Sensasi dimana penderita merasa dirinya berputar thd sekelilingnya
(vertigo subyektif) atau sebaliknya (vertigo obyektif). Berasal dari kata Vertere art. Berputar
Klasifikasi : 1.Vertigo sentral /kronis 2.Vertigo peripir/ Akut : Vertigo spontan Vertigo provokasi ( PPV / BPPV ) ... 20 30 % VERTIGO 2 3 Vertigo Perception of movement illusion of movement Peripheral or Central
Syncope Transient loss of consciousness with loss of postural tone Prevalence 1 in 5 adults report dizziness in last month Increases in elderly Worsened by decreased visual acuity, proprioception and vestibular input
Complex interaction of visual, vestibular and proprioceptive inputs that the CNS integrates as motion and spatial orientation.
3 semicircular canal ..... rotational movement (cupula)
2 otolithic organs utricle & saccule ........ linear acceleration (Macula) Sistem Keseimbangan ada 3 komponen
1. Sistem Visual (mata) 2. Sistem vestibuler Formatio retikularis 3. Sistem proprioseptif (SSP) (kulit, otot, sendi)
1. Otot Postur ( reflek vestibulospinal) 2. Otot bola mata (refleks vestibulookuler)
SENSORIS PUSAT MOTORIS 6 MEKANISME KESEIMBANGAN SISTEM VESTIBULARIS 7
N. Vestibularis
Bola mata Palor Laring Otot postur (Nistagmus) Keringat dingin Diafragma Klj. Ludah GIT LABIRIN Nukleus Vestibularis Korteks cerebri serebellum Formatio Retikularis N.III Simpatis N. X Kornu ant. Medula sp. 8
9 Evaluation of the vertigo 1. What type of dizziness is it? 2. How long does it last? Continuous or episodic 3. Spontaneous or positional 4. Duration of vertigo if episodic 5. Are there otologic symptoms? 6. Are there focal neurological symptoms?
10 Otologic Symptoms of the Vertigo Hearing Loss: progressive, sudden Tinnitus: continuous or episodic Aural fullness Ear pain, or chronic drainage History of ear surgeries/infection
11 Neurological Symptoms of Vertigo Vertigo if secondary to cerebrovascular insufficiency is indicative of posterior circulatory problems Visual loss Loss of consciousness Weakness especially if on one side Incoordination as if drunk, esp if in spells Difficulty swallowing Slurring of the speech
Klinis Vertigo Gejala respon motoris otak :
1. III (Mata) : rasa berputar , Nistagmus 2. Simpatis : palor ( pucat ), keringat dingin 3. X (Vagus) : mual, muntah 4. Otot postur : jatuh 5. Telinga : tinitus, pendengaran menurun
12
13 Dix-Hallpike Maneuver Dix-Hallpike maneuver (used to diagnose benign paroxysmal positional vertigo). This test consists of a series of two maneuvers: With the patient sitting on the examination table, facing forward, eyes open, the physician turns the patient's head 45 degrees to the right (A). The physician supports the patient's head as the patient lies back quickly from a sitting to supine position, ending with the head hanging 20 degrees off the end of the examination table. The patient remains in this position for 30 seconds (B). Then the patient returns to the upright position and is observed for 30 seconds. Next, the maneuver is repeated with the patient's head turned to the left. A positive test is indicated if any of these maneuvers provide vertigo with or without nystagmus. Differential of Vertigo Peripheral Central Onset Sudden Usually slow Severity of Vertigo I ntense Usually mild Pattern Paroxysmal Constant Exac. by movement Yes Variable Autonomic Frequent Variable Laterality Unilateral Uni or bilat Nystagmus Horizontorotary Any / Rotatoir Fatigable/Fixation Yes No Auditory symptoms Yes No TM May be abnormal Normal CNS symptoms Absent Present 14
15 Duration of vertigo Duration
1. BPPV Seconds, always < 1 min
2. VBI Few minutes, focal neurological signs
1. Migraine Varies sec, minutes, hours or days 2. Menieres 20 minutes to hours 3. Vest.neuritis Days 4. Stroke Days 5.
16 Peripheral Vertigo-Differential Labyrinthine Disorders Most common cause of true vertigo Five entities 1. Benign paroxysmal positional vertigo (BPPV) 2. Labyrinthitis 3. Mnire disease 4. Vestibular neuronitis 5. Acoustic Neuroma
17 Management Severe Mnire disease may require chemical ablation with gentamicin Attempt Epley maneuver for BPPV Mainstay of peripheral vertigo management are antihistamines that possess anticholinergic properties -Meclizine -Diphenhydramine -Promethazine -Droperidol -Scopolamine
For neurovegetatif symptom ....... Anti emetic
18 Pharmacotherapy
19 Epley Maneuver
20 Positional Vertigo / PPV / BPPV Sudden attacks of vertigo precipitated by certain head positions. Rolling over in the bed, reaching for an object from the top shelf, washing the hair Vertigo is of short duration ( < 1min )
Etiology: Litiasis theory, originally describe by Schucknecht in1974 Degeneration of the salt-like crystals (otoliths) in the utricle which break free and float into or attach to semicircular canals. Proprioceptive mismatch btw the general proprioception (from muscles, ligament and joints) and special proprioception (from maculae and cristae); spino-cerebello-vestibular circuitry.
21 Etiology of BPPV in 240 patients (Baloh et al., 1987)
Idiopathic in 49% Traumatic in 18% Viral Labyrinthitis in 15% VBI in 5% Menieres in 2% Surgery in 4% Ototoxicity in 2%
22 BPPV Extremely common Otoconia displacement No hearing loss or tinnitus Short-lived episodes brought on by rapid changes in head position Usually a single position that elicits vertigo Horizontorotary nystagmus with crescendo-decrescendo pattern after slight latency period Less pronounced with repeated stimuli Typically can be reproduced at bedside with positioning maneuvers
23
24 Two main types
Dix-Hallpike maneuver elicited Head hyperextension and rotation to AS Induced typical horizontal-rotatory geotropic (towards the ground) nystagmus Nystagmus appears some seconds delay Habituation phenomena MacClure maneuver elicited Pt supine, rolling the head from side to side Pure horizontal geotropic and ageotropic nystagmus
25 Treatment for PPV Semont maneuver Epley maneuver Personal maneuver for PPV elicited by Dix- Hallpike positioning ( Epley modified)
Lempert maneuver horizontal semicircular lithiasis post. Semicircular canal lithiasis 80~90%effective
26 1. Semont maneuver Right ear lat canal PPV 1. Head turn towards left side(SS) 2. Lying on R side, head is rotated upward 105, 3mins 3. Lying on L side, head is rotated downward 195, 3 mins 4. Slowly sit-up
27 2. Epley maneuver Left ear post. Canal PPV Each stage wait 30 s
28 3. Modified Epley Left ear BPPV 30 SEC.
29 4. Lempert maneuver Right ear PPV
30
31 Labyrinthitis Associated hearing loss and tinnitus Involves the cochlear and vestibular systems Abrupt onset Usually continuous Four types of Labyrinthitis Serous Acute suppurative Toxic Chronic
32 Serous Adjacent inflammation due to ENT or meningeal infection Mild to severe vertigo with nausea and vomiting May have some degree of permanent impairment
Acute suppurative labyrinthitis Acute bacterial exudative infection in middle ear Secondary to otitis media or meningitis Severe hearing loss and vertigo Treated with admission and IV antibiotics
33 Chronic Localized inflammatory process of the inner ear due to fistula formation from middle to inner ear
Most occur in horizontal semicircular canal
Etiology is due to destruction by a cholesteatoma
34 Vestibular Neuritis Subacute onset of vertigo, often with nausea and vomiting Suspicion for viral cause but evidence for ischemic causes Sudden onset vertigo that increases in intensity over several hours and gradually subsides over several days Mild vertigo may last for several weeks May have auditory symptoms Highest incidence in 3 rd and 5 th decades Temporal bone histopathology: Scarpas ganglion neuronal loss
35 Vestibular Ganglionitis Usually virally mediated-most often VZV
Affects vestibular ganglion, but also may affect multiple ganglions
36 Mnire Disease First described in 1861 Triad of vertigo, tinnitus and hearing loss Due to cochlea-hydrops Unknown etiology Possibly autoimmune Abrupt, episodic, recurrent episodes with severe rotational vertigo Usually last for several hours
37 Often patients have eaten a salty meal prior to attacks May occur in clusters and have long episode-free remissions Usually low pitched tinnitus Symptoms subside quickly after attack No CNS symptoms or positional vertigo are present
38 Acoustic Neuroma Peripheral vertigo that ultimately develops central manifestations Tumor of the Schwann cells around the 8 th CN Vertigo with hearing loss and tinnitus With tumor enlargement, it encroaches on the cerebellopontine angle causing neurologic signs Earliest sign is decreased corneal reflex Later truncal ataxia Most occur in women during 3 rd and 6 th decades
41 Most commonly will also have: -Dysarthria -Ataxia -Facial numbness -Hemiparesis -Diplopia -Headache Tinnitus and hearing loss unlikely Vertical nystagmus is characteristic of a (superior colliculus) brain stem lesion Up to 30% of TIAs are VBI with pontine symptoms and a focal neurologic lesion
Suspected in any patient with sudden onset headache, vertigo, vomiting and ataxia
May have gaze preference
Motor-sensory exam usually normal
Gait disturbance often not recognized because patient appears too ill to move
43 3. Multiple Sclerosis Vertigo is presenting symptom in 7-10% Thirty percent develop vertigo in the course of the disease May have any type of nystagmus Internuclear ophthalmoplegia is virtually pathognomonic Onset during 2 nd to 4 th decade Rare after 5 th decade Usually will have had previous neurological symptoms Due to damage to the inner ear and central vestibular nuclei, most often labyrinthine concussion Temporal skull fracture may damage the labyrinth or eighth cranial nerve Vertigo may occur 7-10 days after whiplash Persistent episodic flares suggest perilymphatic fistula Fistula may provide direct route to CNS infection 4. Head and Neck Trauma
44 5. Vertebral Basilar Migraine Syndrome of vertigo, dysarthria, ataxia, visual changes, paresthesias followed by headache Distinguishing features of basilar artery migraine -Symptoms precede headache -History of previous attacks -Family history of migraine -No residual neurologic signs Symptoms coincide with angiographic evidence of intracranial vasoconstriction
45 6. Metabolic Abnormalities Hypoglycemia Suspected in any patient with diabetes with associated headache, tachycardia or anxiety
Hypothyroidism Clinical picture of vertigo, unsteadiness, falling, truncal ataxia and generalized clumsiness DD vertigo sentral dg peripir VERTIGO SENTRAL VERTIGO PERIPIR 1. Onset 2. Durasi 3. Perubahan posisi 4. Jenis Nistagmus 5. Gejala kranial (kesadaran turun) 6. Gejala vestibuler (tinitus, gg. Pend.) 7. Gejala vegetatif (mual, muntah) Pelan-pelan Lama Tidak terpengaruh Nistagmus Rotatoir
Positip
Negatip
Negatip Mendadak Tidak lama Terpengaruh Nistagmus horisontal
Negatip
Positip
Positip 46 47 Tes Fungsi Vestibuler Macam Tes Vestibuler/Keseimbangan
Prosedur : 1. Penderita bediri tegak, kaki rapat, mata tertutup dan tangan menggantung atau 2. Satu kaki di depan kaki lainnya dan tangan ekstensi
Penderita goyang atau jatuh ke satu sisi
Lesi vestibuler baru pada sisi yg sama 48 Tes fungsi vestibulum UJI KALORI
Prosedurnya :
1. Posisi pasien : tidur telentang dg kepala flexi 30 atau duduk dg kepala ekstensi 60 2. Irigasi telinga dg air es 5 cc selama 20 dt (cara Kobrak) Lamanya nistagmus : 120 - 150 dt (normal) < 120 dt (paresis kanal) 3. Irigasi telinga dg air 30 dan 44 sebanyak 250 cc, selama 40 dt. (Cara Dick & Hall Pike) 49
Kesimpulan : No.
Telinga Suhu Arah Nistagmus Waktu Nistagmus 1. 2. 3. 4. Kiri Kanan Kiri Kanan 30 C 30C 44C 44C Kanan Kiri Kiri Kanan Detik
(1 + 3) - (2 + 4) Sensitifitas Ki Ka : ------------------------ X 100 % (1 + 2 + 3 + 4)
< 40 dt ( < 20 % ) Normal > 40 dt ( > 20 % ) paresis kanal 50 Tes Gait Prosedur : 1. Penderita berjalan mengikuti garis lurus dg mata terbuka kemudian tertutup atau 2. Berjalan dimana tumit bertemu dg jari kaki
Jalannya cendrung ke satu sisi/jatuh
Lesi vestibuler pd sisi yg sama 51 TES VESTIBULER Utk menilai sistem vestibuler/ keseimbangan tubuh 52 Tes Fungsi Saraf Kranial Saraf I : tes penciuman Saraf II : tes penglihatan Saraf III,IV, VI : penderita disuruh memandang ke segala arah, apakah timbul nistagmus Saraf V : tes sensitifitas refleks wajah / refleks kornea Saraf VII : apakah ada perot Saraf VIII : tes audiometri dan vestibulum Saraf IX : apakah faring simetris Saraf XI : tes mengangkat bahu Saraf XII : apak ada deviasi lidah 53 54
55 1.Nystagmus due to peripheral causes has all of the following features excep
a. Diminishes with fixation b. Unidirectional fast component c. Can be horizontorotary or vertical d. Nystagmus increases with gaze in direction of fast component e. Can be accentuated by head movement
c. Can be horizontorotary or vertical Peripheral nystagmus is typically horozonto-rotary, not pure horizontal or rotary and is definitely not vertical.
56 2. Nystagmus due to central causes has all of the following features except: a. Does not change with gaze fixation b. Can be unidirectional or bidirectional c. Can be horizontal, rotary or vertical d. Nystagmus increases with gaze in direction of fast component e. Can be dramatically accentuated by head movement. e. Can be dramatically accentuated by head movement Vertigo and nystagmus produced by central causes does not significantly worsen with head movement
3. All of the following will have hearing loss and tinnitus associated with the vertigo except: a. Vestibular neuronitis d. Acoustic neuroma b. Acute labrynthitis e. Meniere ds c. BPPV c. BPPV will not have associated hearing loss or tinnitus All of the other responses will have hearing loss and tinnitus to varying degrees
57 5. All of the following have been implicated in causing vertigo except: a. Loop diuretics e. Fluoroquinolones b. Anticonvulsants f. All of the above c. Aminoglycosides d. NSAIDS
F All of the above Many everyday medications can cause vertigo which is easily reversible if recognized.