No.GejalaBPPVInflamasi N. Vestibular (neuronitis)LabhyrintithisMenieres diseasePenekanan N. Vestibular (schwanoma, meningioma)

1.Pusing berputar+

sudden, < 1min++++

2.Defisit neurologis+ + +

kalau sdh parah

(CN.V)

3.Tekanan pada telinga+ + +

4.Tinnitus +++

5.Gangguan pendengaran -+ + +sensory neural+ + +sembuh setelah serangan, tp memberat jika muncul kembali+

Tidak simetris

6.Nausea and Vomitting++ + +

7.Kehilangan keseimbangan+

lama, bahkan setelah infeksi sembuh+

(ke samping)+

8.Gangguan penglihatan (merasa benda nya bergerak / loncat)+ + +

9.Sensasi berputar dipicu oleh perubahan / pergerakan kepala+ + +

10.Muncul tiba-tiba+

11.Serangan nyaDetik - minMin - hours

12.Nystagmus+

sec - min+

+

13.Demam (riwayat infeksi virus respiratory atau ear)+ + ++ + +

14.Penggunaan Obat + + +

Aspirin

15.Dix hall pike+

16.DamageVestibular ajaVestibular & 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 diureticii. Drugs :i. During attack:

ii. Pencegahan:

1. Prochlorperazine (buccastem)2. Antihistamines ( cinnarizine, cyclizineand promethazine teoclate)3. Betahistine5. Benzodiazepine

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.Types of non-destructive surgery include:

ii. endolymphatic sac decompression this can help reduce the pressure in your inner ear by increasing the drainage of the fluid of your inner ear, although evidence of its effectiveness forMnire's disease is limited

iii. inserting ventilation tubes (grommets) these are inserted into your ear to reduce the changes in pressure that cause Mnire's disease

iv. injecting steroid medication through the eardrum this is a newer type of treatment and there is only limited evidence to suggest it is effective

v. micropressure therapy a newer type of treatment with little evidence regarding its safety and effectiveness grommets are 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.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).

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

Destructive surgery may be considered if only one ear is affected by Mnire's disease. The hearing in the affected ear must be considered to be 'socially inadequate' (you cannot hear enough to function in social situations). As an approximate guide, if you cannot hear sounds that are below 50 decibels, this may count as socially inadequate.

Destructive surgery is used to destroy the part of your inner ear that is causing your vertigo attacks. However, these operations can cause permanent hearing loss in the treated ear so will only be considered if you already have permanently reduced hearing in the affected ear.

Destructive surgery canbe done by:

destroying the balance part of your audio-vestibular nerve the nerve that transmits sounds and balance information to the brain

destroying part of your vestibular labyrinth (labyrinthectomy) the system of tiny, fluid filled channels in the ear

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

Corticosteroids such as prednisolone may be recommended if your symptoms are particularly severe. They are often effective at reducing inflammation.Antibiotic ( kalo penyebab nya bakteri

Vestibular SCHWANNOMA1. 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 PembedaVertigo PeriferVertigo Sentral

OnsetAkutKronik

IntensitasSedang - beratRingan - sedang

Mual muntahSeringJarang

Gannguan pendengaranSeringJarang

TinnitusSeringJarang

Defisit neurologisTidak adaSering

NistagmusRotary / horizontalMultidirectional

Vertigo CENTRAL vs PERIFER

Central vertigo often produces other neurologic symptoms, although this generalization has many exceptions. The symptoms are 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):

Hypertension

Atrial fibrillation

History of prior CVA

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

> Status generalis

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

V

: Sensorik

Motorik ( masseter

Corneal reflex

VII

: Menyeringai

Angkat alis

Tutup mata kuat

VIII

: Cochlear ( gesekan jari

Vestibular :

Berdiri 2 kaki ( mata buka mata tertutup

Berdiri 1 kaki ( mata buka mata tertutup

Jalan tandem

Fukuda

Past pointing

IX, X

: dysphagia

Dysphonia

Arkus faring

Uvula

Refleks faring

XI

: Trapezius ( angkat bahu

Sternocleido ( tengok kanan kiri

XII

: 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 : raba8. Propeoceptive : posisi sendi

9. Koordinasi: Finger to nose

Disdiadokinesia

10. Otonom

Miksi

Defekasi

Diagnosis

Klinis

Topis

Etiologis

Klinis