIONS AND TREATMENTS DONE?
The Vestibular Disorders Association (VEDA) maintains a large and comprehensive list of doctors who have indicated a proficiency in treating BPPV. Please contact them to find a local treating doctor.
MORE INFORMATION
Literature-and DVDs
- DVD illustrating Brandt-Daroff, Home-Epley and log roll
- VEDA has recently published a patient-oriented book on BPPV.
REFERENCES CONCERNING BPPV:
Click here for very recent, but possibly less relevant references.
Published literature referred to above:
- Amin M, Giradi M, Neill M, Hughes LF, Konrad H. Effects of exercise on prevention of recurrence of BPPV symptoms. ARO abstracts, 1999, #774
- ATACAN E, Sennaroglu L, Genc A, Kaya S. Benign paroxysmal positional vertigo after stapedectomy. Laryngoscope 2001; 111: 1257-9.
- Bertholon, P., A. M. Bronstein, et al. (2002). "Positional down beating nystagmus in 50 patients: cerebellar disorders and possible anterior semicircular canalithiasis." J Neurol Neurosurg Psychiatry 72(3): 366-72.
- Brandt T, Daroff RB. Physical therapy for benign paroxysmal positional vertigo. Arch Otolaryngol 1980 Aug;106(8):484-485.
- Brandt T, Steddin S, Daroff RB. Therapy for benign paroxysmal positioning vertigo, revisited. Neurology 1994 May;44(5):796-800.
- Buckingham RA. Anatomical and theoretical observations on otolith repositioning for benign paroxysmal positional vertigo. Laryngoscope 109:717-722, 1999
- Epley JM. The canalith repositioning procedure: For treatment of benign paroxysmal positional vertigo. Otolaryngol Head Neck Surg 1992 Sep;107(3):399-404.
- Fife TD. Recognition and management of horizontal canal benign positional vertigo. Am J Otol 1998 May;19(3):345-351.
- Fujino A and others. Vestibular training for benign paroxysmal positional vertigo. Arch Otolaryngol HNS 1994:120:497-504.
- Froehling DA, Silverstein MD, Mohr DN, Beatty CW, Offord KP, Ballard DJ. Benign positional vertigo: incidence and prognosis in a population-based study in Olmsted County, Minnesota. Mayo Clin Proc 1991 Jun;66(6):596-601.
- Gacek RR. Technique and results of singular neurectomy for the management of benign parodxysmal positional vertigo.l Acta Oto-laryngologica 1995 115(2) 154-7
- Gacek RR, Gacek MR. The three faces of vestibular ganglionitis. Ann ORL 111:2002, 103-113
- Hain TC, Helminski JO, Reis I, Uddin M. Vibration does not improve results of the canalith repositioning maneuver. Arch Oto HNS, May 2000:126:617-622
- Harvey SA, Hain TC, Adamiec LC. Modified liberatory maneuver: effective treatment for benign paroxysmal positional vertigo. Laryngoscope 1994 Oct;104(10):1206-1212.
- Herdman SJ. Treatment of benign paroxysmal vertigo. Phys Ther 1990 Jun;70(6):381-388.
- Herdman SJ, Tusa RJ, Zee DS, Proctor LR, Mattox DE. Single treatment approaches to benign paroxysmal positional vertigo. Arch Otolaryngol Head Neck Surg 1993 Apr;119(4):450-454.
- Ishiyama A, Jacobson KM, Baloh RW. Migraine and benign positional vertigo. Ann Otol Rhinol Laryngol. 2000;109:377-380
- Jen JC and others. Spinocerebellar ataxia type 6 with positional vertigo and acetazolamide responsive episodic ataxia. J. Neuro Neurosurg Psych 1998:65:565-568
- Korres S and others. Occurrence of semicircular canal involvement in Benign Paroxysmal Positional Vertigo. Otol Neurotol 23:926-932, 2002
- Lanska DJ, Remler B. Benign paroxysmal positioning vertigo: classic descriptions, origins of the provocative positioning technique, and conceptual developments. Neurology 1997 May;48(5):1167-1177.
- Lempert T, Wolsley C, Davies R, Gresty MA, Bronstein AM. Three hundred sixty-degree rotation of the posterior semicircular canal for treatment of benign positional vertigo: a placebo-controlled trial. Neurology 1997 Sep;49(3):729-733.
- Lim DJ (1984). The development and structure of otoconia. In: I Friedman, J Ballantyne (eds). Ultrastructural Atlas of the Inner Ear. London: Butterworth, pp 245-269.
- Massoud EA, Ireland DJ. Post-treatment instructions in the nonsurgical management of benign paroxysmal positional vertigo. J. Otolarynglogy 25(2):121-5, 1996
- Moriarty, B., et al. (1992). "The incidence and distribution of cupular deposits in the labyrinth." Laryngoscope 102(1): 56-9.
- Nunez RA, Cass SP, Furman JM. Short and long-term outcomes of canalith repositioning for benign paryxosmal positional vertigo. Otol HNS, May 2000:122:647-52
- Oghalai, J. S., et al. (2000). "Unrecognized benign paroxysmal positional vertigo in elderly patients." Otolaryngol Head Neck Surg 122(5): 630-4.
- Parnes LS, McClure JA. Posterior semicircular canal occlusion for intractable benign paroxysmal positional vertigo. Ann Otol Rhinol Laryngol 1990 May;99(5 Pt 1):330-334.
- Parnes LS. Update on posterior canal occlusion for benign paroxysmal positional vertigo. Otolaryngol Clin North Am 1996 Apr;29(2):333-342.
- Parnes LS, Price-Jones RG. Particle repositioning maneuver for benign paroxysmal positional vertigo. Ann Otol Rhinol Laryngol 1993 May;102(5):325-331.
- Radtke, A., et al. (1999). "A modified Epley's procedure for self-treatment of benign paroxysmal positional vertigo." Neurology 53(6): 1358-60.
- Rizvi SS, Gauthier MG. Unexpected complication of posterior canal occlusion surgery for benign paroxysmal positional vertigo. Otol and Neurotol 23:938-940, 2002
- Schuknecht, H. F. (1969). "Cupulolithiasis." Arch Otolaryngol 90(6): 765-78.
- Schuknecht, H. F., et al. (1973). "Cupulolithiasis." Adv Otorhinolaryngol 20: 434-43.
- Semont A, Freyss G, Vitte E. Curing the BPPV with a liberatory maneuver. Adv Otorhinolaryngol 1988;42:290-293.
- Smouha EE. Time course of recovery after Epley maneuvers for benign paroxysmal positional vertigo. Laryngoscope 1997 107(2) 187-91
- Welling DB, Barnes DE. Particle Repositioning maneuver for benign paroxysmal positional vertigo. Laryngoscope 1994 Aug;104(8 Pt 1):946-949.
(c) 1997-2005 Timothy C. Hain, thain@dizziness-and-balance.com
2009年5月11日 星期一
頭暈及眩暈
頭暈及眩暈
『頭暈』係指頭昏昏、腦重重、眼花繚亂的、尚不致天眩地轉，大多是內科之疾病所致。而『眩暈』係天眩地轉的，病人感覺周圍環境在轉動，併有噁心、嘔吐，這大多是內耳前庭病變所致。人體的平衡，主要由三個系統來維持；分別是視覺、本體感覺及內耳前庭（見附圖）。例如，我們將頭轉向右邊，右耳內耳前庭之水平半規管會興奮電位，而左側則相對減低電位，因之產生前庭眼反射反應。加之視覺訊息及頸部本體感覺之變化，人自出生以來，這三個系統互動之關係便一直被整合儲存在左腦幹之資料中心；因之人會逐漸調適各種平衡動作。當這三個系統有『不協調』時，便會產生頭暈及眩暈。舉例說明老年人易於頭暈；首先，其視力減退，神經退化（包括前庭神經），致前庭眼反射不良；頸部脊關節退化性骨刺，致腦內血液循環不良。若再加上高血壓、糖尿病等，病人自然整日多頭昏腦脹的。臨床上，若是眩暉併有噁心、嘔吐者，大多是周邊前庭系統病變。但若只是頭昏、眼花繚亂不併有噁心、嘔吐時，則多為全身系統性的內科疾病所致。另外，焦慮及憂鬱等身心症病人亦常抱怨整天頭昏腦重的。
1. 心臟血管疾病： 如心臟瓣膜疾病、心律不整、糖尿病等均使血液循環不良，易致腦部缺血而頭暈。在姿
態性低血壓方面，老年人約２０％其血管交感神經較弱，不易維持血管之正常壓力。若
再加上體質不佳，如：咳嗽及大便時使胸壓上升，致血液回流欠佳。或太熱天洗熱水
澡、運動、小便時會使血管擴張。又如四肢麻痺或靜脈屈張時使血液回流不良。而老年
人其頸動脈竇因血管硬化後變的較敏感，當其突然轉頭或打緊領帶、刮鬍鬚時，便會使
心跳減慢、血流不良。以上情形均會使腦部缺血缺氧，因之頭暈，甚至喪失意識而暈
厥。另外有些藥物亦可致姿態性低血壓而頭暈，如利尿劑、抗憂鬱藥、鎮定劑、鴉片
劑、巴金森疾病用藥等。
2. 血液疾病：
如貧血、紅血球過多症。
3. 內分泌疾病：
臨床上有些病症會致低血糖而頭暈。如：胰島素腫瘤、腦下垂體功能低下、腎上腺功能
低下、酒精性肝硬化等。
利尿劑及降血壓藥均可使血壓過低而頭暈。貝他-阻斷器用藥會使心臟血液輸出量降低而
頭暈。毛地黃及抗憂鬱藥可致心律不整而頭暈。鎮劑使用不當而頭暈。降血糖用藥不慎
致血糖過低而頭暈。長期使用止痛劑會傷胃腸。因之慢性胃出血而貧血頭暈。
又稱『內耳積水』。反覆發作之眩暈，併有單側耳鳴、耳悶塞感及聽力障礙。病人常先
感到耳悶塞，耳鳴聲變大時，隨即眩暈發作併有噁心、嘔吐。其發作是來的快，去的也
快。約耗時數分鐘至二十四小時內。其病理原因是內耳積水。治療方式參考『美尼爾氏
症』專文。
2. 反覆型前庭病變：
又稱『內耳不平衡』。亦有人以為是前庭性美尼爾氏症。其反覆眩暈、噁心、嘔吐發 3. 前庭神經炎：
作，但並無耳鳴、耳悶塞感及聽力減損之症狀。經長期觀察，這種病人約只有１０％至 ２０％會發展成典型之美尼爾氏症。其病理原因是前庭神經病毒感染、潛藏之後，反覆
發作的。治療方法相似於美尼爾氏症。
病人生平第一次突發眩暈，並無耳鳴、聽障及其他神經症狀。眩暈時併有噁心、嘔吐及
走路不穩，大約經過一週之後，病人才會覺得穩定。要到完全復原則須時數週。治療方
式為臥床靜養、抗暈藥等保守療法即可。病人發作前常先有一上呼吸道感染，而後，併
發前庭神經炎。大多病人不會復發，只有少數會再復發，即會變成反覆型前庭病變。
4. 突發性耳聾：
病人常在一夜之間，早上起床後，便覺得單側聽力減損；有時併有耳鳴及眩暈。若不予
以治療，於二週內，約有一半病人會自行復原。但醫界仍以為要把握病發之初期兩週內
，予以積極治療，以便提高治癒率。其病因主要為內耳病毒感染及內耳血液循環障礙。
治療方針主要是予以短期大量類固醇及二氧化碳混合氧氣之治療。一般若聽力減損
在90分貝以內者癒後良好，反之則不好。這種病人要排除聽神經瘤的可能。另外少數會
有復發之現象。有些則以後會併有眩暈而變成美尼爾氏症。
病人常是起床時，頭部感到一陣眩暈，若頭暫不動休息一下，則馬上又恢復。其發作時
間只是數秒鐘，且不會有噁心、嘔吐或耳鳴，聽障等症狀。其可能原因為頭部外傷及年
齡老化。一般病人在一年內會痊癒，這期間只須予以頭頸部之眩暈復健運動。少數病人 症狀持續超過一年時，便形成慢性；這時便可考慮手術。
6. 耳帶狀 疹：
病人常在上呼吸道感染後，會感到耳痛及外耳部分有水泡及結痂。而復常併有顏面神經
麻痺或眩暈之症狀。極少數會併有其他第五、六、九、十的腦神經症狀。此種眩暈症狀
可持續數日，有點像前庭神經炎之病程，只須休息及症狀治療。而顏面神經麻痺之恢復
率約只有６０％～７０％，治療上可考慮類固醇及Acyclovir。
a. 病毒性內耳炎：
流行性腮腺炎、痳疹、單純性 疹和帶狀 疹等可能侵犯內耳而產生較輕微之聽障及
眩暈。
b. ‚化膿性內耳迷路炎：
會造成嚴重聽障及眩暈、噁心、嘔吐。如腦膜炎患者，因腦脊髓液和外淋巴液有交
通，故可因之引起內耳炎，這是引起後天性聽障之主因。必須針對病原菌扱以抗生
素。
ƒ c. 內耳瘻管：
中耳炎膽脂瘤可併發內耳瘻管，可因之造成漿液性內耳迷路炎而眩暈。有時外耳道稍
有壓力刺激（如風吹進耳道），即可能致眩暈。必須作中耳炎手術。
係由前庭神經長出神經鞘瘤。初期的症狀為單側耳鳴併有漸進性聽障。約有一半病人會
併有眩暈及平衡失調。其他症狀可為頭痛、顏面神經障礙、顏面麻木、小腦症狀及第
九、十等腦神經症狀。須予以手術治療。
a. 顳骨骨折：
病人有頭部外傷、昏迷、及外耳道出血之症狀。易併有顏面神經麻痺及聽障、眩暈之症
狀，甚至會有腦脊髓液漏。顏面神經麻痺可以是立即型者、預後不良，須考慮手術。反
之為遲緩型者，預後良好，觀察數週即可痊癒。腦脊髓液漏則予以臥床休養一至二週，
大多可自行癒痊。聽障則須評估是為中耳亦或內耳之病變，是否須要手術。而眩暈則以
休養及藥物治療為主。
‚ b. 內耳迷路振盪：
頭部外傷並無骨折時，經過數日或數週之後，可發生耳鳴、眩暈及高頻聽障的症狀。治
療方法以靜養及藥物為主。
三、腦中樞疾病之眩暈：
a. 椎基底動脈供血不足症：
造成腦幹前庭神經核之缺血而致頭暈及眩暈，較少出現耳鳴及聽障。同時亦伴有手腳麻
木，顏面麻木、吞嚥困難及複視、頭痛等症狀。
病人突發眩暈、嘔吐，且站立不穩等。
ƒ c. 偏頭痛，病人流淚、眼花、頭痛發作時，可以併有眩暈之症狀。有些則是頭痛發作過
後，才有眩暈。
2. 多發性硬化症：
西方人較常見。乃腦神經元隨處任意地退化，造成多發的神經症狀。病人亦會有頭暈及
眩暈。
腦幹腫瘤，小腦橋腦腳之聽神經瘤，小腦腫瘤均可致頭暈及眩暈。
細菌性腦膜炎可影響前庭神經。中耳炎併有顱內感染時，可因之造成腦膜炎及腦膿瘍。
腦基底病變致協調動作受損，會有頭暈，走路不穩，身體姿態不穩等。
可致走路不穩、眩暈及眼振等。通常其平衡失調之動作是持續性的，不像周邊前庭病變
所致的只是陣發性質。
2009年5月10日 星期日
現代人文明病-眩暈
現代人的文明病---眩暈症
From : 馬偕醫院耳鼻喉科
林鴻清醫師
林鴻清醫師
頭暈及眩暈是現代人常見的困惱 。這二者不太一樣 ，頭暈時人是感覺頭昏昏、腦重重 ；而眩暈時人會天眩地轉的 ，有如世界末日。 就好發族群來看，20-60歲是常見的病人； 其中女性多於男性 。致於其可能的原因主要有三大類：分別是內科疾病的頭昏 ，內耳前庭神經性眩暈 ，及腦中樞疾病之眩暈。由於原因的確定是治療的關鍵 ，故本文有較大篇幅介紹頭暈及眩暈的原因。 最後 在文章的後半 ，對於眩暈的治療及預防原則，會予以詳述。
II. 頭暈及眩暈的機轉
『頭暈』係指頭昏昏、腦重重、眼花繚亂的、尚不致天眩地轉，大多是內科之疾病所致。而『眩暈』係天眩地轉的，病人感覺周圍環境在轉動，併有噁心、嘔吐，這大多是內耳前庭病變所致。人體的平衡，主要由三個系統來維持；分別是視覺、本體感覺及內耳前庭（見附圖）。人自出生以來，這三個系統互動之關係便一直被整合儲存在腦幹之資料中心；因之人會逐漸調適各種平衡動作。當這三個系統有『不協調』時，便會產生頭暈及眩暈。舉例說明老年人易於頭暈；首先，其視力減退，神經退化（包括前庭神經）；頸部脊關節退化性骨刺，致腦內血液循環不良。若再加上高血壓、糖尿病等，病人自然整日頭昏腦脹的。臨床上，若是眩暈併有噁心、嘔吐者，大多是內耳前庭系統病變。但若只是頭昏、眼花繚亂不併有噁心、嘔吐時，則多為全身系統性的內科疾病所致。當然頭暈及眩暈的症狀之外若併有腦神經的症狀時， 則要考慮腦中樞疾病。另外， 焦慮及憂鬱等身心症病人亦常抱怨整天頭昏腦重的。更年期的婦女也常有頭暈的困惱
III. 好發族群
30-70歲之間是常見的病人 ； 其中女性多於男性 ( 2:1), 具有眩暈家族遺傳體質的人也較易患病。
IV. 常見的原因 (分為三大類)
一、內科疾病的頭昏：
1. 心臟血管疾病：
(1) 心臟瓣膜疾病、心律不整、高血壓、糖尿病等均使血液循環不良，易致腦部缺
血而頭暈。
(2) 姿態性低血壓：老年人約20％其血管交感神經較弱，不易維持血管之正常壓
力。若再加上體質不佳。如：咳嗽及大便時使胸壓上升，致血液回流欠佳。
或大熱天洗熱水澡、運動、小便時會使血管擴張 導致缺血缺氧而頭暈。 2. 血液疾病及代謝疾病：
(1)貧血會使血液循環不良。
(2)膽固醇及血脂肪過高時 也會導致頭暈及頸部酸痛
3. 內分泌疾病：
(1)糖尿病會致血糖過低或過高時
(2)甲狀腺功能失調
(3)更年期症候群
4. 藥物副作用致頭暈：
(1)利尿劑及降血壓藥使用不當時， 均可使血壓過低而頭暈。
(2)毛地黃及抗憂鬱藥可致心律不整而頭暈。
(3)鎮定劑使用不當會頭暈。
(4)降血糖用藥不慎，致血糖過低時會有頭暈的症狀。
(5)長期使用止痛劑會傷胃腸。因之慢性胃出血， 可導致貧血頭暈。
5. 身心症：女性較多見，尤其是更年期的婦女， 長時間的焦慮 、失眠及憂鬱等 ，
也常常抱怨頭暈。
二、內耳前庭神經性眩暈：
1. 美尼爾氏症：
又稱『內耳積水』。反覆發作之眩暈，併有單側耳鳴、耳悶塞感及聽力障礙。
病人常先感到耳悶塞，耳鳴聲變大時，隨即眩暈發作併有噁心、嘔吐。其發作是
來的快，去的也快。約耗時數分鐘至二十四小時內。其病理原因是內耳積水。 2. 反覆型前庭病變：
又稱『內耳不平衡』。亦有人以為是前庭性美尼爾氏症。其反覆眩暈、噁心、嘔
吐發作，但並無耳鳴、耳悶塞感及聽力減損之症狀。經長期觀察，這種病人約只
有１０％至２０％會發展成典型之美尼爾氏症。其病理原因是前庭神經病毒感染
、潛藏之後，反覆發作的。
3. 良性姿態性偶發性眩暈：
病人常是起床時，頭部感到一陣眩暈，若頭暫不動休息一下，則馬上又恢復。其
發作時間只是數秒鐘，且不會有噁心、嘔吐或耳鳴，聽障等症狀。一般病人在一
年內會痊癒，這期間只須予以頭頸部之眩暈復健運動。
4. 前庭神經炎：
病人發作前常先有一上呼吸道感染，生平第一次突發眩暈，並無耳鳴、聽障及其
他神經症狀。眩暈時併有噁心、嘔吐及走路不穩，大約經過一週之後，病人才會
覺得穩定。要到完全復原則須時數週。
5. 突發性耳聾：
病人常在一夜之間，早上起床後，便覺得單側聽力減損；有時併有耳鳴及眩暈。
若不予以治療，於二週內，約有一半病人會自行復原。但醫界仍以為要把握病發
之初期兩週內，予以積極治療，以便提高治癒率。
6. 內耳炎：
流行性腮腺炎、痳疹、單純性 疹和帶狀 疹等可能侵犯內耳而產生較輕微之聽
障及眩暈。
7. 聽神經瘤：
初期的症狀為單側耳鳴併有漸進性聽障。約有一半病人會併有眩暈及平衡失調。
8. 頭部外傷：
內耳迷路振盪：頭部外傷並無骨折時，經過數日或數週之後，可發生耳鳴、眩暈
及高頻聽障的症狀。治療方法以靜養及藥物為主。
三、腦中樞疾病之眩暈：
1. 腦血管疾病：
a. 椎基底動脈供血不足症：造成腦幹前庭神經核之缺血而致頭暈及眩暈，較少出
現耳鳴及聽障。同時亦可能伴有手腳麻木，顏面麻木、吞嚥困難及複視、頭痛
等症狀。‚
b. 腦幹及小腦出血：病人突發眩暈、嘔吐，且站立不穩等。ƒ
c. 偏頭痛：病人流淚、眼花、頭痛發作時，可以併有眩暈之症狀。
2. 多發性硬化症：
西方人較常見。乃腦神經元隨處任意地退化，造成多發的神經症狀。病人亦會有
頭暈及眩暈。
3. 腦瘤：腦幹腫瘤，小腦橋腦腳之聽神經瘤，小腦腫瘤均可致頭暈及眩暈。
4. 腦內感染：細菌性腦膜炎可影響前庭神經。
5. 巴金森氏疾病：
腦基底病變致協調動作受損，會有頭暈，走路不穩，身體姿態不穩等。
6. 小腦疾病：
可致走路不穩、眩暈及眼振等。通常其平衡失調之動作是持續的，不像內耳前庭
病變所致的只是陣發性質。
IV. 治療及預防
治療之目標可分為四大項。
1. 確定造成頭暈及眩暈之原因
例如若是內科疾病所致，即應針對糖尿病、高血壓、及貧血等因素治療。 當然，
若是腦中樞疾病的因素更須即早確認。最後剩餘下來要考量的，便是內耳前庭的
問題。
2. 眩暈發作急性期之症狀治療
較常使用者為抗組織垵，如Meclizine及Cinnarizine等。
3. 刺激腦平衡中樞的代償
若是單側內耳前庭功能突然失調時 (例如，前庭神經炎)，人的腦中樞會逐漸代
償，故病人宜做復健體操，儘早恢復日常生活，不宜終日臥床。
4. 預防
(1)飲食：咖啡、濃茶、煙、酒、巧克力及太鹹食物均須避免。
(2)生活：宜避免工作壓力及睡眠不足等。
(3)藥物：主要是血管擴張(如Betahistine)及利尿劑，一般建議要服藥三個月才可達
預防之效。
(4)手術：內耳不平衡之病例90%經由飲食、生活及藥物之三要素，即可控制良好
，唯少數人才須考慮做內耳之眩暈手術。
(5)復健：以良性姿態性偶發性眩暈及視覺性眩暈最為有效。
V. 結語
眩暈頭暈是一種症狀，必須先正確診斷原因。頭暈大多是內科疾病所致，眩暈則多數是內耳不平衡的因素。至於腦中樞疾病所致的頭暈、眩暈則較常出現於具高血壓 糖尿病之老年病人，且常併有手腳麻、 臉麻、嘴角歪等症狀。大多之眩暈病人可經由飲食、生活及藥物三方面配合達到良好的控制，能使生活趨於正常。
2009年4月26日 星期日
耳石脫落症 (個案 紀牧師娘經驗分享)
< 個案 紀牧師娘 親身經驗分享 > 本文轉貼自筆者BLOG
四月19日清晨醒來，睜開眼睛剎那間，天花板不斷旋轉，我不敢隨即起床，閉上眼睛等候片刻之後，
我再睜開。感謝主，比之前好些了，我才試著坐起來，幾分鐘後就跟平常一樣作息。
隔天20日也一樣暈眩，但是沒有昨天那麼嚴重。剛好我們有事到馬偕醫院，
跟院牧部主任韋牧師一同探望了，住院中的幾位牧者朋友。
在其間談起暈眩的事，韋牧師好意為我加掛林鴻清醫師的耳鼻喉科，經診斷結果；
我再次得了「良性陣發性頭位眩暈症」，也就是「耳石脫落症」。
為什麼說再次呢？林醫師從電腦很快的看了我的求診記錄，沒錯，在2000年的四月25日我曾經來此就診，
病因就是耳石脫落症。這使我嚇了一跳，原來九年前我求診於同一位醫師。
使我回想起當年接受「耳石復位術」的治療過程。
當時首先我經過一些檢查後，林醫生才作如此診斷。然而這次林醫生聽完我的暈眩敘述，
一下子就作這樣的判斷，上回是右耳，這次是左耳，並非右耳復發。
林醫師已經是非常有經驗的醫師，詢問結果，他在馬偕工作已有21年之久。
在等候就診的時候，坐在鄰座的一位女士，她就是經人介紹前來求醫的呢！
可見林醫師在耳鼻喉科有好名聲。
所謂「耳石復位術」治療，操作過程；我坐在醫療床上，兩腳伸直，林醫師將我的頭轉到左邊，
然後一聲「Go！」讓我躺下，要我張開眼睛直視，從眼睛就可偵查出，我有此症狀。
然後要我向右邊側躺，動作伶俐，使力的把我的頭轉向右方，也就是讓頭向下，
接著在左耳後方輕輕敲打好幾下，然後扶我坐正，如開始的時候。
如此連續作兩次，約耗時十分鐘，治療就結束。
九年前，當我作此治療時，心中很不以為然，心想老遠跑來醫院，等候半天，作那幾個動作，
沒幾分鐘就結束，真的有效嗎？半信半疑，但是尊重專業，我一共去了三回，果真無藥而癒。
林醫師給我看了一篇他在馬偕院訊發表的文章；眩暈可以治癒嗎？
從文中瞭解此種症狀，發作後幾個月內通常可以自行恢復的。
但有過暈眩的人，就知道暈眩是多麼不舒服的感受。
然而作「耳石復位術」治療，只要一兩個禮拜就可以痊癒，何樂而不為呢！
紀牧師娘 筆
原文連結： http://www.wretch.cc/blog/pearlchi/14823709
2009年3月19日 星期四
從「良性陣發性頭位眩暈症」談起
病例一
三十歲男性，最近有頭部外傷後，在開車中，頭部突然看左右後視鏡時，會有眩暈之情形。
病例二
六十五歲女性，並無頭部外傷，為有高血壓及高血脂症，最近在床上翻身轉頭時，即會造成頭暈目眩。
臨床症狀
以上二病例，係較典型之「良性陣發性頭位眩暈」，亦有人稱為「良性陣發性姿勢性頭位眩暈」。病人常是起床時，頭部感到一陣眩暈，若頭暫不動休息一下，則馬上又恢復。其發作時間只是數秒鐘，且不會有噁心、嘔吐或耳鳴、聽障等症狀。亦即，「良性陣發性頭位眩暈症」有一特點就是耳向下轉到一定角度約幾秒以後會產生回轉性眩暈，但反覆轉動，眩暈感會消失，且不是每次都會誘發。如果每次頭動就暈，且持續不停的暈，可能是腦室腫瘤或小腦正中部出血，此謂之惡性頭位眩暈症。
發生率
此病約佔眩暈門診病人約10~20%，亦即幾乎是眩暈原因中最常見的一種。
病因
目前最常見的理論認為是，鬆動的耳石從橢圓囊掉落到後半規管壺腹刺激壺腹鼎(capula)而造成眩暈，即耳管石沉澱現象(canalo-
lithiasis)。至於造成耳石脫落原因為何？大部分病例是不明原因的，可找出最常見的原因是頭部外傷，其他的原因包括中耳手術後、慢性中耳炎、膽脂瘤、耳硬化症、前庭神經炎、病毒性迷路炎、心血管危險因子及內耳前庭老年性退化變性等。至於在不明原因的病例中，我門的研究顯示，約有三分之ㄧ係為大於六十歲的老人，故推測和內耳前庭老化有關。
耳石復位術的理論及應用
一九九二年，Parnes及McClure在良性陣發性姿勢性眩暈的人接受手術時發現在後半規管淋巴內有自由漂浮的粒子，首次證實管耳石沉澱現象的理論。一九九二年，Epley報告對三十位以Hallpike氏檢查已發典型迴旋向地性眼振的良性陣發性姿勢性眩暈的病人，以耳石復位法(canalith repositioning procedure, CRP)治療，結果三十位病人均獲得明顯改善。故自此一學界注意到，耳石復位術對此種病人具有療效。
臨床療效及經驗
本院耳鼻喉科，自一九九六年開始根據Epley的方法，對此種病人施行耳石復位術。一年間共施行六十位病人，約有98%病人在一週內
，眩暈有明顯改善，且均感滿意。追蹤一年，其復發之機率約在7%左右。這些成果資料和國外相似。在實際的「耳石復位術」操作，每位病人約耗時十分鐘。
預防
接受耳石復位術治療後的病人，在之後四十八小時內，頭部不宜做急遽轉動，如低頭穿鞋子，及洗臉等。
結語
雖然「良性陣發性姿勢性眩暈」在發作後「數個月」內通常會自行恢復正常，然而「耳石復位法」是一種簡單、安全、有效的治療方法，病人大部分在治療後一至二週內即治癒，可使病人於短時間內就能免除眩暈。故適合作為治療良性陣發性姿勢性眩暈的第一線選擇。
三十歲男性，最近有頭部外傷後，在開車中，頭部突然看左右後視鏡時，會有眩暈之情形。
病例二
六十五歲女性，並無頭部外傷，為有高血壓及高血脂症，最近在床上翻身轉頭時，即會造成頭暈目眩。
臨床症狀
以上二病例，係較典型之「良性陣發性頭位眩暈」，亦有人稱為「良性陣發性姿勢性頭位眩暈」。病人常是起床時，頭部感到一陣眩暈，若頭暫不動休息一下，則馬上又恢復。其發作時間只是數秒鐘，且不會有噁心、嘔吐或耳鳴、聽障等症狀。亦即，「良性陣發性頭位眩暈症」有一特點就是耳向下轉到一定角度約幾秒以後會產生回轉性眩暈，但反覆轉動，眩暈感會消失，且不是每次都會誘發。如果每次頭動就暈，且持續不停的暈，可能是腦室腫瘤或小腦正中部出血，此謂之惡性頭位眩暈症。
發生率
此病約佔眩暈門診病人約10~20%，亦即幾乎是眩暈原因中最常見的一種。
病因
目前最常見的理論認為是，鬆動的耳石從橢圓囊掉落到後半規管壺腹刺激壺腹鼎(capula)而造成眩暈，即耳管石沉澱現象(canalo-
lithiasis)。至於造成耳石脫落原因為何？大部分病例是不明原因的，可找出最常見的原因是頭部外傷，其他的原因包括中耳手術後、慢性中耳炎、膽脂瘤、耳硬化症、前庭神經炎、病毒性迷路炎、心血管危險因子及內耳前庭老年性退化變性等。至於在不明原因的病例中，我門的研究顯示，約有三分之ㄧ係為大於六十歲的老人，故推測和內耳前庭老化有關。
耳石復位術的理論及應用
一九九二年，Parnes及McClure在良性陣發性姿勢性眩暈的人接受手術時發現在後半規管淋巴內有自由漂浮的粒子，首次證實管耳石沉澱現象的理論。一九九二年，Epley報告對三十位以Hallpike氏檢查已發典型迴旋向地性眼振的良性陣發性姿勢性眩暈的病人，以耳石復位法(canalith repositioning procedure, CRP)治療，結果三十位病人均獲得明顯改善。故自此一學界注意到，耳石復位術對此種病人具有療效。
臨床療效及經驗
本院耳鼻喉科，自一九九六年開始根據Epley的方法，對此種病人施行耳石復位術。一年間共施行六十位病人，約有98%病人在一週內
，眩暈有明顯改善，且均感滿意。追蹤一年，其復發之機率約在7%左右。這些成果資料和國外相似。在實際的「耳石復位術」操作，每位病人約耗時十分鐘。
預防
接受耳石復位術治療後的病人，在之後四十八小時內，頭部不宜做急遽轉動，如低頭穿鞋子，及洗臉等。
結語
雖然「良性陣發性姿勢性眩暈」在發作後「數個月」內通常會自行恢復正常，然而「耳石復位法」是一種簡單、安全、有效的治療方法，病人大部分在治療後一至二週內即治癒，可使病人於短時間內就能免除眩暈。故適合作為治療良性陣發性姿勢性眩暈的第一線選擇。
2009年3月16日 星期一
耳石脫落症(個案 姚文琴經驗分享)
< 個案 姚文琴 親身經驗分享>
多年前突然在睡夢中天旋地轉驚醒過來，再躺下又一陣天旋地轉心想我到底怎麼了？
病急就亂投醫，腸胃科看婦科也看，都說是貧血勞累所致，多休息就好了。將近半年的時間病情更為嚴重，走路跌倒嘔吐樣樣都來痛苦至極。直到一天在自由時報上看到了兩個大字「暈眩」。瞪大了眼把內容看完，文章內容完全是我的症狀，心想找到了救星。
經過林鴻清醫師的診視，確定是耳朵內管平衡的三半規管出了問題。簡單的說就是耳石脫落。多次的耳石復位治療讓我迅速脫離病魔的欺凌。感謝林醫師細心的治療耐心的解說，讓我了解我的病情。
那什麼是三半規管呢？本人淺見類似坐骨神經長了骨刺，骨刺碰到了神經產生巨痛無法動彈，那耳石就像是骨刺、三半規管是神經，暈眩就是巨痛。
我發現這毛病無法根治，只能從日常生活中改變生活習慣，睡眠要充足、不吃刺激性食物，尤其行動要緩慢，切記自己像個七老八十的老人凡事放慢腳步，肢體動作要小，就能讓發病時間拉長。總之發病時別緊張接受它，與它共存並配合復位治療很快能減輕痛苦的。
最後請相信這無法解釋的文明病別再說是貧血了。
2008年3月31日 星期一
平衡與昡暈之一。美尼爾氏症(總論)
美尼爾氏症眩暈
By :馬偕醫院 耳鼻喉科 林鴻清醫師
美尼爾氏症（Meniere disease）係耳科眩暈（Vertigo）門診中最出名的一種，於1861年，首先由法國醫師meniere所發現之疾病。係因內耳淋巴液水腫，引致耳蝸前庭病變。主要症狀為反覆發作之眩暈併有單側之感音神經性聽力障礙、耳鳴及耳悶塞感。
流行病學：
典行之美尼爾氏症佔耳科眩暈門診之10%左右。女性略多於男性，好發年齡在於40~60歲左右。跟家族遺傳有關係。
臨床症狀：
發作時，病人覺得天旋地轉，四周環境在轉動；並伴有噁心、嘔吐、盜汗，但不致於意識喪失。頭一轉動眩暈加遽，感覺上有如世界末日。在發作前，患側耳常會先有耳鳴、耳悶塞感、及聽力變差，接著便眩暈發作。一但眩暈緩和後，耳鳴及聽障又會變好。其眩暈發作時間可持續從五分鐘至二十四小十左右。而病人常是幾個月內會有密集多次發作，接著會有數個月甚或數年之緩解期。在這緩解期間，可以毫無症狀；但若是老病號，在緩解期，病人若突然轉頭，仍會有短暫眩暈之情形。若到了更晚期，病人有時會有從站立中突然掉落至地面之情形，但絕不致於喪失意識。由這點可以和暈厥（Syncope）作鑑別。美尼爾氏症病人逐漸地聽力喪失會穩定住，隨之其眩暈亦趨緩。病然的聽障係波動性、漸進性之感音神經性聽力減損，一般在五十至六十分貝左右便不再惡化。其耳鳴之發作，當聽力喪失嚴重時會變大聲，在病的初期，其耳鳴可有短暫之緩解；當至晚期時，耳鳴會一直持續著。當眩暈發作時，病人可有水平性或水平迴旋混合型的自發眼振。而內耳溫差試驗，患側耳可有50%以上呈管性麻痺（canal palsy）。另外值得注意的是：若是右耳患美尼爾氏症，將來其左耳罹患相同病的機會為30%至50%。
病理病因
其可能原因為中耳炎、耳外傷、耳硬化症、梅毒等，其會造成內淋巴液水腫，致膜性迷路破裂，導致富含鉀離子的內淋巴液與外淋巴液相混，使原富含鈉離子之外淋巴液發生「鉀中毒」。而耳蝸前庭神經原係溶在外淋巴液中，一旦接觸到高濃度之鉀離子，即會引起眩暈、耳鳴及聽障。
治療
任何治療之目標僅在於控制眩暈，對於耳鳴及聽障則效果不彰。另外就內科藥物及外科治療評估，其控制率約在60%至80%間。故病人求醫的心理
藥物治療：
可分為預防性藥物(利尿劑、血管擴張劑)及眩暈急性發作時之控制藥物。
急性發作時使用抗暈藥及鎮定劑均可使眩暈及嘔吐穫得控制；若需長時間服藥，乃是為了預防眩暈反覆發作之用。
限鹽及利尿劑：用為預防眩暈之發作。利尿劑(chlorothiazide)為目前醫學文獻上指出最為有效預防美尼爾氏症眩暈之反覆發作。 唯需持續用藥四個月才能見效。
血管擴張劑（如口服組織胺Betahistine）：預防眩暈之用。亦有頗多醫學文獻指出Betahistine可以有效預防美尼爾氏症之眩暈發作。一般建議持續服用藥物三個月。
抗暈藥：當眩暈發作時，使用前述二種預防型藥物之方法，已緩不濟急；必須使用抗組織胺以為前庭抑制之用，如、Meclizine及Cinnarizine；或Valium之類的輕微鎮定劑。
抗焦慮藥、抗憂鬱藥及安眠藥之使用：眩暈之病患多數併有焦慮、憂鬱及失眠之情形；適當予以控制此方面之身心症，才能有效控制眩暈。
外科手術：
一般病人若能獲得適確之藥物治療，大約90%病人可將眩暈控制良好。只有少數對藥物無效時，才需考慮手術。手術方法有下列之三種。
- 內淋巴束手術（保守性手術）：
是予以內淋巴水腫減壓之用。唯多年觀察，發覺其效果和沒開刀之對照組相同，眩暈復發率仍高，故逐漸不被認可。唯因其手術安全性高，仍有些耳科醫師採用。 - 內耳全切除術（破壞性手術）：
其眩暈控制率可達93%（5年內），唯因手術使患側耳之聽力完全喪失，故對於雙側性美尼爾氏症患者要詳加評估。且術後約有兩成比率之個案會抱怨持續性的不穩定感，特別在年齡較大之病人。另外當常時追蹤至10年時，其眩暈控制率會降至76%。其理由是長時間造成年齡老化、而至基底椎動脈血液循環不良；另外因為年齡老化會導致視力不良亦可以加重平衡障礙。另外一種可能為病人又發展出對側耳之美尼爾氏症。 - 前庭神經切除術（破壞性手術）：
其眩暈控制率同內耳全切除術可達93-95 %（5年內），其優點是可以不破壞耳蝸聽力，唯手術須進入顱腔腦膜內，故困難度、危險度較高。且當常時間追蹤至10年時，其眩暈控制率亦會下降如同內耳全切除術之76%。其理由則同上。 - 化學性內耳切除術（中耳Gentamicin注射）：
這種方法亦保留在對保守藥物治療無效時。其眩暈控制率等同內耳全切除術及前庭神經切除術，可達90 %以上。慶大黴素 (Gentamycin) 對內耳耳蝸較不敏感，對於內耳前庭則較具毒性，故當藥物予以注入中耳腔，其劑量足以破壞前庭器時，尚不易致傷害到耳蝸神經。唯仍有造成聽力惡化之後遺症，故施行前必須詳加咨詢、評估。
飲食注意原則
飲食之大原則是：咖啡、濃茶、煙、酒、巧克力及太鹹食物均須儘量避免。
主要精神要在維持身體內血液及體液之穩定容量，以避免因為體液 量之波動而影響內耳淋巴液水腫；因之加重內耳不平衡之症狀。
每天之飲食和喝水必須規則均衡， 使得體液量不會因為大吃大喝而明顯波動。每天之喝水要足夠， 盡量以開水 、牛奶、 低糖果汁為主；而要盡量避免喝咖啡、濃茶(含咖啡色者)、汽水。當大熱天或運動前預計會身體流失體液時，應該事前就先補充多些水份。
避免吃太鹹 或太甜之食物 ，因為會造成內耳液體壓力之波動。故宜避免吃罐頭食品、冷凍或家加工之食物(容易太鹹)。另外，外食之中國菜中易含有味精(含鈉離子屬於鹹性食物)，亦須儘量避免。而宜多攝取新鮮之疏菜水果及全麥食物。避免吃含咖啡因之飲料與食物(如：咖啡、濃茶、巧克力)節制酒精之飲用：因酒精也會改變內耳液體壓力之波動。
生活注意原則：
生活上，宜避免工作壓力及睡眠不足等。臨床經驗上，眩暈病患有很高比率併有睡眠障礙；故治療眩暈之課題、常須同時處理病患失眠。
作者: 林鴻清醫師 馬偕紀念醫院耳鼻喉科 資深主治醫師
E-mail : hclin59@ms29.hinet.net
- 學經歷：
中國醫藥學院醫學系畢 (1986)
英國倫敦大學聽力醫學碩士 (1996)
美國南加大耳科中心研究 (1991)。
中華民國耳鼻喉科專科醫師台灣耳鼻喉科醫學會理事、監事
中山醫學大學兼任副教授 - 聯絡方式
馬偕紀念醫院耳鼻喉科
台北市中山北路2段92號
TEL : (02)25433535 – 2209FAX : (02)28744663
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