【作者】 李亮；

【导师】 林鹏； 陈太生；

【作者基本信息】 天津医科大学 ， 耳鼻咽喉科学， 2008， 硕士

【摘要】 目的冷热试验(caloric test,CT)是眩晕临床诊疗中不可或缺的检查项目,主要通过单侧反应减退(unilateral weakness,UW)、优势偏向(directionalpreponderance,DP)两个参数评估前庭系统是否存在损伤、损伤的程度与侧别。UW参数的临床意义较为明确并已形成共识,但是目前对DP的认知仍十分模糊,甚至认为其临床意义不明确或没有临床价值而放弃对DP的关注,以致近年来的相关文献甚少。DP异常一直被认为可能是前庭中枢性病变的特征,但是近年来我们发现其并非前庭中枢性眩晕患者独有,在前庭周围性眩晕患者也可出现,并且异常DP参数通常伴随UW、自发性眼震(spontaneous nystagmus,SN)两个参数出现。UW和SN参数分别是反应一侧前庭功能下降及前庭代偿的指标,据此我们推测DP也与前庭代偿有关。本研究旨在通过对来我科就诊的眩晕患者进行前庭功能系列检查,进而分析冷热试验DP参数在眩晕诊断及前庭代偿评估中的应用价值。方法以2006年1月份到2007年7月份来天津市第一中心医院就诊的989例眩晕患者为研究对象,排除原因不明者144例,共计有845例患者进入本研究,男394例,女451例。应用法国Synapsys公司生产的视频眼震电图仪常规进行自发眼震和双耳交替冷热试验等前庭功能项目检测。以DP、UW、SN的方向、强度为评定参数。分析异常DP参数在前庭中枢性及前庭周围性眩晕患者的分布,前庭周围性眩晕患者DP与SN、UW的相关性,结合病程分析这三个参数在前庭周围性病变中的演变特征,探讨DP参数在前庭代偿评估中的意义。结果1.845例眩晕患者中前庭周围性697例(82.5%),前庭中枢性148例(17.5%)。冷热试验DP参数异常者396例(46.9%),其中前庭周围性334例(47.9%),前庭中枢性62例(41.9%),x~2=1.78(P＞0.05)差异无统计学意义。2.前庭周围性眩晕患者DP异常伴有SN者104例,其中DP与SN同方向95例,反方向9例。(1)DP与SN同方向时,Spearman等级相关系数为0.566(P＜0.001),DP值与SN强度存在正相关关系。(2)DP与SN反方向者共9例。主要出现在梅尼埃病、前庭神经元炎和伴眩晕的突发聋的病例中。3.前庭周围性眩晕患者DP异常伴有UW异常共有241例,DP与UW同方向98例,反方向143例。(1)DP与UW同方向时,Spearman等级相关系数为0.042(P＞0.05),两者并不存在相关关系。(2)DP与UW反方向时,Spearman等级相关系数为0.077(P＞0.05),两者亦不存在相关关系。4.DP、UW、SN三个参数在前庭周围性病变前庭代偿不同阶段的分布及其与病程的相关关系:在前庭周围性病变的急性期、静态代偿阶段、动态代偿阶段的病程分布呈正偏态分布,其中位数分别为:2天、6.5天和15天。三组之间经过多个独立样本秩和检验,x~2=37.7(P＜0.001),差异有统计学意义。结论冷热试验DP异常结果并非前庭中枢性眩晕患者独有,在前庭周围性眩晕患者也可出现,DP对于前庭系统病变的中枢或周围性定性诊断缺乏特异性,确切的定性、定位诊断需要与其它前庭功能检查结果综合分析并结合病史调查和影像学检查等。多数情况下,DP与SN方向相同并且DP与SN值存在相关关系,提示DP也是两侧前庭系统存在不平衡或非对称的客观指标之一;本研究显示在眩晕患者的病程中DP参数呈动态变化,在静态至动态代偿阶段分别朝向健侧和患侧,在静态代偿阶段和SN一样反映两侧前庭神经核静息电位的不对称性,在动态代偿阶段反映了前庭系统的动态敏感性的不对称,可以作为前庭静、动态代偿的评定指标,对于前庭康复及其评定有指导价值。更多还原

【Abstract】 ObjectiveCaloric test is the most important inspection item in the diagnosis and treatment of vertigo,nystagmus directional preponderance(DP)is the chief parameter of caloric test,The abnormal result of directional preponderance had been considered as the characteristic of vestibular centra disease,but during the past few years we find it can also be the manifestation of the vestibular peripheral vertigo;we also find directional preponderance always appear with spontaneous nystagmus and unilateral weakness,these parameters have relation with vestibular compensation,on these grounds we suppose directional preponderance is also a parameter of vestibular compensation.We do vestibular function examination for vertigo patient who visit our department.The aim of this study is to analyze the value of directional preponderance in the diagnosis of vertigo and vestibular compensation evaluation.MethodWe consider the vertigo patient who visit our department between January 2006 and july 2007 as study object.There are 845 cases who had definite diagnosis,male 394 cases and 451 cases.We use Video-Nystagmography to trace the spontaneous nystagmus and do the caloric test routinely.We select directional preponderance, spontaneous nystagmus and unilateral weakness as the observation parameters,then analyze the distribution of the abnormal result of directional preponderance in the vestibular centra and peripheral disease;We do correlation analysis between DP and SN in the vestibular peripheral vertigo,also we do correlation analysis between DP and UW in the vestibular peripheral vertigo.Then we analyze the development of the three parameters with course of disease in the vestibular peripheral disease.Result1.There are 697 cases with vestibular peripheral disease and 148 cases with vestibular centra disease.There are 396 cases that the DP≥25%altogether,334 cases with vestibular peripheral disease and 62 cases with vestibular centra disease,x~2=1.78 (P＞0.05).There is no statistically significance.2.There are 104 cases that the DP≥25%and SN＞2°/s,95 cases DP and SN in the same direction and 9cases in the oppsite direction.(1).When DP had the same direction with SN,Spearman rank correlation coefficient is 0.556(P＜0.001),DP and SN have correlativity.(2).When DP had the oppsite direction with SN,there is only 9 cases.The major diagnosis of these cases is Meniere disease,vestibular neuronitis and sudden hearing loss.3.There are 241 cases that the DP≥25%and UW≥15%,98 cases DP and UW in the same direction and 143 cases in the oppsite direction.(1).When DP had the same direction with UW,Spearman rank correlation coefficient is 0.042(P＞0.05),DP and UW have no correlativity.(2).When DP had the oppsite direction with UW,Spearman rank correlation coefficient is 0.077(P＞0.05),DP and UW have no correlativity.4.The distribution of DP、UW and SN in the different stage of vestibular compensation and its correlativity with the course of disease:The course of disease in the different stage of vestibular compensation in the vestibular peripheral disease is skewness distribution.Their median is 2 days,6.5 days and 15days.Through Kruskal-Wallis Test,x~2=37.7(P＜0.001),there is statistical significance among the three stage.ConclusionDP of caloric test can be abnormal in the vestibular centra and peripheral disease,when diagnosis it must be consider other vestibular functional examination and Images etc;mostly DP has the same direction of SN,DP and SN have correlativity. The results suggest that DP is varying in the different stages of vestibular compensation,and DP can reflect the dynamic sensitivity of the vestibular system. This indicate DP can also be consider as the parameter of vestibular compensation. DP can guide the vestibular rehabilitation evaluation.更多还原