VERTIGO

Ika Marlia
Bagian Neurologi RSUDZA/FK UNSYIAH
Banda Aceh
 VERTIGO
• SUATU ILUSI DIMANA SESEORANG MERASA TUBUHNYA BERGERAK TERHADAP
LINGKUNGANNYA, ATAU LINGKUNGAN BERGERAK TERHADAP DIRINYA
ANATOMI SISTEM VESTIBULAR PERIFER
 BPPV
Benign Paroxysmal Positional
Vertigo

Dr. Ika Marlia, M. Sc, Sp.S

 INTRODUCTION
Benign paroxysmal positional vertigo (BPPV) is the most
common peripheral vestibular end-organ disease and is typified by a sudden,
transient gyratory sensation which is accompanied by characteristic
nystagmus.
Symptoms are provoked by positional changes of the head with
respect to gravity and can range in severity from mild dizziness to debilitating
episodes that may induce nausea or vomiting, and significantly hinder daily
functioning.
Vertigo is defined as the subjective perception of rotational or
translational movement in the absence of an external stimulus. In the case of
BPPV, aberrant signals from semicircular canals create an illusion of motion
which results in vertigo.
PREVALENCE
A diagnosis of BPPV is established in 17%–42% of
patients with vertigo.

One European cross-sectional study estimated the lifetime

prevalence of BPPV to be 2.4%, and data from subsequent
research reported the incidence to be 10.7 to 64 cases per
100,000 per year. While BPPV can present at any age, its
peak onset occurs in the fifth and sixth decades of life.
Furthermore, the disorders disproportionately affect women
at a ratio of 2 or 3 to 1
 PATHOPHYSIOLOGY
Fig. 1. Left inner ear. Demonstration of canalithiasis of
the posterior canal and cupulolithiasis of the horizontal
canal.
“How endolymphatic debris influences cupular
dynamics”
Cupulolithiasis  the particulate matter becomes
adherent to the cupula itself. This cupular loading
renders the system sensitive to gravitational forces,
and the resulting alterations in cupular deflection lead
to pathological perceptions of motion. This
mechanism may represent the more chronic form of
BPPV.
Canalithiasis  cites freefloating particles within
the lumen of the canal as the causal factor. The
aberrant signal results when gravity pulls the particles
through the endolymph canal creating a plunger-like
effect which in turn causes ipsidirectional cupular
displacement
Notes:
A. Cupulolithiasis: adherence of
debris to the cupula making it
gravity sensitive (1. Sensory
epithelium. 2. Cupula. 3.
Otoconia. 4. Ampulla).
B. Cupulolithiasis: cupula deflection
after canal rotation.
C. Canalolithiasis: position of
particles before canal rotation.
D. Canalolithiasis: movement of
particles and cupula deflection
after canal rotation
Fig 2. Theories of posterior semicircular canal
stimulation in BPPv.
 ETIOLOGY BPPV may be distinguished from idiopathic
and secondary BPPV induced by the
detachment of otoconia due to various
& RISK FACTORS causes.

The main causes of secondary BPPV:

• Meniere disease (0.5%–30%)
The role of the most common comorbidities: • Head injury (8.5%–27%)
• Vestibular neuritis (0.8%–20%)
• Hypertension • Sensorineural hearing loss (0.2%–5%)
a significant risk of BPPV
• Diabetes mellitus recurrence
Less frequent causes of BPPV :
• Osteoporosis • Myocardial infarction
• Arthritis • Sarcoidosis
• Active ulcerative colitis
• Depression • Leukemia
• Carcinomas treated by chemotherapy and/or radiotherapy
 DIAGNOSIS
The diagnostic work in patients suffering from vertigo starts with a thorough evaluation of their
medical history.
• symptoms and duration,
• previous surgical interventions,
• history of infections or trauma and medications
• general physical and neurological examination.
• Vertigo is usually intense but has a brief duration of a few seconds only, followed by a longer
period with postural unsteadiness.
 Diagnostic Maneuvers
The Dix-Hallpike maneuver
is the definitive test for posterior canal BPPV

Fig. 3. Dix-Hallpike maneuver (right

ear).
A. the patient is seated with the head
rotated at 45°
B. the patient is quickly lowered into
supine position with neck extended
below the level of the table. With
head extended, examiner observes
the patient for nystagmus.

The response is considered positive when the patient

complains of vertigo and an accompanying nystagmus is
observed.
Back
back
back
back
back
 TREATMENT
• In general, vestibular suppressants and antiemetic medications are not
recommended in the treatment of BPPV.
• The guidelines of the American Academy of Otolaryngology – Head and Neck
Surgery Foundation (2008 and 2017) recommend against routine treatment of
BPPV with vestibular suppressant drugs such as antihistamines,
benzodiazepines or anticholinergics.
• Several therapeutic maneuvers were invented for the therapy of BPPV. The
major evolution in the treatment of BPPV was the “canalith repositioning
procedure” (CRP) induced by epley in 1992, based on the mechanism of
canalolithiasis
Fig.4 The epley canalith repositioning procedure
when the posterior semicircular canal of the left
ear is affected.

Notes:
A. The patient is sitting with the head turned
horizontally 45° to the affected (left) ear.
B. Left head-hanging position.
C. Rightward roll, right head-hanging position.
D. Further rightward roll.
E. Sitting up.
The head is held still in all positions for 1–3
minutes.
Fig. 5. Particle repositioning maneuver (right ear). Sequential movements
and the corresponding position of the utricle and semicircular canals.
Fig. 6. The Semont maneuver when the
posterior semicircular canal of the left ear
is affected.

Notes:
(A) The patient sits with the head turned
horizontally 45° to the healthy (right)
ear.
(B) Moving to left side-lying position (nose
up).
(C) Moving to the right side-lying position
(nose down). Then the patient returns
to initial position (D).
Again the head is held still in all positions
for 1–3 minutes.
 CONCLUSION
Benign paroxysmal positional vertigo is the most common peripheral
vestibular disorder and presents as brief, episodic, positionally provoked
vertigo.

The diagnosis can be made through clinical history along with diagnostic
maneuvers, and typically does not require additional ancillary testing.

While benign and often selflimiting, BPPV can have a considerable impact on
quality of life.

The particle repositioning maneuver is a simple and effective way to treat

posterior canal BPPV, the most common variant.
Meniere’s
Disease
“Meniere’s disease (MD) is a heterogeneous group of disorders defined by three
core symptoms: episodic vertigo, tinnitus, and sensorineural hearing loss.”

Sensorineural
hearing loss (SNHL),
which initially
fluctuates and
involves low and
Episodes of vertigo medium frequencies
associated with
ipsilateral cochlear
symptoms, such as
tinnitus or aural
fullness
The AAO-HNS criteria
▷ The Definite Meniere’s disease is characterized
with
○ episodic vertigo and
○ fluctuating low to medium frequency sensorineural
hearing loss,
○ fullness, and
○ tinnitus being manifested at least with two
episodes.

▷ The duration is mentioned to be between 20

min to 12 hours.
 Increased pressure
Accumulation of in the cochlear duct
endolymph (endolymphatic
hydrops [EH])

Damages the organ

Hearing organ
of corti

Overpressure leads
Loss of
to the rupture of
endocochlear
the inner ear
potential
membranes
 Repeated exposure
of hair cells to toxic
levels of a k+-
enriched perilymph
Long-term
vestibular
and auditory The overpressure
damage in
MD
Sudden rupture of
distended
membranes
 PEMERIKSAAN PENUNJANG
• LABORATORIUM
• TIDAK ADA YG SPESIFIK KECUALI PENYEBABNYA INFEKSI
• TES PENALA : KESAN TULI SENSORINEURAL
• OTOSKOPI : NORMAL
• TES KALORI
• PENURUNAN FUNGSI BAIK TERHADAP RANGSANGAN PANAS MAUPUN
DINGIN
• AUDIOGRAM : TULI SENSORINEURAL TERUTAMA NADA RENDAH
• TES GLISERIN
• UNTUK MEMBUKTIKAN ADANYA HIDROPS ENDOLYMPH
• UNTUK MENENTUKAN PROGNOSIS
• ELEKTROKOKLEOGRAFI (ECoG)
• MENILAI AKUMULASI CAIRAN YANG BERLEBIHAN PADA TELINGA TENGAH
• BRAINSTEM EVOKED RESPONSE AUDIOMETRY (BERA)
• UNTUK MENGETAHUI KERUSAKAN SISTEM KESEIMBANGAN TELINGA
BAGIAN DALAM
TATALAKSANA
THANK YOU