Penyakit Sistem Vestibuler

Santoso
Sistem Keseimbangan

2
Dizziness, Disequilibrium and Vertigo

• There are three symptoms that are often refered to

as dizziness by patients:
• Dizziness
• Disequilibrium
• Vertigo
Dizziness

• Is a nonspecific term that describes a sensation of alterred spatial

orietaiton
• Any sensation of discomfort of head.
• Head lightness or wooziness
Vertigo

• Defined as any abnormal sensation of motion

between patient and surrounding.
• Feeling of linear motion of falling.
• Classification
• Peripheral type
• Central type
Disequilibrium

• Unsteadiness or imbalance
• Patient may feel normal when they are stationary, but notice
difficulty when they walk.
• Often ,they have no symptoms of dizziness.
• Disequilibrium suggests a central lesion, but it may be
peripheral. Patients with bilateral peripheral vestibular loss
may note unsteady gait.
 Dizziness

Vertigo Vertigo Non Disequilibrium Presyncope

Vestibuler Vestibuler

Perifer Central Visual Cerebellum Cardio

Proprioseptif Neuropathy vascular

Labirin Nucleus
↓ Vestibularis
Nervus ↓
Vestibularis Otak

7
 Dizziness

Vertigo Vertigo Non Disequilibrium Presyncope

Vestibuler Vestibuler

Berputar # Melayang # Kaki goyah, tidak stabil Rasa mau pingsan

Perifer Central Visual
# Mengambang # KepalaCerebellum
tidak melayang Cardio
# Goyang # Membaik bila duduk
Proprioseptif Neuropathy vascular
# Berenang

Stroke
BPPV
Tumor
Menieres
disease MS
Neuritis
vestibularis

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 Dizziness

Vertigo Vertigo Non Disequilibrium Presyncope

Vestibuler Vestibuler

Keluhan :
Berputar Melayang, mengambang, goyang
Perifer Central Visual Cerebellum Cardio
Durasi : Proprioseptif Neuropathy
Episodik Konstan/kontinyu vascular

Pencetus : Stroke
BPPV
Gerakan kepala/badan Gerakan objek visual
Tumor
Menieres
Gejaladisease
penyerta : MS
ANS, gg. pendengaran (-)
Neuritis
vestibularis

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 Dizziness

Vertigo Vertigo Non Disequilibrium Presyncope

Vestibuler Vestibuler

Perifer Central
Perifer
VERTIGO Central Visual Cerebellum Cardio
Onset : Mendadak Perlahan
Proprioseptif Neuropathy vascular
Intensitas : Berat Ringan
Frekuensi : Episodik Konstan/kontinyu
Ggg.ANS : Berat
Stroke Ringan
Def. Neuro : (-) (+)
BPPV
Tumor
Menieres
disease MS
Neuritis
NISTAGMUS
vestibularis Unidirectional (fixed direction)
Arah: Bidirectional (changed direction)
Horizontal, rotatoar Bisa semua jenis
Tipe : Mensupresi Tidak mensupresi
Fiksasi visual:
10
Diagnosis

• The history and neurological examination are essential .

• Point to the history include weather the symptom is that of
dizziness, vertigo and disequilibrium
• Weather the symptoms have an inciting factor, duration,
frequency, past history, and severity.
Diagnosis

• Complete neurological examination is necessary.

• CAE
• ENG
• MRI of brain.
• MRI should be perform on all patientsof a central process
and who had symtoms for 2 weeks or mor
• CD and TCD for possible stroke
Treatment

• According to the cause.

• For case of peripheral vertigo, vestibular supressant
may be used to relieved symptoms but should be
discontinue use as soon as possilbe ,as long term
use ma delay compensation.
Treatment

• Anticholinergic drug : scopolamine or glycopyrrolate

• Antihistamine: meclizine
• Benzodiazepine
Common casue of peripheral vertigo

• BPPV
• Bacterial or viral infection
• Vestibular neuritis
• Meniere disease
• Tumor
• Trauma
• Drug: alcohol, aminoglycoside
Common cause of central vertigo

• Menigitis
• Vascular disease: VBI, brainstem or cerebellar hemorrhage or infarct.
• Migraine
• Tumors
• Trauma
• Multiple sclerosis
BPPV

• Recurrent vertigo, with change head position

• No hearing loss
• No tinnitus
• Self limited within a few months
Basic Anatomy
BPPV

• Barany 1921
• Dix-Hallpike 1952 – important features of nystagmus
• Abnormal sensation of motion elicited by certain critical positions
• Provocative position  nystagmus
• At least 20% of vertigo
• Underestimated
BPPV …

• Subclassification : scc post/lat/ant/bilat

• Pathophysiology :
• Canalithiasis
• cupulolithiasis
Pathophysiology
Pathophysiology (cont.)

• Cupulolithiasis :
• Harold Schuknecht 1962
• Densities (otocania) adherent to cupula of crista ampullaris
• Basophilic particles -1969
• Canalithiasis :
• John Epley – 1980
• Densities free floating in canal portion
• Parnes , McClure – 1991 found particles in post SCC
BPPV ...

• Frequency : 10-64/100000
• Sex : 64% women
• Age : older population ( 51-57)
younger than 35 – head trauma.
• History :
• sudden
• days-weeks
• occassionally months -years
• episodes.
• Physical :
• neurological examination – normal
• except – Dix-Hallpike  pathognomonic
BPPV …

• Nystagmus : characterization and types

• RT / LT , vertical / horizontal , changing
• Tortional = Rotational – clockwise / counterclockwise
• Geotropic- toward the earth
• Ageotropic – opposite
BPPV …

• Classic post SCC – geotropic rotatory nystagmus

• Horizontal SCC – purely horizontal nystagmus
• Non-fatiguing nystagmus – cupulolithiasis > canalithiasis
Classic BPPV

• Involved the POST SCC

• Geotropic NG with affected ear down
• Rotatory , fast phase toward the undermost ear
• Latency – few seconds
• Duration – limited < 20 seconds
• Reversal upon return upright position
• Response decline upon repetitive provocation
Lat. SCC PPV

• Most common atypical BPPV

• 3-9% of cases
• Consequence of Epley maneuver
• Horizontal purely nystagmus
• Cupulolithiasis rather than canalithiasis
• Modified Epley / lampert maneuver …
Lat. SCC PPV
Ant. SCC PPV

• Rare – 2%
• Down-beating /torsional NG for the opposite ear on Dix-Hallpike
maneuver
BPPV - Causes

• Predisposing factors :
• Inactivity
• Acute alcoholism
• Major surgery
• CNS disease
Causes ( cont. )

• Idiopathic – 39%
• Ear disease – 29%
• OM – 9%
• Vestibular neuritis – 7%
• Menier’s dis – 7%
• Otosclerosis – 4%
• Sudden SNHL – 2%
• Trauma – 21%
Causes ( cont. )

• Trauma – 21%
• CNS diseases – 11%
• Acustic neuroma – 2%
• Cervical vertigo – 2%
BPPV - D.D

• Menier’s disease
• Inner ear concussion
• Alcohol intoxication
• Labyrinthitis
• Vascular loop syndrome
• Post. Fossa lesions : acustic neuroma , meningioma
• Central origion : stroke , MS , cerebellar degeneration
• Vertibral artery insuffeciency
• Cervical vertigo
BPPV - Treatment

• Watchful waiting
• Vestibular suppressant medications
• Vestibular rehabilitation
• Canalith repositioning
• Surgery care
• Labyrinthectomy
• Post. Canal occlusion
• Singula neurectomy
• Transtympanic aminpglycoside application
Epley maneuver
Semont maneuver
Mastoid oscillator
Brandt-Daroff Excercise
Lampert maneuver- Lat. SCC BPPV
Vestibular rehabilitaions
Complications of CRP

• Failure – 25% (12%-56)

• Recurrence – 13% in 6 months
• Side effects
• Nausea
• Vomiting
• Fainting
• Sweating
• Worse vertigo – LAT SCC PPV
Meniere Disease

• Vertigo, hearing loss ,tinnitus and aural fullness

• Endolymphatic hydrop
Vestibular Neuritis

• Vertigo associated with suddenly onset, severely with N/V and

nystagmus
• Often previously viral infection
CP Angle Tumor

• Asymmetrical sensorineural hearing loss, unilateral tinnitus

or vertigo.
Drug toxicity

• Many drug, esp. alcohol may cause dizziness

• Cessation of use a drug, usually casues clearing of the
symptoms in a few days.
Cardiac Arrythmia

• Low cardiac output:

 low brain perfusion  dizziness
Prebycusis and Presbyastasis

• Age related hearing loss

esp. high tone
• Age related loss of balance
Pyschophysiologic

• Acute anxiety
• Acute panic
• Hyperventilation
Terima Kasih