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SISTEM

VESTIBULER
&
GANGGUAN
VESTIBULER
dr. Ahmad Muzayyin, Sp.S.,
M.Kes.

SISTEM VESTIBULER
Mempertahankan keseimbangan :
Sistem vestibuler
Sistem propiosepsi dari otot & sendi
Sistem optikal

SISTEM VESTIBULER
Sistem vestibuler :
Labirin
Saraf vestibularis
Jaras vestibularis sentral

SISTEM VESTIBULER
Labirin : organ membranosa berisi
endolimfe yg terpisah dari labirin tulang
oleh ruangan tipis yg diisi perilimfe.
(utrikulus, sakulus, 3 kanalis
semisirkularis).
Saraf vestibularis perifer : reseptor organ
s/d nukleus vestibularis.
Nukleus vestibularis : superior
(Bechterew), lateral (Deiter), medial
(Schwalbe), inferior (Roller).

SISTEM VESTIBULER
Semua nukleus vestibularis
dihubungkan dg nukleus saraf
motorik okular oleh fasikulus
longitudinalis medialis.

VERTIGO

DEFINISI:
Vertigo adalah perasaan
penderita merasa dirinya atau
lingkungan sekitarnya berputar

PATOFISIOLOGI
VERTIGO
Reseptor
Mata
Vestibuler
Propioseptik

Pengelola data
Saraf Pusat

Efektor

Otot skelet
Mata
Leher
Badan
Anggota gerak

CHARACTERISTICS OF PERIPHERAL
AND CENTRAL VERTIGO

Peripheral Vestibular Disorders

BPPV
Labrynthitis
Menieres disease
Acoustic Neuroma
Motion sickness
Cervicogenic
Perilymphatic
fistula

Vestibular
neuronitis
Semicircular canal
infection
Semicircular canal
water penetration

Assessment of the dizzy patient,


Australian Family Physician Vol. 31,
No. 8, August 2002

Central Vestibular
Disorders
Brain stem lesion
Basilar artery
migraine
TIA
Stroke
MS
Cerebellar lesions

Metastatic Tumor
Meningioma

Assessment of the dizzy patient,


Australian Family Physician Vol. 31,
No. 8, August 2002

Perbedaan Klinis Vertigo Vestibuler vs Non


Vestibuler
Gejala

V. Vestibuler

V. Non Vestibuler

Sifat

berputar

Melayang, hilang
keseimbangan, lightheaded

serangan

Episodik

kontinyu

Mual, muntah

++

Gangguan
pendengaran

+/-

Gerakan Pencetus

Gerakan kepala

Gerakan obyek visual

Situasi pencetus

Ramai orang, lalu lintas macet,


supermarket

Perbedaan Klinis Vertigo Vestibuler


Tipe Perifer dan Tipe Sentral
Gejala

T. Perifer

T. Sentral

Bangkitan Vertigo

Lebih Mendadak

Lebih Lambat

Derajat Vertigo

Berat

Ringan

Pengaruh gerakan
kepala

Gejala Otonom (mual


dan muntah)

++

Gangguan
pendengaran (tinitus,
tuli)

Tanda Fokal Otak

Vertigo Berdasarkan Gejala


Klinis
Vertigo yang paroksismal
Vertigo yang kronis
Vertigo yang serangannya akut,
berangsur-angsur menghilang

Vertigo Paroksismal
Serangan mendadak, beberapa menit
atau hari, hilang sempurna, bisa
muncul kembali, diantara serangan
bebas sama sekali
Vertigo jenis ini :

1. Vertigo dengan

keluhan telinga. Sindroma


Meniere,
Morbus Meniere, Arakhnoiditis ponto
serebelaris, Sindroma Lermoyes, serangan
iskemia sepintas arteria vertebralis,
Sindroma Cogan, tumor fossa kranii
posterior, kelainan gigi/odontogen.

2. Vertigo tanpa keluhan telinga.


Iskemia sepintas arteria vertebro
basilaris,
Epilepsi, lesi lambung, ekuivalen
migren,
vertigo pada anak (vertigo de L
enfance),
labirin picu (Trigger Labyrinthyh).
3.

Perubahan posisi.

Vertigo Kronis
Menetap lama, konstan tidak ada serangan akut
1. Disertai keluhan telinga :
Otitis Media Kronika, Meningitis TBC, Labirinitis
kronika, Lues serebri, tumor serebelopontin.
2. Tanpa keluhan telinga :
Kontusio serebri, Ensefalitis pontis, Sindroma pasca
komosio, Pelagra, Siringobulbi, Sklerosis multiple,
kelainan okuler, intoksikasi obat, kelainan psikis,
kelainan endokrin, kelainan kardiovaskuler.
3. Dipengaruhi posisi :
Hipotensi orthostatik, Vertigo servikalis.

Vertigo Akut
Berangsur-angsur berkurang, tidak bebas total.
1. Dengan keluhan telinga :

Trauma labirin, Herpes Zoster Otikus, Labirinitis


akuta, Perdarahan labirin, Neuritis N. VIII,
Cedera a. auditiva interna, a. vestibulokohlearis.
2. Tanpa keluhan telinga :
Neuronitis vestibularis, Neuritis vestibularis,
Sindroma arteria vestibularis anterior,
Ensefalitis vestibularis, Vertigo epidemika,
Sklerosis multiple, Hematobulbi, Sumbatan
arteria serebeli inferior posterior.

MENCARI PENYEBABNYA
Penyakit Sistem Vestibular Perifer
1.
2.

Telinga bagian luar : Serumen, benda asing.


Telinga bagian tengah :
Retraksi membran timpani, Otitis Media Purulenta
Akuta, Otitis Media dengan efusi, Labirinitis,
Kolesteatoma, Rudapaksa.
3. Telinga bagian dalam :
Labirinitis akut toksik, Trauma, Serangan vaskuler,
Alergi, Hidrops labirin, mabuk gerakan, Vertigo postural.
4. Nervus VIII : Infeksi, Trauma, Tumor.
5. Inti Vestibularis :
Infeksi, Trauma, Perdarahan, Thrombosis a. serebeli
posterior inferior, Tumor.

Penyakit susunan saraf pusat


1. Hipoksia - Iskemia otak :
Hipertensi kronis, Arteriosklerosis, Anemia,
Fibrilasi atrium paroksismal, Stenosis /
insufisiensi aorta, Sinkop, Hipotensi
ortostatik, Blok jantung.
2. Infeksi : Meningitis, Ensefalitis, abses, Lues.
3.
4.
5.
6.

Trauma kepala
Tumor
Migren
Epilepsi

Kelainan Endokrin :
Hipotiroid, Hipoglikemi, Hipoparatiroid,
Tumor medula adrenal, menstruasi, hamil,
menopause.
Kelainan Psikiatri
Depresi, Neurosa cemas, sindroma
hiperventilasi, Phobia.
Kelainan mata
Kelainan propioseptif
Polineuropati, mielopati, trauma,
arthrosis cervikalis.

Vertigo

Episodic
positional

Episodic
Non-positional

Schimp D. A diagnostic algorithm


for the dizzy patient Chiropractic
Technique, vol 6(4) Nov 1994

Non-episodic
Non-positional

Episodic
positional
Benign
positional

Cervicogenic

Vertebobasilar
ischemia

sudden

sudden

gradual

Fades 30-60
seconds

persists

progression

Benign Paroxysmal Positional


Vertigo (BPPV) 20%

Brief episodes recurrent


Moderate to severe
Associated with head position
Gradually diminishes over a month or two
No hearing loss
Latency or delayed onset
Positive Nylen-Barany maneuver
Caused by otoconia (debris) floating in SC

Nylen-Barany / DixHallpike
Patient seated, head turned 45
degrees
Patient quickly lays supine
Latency period, then horizontal or
rotational nystagmus
Nystagmus decreases after 10-20
seconds
Affected ear is the side head is
turned toward when nystagmus and
vertigo occurs

Nylen-Barany Maneuver

Dizziness, Hearing Loss, and


Tinnitus R.W. Baloh, F.A. Davis
Company 1998

Treatment Options for


BPPV

Epleys
Sermonts
Habituation exercises (Brandt-Daroff)
Cervical adjusting

Modified Epleys
Maneuver
Patient placed supine with head
turned 45 degrees toward the
affected ear (30 sec.)
Dr. turns head 90 degrees so affected
ear is up. (30 sec.)
Patient rolls on to side, head looking
toward the floor (30 sec.)
Patient is lifted into sitting position
Procedure is repeated until no
nystagmus

Modified Epley Maneuver

Dizziness,Hearing Loss, and


Tinnitis R.W. Baloh, F.A. Davis
Company 1998

Modified Epley Maneuver

Dizziness,Hearing Loss, and


Tinnitis R.W. Baloh, F.A. Davis
Company 1998

Sermonts Maneuver
Patient can be instructed to do this at
home.
Patient turns head 45 degrees away
from the affected side
Quickly lays down maintaining head
position (4 minutes)
Brought up and placed on other side
with same head position. (4 min) Sit
up normal

Sermonts Maneuver

Archives Otolaryngol Head Neck


Surgery, Vol 119, p452, 1993

Post Maneuver
Instructions
Patient waits 10 min. before leaving
office.
Other person drives them home.
Sleep half-reclined 2-3 days.
Avoid laying on bad side.
Avoid extreme head extension for 2-3
days

Cervicogenic Vertigo
Hx of neck trauma, muscle spasm
Limited cervical ROM
Positive chair rotation test (FitzRitson)
Patients may complain of
dysequilibrium (tilt) more than
rotational vertigo
Overstimulation of upper cervical
proprioceptors
May overlap BPPV or Menieres
disease

Vertebrobasilar
Insufficiency TIAs

Vertigo with associated Neurological signs


Diplopia
Ataxia
Drop attacks
Dysarthria
Paralysis/weakness/Numbness
Headache
Risk factors (HTN, Diabetes, Coronary
Disease)

Episodic non-positional

Menieres

Perilymph fistula

Menieres Disease
Sudden and recurrent (paroxysmal)
attack of severe vertigo
Low-tone hearing loss
Low-tone tinnitis
Sense of fullness in the ear
Vertigo lasts for hours to a day then
burn out
Hearing loss may progress

Cause of Menieres
Overproduction or retention of
endolymph
Possible autoimmune etiology
Head trauma
Previous infection
Pregnant females are more prone

Management of
Menieres
Salt-restriction diet
Diuretic therapy
Cervical adjusting (overlaps with
cervicogenic vertigo

Perilymphatic Fistula
Hx of barometric pressure changes
(airplane or weight lifting)
Opening develops between middle
and inner ear (oval window rupture)
Rare cause of vertigo
Bearing down reproduces
Tx - surgical

Non-episodic
Non-positional vertigo

Labyrinthitis

Acoustic neuroma

Cerebral hemorrhage

Labyrinthitis
Sudden severe vertigo that last days
to weeks
Maybe nausea and vomiting
Viral infection - no hearing loss
Bacterial infection hearing loss

Acoustic Neuroma

Mild but constant hearing loss


Dizziness with possible tinnitis
Gradual onset
Benign schwannoma of 8th CN
Other CN findings as tumor grows
Surgical excision

Cerebral Hemorrhage

Sudden vertigo and nausea


Vomiting associated with a headache
Inability to stand
Nystagmus, nuchal rigidity, facial
paralysis, ataxia, dysrythmia, small
reactive pupils
in 2/3 of HTNpatients

Gambar 1. Alur diagnosis vertigo


(Sutarni, 2006).

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