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VERTIGO - Coggle Diagram
VERTIGO
BALANCE PATHWAYS
- Maintaining balance depends on information received by the brain from three peripheral sources: eyes, muscles and joints, and vestibular organs.
- All three of these information sources send signals to the brain in the form of nerve impulses from special nerve endings called sensory receptors.
DEFENITION, RISK FACTOR & ETIOLOGI
RISK FACTOR
- Age >50 yearsold
- Gender, Woman > Man
- Head Trauma History
- Infection history
- Drugs (antidepressants or antipsychotics)
- Psychologis (Stress)
- Alcohol and smoking
ETIOLOGY
Peripheral Vertigo
- Acute vestibulopathy (vestibular neuritis or labyrintis)
- Meniere's disease
- Benign positional paroxysmal vertigo
- Perilymphatic fistula
- Cholesteatoma erosion
- Herpes Zoster Oticus
- Otosclerosis
Central Vertigo
- Migrainous vertigo
- Multiple sclerosis
- Cerebellopotine angle tumor
DEFENITION
Vertigo is a common presenting complaint in primary care offices and emergency departments. It is a symptom of vestibular dysfunction and has been described as a sensation of motion, most commonly rotational motion. It is important to differentiate vertiginous symptoms from other forms of dizziness, such as lightheadedness, which is most often associated with presyncope.
PATHOPHYSIOLOGY
- Asymmetry in the vestibular system accounts for the symptom of vertigo. Asymmetry may result from damage or dysfunction in the peripheral system, such as the vestibular labyrinth or vestibular nerve or a central disturbance in the brainstem or cerebellum.
- Though there may be a permanent vestibular disturbance, the symptom of vertigo is never permanent as the central nervous system adapts over days to weeks.
DIFFERENTIAL DIAGNOSIS
- Anxiety disorders
- Benign positional vertigo
- Brain neoplasms
- Chronic anemia
- Giant cell arteritis
- Herpes simplex encephalitis
- Labyrinthitis
- Mastoiditis
- Ménière disease
- Meningitis
- Migraine headache
- Multiple sclerosis
- Stroke
- Vertebrobasilar atherothrombotic disease
- Vestibular neuronitis
TREATMENT & EDUCATION
TREATMENT
- Epley maneuver (an extended version of the Dix Hallpike maneuver used as treatment) resolves 80% of cases.
- The condition usually subsides spontaneously in weeks to months, but 30% recur within 1 year. Long-term use of antivertigo medications (eg, meclizine) are generally contraindicated, as they have limited efficacy, they are sedating, and they inhibit vestibular compensation, which may lead to chronic unsteadiness.
EDUCATION
- Do not drive , walk without help, or operate heavy machinery when you are dizzy.
- Move slowly when you move from one position to another position. Get up slowly from sitting or lying down. Sit or lie down right away if you feel dizzy.
- Drink plenty of liquids. Liquids help prevent dehydration. Ask how much liquid to drink each day and which liquids are best for you.
- Vestibular and balance rehabilitation therapy (VBRT) is used to teach you exercises to improve your balance and strength. These exercises may help decrease your vertigo and improve your balance. Ask for more information about this therapy.
DIAGNOSIS APPROACH
- Dix-Hallpike maneuver: Have the patient turn his or her head 45 degrees right or left and go from a sitting to a supine position. If vertigo and the typical nystagmus (fast phase toward the affected side) are reproduced, benign paroxysmal positional vertigo is the likely diagnosis.
- Nystagmus that persists for > 1 minute, gait disturbance, or vomiting should raise concern for a central lesion.
MENIERE'S DISEASE
DEFENITION, RISK FACTOR & ETIOLOGY
RISK FACTOR
Risk factors include a family history of Meniere disease, preexisting autoimmune disorders, allergies, trauma to the head or ear, and, very rarely, syphilis. Peak incidence is between ages 20 and 50.
ETIOLOGY
he cause of Meniere's disease is unknown. Symptoms of Meniere's disease appear to be the result of an abnormal amount of fluid (endolymph) in the inner ear, but it isn't clear what causes that to happen.
DEFENITION
Meniere disease is a disorder of the inner ear characterized by hearing loss, tinnitus, and vertigo. In most cases, it is slowly progressive and has a significant impact on the social functioning of the individual affected.
DIAGNOSIS APPROACH
- The diagnosis is made clinically and is based on a thorough history and physi- cal exam. Two episodes lasting ≥ 20 minutes with remission of symptoms between episodes, hearing loss documented at least once with audiometry, and tinnitus or aural fullness are needed to make the diagnosis once other causes (eg, TIA, otosyphilis) have been ruled out.
- High resolution MRI imaging may directly show endolymphatic hydrops in the affected organs.
- Vestibular (caloric) function testing may show a significantly under-functioning affected organ in 42% to 74% and a full loss of function in 6% to 11%.
PATHOPHYSIOLOGY
Meniere’s disease is a disorder of the inner ear characterized by intermittent episodic vertigo, fluctuating hearing loss, ear fullness and tinnitus. The pathophysiology is commonly explained by a distension of membranous labyrinth by the endolymph, equally called endolymphatic hydrops.
TREATMENT & EDUCATION
TREATMENT
- Sodium restriction diet: Low-level evidence suggests that restricting the sodium intake may help to prevent Meniere attacks.
- Betahistine: Substantial disagreement in the medical community about the use of betahistine exist. A Cochrane review found low-level evidence to support the use of betahistin with substantial variability between studies. Medical therapy in many medical centers often starts with betahistine orally.
- Intratympanic steroid injections may reduce the number of vertigo attacks in patients with Meniere disease.
- Intratympanic gentamycin injections: Gentamycin has strong ablative properties towards vestibular cells. Side effects are a sensorineural hearing loss because of a certain amount of toxicity towards cochlear cells.
- Surgery with vestibular nerve section or labyrinthectomy: Nerve section is a therapeutic option in patients who failed the conservative treatment options and labyrinthectomy when surgical options failed. Labyrinthectomy leads to a complete hearing loss in the affected side.
EDUCATION
- Sit or lie down when you feel dizzy. During an episode of vertigo, avoid things that can make your signs and symptoms worse, such as sudden movement, bright lights, watching television or reading. Try to focus on an object that isn't moving.
- Rest during and after attacks. Don't rush to return to your normal activities.
- Be aware you might lose your balance. Falling could lead to serious injury. Use good lighting if you get up in the night. A cane for walking might help with stability if you have chronic balance problems.
COMPLICATION & PROGNOSIS
COMPLICATIONS
- Injury due to falls
- Anxiety regarding symptoms
- Accidents due to vertigo spells
- Disability due to unpredictable vertigo
- Progressive imbalance and deafness
- Intractable tinnitus
PROGNOSIS
- According to Perrez-Garrigues et al. the number of episodes of vertigo is higher in the first years of the disease and decrease in later years regardless whether patients receive treatment; most patients reach a "steady-state phase free of vertigo."
- As with vertigo, loss of hearing is highest in the early years of the disease and stabilizes in later years. Usually, there is no recovery from the hearing loss.