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No

Gejala

1.

Pusing berputar

2.

Defisit neurologis

3.
4.
5.

Tekanan pada telinga


Tinnitus
Gangguan pendengaran

6.
7.

Nausea and Vomitting


Kehilangan keseimbangan

8.

Gangguan penglihatan (merasa


benda nya bergerak / loncat)
Sensasi berputar dipicu oleh
perubahan / pergerakan kepala
Muncul tiba-tiba

9.
10
.
11
.
12
.
13
.
14

Serangan nya
Nystagmus
Demam (riwayat infeksi virus
respiratory atau ear)
Penggunaan Obat

BPPV

Inflamasi N.
Vestibular
(neuronitis)

Labhyrintithis

Menieres disease

+
sudden, <
1min

Penekanan N.
Vestibular
(schwanoma,
meningioma)
+
+++
kalau sdh
parah
(CN.V)

+
lama, bahkan
setelah infeksi
sembuh

+
+++
sensory
neural
+
+
(ke samping)

+++
+
+++
sembuh setelah
serangan, tp
memberat jika muncul
kembali
+++

+++
+++
+
Detik - min

Min - hours

+
sec - min

+
+++

+++
+++

+
+
Tidak simetris

.
15
.
16
.

Aspirin
Dix hall pike

Damage

Vestibular aja

Vestibular &
cochlear

BPPV
1. Classic BPPV involving the posterior semicircular canal is characterized by the following:
a. geotropic nystagmus with the problem ear down,
b. predominantly rotary nystagmus toward the undermost ear, latency of a few seconds, duration limited to less than 20 seconds,
c. reversal of nystagmus when the patient returns to an upright position, and a decline in response with repetitive provocation.
2. Treatment is often supportive as a large percentage of patients will have spontaneous resolution of their symptoms.
a. For those with persistent symptoms, the first line of treatment is
i. canalith repositioning maneuvers.
1. These maneuvers attempt to reposition the free-floating canalith particles from the semicircular canals to the utricle using gravity.
a. The Epley manoeuvre

b. Brandt-Daroff exercises

c. Semont

b. Patients with symptoms refractory to repositioning maneuvers may be candidates for singular neurectomy or posterior semicircular canal occlusion.
c. Obat tidak diberikan secara rutin pada BPPV. Malah cenderung dihindari karena penggunaan obat vestibular suppresant yang berkepanjangan hingga lebih dari 2
minggu dapat mengganggu mekanisme adaptasi susunan saraf pusat terhadap abnormalitas vestibular perifer yang sudah terjadi.

MENIEREs DZ
1. The exact cause of Meniere's disease is unknown (autoimmune ?). It may occur when the pressure of the fluid in part of the inner ear gets too high.
2. Typically, these patients complain of spontaneous episodic attacks of tinnitus, aural fullness, fluctuating hearing loss, and vertigo superimposed on a gradual
decline in hearing.
a. TRIAS: tinnitus + vertigo + tuli sensorineural pada nada rendah.
Attacks typically last minutes to hours; however, most commonly subside after 2 to 3 hours.
3. Diagnosis is established with a thorough history detailing the aforementioned complaints, possibly accompanied by nausea, vomiting, diaphoresis (keringetan )
i. Audiologic and vestibular testing is unreliable,
ii. May show caloric weakness on electronystagmography (ENG) and sensorineural hearing loss on audiography.
iii. MRI kepala dan kanal auditori internal
4. Treatment
i. Treating the fluid balance changing to a low-salt diet (< 1500mg /hari) and using a diuretic
ii. Drugs :
i. During attack:
1. Prochlorperazine (buccastem)

ii. Pencegahan:

evidence regarding its safety and effectiveness grommets are

2. Antihistamines ( cinnarizine, cyclizine and promethazine teoclate)

inserted into your ear and are attached to a small pressure


generator for a few minutes, several times a day, to alter the
pressure in the inner ear.

3. Betahistine
5. Benzodiazepine

Selectively destructive surgery


In selectively destructive surgery, the balance part of the inner ear is
destroyed with a medicine called gentamicin. This is injected through the
ear drum (the thin layer of tissue separating the outer ear from the middle
ear) and enters the labyrinth (the system of tubes in the inner ear).

i. Surgery
Non-destructive surgery
Non-destructive surgery may be used if your hearing in the affected ear is
'socially adequate' (you can hear sounds that are below 50 decibels). This
type of surgery aims to change the progression of Mnire's disease by
reducing the severity and frequency of your symptoms.

Gentamicin should mainly damage the balance part of your ear, but there is a
risk it could it damage your hearing too.
Some surgeons prefer to apply the gentamicin directly to the inner ear during
a minor operation. This means they can control the exact dose of gentamicin
that enters your ear.
Destructive surgery

Types of non-destructive surgery include:


ii. endolymphatic sac decompression this can help reduce the

Destructive surgery may be considered if only one ear is affected by

pressure in your inner ear by increasing the drainage of the fluid of

Mnire's disease. The hearing in the affected ear must be considered to be

your inner ear, although evidence of its effectiveness for Mnire's

'socially inadequate' (you cannot hear enough to function in social

disease is limited

situations). As an approximate guide, if you cannot hear sounds that are

iii. inserting ventilation tubes (grommets) these are inserted into

below 50 decibels, this may count as socially inadequate.

your ear to reduce the changes in pressure that cause Mnire's

Destructive surgery is used to destroy the part of your inner ear that is

disease

causing your vertigo attacks. However, these operations can cause

iv. injecting steroid medication through the eardrum this is a

permanent hearing loss in the treated ear so will only be considered if you

newer type of treatment and there is only limited evidence to

already have permanently reduced hearing in the affected ear.

suggest it is effective

Destructive surgery can be done by:

v. micropressure therapy a newer type of treatment with little

destroying the balance part of your audio-vestibular nerve

the nerve that transmits sounds and balance information to the


brain

After the surgery, your other ear will take over your hearing and balance
functions.

destroying part of your vestibular labyrinth


(labyrinthectomy) the system of tiny, fluid filled channels in
the ear

Labyrinthitis
is an inner ear infection that causes the labyrinth (a delicate structure deep inside your ear) to become inflamed.
1. Symptoms:
a. present with complaints indicative of both vestibular and cochlear damage. Vertigo presents suddenly and is accompanied by hearing loss. ENG
may reveal nystagmus, and audiometry will reveal a sensorineural hearing loss or mixed hearing loss if middle ear effusion is present. Depending
on the source of infection, patients may also present with findings consistent with otitis media, mastoiditis, or meningitis.
2. Tatalaksana
a. mandiri

minum banyak air putih (sedikit tp sering)

during an attack, lie still in a comfortable position (on your side is


often best)

avoid chocolate, coffee and alcohol

stop smoking

avoid bright lights

cut out noise and anything that causes stress from your surroundings

b. Medikamentosa :
Benzodiazepine
Benzodiazepines reduce activity inside your central nervous system. This

means your brain is less likely to be affected by the abnormal signals coming
from your vestibular system.

Antiemetic Prochlorperazine 5mg tablets

symptoms are particularly severe. They are often effective at reducing


inflammation.

Corticosteroids
Corticosteroids such as prednisolone may be recommended if your

Antibiotic kalo penyebab nya bakteri

Vestibular SCHWANNOMA
1. Patients may present with episodic or positional vertigo, disequilibrium, tinnitus, and usually asymmetric hearing loss.
a. Early in the disease, when the tumor is small, patients complain of dizziness, hearing loss, and tinnitus, due to compression of the
vestibulocochlear nerve.
b. The slow growth often allows for central compensation, alleviating (membuat jd lebih ringan) vertigo.
c. With continued growth, the tumor can press against the facial or trigeminal nerve causing facial weakness and numbness, respectively.
d. Eventually, the tumor grows to a size where it compresses the brainstem and cerebellum causing truncal ataxia, dysmetria, disequilibrium, and
possibly death.
2. Diagnosis : MRI (NK or K) atau CT scan (kontrast)
3. Tatalaksana:
a. Surgery
b. Radiation therapy
c. Observation

Pembeda
Onset
Intensitas
Mual
muntah
Gannguan
pendengaran
Tinnitus
Defisit
neurologis
Nistagmus

Vertigo Perifer
Akut
Sedang - berat
Sering

Vertigo Sentral
Kronik
Ringan - sedang
Jarang

Sering

Jarang

Sering
Tidak ada

Jarang
Sering

Rotary / horizontal

Multidirectional

Central vertigo often produces other neurologic symptoms, although this


generalization has many exceptions. The symptoms are

Vertigo CENTRAL vs PERIFER

characterized as follows:
Gradual onset
Tend to be much less intense than those associated with peripheral
vertigo

In assessing the possibility of central vertigo related to cerebrovascular


disease, inquire about important risk factors. The following are
associated with an increased incidence of cerebrovascular accident
(CVA):
o Hypertension
o Atrial fibrillation
o History of prior CVA
o Advanced age

Tatalaksana vertigo terbagi menjadi 3 bagian utama yaitu kausal, simtomatik


dan rehabilitatif. Sebagian besar kasus vertigo tidak diketahui kausanya
sehingga terapi lebih banyak bersifat simtomatik dan rehabilitatif.
Terapi simtomatik bertujuan meminimalkan 2 gejala utama yaitu rasa
berputar dan gejala otonom. Untuk mencapai tujuan itu digunakanlah
vestibular suppresant dan antiemetik. Beberapa obat yang tergolong
vestibular suppresant adalah antikolinergik, antihistamin, benzodiazepin,
calcium channel blocker, fenotiazin, dan histaminik. [Tabel 4]
Antikolinergik bekerja dengan cara mempengaruhi reseptor muskarinik.
Antikolinergik yang dipilih harus mampu menembus sawar darah otak
(sentral). Idealnya, antikolinergik harus bersifat spesifik terhadap reseptor
vestibular agar efek sampingnya tidak terlalu berat. Sayangnya, belum ada.
Benzodiazepin termasuk modulator GABA yang bekerja secara sentral
untuk mensupresi repson dari vestibular. Pada dosis kecil, obat ini
bermanfaat dalam pengobatan vertigo. Efek samping yang dapat segera
timbul adalah terganggunya memori, mengurangi keseimbangan, dan
merusak keseimbangan dari kerja vestibular.
Antiemetik digunakan untuk mengontrol rasa mual. Bentuk yang dipilih
tergantung keadaan pasien. Oral untuk rasa mual ringan, supositoria untuk
muntah hebat atau atoni lambung, dan suntikan intravena pada kasus gawat
darurat. Contoh antiemetik adalah metoklorpramid 10 mg oral atau IM dan
ondansetron 4-8 mg oral.
Terapi rehabilitasi bertujuan untuk membangkitkan dan meningkatkan
kompensasi sentral dan habituasi pada pasien dengan gangguan vestibular.
Mekanisme kerja terapi ini adalah substitusi sentral oleh sistem visual dan
somatosensorik untuk fungsi vestibular yang terganggu, mengaktifkan
kendali tonus inti vestibular oleh serebelum, sistem visual dan
somatosensorik, serta menimbulkan habituasi, yaitu berkurangnya respon
terhadap stimulasi sensorik yang diberikan berulang-ulang.

CHECKLIST PF VERTIGO

XI

> Status generalis

XII

KU:

, Kesadaran:

, TTV:

> Status Neurologis


1. GCS
2. Tanda rangsang meningeal
3. Saraf Kranialis
II

: Visus , Lapang Pandang,

II, IV, VI

: sikap bola mata


Celah palpebra
Pupil Ukuran, bentuk, RCL, RCTL, konvergen
Nistagmus yg dgn rangsang gaze
Gerakan bola mata
Diplopia
: Sensorik
Motorik masseter
Corneal reflex
: Menyeringai
Angkat alis
Tutup mata kuat
: Cochlear gesekan jari
Vestibular :
Berdiri 2 kaki mata buka mata tertutup
Berdiri 1 kaki mata buka mata tertutup
Jalan tandem
Fukuda
Past pointing
: dysphagia
Dysphonia
Arkus faring
Uvula
Refleks faring

V
VII
VIII

IX, X

: Trapezius angkat bahu


Sternocleido tengok kanan kiri
: Lidah di dalam
Lidah di luar
Tremor fasikulasi kekuatan lidah

4. Motorik
Extrimitas atas :
Sendi bahu
Bicep
Triceps
Genggam jari
Extrimitas bawah
Pinggul
Hamstring
Ankle dorsi flexi
Patrick kontra Patrick
5. Refleks Fisiologis
6. Reflex patologis
Babinski chadog
Hoffman traumar
7. Sensorik

: raba

8. Propeoceptive

: posisi sendi

9. Koordinasi : Finger to nose


Disdiadokinesia
10. Otonom
Miksi
Defekasi
Diagnosis
Klinis
Topis
Etiologis
Klinis

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