ANATOMI DAN FISIOLOGI ORGAN

KESEIMBANGAN SERTA
RELEVANSINYA DI BIDANG KLINIK

Dr Adlin Adnan SpTHT

Sub-Dept. Neurotologi THT FKUSU/RSHAM
Medan
SISTEM KESEIMBANGAN
Dikutip dari: Hisayoshi Ishizaki,MD.,Ph.D. Lecture Note & Comments on Scientific Meeting.
General Remarks on Ear Health Care Project. 26-11-2003/ 25-11-2005
SKEMA FISIOLOGI KESEIMBANGAN
 footsole pressure SOMATOSENSORI

reseptor VISUAL
gravitasi CNS
INTERPRETASI
VESTIBULER BELAJAR
pendengaran
ADAPTASI
proses KOMPENSASI ritme
autonom sirkadian

stabilitasi image
orientasi ruangan
kontrol keseimbangan
ORGAN VESTIBULER / LABIRIN
VESTIBULER / LABIRIN : memberitahu otak
tentang bagaimana posisi kepala kita berorientasi
terhadap ruangan di sekitarnya
PERSARAFAN VESTIBULER
PERDARAHAN VESTIBULER
SKEMA ORGAN VESTIBULER
MAKULA DAN KUPULA
OTOLIT / DEBRIS UTRIKULUS
 kinocilium
stereocilia
tip links B

nerve fibre
ARAH POLARISASI SEL RAMBUT
AMPULOPETAL DAN AMPULOFUGAL
 ion channels

myosine
filaments

80 mV 60 mV 120 mV

action potentials
KSS HORISONTAL DENGAN BIDANG
HORISONTAL BUMI
POSISI KANALIS SEMISIRKULARIS
optimal
minimal
FISIOLOGI KANALIS SEMISIRKULARIS
(KSS)

Gambar 2. Orientasi KSS dan respon terhadap

percepatan angular kepala
 FISIOLOGI UTRIKULUS

 Gambaran pada
utrikulus saat
gerakan kepala
linier anterior -
posterior
 utriculus

medial lateral
sacculus
DEPAN-BELAKANG
KANAN-KIRI

DEPAN-BELAKANG
ATAS-BAWAH
FISIOLOGI KSS DAN UTRIKULUS
PERANAN VESTIBULER
TERHADAP KONTROL
POSTURAL

- Mengatur tonus otot

terhadap gravitasi
Centre Of Mass
- Mengatur keseimbangan
COM – base of support

- Mengatur keseimbangan
pada kecepatan rendah
(slow tandem walk test)

base of support
 VISUAL atau MATA
Memberi informasi kepada otak tentang posisi
tubuh terhadap lingkungan berdasarkan sudut
dan jarak dengan obyek sekitarnya
 PROPIOSEPTIK / SOMATOSENSORIK

Memiliki 2 fungsi utama :

1. Sebagai mekanoreseptor,
memberi informasi posisi
tubuh sepanjang waktu

2. Memberi informasi titik

tumpu beban tubuh
REFLEKS VESTIBULO-OKULER (VOR)

Berfungsi untuk menstabilkan

bayangan obyek di retina
pada saat terjadi pergerakan
kepala
REFLEKS VESTIBULO-OKULER (VOR)

Kumar A, Aplebaum EL. Evaluation of the Vesibular System.In:Nadol JB, Schuknecht HE,editors. Surgery
of the ear and temporal bone.1st ed;New york.;Raven press.1993.p.57-70
 NISTAGMUS VESTIBULER
 Gerak mata ritmik, involunter, sering dikaitkan dengan
kelainan vestibuler
NISTAGMUS VESTIBULER
KACA MATA FRENZEL
 ex-torsion in-torsion
up

down nose
right left
NISTAGMUS VESTIBULER
50 cm 50 cm

50 cm
 NISTAGMUS ONE DIRECTIONAL  PERIFER
NISTAGMUS BIDIRECTIONAL  SENTRAL

right beating left beating

REFLEKS VESTIBULO-SPINAL (VSR)

Memiliki fungsi utama

mencegah agar
tubuh
tidak jatuh dengan
mempertahankan
posisi
tubuh dan titik
tumpu
beban.
JARAS REFLEKS VESTIBULO-SPINAL

Dikutip dari: Hisayoshi Ishizaki,MD.,Ph.D. Lecture Note & Comments on Scientific Meeting. General
Remarks on Ear Health Care Project. 26-11-2003/ 25-11-2005
 FISIOLOGI VSR
 Refleks Vestibulo-Spinal (VSR)
 Membantu stabilitas postur

 Dapat secara volunter atau involunter

 Cara volunter  memindahkan tumpuan dari

pusat gravitasi (B), meraih obyek (C)

A B C
 FISIOLOGI VSR
 Refleks Vestibulo-Spinal (VSR)
 Membantu stabilitas postur

 Dapat secara volunter atau involunter

 Cara involunter  ankle strategy (A), hip strategy (B),

suspensatory strategy (C), stepping strategy (D)
GANGGUAN KESEIMBANGAN
 GANGGUAN FUNGSI
KESEIMBANGAN
BANYAK FUNGSI = BANYAK KELUHAN

TIDAK HANYA VERTIGO

- stabilitasi image di retina
- kontrol keseimbangan
- orientasi ruangan
 footsole pressure SOMATOSENSORI

reseptor VISUAL
gravitasi CNS
INTERPRETASI
VESTIBULER BELAJAR
pendengaran
ADAPTASI
proses KOMPENSASI ritme
autonom sirkadian

stabilitasi image
orientasi ruangan
kontrol keseimbangan
 KELUHAN GANGGUAN KESEIMBANGAN
Rasa melayang
(Lightheadness)

Vegetatif/otonom Pusing/pening
(Dizziness)

Pusing berputar GANGGUAN Rasa tidak menapak

(Vertigo) KESEIMBANGAN (Unfootedness)

Postur tdk stabil Rasa masih bergerak

(Postural instability) (After motion)

Rasa goyang
(Unsteadiness)
SYMPTOMS DUE TO VESTIBULAR DEFICITS
Vertigo
Spinning or any other any unequivocal sensation of a movement perceived in the head.
Spontaneous vertigo
Vertigo which appears unprovoked by any movement, change of position or situation.
Positional vertigo
Vertigo provoked by and occurring after a change of head position relative to gravity.
Visual vertigo
Illusion of self-movement or disorientation provoked by moving or complex visual surrounds,
oscillopsia or diplopia.
Dizziness
Any discomfort perceived in the head resulting from disturbed spatial orientation, or diminished spatial
awareness other than an identifiable illusory motion.
Spontaneous dizziness
Dizziness which is not provoked by any movement, change of position or situation.
Head motion induced dizziness (head motion intolerance)
Dizziness provoked by head movements in any plane or direction.
Visual symptoms
Oscillopsia
Illusory motion of the visual surround in any plane.
Reduced dynamic visual acuity
Blurred vision during and shortly after (usually fast) head movements.
Visual tilt
Perception of the visual surrounding as oriented off the true vertical.
Postural symptoms
Unsteadiness
Feeling of being unstable while standing or walking.
Lateropulsion
Tendency to veer to a side while walking, standing, sometimes even when sitting.
 ETIOLOGI GANGGUAN
KESEIMBANGAN
 Gangguan keseimbangan Sentral (daerah
otak)
 Gangguan keseimbangan perifer (terdapat
pada daerah telinga dalam)
 Sebagian besar kasus gangguan
keseimbangan disebabkan oleh kelainan
yang terdapat pada daerah telinga dalam
GANGGUAN KESEIMBANGAN
SENTRAL
 Pada nukleus vestibularis sampai batang
otak dapat terjadi TIA/stroke
vertebrobasilaris, tumor, trauma, migren
basilaris, multipel sklerosis (degeneratif)
 Pada serebelum dapat terjadi stroke,
tumor, kelainan degeneratif
 Pada otak (korteks serebri) dapat terjadi
epilepsi, kelainan degeneratif
 GANGGUAN KESEIMBANGAN
PERIFER (daerah telinga dalam)
Dapat disebabkan oleh :
- BPPV (Benigne Paroxysmal Positional
Vertigo)
- Menier’s disease

- Infeksi (neuritis vestibuler, OMSK)

- Ototoksik (obat yang menyebabkan toksik/racun

pada telinga dalam)
- Penyumbatan pembuluh darah (oklusi a. labirin)

- Trauma

- Tumor (neuroma akustik)

- Kelainan degeneratif (presbiastasia)

KANALOLITIASIS DAN KUPULOLITIASIS
KANALOLITIASIS DAN KUPULOLITIASIS
 •
KANALOLITIASIS KSS POSTERIOR

SUPINE

utriculus

DUDUK

Canalolithiasis: Perubahan posisi  vertigo dan nistagmus

CUPULOLITHIASIS : head position leads to
persisting vertigo and nystagmus (slow central
adaptation)

utriculus

suppine
Deposit kupula pd os
temporal manusia :
A. Pembesaran 400x
mikroskop cahaya
B. Deposit kecil ditengah
dengan presipitasi
utrikulopetal
C. Deposit sedang
utrikulofugal
D. Deposit utrikulopetal
besar dengan debris
PATOGENESIS MENIER’S DISEASE
PATOGENESIS MENIER’S DISEASE
PATOGENESIS PENYAKIT VESTIBULER
 Most common vestibular syndromes
- Benign Paroxysmal Positioning Vertigo/BPPV
attacks, 10 – 60 secs, by change of head relative to gravity, nystagmus
- Motion sickness
continuous, hours to days, by boat/car/airplane, incorrect perception of gravity vector
- Phobic postural vertigo / visual vertigo / anxiety / psychogenic vertigo
subjective, fluctuating instability, fear to fall and vegetative symptoms, hours,
induced by crowds, visual stimulation, improves by alcohol, avoidance behaviour,
secundary to vestibular deficits ?
- Vestibular migraine
attacks, minutes to hours, often also migraneous symptoms, postural imbalance,
sometimes oculomotor deficits and/or spontaneous or positioning nystagmus
- Meniere’s disease
attacks, hours, spontaneous, fluctuating hearing loss, tinnitus or fullness
- Vestibular neuritis
1 attack acute vertigo / nausea/ oscillopsia, days, HSV-I, harmonie vestibulaire + HI
- Bilateral vestibulopathy (due to intoxication, MD, meningitis, encephalitis)
unsteadiness in dark or on uneven ground, oscillopsia during walking and head turning
- Vestibular paroxysms
attacks, secs, spontaneous
- Central vestibular vertigo
continuous, abnormal oculo-motor function
- Fistula – superior canal dehiscence syndrome
attacks, secs, sound or pressure induced
- Unknown vestibular syndromes
 MEKANISME TUBUH PADA
GANGGUAN VESTIBULER
1. Asimetri vestibuler mendadak/sudden
vestibular asymmetry
2. Daya pengembalian keseimbangan/tonic
rebalancing
3. Hilangnya inhibisi kontralateral/loss of
cotralateral inhibition
4. Penyeimbangan oleh serebelum/cerebelar
clamps
5. Fenomena Bechterew
 MEKANISME TUBUH PADA
GANGGUAN VESTIBULER
6. Peran hubungan antar komisura
7. Oscillopsia
8. Ketidakstabilan bayangan obyek di
retina/retinal slip
9. Koreksi VOR/Recalibrating VOR
10. Penurunan bertahap keadaan asimetris-
dinamik/Gradual reduction in dynamic
asymmetry
Diagnosis and Rehabilitation Strategy
(RICHARD E.GANS)
Category Diagnose Strategy
1. Vestibulopathy High frequency Adaptation (self-
noncompensated directed)
weakness
2. Vestibulopathy Unilateral weakness Adaptation
without unsteadiness

3. Vestibulopathy Unilateral weakness with Adaptation and

unsteadiness substitution

4. Dysequilibrium Bilateral weakness Substitution

(peripheral)
5. Dysequilibrium Bilateral weakness Substitution
(central)
6. BPPV BPPV (Benign Canalith Repositioning
Paroxysmal Positional Liberatory, Rolling,
Vertigo) Brandt-Daroff