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8/13/2019 DR SS Vertigo PIN Nyeri Nyeri Kepala Dan Vertigo Surabaya 2006
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INTRODUCTION
Vertigo:
Common chief complaint
Symptom of multiple diseases
40% all American for Dizziness
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Causes
of
vertigo
A. General medical C. Otological
1. Haematological 1. Menieres disease
Anaemia, Hyperviscosity, Miscellaneous 2. Post-traumatic syndrome
2. Cardiovascular 3. Positional nystagmus
Postural hypotension 4. Vestibular neuronitis
Carotid sinus syndrome 5. Infection
Dysrhythmia 6. Otosclerosis and Pagets disease
Mechanical dysfunction 7. Vascular accidents
3. Metabolic 8. Tumours
Hypoglycaemia 9. Auto-immune disorders
Hyperventilation 10. Drug intoxication
B. Neurological D. Miscellaneous
1. Supratentorial 1. Ocular
Epilepsy, Syncope, Psychogenic 2. Cervical
2. Infratentorial 3. Multisensory dizziness syndrome
Multiple sclerosis, Ischaemia
Infective disorders
Degenerative disorders
TumoursForamen magnum abnormalities
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DIFFERENTIAL DIAGNOSIS
1. Vertigo Dizzy
Vomitus
Disequilibrium
3. Epilepsy:
Aura
Unconsciousness
EEG
Head CT Scan
2. Syncope Absence
Light headaches
Nausea
Visual disturbances Unconsciousness
Low blood pressure
Postural Hypotension
ECG deviation
< Doppler
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DIFFERENTIAL
DIAGNOSIS
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The Type of Vertigo
Central
Peripheral
Mixed type
Gold Standard?
Anamnesis Observation
Diagnosis
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DIAGNOSIS OF VERTIGO
AnamnesisTherapy (+)
Peripheral > Central
CentralRisk Factors
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ALGORITHM to DIAGNOSE AND MANAGE OF VERTIGO
Full history and examination
MedicalInvestigation
Neuro-otologicinvertigation
NeurologicInvestigation
Central
Vertigo
Peripheral
vertigo
Medical
Treatment of
Acute Attack
Medical
Treatment of
Chronic Recurrent Vertigo
Physical exercise
Regimens of maneuvers
Psychological support
Vestibular sedatives
FailureSurgery (?)
(+ / - )
Mixed Type
Vertigo
Supportive
Symptomatic
Causative
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Differential Diagnosis andManagement for the Chiropractor,
Peripheral or Central Causes?
Peripheral
Labyrinth or vestibular
nerve dysfunction
Recurrent
Nystagmus-horizontal
Position change
Moderate to severe
vertigo
Central
Cerebellum or brain
stem dysfunction
Continuous
Nystagmus-vertical
Non-positional
Mild vertigo
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Schimp D. A diagnostic algorithm forthe dizzy patient Chiropractic
Vertigo
Episodic
positional
Episodic
Non-positional
Non-episodic
Non-positional
DIAGNOSTIC ALGORITHM FOR THE DIZZI PATIENT
1 2 3
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Episodic
positional
Benign
positionalCervicogenic
Vertebobasilar
ischemia
gradualsudden sudden
Fades 30-60
secondspersists progression
1
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Episodic non-positional
Menieres Perilymph fistula
Non-episodic
Non-positional vertigo
Labyrinthitis Acoustic neuroma Cerebral hemorrhage
2
3
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BPPV Benign Recurrent of Vertigo
BPPV: Acute Vertigo
Benign
Movement / provocation of head Horizontal nystagmus
Benign Recurrent of Vertigo
Acute
Several minutes hours
Static of disequilibrium
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Diagram - interaction of
autonomic, psychological, and vestibular symptoms
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EXAMINATION
Blood laboratorynot specific
Neurological examination
Radiology examination BERA (Brainstem Evoked
Response Auditory)
Audiometry ?
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NEUROLOGICAL EXAMINATION
Within normal limits
Anamnesis >> important
Acute vertigoemergency case Peripheral vertigoacute onset, horizontal nystagmus
Central vertigoRisk factors(?), vertical / rotational
nystagmus
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NEUROLOGICAL EXAMINATION (cont)
Provocation test to increase vertigo symptoms :
Hallpike Dick maneuver
Examination of:
1. Consciousness
2. Cranial Nerve
3. Motoric
4. Sensory
5. Cerebellar functions
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SPECIFIC EXAMINATION FOR VERTIGO
Heart rate and rhythm of the heart
Palpation on the Carotid artery
Auscultation of the Carotid artery
Romberg test
Tandem gait
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ANOTHER STIMULATION FOR VERTIGO
Orthostatic hypotension Valsava maneuver
Rotational of the head
Nylen Barani Test
Hallpike-Dick Maneuver Caloric test
Neuro-ophtalmology examination
Otology Examination
Head Ct Scan / MRI
Audiometry
BERA
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Hallpike Dick Maneuver
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TREATMENT
Supportive
Symptomatic
Causative Operative
Onset of Therapy:
Acute
Chronic
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Acute Phase
1. Anti Cholinergic
Sulfas atropine 0,4 mg im
Scopolamine 0,5 mg i.v; repeated every 3 hours
2. Sympathycomimetic
Epidame 1,5 mg i.v repeated every 30 minutes
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Inhibition of Vestibular Nucleus
1. Anti histamine :
Diphenhidramine 1,5 mg im/ p.o repeated every 2 hours
Dimenhidrinate 50-100 mg every 8 hours
Flunarizine
2. Sedative :
Phenobarbital 10-30 mg/ 6 hours Diazepam 5-10 mg
Chlorpromazine (CPZ) 25 mg
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CAUSATIVE THERAPHY
1. Vertebrobasilar insufficiency Anti platelet aggregation
Vasodilators
Flunarizine
2. Epilepsy Phenitoine
Carbamazepine
3. Migraine Ergotamine
Flunarizine
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OPERATIVE THERAPHY
Tumors
Cervical spondylosis
Basilar impression
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CONCLUSION
Incidence of vertigo : 10-15%
Uncomfortable but not fatal
Differential diagnosis of Central and peripheralvertigo treatment
Maneuver to precipitate vertigo
Recurrent must be prevent Etiology and symptomatic treatment
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