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Abdul Gofir
RS Sardjito/FK-UGM
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Timothy 2006
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Patofisiologi
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NORMAL PROCESSING
Vestibular system
Visus
Propiocepsis
Sensory information
= coordinated
CENTRA = known pattern
Oculomotor centra
Stabilization of visual field
Muscles of the body
Static and kinetic equilibrium
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ABNORMAL PROCESSING
Vestibular system
Visus
Propiocepsis
Sensory information
=abnormal
stimuli
=Excesive
=Discordant information
CENTRA
ALARM
WARNING
= unknown patern
NEUROVEG.
CENTRA
CORTEX
BECOMES CONSCIOUS
AFFECTIVE COMPONENT
VERTIGO
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PATOFISIOLOGI VERTIGO
Reseptor
Mata
Vestibuler
Propioseptik
Pengelola data
Saraf Pusat
Efektor
Otot skelet
Mata
Leher
Badan
Anggota gerak
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VERTIGO TEORY
1. Sensoris Conflict
Rangsangan di atas ambang fisiologis
Banjir informasi
2. Neural mismatch
Comparator - memori
4. Neurohumoral
Receptor
Cerebral cortex
Hypothalamus
Retina
Vestibular
Cerebellum
Pituitary
Motion
stimuli
Vestibular
Apparatus
Vestibular
Nuclei
CTZ
Somatosensory
Receptors
Autonomic
centres
Vomiting centre
KONFLIK SENSORIS
NAUSEA
Dizziness
Somnolence
Headache
Depression
Performancedecrement
Increased
Secretion of
ADH, ACTH,
GH, PRL
SWEATING
PALLOR
Decreased Gastric
motility,
Cardiovasculer &
Inspiratory changes
VOMITING
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Neural Mismatch
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Sensory Rearrangement
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NEUROHORMONAL
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Head Acceleration
Endolymph Displacement
Cupular Angle
Cilia Bending
Receptor Cell Potential
Synaptic Action
Generator Potential
Primay Afferent
Action Potentials
CNS
Perception
VOR
Posture
Ket:
CNS: Central Nervous System
VOR: Vestibulo Ocular Reflex
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STRESS
Behavioral Changes
CIRCADIAN RYTHMS
SSP
HIPPOCAMPUS
CORTEX
5-H-T GABA
(+)
Ach (-)
(+)
LO
(+)
?
IL
CRF
(-)
LYMPHOCYTES
PITUITARY
CSS
ADR.MED
(-)
ACTH
ACTH
A
N
T
I
G
E
N
S
(-)
ADR CORTEX
STEROIDS
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IMUNOLOGICAL
RESPONSES
IMUNOSUPRESSION
KETERANGAN:
5 HT
: Serotonin
Ach
: Acetyl Cholin
GABA
: Gama Amino Butyric Acid
CSS
: Central Sympathic System
ADR.MED
: Adrenal Medula
(+)
: Exitatory
(-) : Inhibitory
CRF
: Corticotropin Releasing Factor
ACTH : Adreno Corticotropic Hormon
ADR. Cortex : Adrenal Cortex
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Cervicogenic Vertigo
Vertigo Perifer
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Benign Paroxysmal
Positional Vertigo (BPPV)
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Canalolithiasis Theory
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Causes
Idiopathic
Infection (viral neuronitis)
Head trauma
Degeneration of the peripheral end organ
Surgical damage to the labyrinth
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Symptoms
Starts suddenly
first noticed in bed, when waking from sleep.
Any turn of the head bring on dizziness.
Patients often describe the occurrence of
vertigo with
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Diagnosis
Lab Studies:
Imaging Studies:
Procedures:
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Treatment
Medications
The
Canalith
Repositioning
Procedure (CRP)
Surgery
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Canalith Repositioning
Procedure
( CRP )
The treatment of choice for BPPV.
Also known as the Epley maneuver,
The patient is positioned in a series of steps so as to slowly
move the otoconia particles from the posterior semicircular
canal back into the utricle.
Takes approximately 5 minutes.
The patient is instructed to wear a neck brace for 24 hours and
to not bend down or lay flat for 24 hours after the procedure.
One week after the CRP, the Dix-Hallpike test is repeated.
If the patient does experience vertigo and nystagmus, then the
CRP is repeated with a vibrator placed on the skull in order to
better dislodge the otoconia.
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Clinical Trial
Ruckenstein (2001) Therapeutic efficacy of the Epley
canalith repositioning maneuver. Laryngoscope
Eighty-six patients
74% of cases that were treated with one or two
canalith repositioning maneuvers had a resolution of
vertigo as a direct result of the maneuver.
A resolution attributable to the first intervention was
obtained in 70% of cases within 48 hours of the
maneuver.
An additional 14% of cases that were treated had a
resolution of vertigo.
Only 4% of cases (three patients) manifested BPV
that persisted after four treatments.
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Differential Diagnosis
Ataksia Vestibuler
Ataksia Serebellar
Beberapa hariLebih permanen
minggu kemudian
lenyap
Vertigo
Vertigo (-)
Jatuh ke satu sisi
(-)
Tampak deviasi bila
(-)
menunjuk
Dipengaruhi posisi
(-)
kepala
BAEP / BERA
ABR
Auditory Brainstem Response
Latency:
Latency is the time from the stimulation
onset to the peak point of a wave. The
waveforms are called wave I, wave II,
wave III, wave IV, wave V, wave VI and
wave VII in order of appearance. The
waves I, III and V are stable and have
large amplitude. Depending on the
patient, the peaks of the waves II, IV
and V may not be obtained. The wave II
may have an equivocal waveform and
the waves IV and V may make a fused
waveform.
BAEP
Peripheral or Central
Cause?
Central
Peripheral
Labyrinth or
vestibular nerve
dysfunction
Recurrent
Nystagmus-horizontal
Position change
Moderate to severe
vertigo
Cerebellum or
brain stem
dysfunction
Continuous
Nystagmus-vertical
Mild vertigo
Non-positional
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CHARACTERISTICS OF PERIPHERAL
AND CENTRAL VERTIGO
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Central Vestibular
Disorders
Metastatic Tumor
Meningioma
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BPPV
Labrynthitis
Menieres disease
Acoustic Neuroma
Motion sickness
Cervicogenic
Perilymphatic
fistula
Vestibular
neuronitis
Semicircular canal
infection
Semicircular canal
water penetration
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Dysarthria
Cerebellar Hemorrhage
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Acoustic Neuroma
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Pengobatan
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1. PENGOBATAN KAUSAL
Kebanyakan kasus vertigo tidak diketahui
sebabnya, kalau penyebabnya diketahui
pengobatan kausal merupakan pilihan utama
2. PENGOBATAN SIMPTOMATIK
Pengobatan ini ditujukan pada dua gejala
utama yaitu rasa vertigo ( berputar,
melayang ) dan gejala otonom (mual,
muntah) Gejala yang paling berat pada
vertigo vestibuler fase akut, menghilang
beberapa hari karena ada kompensasi Back
Ca entry Blocker
Antihistamin
Antikolinergik
Monoaminergik
Bensodiasepin
Antidopaminergik
Histaminik
Antiepileptik
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ANTIHISTAMIN
Efek antikolinergik dan merangsang inhibitori
monoaminergik, akibatnya inhibisi nervus vestibularis.
Obat : Sinarisin
( Merron ), dimenhidrinat (Dramamine), prometasin
(Phenergan), meclizine, cyclizine
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ANTIKOLINERGIK
Mengurangi eksitabilitas neuron dengan
menghambat jaras eksitatori kolinergik ke nervus
vestibularis, mengurangi firing rate dan respon
nervus vestibularis terhadap rangsang. Obat :
Skopolamin, atropin
MONOAMINERGIK
Merangsang jaras inhibitori-monoaminergik pada
n. vestibularis sehingga eksitabilitas neuron
berkurang.
Obat : Amphetamine, efedrin
BENZODIAZEPIN
Menurunkan resting aktiviti neuron
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ANTIDOPAMINERGIK (FENOTIASIN)
Bekerja pada CTZ dan pusat muntah di medula
oblongata. Obat : Clorpromazin (largactil),
proclorperazine (Stemetil), Halloperidol (Haldol)
HISTAMINIK
Inhibisi neuron polisinaptik pada nervus
vestibularis lateralis. Obat : betahistin
ANTIEPILEPTIK
Karbamasepin, fenitoin pada temporal lobe
epilepsi dengan gejala vertigo
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Flunarizine
Depresor labirin
Lanjutan
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Betahistine
Analog histamin
Meningkatkan aliran darah
a.vertebrobasiler
Memperbaiki mikrosirkulasi telinga
dalam
Menghambat neuron polisinaptik
Dosis 1 tablet 3 kali sehari
Hati-hati pada penderita gastric ulcer,
asma bronchiale, pheochromocytoma
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Drug-Induced Dizziness
Eaton, 2003
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Dysequillibrium
Is a feeling that a fall is
imminent and is characterized
by unsteadiness or imbalance
that occurs only when erect and
primarily involves the trunk and
lower extremities rather than
the head; the sensation
diappears when sitting
or2003lying
Eaton,
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VERTIGO
DEFINISI:
Vertigo adalah perasaan penderita
merasa dirinya atau dunia berputar
ETIOLOGI
1. Otologi:
24-61% kasus
Meniere Desease
Parese N VIII Uni/bilateral
Otitis Media
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2. Neurologik
23-30% kasus
Gangguan serebrovaskuler batang otak/
serebelum
Ataksia
karena neuropati
Gangguan visus
Gangguan serebelum
Gangguan sirkulasi LCS
Multiple sklerosis
Malformasi Chiari
Vertigo servikal
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3. Interna:
+/-
tekanan darah
Aritmia kordis
Penyakit koroner
Infeksi
Hipoglikemia
Intoksikasi Obat: Nifedipin,
Benzodiazepin, Xanax,
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