1

P E N DA H U L U A N
Balance results from a complex interaction of
sensory information from several sources :

1) Vestibular system (labiryinth)

→ sensory hair cells within the
inner ear monitor the position
and motion of the head in the
environment

2
P E N DA H U L U A N
Balance results from a complex interaction of
sensory information from several sources :

2) The eye → visual

cues are important in
maintaining balance
and oculomotor control

3
P E N DA H U L U A N
Balance results from a complex interaction of
sensory information from several sources :

3) Proprioceptive :
a) Skin pressure receptors → provide
information about which part of the
body is in contact with the ground

4
P E N DA H U L U A N
Balance results from a complex interaction of
sensory information from several sources :

3) Proprioceptive :
b) Muscle and joint sensory
receptors → provide information
on the position of the limbs in
the environment

5
P E N DA H U L U A N

Balance results from a complex interaction of

sensory information from several sources :

T I N G K AT R E S E P S I

6
P E N DA H U L U A N

Sensory information from all relevant

sources → is processed in the CNS →
specifically the brain stem and cerebellum

T I N G K AT I N T E G R A S I

7
P E N DA H U L U A N

Sensory information from all relevant

sources → is processed in the CNS →
specifically the brain stem and cerebellum

with additional input from the cerebral cortex

T I N G K AT P E R S E P S I

8
P E N DA H U L U A N

The output from this processing → controls

motor responses relating to eye movement,
postural control and perceptual output →
allowing the body to navigate in the
environment

Controls eye Postural control

movements via muscles

Balance 9
P E N DA H U L U A N
Contradictory or missing information from any
of the sensory systems, or an impairment of the
central processing of information

dizziness / imbalance
dysfunction
Controls eye Postural control
movements via muscles

Balance 10
 TIPE SENSASI SISTEM
1) Vertigo :
a. Vertigo Vestibuler Spinning Vestibuler
b. Vertigo Non Vestibuler Light headed • Visual
• Proprioseptif
2) Presyncope Fainting Kardiovaskular
3) Dysequilibrium Falling • Serebellar
Unsteady • Spinal
11
● Vertigo → suatu bentuk gangguan
orientasi ruangan di mana dpt bersifat :
♦ vertigo subjektif → perasaan dirinya
bergerak thd ruangan sekitarnya
♦ vertigo objektif → ruangan sekitarnya
bergerak thd dirinya
● Prevalensi vertigo → sekitar 4–7%
● Populasi usia > 75 thn → prevalensi 13-38%

12
● Vertigo → suatu gejala subjektif
● Istilah yg digunakan penderita → berbeda
● Pusing, puyeng, oyong, melayang, dsb
● Minta penderita utk menguraikan apa yg
dirasakan pada saat serangan vertigo
→ rasa berputar, rasa tertarik ke bumi,
melayang, penglihatan bergoyang, dsb

13
 VERTIGO VESTIBULAR VERTIGO NON VESTIBULAR
Rasa Melayang, Goyang,
Sifat Vertigo Rasa Berputar
Sempoyongan
Sifat Serangan Episodik Kontinu

Mual / muntah (+) (-)

Ggn Pendengaran (+) / (-) (-)

Gerakan Pencetus Gerakan Kepala Gerakan Objek Visual

Ramai orang, lalu lintas,
Situasi Pencetus (-)
macet, sibuk, pasar, swalayan
Letak Lesi Sistem Vestibular Sistem Visual, Somatosensorik

14
 VERTIGO VESTIBULAR

PERIFER SENTRAL

Bangkitan Vertigo Mendadak Lebih Lambat

Intensitas Berat Ringan

Pengaruh Gerakan Kepala (+) (-)

Gejala Otonom (++) (±)

Gangguan Pendengaran (+) (-)

Tanda Fokal Otak (-) (+)

15
ANATOMI SISTEM VESTIBULAR

SENTRAL PERIFER

16
16
ANATOMI SISTEM VESTIBULAR

PERIFER :

 End organ vestibuler :

- kanalis semisirkularis
- utrikulus
 Ganglia vestibularis
- sakulus
Scarpey
- saccu-endolimpatikus
 Nervus vestibularis
17
17
ANATOMI SISTEM VESTIBULAR

SENTRAL :

 Nukleus vestibularis
di medulla oblongata
 Serebelum dan
Connecting Central
Pathway

18
ETIOLOGI VERTIGO

19
ETIOLOGI VERTIGO
O TO L O G I C V E RT I G O :

 BPPV
 Meniere’s Disease
 Vestibular Neuritis
 Labyrinthitis
 Bilateral Vestibular Parese
 Perilymph Fistula
 Trauma
 Tumors compressing N.VIII
 Obat-obatan
20
ETIOLOGI VERTIGO

CENTRAL VERTIGO :

 Stroke dan TIA (VB Insuf)

 Basilar Artery Migraine
 Seizures
 Multiple Sclerosis
 Chiari Malformation

21
ETIOLOGI VERTIGO
NON VESTIBULAR VERTIGO :
■ Polyneuropathy
■ Myelopathy
■ Multisensory Deficit
MEDICAL / SYSTEMIC
VERTIGO :
 Postural Hypotension
 Cardiac Arrhytmia
 Hypoglicemia and DM
 Medication Effects
 Viral Syndrome
■ Cervical Trauma
■ Arthritis Cervicalis
UNLOCALIZED
VERTIGO SYNDROMES
 Anxiety and Panic
 Posttraumatic Vertigo
 Hyperventilation
 Malingering
 Unknown
22
 BPPV is the most common cause of Vertigo
Survey of 625 ENT specialists in France
% patients per 100 cases

Cause of vertiginous symptoms

Toupet M et al. Rev SFORL 2004;83:57–63.

23
● Benign Paroxysmal Positional Vertigo
● Karakteristik :
♦ serangan vertigo perifer
♦ berulang dan singkat
♦ berhubungan dgn perubahan posisi
kepala dari tidur melihat ke atas
kemudian memutar kepala

24
● Prevalensi 2,4% meningkat sesuai usia
● Wanita >> laki-laki untuk semua umur
● Etiologi :
♦ Idiopatik → 50%
♦ simptomatik : pasca trauma, pasca
labirintitis, pasca operasi, dll
● Prognosis : kambuh 40-50% dalam 5 thn

25
● Patofisologi :
♦ Makula dalam utrikulus → diduga
merupakan sumber partikel kalsium
→ menyebabkan BPPV
♦ Partikel kalsium karbonat (otokonia) →
memiliki densitas 2x lipat dr endolimf
→ berespons thd perubahan
gravitasi & gerakan akselerasi lain

26
 Anterior SCC
Lateral SCC
Posterior SCC
Ampula
Common membranous
crus
utrikulus
Ampula sakulus

Sekum kupular
Sekum vestibular Skala timpani
Skala vestibulum
Duktus koklea
 Otolit

Membran gelatinous

Stereovilli

Sel sensorik

Sel penunjang
BPPV

● Patofisologi :
1. Hipotesa kupulolitiasis
Adanya debris yang berisi kalsium
karbonat berasal dari fragmen otokonia
→ terlepas dari makula utrikulus yang
berdegenerasi → menempel pada
permukaan kupula kanalis
semisirkularis posterior
BPPV

● Patofisologi :
1. Hipotesa kupulolitiasis
Perubahan posisi → kanalis posterior
berubah posisi → kupula bergerak
secara sentrifugal → muncul nistagmus
dan vertigo
BPPV

● Patofisologi :
2. Hipotesa kanalitiasis
Kristal kalsium karbonat bergerak di
dalam kanalis semisirkularis →
endolimf bergerak → menstimulasi
ampula dalam kanalis → muncul
nistagmus dan vertigo
Diagnosis jenis vertigo, lesi anatomis, dan
penyebab nya ditegakkan berdasarkan :
1) Anamnese :
● Bentuk serangan
● Sifat serangan dan intensitas
● Keadaan yang memprovokasi
● Gangguan otonom, ggn pendengaran
● Penggunaan obat, penyakit sistemik
32
 “Apakah anda terasa mau pingsan ?” (“Pingsan /
fainting”) → PRESYNCOPE
 “Apakah anda merasa kedua tungkai tidak stabil,
dan menjadi stabil kalau duduk ?” (“ Jatuh / falling”)
→ DYSEQUILIBRIUM
 “Apakah lingkungan anda kelihatannya berputar,
atau anda sendiri terasa berputar ?” (“ Berputar /
spinning”) → VERTIGO VESTIBULAR
 “Apakah merasa lingkungan bergoyang, atau anda
sendiri terasa bergoyang ?” (“Melayang / light-
headed”) → VERTIGO NON VESTIBULAR

33
Diagnosis jenis vertigo, lesi anatomis, dan
penyebab nya ditegakkan berdasarkan :
2) Pemeriksaan fisik / neurologis :
a) Fungsi vestibuler / serebelum :
● Romberg test ● Tandem Gait test
● Past-pointing test ● Fukuda test
● Head-shaking test
b) Saraf kranialis
c) Fungsi motorik dan sensorik
34
Diagnosis jenis vertigo, lesi anatomis, dan
penyebab nya ditegakkan berdasarkan :
3) Pemeriksaan khusus neuro otologi :
a) Nylen Barani atau Dix Hallpike test
b) Test kalori
c) Elektronistagmografi (ENG)
d) Audiometri
e) Brainstem Auditory Evoked Potential (BAEP)

35
Diagnosis jenis vertigo, lesi anatomis, dan
penyebab nya ditegakkan berdasarkan :
4) Pemeriksaan penunjang :
a) Laboratorium, EKG
b) EEG, EMG
c) Neuroimaging

36
 Kepala menengok

30-45° ke sisi kiri /

kanan, menatap dahi

pemeriksa,

perhatikan adanya

nistagmus spontan

37
 Kepala pasien
dipegang, lalu
tubuh dibaringkan
dengan cepat sampai
kepala menggantung
15-30° di bawah
garis horisontal
→ nistagmus 10-15‫״‬

38
Setelah itu pasien

dikembalikan ke

posisi duduk

dengan cepat,

perhatikan adanya

nistagmus selama

10-15‫״‬
39
 Hal yang sama
dilakukan kembali
pada sisi yang lain
→ nistagmus
posisional → dapat
membedakan
kelainan perifer atau
sentral
40
 Nistagmus Posisional

Perifer Sentral

Latensi (+) 2-20 dtk (-)

Fatique (+) (-)

Vertigo (+) (+ / -)

Ke telinga atas /
Arah Nistagmus Ke telinga bawah
bervariasi

Lamanya < 1 menit > 1 menit

41
 DURASI EPISODE VERTIGO

Detik : Menit s/d Jam : Sehari lebih :

BPPV Meniere’s disease Vestibular neuritis

Perilymph fistula Multiple sclerosis
Migraine Ischaemia impacting
Transient ischemic attack on the brain stem

42
 Effective management requires identification of
vertigo type and cause.
 Aim of treatment :
1. Treat the underlying cause :
● Pharmacotherapy
● Particle repositioning procedure
● Surgery
2. Manage symptoms :
● Pharmacotherapy
3. Promote long-lasting neural reorganisation :
● Vestibular rehabilitation exercises
43
TIPE VERTIGO PENGOBATAN
PERIFER :
BPPV Canalith repositioning manoeuvre
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

SENTRAL :
Migraine Beta-blockers, calcium channel blockers, tricyclic amines
Vascular disease Control of vascular risk factors, e.g., antiplatelet agents
Cerebellopontine tumours Surgery

44
TERAPI SIMPTOMATIK VERTIGO :

SUPRESAN
ANTI EMETIKUM
VESTIBULAR

45
 TERAPI SIMPTOMATIK VERTIGO :
1) Supresan vestibular :

a) Antihistamin b) Benzodiazepine :
antikholinergik : ● Lorazepam
● Dimenhydrinate 0,5 mg 2x sehari
50 mg/4-6 jam ● Diazepam
● Diphenhydramine 2 mg 2x sehari
● Meclizine ● Clonazepam
12,5-50 mg/4-6 jam 0,5 mg 2x sehari
Hain TC and Yacovino D. Pharmacologic Treatment for Persons with Dizziness. Neurol Clin 2005;23:831-853 46
 TERAPI SIMPTOMATIK VERTIGO :
1) Supresan vestibular :

c) Calcium channel d) Obat lainnya :

blocker : ● Betahistine
● Flunarizine ● Ginkgo biloba
10 mg 1x sehari ● Baclofen
● Cinnarizine ● Amantadine
25 mg 3x sehari

Hain TC and Yacovino D. Pharmacologic Treatment for Persons with Dizziness. Neurol Clin 2005;23:831-853 47
 TERAPI SIMPTOMATIK VERTIGO :
2) Anti emetikum :
a) Phenothiazine :
● Prochlorperazine (5-10 mg tiap 6-8 jam)
● Promethazine (25 mg tiap 6-8 jam)
b) Metoclopramide (10 mg 3x sehari)
c) Domperidone
d) Sulpiride
e) Ondansetron (4-8 mg 3x sehari)
Hain TC and Yacovino D. Pharmacologic Treatment for Persons with Dizziness. Neurol Clin 2005;23:831-853 48
49
50
 1. Konfirmasi Vertigo ?

Vertigo Vestibular 2. Tentukan Jenis Vertigo Non Vestibular

Perifer Sentral 3. Tentukan Letak Lesi Visual Somatosensorik

(Proprioseptif)

4. Cari Kausa

5. Pilih Terapi :
● Kausal
● Simtomatik
● Rehabilitasi

51
TERIMA KASIH

52