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1. HOW TO MANAGE PATIENTS WITH VERTIGO ? Andradi S. Department of Neurology. University of Indonesia, Jakarta 2. OUTLINES 1. Vertigo vs Dizziness 2. Vertigo: - Types -…
  • 1. HOW TO MANAGE PATIENTS WITH VERTIGO ? Andradi S. Department of Neurology. University of Indonesia, Jakarta
  • 2. OUTLINES 1. Vertigo vs Dizziness 2. Vertigo: - Types - Pathophysiology - Causes 3. Approach to Patients with Vertigo - Diagnosis - Treatment
  • 3. VERTIGO vs DIZZINESS DIZZINESS : is a balance disorder. VERTIGO : is one of the types of Dizziness
  • 4. Body Balance is Controlled by 3 Sensory Systems: Vestibular, Visual, Proprioceptive VISUAL (Eye) VESTIBULAR PROPRIOCEPTIVE (Muscle, joint, skin) (Labyrinth) CENTRAL NERVOUS SYSTEM (Coordination, integration) Control of eye movement Postural control by muscle BALANCE dysfunction Imbalance /Dizziness Goebel JA. Otolaryngol Clin North Am 2000;33:483–93. Shepard NT, Solomon D. Otolaryngol Clin North Am 2000;33:455–69
  • 5. BALANCE DISORDER / DIZZINESS Four Types Vestibular Vertigo Non-vestibular Vertigo Disequilibrium Presyncope Sensation: “Spinning” Sensation: “Floating” “Swaying” “Rocking “ Sensation: “Falling”  Unstable  Disappear when sitting Sensasi: “Fainting” Sistem: Vestibular Sistem: Visual Proprioseptive Psychogenic Sistem: Spinal • Peripheral nerve Cerebellar Sistem: Cardiovascular
  • 6. DIZZINESS : Frequency 40% Peripheral vestibular dysfunction 10% Central brainstem vestibular lesion 25% Presyncope or disequilibrium 15% Psychiatric disorder 10% Unknown cause December 4, 2001, Swedish Family Medicine, Dobrina Okorn, MD
  • 7. OUTLINES 1. Vertigo vs Dizziness 2. Vertigo: - Types - Causes 3. Approach to Management of Patients with Vertigo - Diagnosis - Treatment
  • 8. VERTIGO Vertigo is an ilusion of movement in which a subject feels him-/herself or the surrounding object is moving. Two types: I. Vestibular Vertigo ( “spinning” vertigo / “true” vertigo) Vestibular dysfunction II. Vertigo Nonvestibular (“non-spinning” vertigo) Visual dysfunction Proprioceptive dysfunction
  • 9. VERTIGO VESTIBULAR vs NONVESTBIULAR VESTIBULAR (vestibular system) NONVESTIBULAR (visual & proprioceptive) Sensation Spinning, rotating Swaying, floating, rocking lightheaded Duration Episodic Constant Precipitating factor Head or body movement Stress, hiperventilation, cardiac arrhythmia Associated symptoms Nausea, vomit, tinitus, deafness, oscillopsia Paleness, paresthesia, syncope
  • 10. VESTIBULAR VERTIGO “True Vertigo”; “Spinning Vertigo”
  • 11. Balance requires information of similar intensity from both vestibular systems Head movement Activation of cells in left vestibular system Activation of cells in right vestibular system Central nuclei 10 10 Normally, the input from left and right vestibular system is of similar intensity (e.g. of size ‘10’)
  • 12. Peripheral vestibular vertigo Dysfunction of vestibular apparatus, vestibular nerve Central nuclei 5 10
  • 13. Central Vestibular Vertigo dysfunction in central processing Central nuclei 10 10
  • 14. Vestibular Vertigo Two types 1. Peripheral Vertigo Lesion site: - Inner ear (canalis semicircularis, sacculus, utriculus) - N. vestibularis. 2. Vertigo Sentral Lesi site: - Brainstem (nucleus vestibularis) - Serebelum - Talamus - Korteks serebri
  • 15. VESTIBULAR VERTIGO PERIPHERAL vs CENTRAL Symptom Peripheral Central Vertigo episodes Mild severe Chronic and unremitting Symptom onset Sudden Gradual Imbalance Mild/mod. Severe Nausea, vomiting Severe Varying Auditory symptoms Common Rare Neurological symptoms Rare Common Changes in mental status/ consciousness Infrequent Sometimes Compensation/resolution Rapid Slow Baloh RW. Otolaryngol Head Neck Surg 1998;119:55–9. Puri V, Jones E. J Ky Med Assoc 2001;99:316–21.
  • 16. CAUSES OF VERTIGO PERIPHERAL – Canalithiasis (BPPV) – Neuritis vestibularis /labyrinthitis – Meniere’s disease – Trauma – Ototoxic drugs (aminoglycosides) CENTRAL 50% 25% 10% – Vascular (vertebrobasilar stroke) 50% – Demyelinating (multiple sclerosis) – Drugs (anticonvulsant, alcohol, hypnotic)
  • 17. OUTLINES 1. Vertigo vs Dizziness 2. Vertigo: - Types - Causes 3. Approach to Management of Patients with Vertigo - Diagnosis - Treatment
  • 18. Approach to Management of Patient with Vertigo Patient complaint (pusing, mabuk) Step 1 Verify : “VERTIGO” or NOT? No Yes step 2 Identify : TYPE of VERTIGO Step 3 Establish: DIAGNOSIS / ETIOLOGY Step 4 Planning THERAPY Headache, stress, other dizziness
  • 19. STEP 1 and STEP 2 Verifying and Identifying Types of Dizziness QUESTION : “Apakah anda terasa mau pingsan ?” ( “Pingsan / fainting”) • PRESYNCOPE “Apakah anda merasa kedua tungkai tidak stabil, dan menjadi stabil kalau duduk ?” • DYSEQUILIBRIUM (“ Jatuh / falling”) “Apakah lingkungan anda kelihatannya berputar, atau anda sendiri terasa berputar ?” - VESTIBULAR VERTIGO” (“ Berputar / spinning”) “ Apakah merasa lingkungan bergoyang, atau anda sendiri terasa bergoyang ?” • VERTIGO NONVESTIBULAR (“Melayang / light-headed”) “Apakah anda merasa gugup atau cemas ? • PSYCHOGENIC (“ Melayang / light-headed”)
  • 20. STEP 3 ESTABLISHING DIAGNOSIS AND ETIOLOGY OF VERTIGO 1. History taking 2. Physical examination a. General PhysicaL Examination b. Routine Neurologic Examination c. Bed-side Neuro-otologic examination 3. Investigations (as indicated) - ENG, EEG, EMG, CTScan, MRI, MRA - Laboratory
  • 21. 1. HISTORY TAKING Sensation - Spinning, rocking, swaying, swimming, light-headed ? Temporal profile - Onset, duration, course. Head/body position - Occurs on lying, turning, rising, sitting up, standing, nodding, bending, head turning Associated symptoms Tinnitus, deafness, cranial nerves symptoms, hemiparesis, hemihipesthesia, hemiataxia. Past history - Head injury, stroke, cardiac and pulmonar disorders, CNS infection, ENT diseases, psychiatric disorder. Medication Drugs that may give rise to dizziness, including garamycin, sedative, tranquilizer.
  • 22. 2. PHYSICAL EXAMINATIONS a. General Physical Examinations Searching for pathology related to current dizziness complaint: - Hypertension, hypotension - Cardiovascular disorder - Pulmonary disease - Malignancy
  • 23. 2. PHYSICAL EXAMINATION b. Routine Neurologic Examination - Mental - Cranial nerves - Motor system - Sensory system - Autonomic system
  • 24. 2. PHYSICAL EXAMINATION c. Bedside Neurootologic Examination I. Otologic examination II. Hearing testing III. Vestibular examination
  • 25. I. Otologic Examination • External ear • Tympanic membrane
  • 26. II. Hearing Testing - Using tuning forks - For differentiating conductive and sensorineural hearing loss √ RINNE test √ WEBER test
  • 27. III. VESTIBULAR EXAMINATION 1. Eye Movement Test 2. Examination of Balance and Coordination
  • 28. 1. EYE MOVEMENT TESTS - Aim: to evaluate Vestibulo-ocular Reflex (VOR) - Manifestation: Nystagmus - Examinations: - ● Spontaneous nystagmus - ● Gazed-evoked nystagmus - ● Head thrust test - ● Head shaking test - ● Dix Hallpike ( for BPPV)
  • 29. 2. EXAMINATION OF BALANCE AND COORDINATION A. Test for BALANCE 1. Seated : hold out arms and legs, eyes open/eyes closed 2. Stand: Romberg test, sharpened Romberg test 3. Gait : broad-based gait 4. Tandem walking, past-pointing, Fukuda test, Babinski-Weil test. B. Test for COORDINATION (cerebellum) 1. Upper extremity a. Finger- to- nose b. Finger-nose-finger c. Adiadochokinesis d. Rebound phenomen 2. Lower extremity a. Heel-knee-shin b. Repetitive heel tapping c. Rebound phenomenon 3. Ocular dysmetria
  • 30. THERAPY OF VERTIGO I. Etiologic Pharmacologic therapy Surgery II. Symptomatic Pharmacologic therapy III. Rehabilitative Vestibular Rehabilitation Therapy (VRT) IV. Prevention of aggravating factor Diet control Life-style modification V. Physical Conditionng Exercise
  • 32. TREATMENT OF THE CAUSES OF VERTIGO CAUSE Peripheral Cause TREATMENT BPPV Canalith repositioning manoeuvre (Brandt-Daroff, Epley, Semont Labyrinthine concussion Vestibular rehabilitation Meniere’s disease Low-salt diet, diuretic, surgery, transtympanic gentamicin Labyrinthitis Antibiotics, removal of infected tissue, vestibular rehabilitation Perilymph fistula Bed rest, avoidance of straining Vestibular neuritis Brief course of high-dose steroids, vestibular rehabilitation CENTRAL CAUSE Migraine Beta-blockers, calcium channel blockers, tricyclic amines Vascular disease Control of vascular risk factors, e.g., antiplatelet agents CPA tumours Surgery Baloh RW. Lancet 1998;352:1841–6. Goebel JA. Otolaryngol Clin North Am 2000;33:483–93.
  • 34. Symptomatic PharmacologicTreatment I. ANTIVERTIGO 1.Vestibular Suppressant a. Ca antagonist : Flunarizin b. Vasodilator : Betahistine c. Tranquilizer : diazepam, haloperidol, sulpiride, clonazepam d. Antihistamine : Difenhidramine, meclizine. 2. CNS stimulant Ephedrin, amphetamin II. ANTIEMETIC 1. Anticholinergic : atropine, scopolamine 2. Antidopaminergic: : Prochlorperazine, metoclopramide. 3. Antihistamine: Difenhidramine III. PSYCHOAFFECTIVE Clonazepam, diazepam for anxiety and panic attack
  • 35. How to Choose Antivertigo Drug ?
  • 36. Vestibular Suppressant Clinical evidence Drugs with sedative effect may disturb central compensation mechanism Ideal Drug √ Effective in suppressing vertigo √ Non-sedative does not disturb central compensation
  • 37. Ideal Vestibular Suppressant a. Ca antagonist : Flunarizin b. Vasodilator : Betahistine c. Tranquilizer : diazepam, haloperidol, sulpiride, clonazepam d. Antihistamin : Difenhidramine, meclizine. a, c, d b (Betahistine) Sedative effect !! - No sedative effect !!
  • 39. VESTIBULAR REHABILITATION THERAPY (VRT) TYPES I. Specific VRT for BPPV II. Balance exercises III. Gaze Stabilization Exercises IV. Visual Dependence Exercises V. Physical conditioning exercise
  • 40. BPPV Benign Paroxysmal Positional Vertigo
  • 41. Vestibular Rehabilitation Therapy 1. Specific Interventions for BPPV a. Semont maneuver b. Epley maneuver c. Brandt Daroff Exercise
  • 42. a. Semont Maneuver
  • 43. b. Epley maneuver 30 sec 30 sec 30 sec Other name: • Canalith repositioning • Particle repositioning
  • 44. c. Brandt Daroff maneuver -Each position 30 sec or vertigo subsides in < 30 sec -If Vertigo >30 sec  sit up 30 sec other side Time Exercise Duration --------------------------------------------Morning 5X 10 min Noon 5X 10 min Evening 5X 10 min ---------------------------------------------
  • 46. PREVENTION OF AGGRAVATING FACTOR Control of Nutrition and Life-style: - • Adequate food and diet - • Avoid excessive alcohol, tobacco - • Medicine: sedative, ototoxic, opioid - • Sleeping, working position.
  • 47. V. PHYSICAL CONDITIONING EXERCISE Recommend doing one or more of the following, 3 times a week: - Walking on a treadmill (1 mile) - Brisk walking outdoors (1 mile or more) - Riding a stationary bicycle - Swimming
  • 49. Therapeutic Modalities Options: 1. Symptomatic treatment 2. Treatment for Specific Conditions 3. Rehabilitative therapy 4. Prevention of aggravating factor SINGLE THERAPY or INTEGRATED THERAPY ?
  • 50. Single Therapy •Etiologic or Specific treatment is paramount, but it does not offer the patient a significant improvement or vertigo symptoms resolution when used alone • Symptomatic drug therapy bring improvement in 75.1% of the patients with peripheral vestibulopathies and 39.8% of the patients with central vestibular disorders • Vestibular rehabilitation therapy were efficient in 51.1% of patient when used alone • Diet and feeding habit change improve vertigo in 42.2% patients with vestibulopathies Gananca et al. Brazilian Journal of Otorhinolaryngology 2007;73(1):12-8
  • 51. INTEGRATED THERAPY Integrated Vestibular Therapy (IVT) A combination therapeutic modalities of Specific Treatment, Symptomatic Treatment, Vestibular Rehabilitaton Therapy, Diet Control and Life-style changes, brought about 96 % of vertigo improvement.
  • 52. CONCLUSIONS Balance function depends on the integrity of vestibular, visual and somatosensory systems. Disorder of these system (s) leads to dizziness, which includes 4 types: Vestibular Vertigo, Nonvestibular Vertigo, Presyncope, and Disequilibrium. Treatment of vertigo includes etiologic, symptomatic, vestibular rehabilitative therapies, dietary and life habit control, and conditioning physical exercise. Integrated Vestibular Therapy (IVT) proved to bring better resolution of vertigo compared to single therapy
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