slide management vertigo in daily practice

8/11/2019 Slide Management Vertigo in Daily Practice

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dr. Kiki Mohammad Iqbal, SpS

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Keseimbangan Tubuh Dikontrol oleh 3 Sistem Sensoris

Vestibu lar, Visual, Propriosep ti f

Balance

dyfunct ion

Imbalance / Dizziness

Central Nervou s System

Skin, Muscle and J oint

(Propr iocept ive)

Postural control

via muscles

Goebel JA. Otolaryngol Clin North Am 2000;33:483

93.

Shepard NT, Solomon D. Otolaryngol Clin North Am 2000;33:45569

Controls eye

movements

Eye

(Visual)Inn er Ear

(Vestibular sy stem )

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Somatosensory

system

Psycho-affectivesymptom

Neurovegetativesymptom

Failure of

Central

Compensation

VERTIGO

Patofisiologi Keseimbangan

Visual

system

Vestibular

system


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Perasaan berputar baik seseorang terhadap

sekelilingnya ataupun sekelilingnya

terhadap seseorang

Vertigo bukan suatu diagnosa penyakit, tapi

hanya merupakan simptom

Dokter harus menentukan apa penyebabnya

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V E R T I G O


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Pada studi berbasis populasi :

Vertigo terjadi pada sekitar 47% 1, 2

Pada populasi dengan usia di atas 75 tahun :

Prevalensi vertigo 13% - 38%

40% perempuan dan 30% laki-laki

mengeluhkan beberapa bentuk gangguan

postural 2

1.Yardley L et al. Br J Gen Pract 1998;48:1131-352.Sixt E, Landahl S Age Ageing 1984;16:3938

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Preva le ns i Ver t ig o


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Vest ibu lar Non Vest ibu lar

Sensasi Spinning Swimming, floating,

swaying, rocking

Lama serangan Episodik Konstan

Pencetus Pergerakan kepala

atau badan

Stress, hiperventilasi,

lingkungan ramai

Gejala penyerta Mual, muntah, tinitus,

ketulian, oscillopsia

Pucat, takikardia,

sinkope

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K la s i f i k a s i Ve r t ig o


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S E N T R A L P E R I F E R

Ver t igo Ves t ib u la r


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5 10

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Disfungsi apparatus vestibular & nervus vestibularis

Vertigo Vestibular Perifer


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Kelainan di nukleus vestibularis dan conn ect ing central pathway

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Vertigo Vestibular Sentral

Disfungsi proses sentral


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S Y M P T O M V E R T I G O

PERIPHERAL CENTRAL

Episodes Acute and

remitt ing

Chronic and

unremit t ingOnset Sudden Gradual

Intensi ty Severe Mild / mod

Nausea, vom it ing Severe Varying

Aud i to ry sym ptoms Common Rare

Neuro log ica l sym ptom s Rare Common

Changes in conscious ness Infrequent Somet imes

Compensat ion / resolut ion Rapid Slow

Baloh RW. Otolaryngol Head Neck Surg 1998;119:559. Puri V, Jones E. J Ky Med Assoc 2001;99:31621.

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Vertigo Perifer vs Sentral


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C o n d i t i o n D e t a i l s

Benign p aroxysm al

posi t ion al vert igo

(BPPV)

Brief, position-provoked vertigo episodes caused by

abnormal presence of particles in semicircular canal

Menieres disease An excess of endolymph, causing distension of

endolymphatic system

Vest ibular neuron i t is Vestibular nerve inflammation, most likely due to virus

Acu te labyr inth i t is Labyrinth inflammation due to viral or bacterial infection

Labyr inthine infarct Compromises blood flow to the labyrinthine

Labyr inth ine

concuss ion

Damage to the labyrinthine after head trauma

Peri lymp h f is tu la Typically caused by labyrinth membrane damage

resulting in perilymph leakage into the middle ear

Auto imm une inner ear

disease

Inappropriate immunological response that attacks inner

ear cells

Decreas

ing

frequency

Baloh RW. Lancet 1998;352:18416. Mukherjee A et al. JAPI 2003;51:1095-101. Parnes LS et al. CMAJ2003;169:68193. Puri V, Jones E. J Ky Med Assoc 2001;99:31621. Salvinelli F et al. Clin Ter 2003;154:3418.

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Penyebab Vertigo Perifer


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C o n d i t i o n D e t a i l s

Migraine Vertigo may precede migraines or occur concurrently

Vascular disease Ischaemia or haemorrhage in vertebrobasilar system

can affect brainstem or cerebellum functionMult ip le sclerosis Demylination disrupts nerve impulses which can

result in vertigo

Vestibular

epi lepsy

Vertigo resulting from focal epileptic discharges in the

temporal or parietal association cortex

Cerebel lopont ine

tumours

Benign tumours in the internal auditory meatus

Baloh RW. Lancet 1998;352:18416. Mukherjee A et al. JAPI 2003;51:1095-101. Salvinelli F et al. Clin Ter 2003;154:3418. Solomon D. Otolaryngol Clin North Am 2000;33:579601. Strupp M, Arbusow V, Curr Opin Neurol 2001;14:1120.

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Penyebab Vertigo Sentral

Decreas

ing

frequency


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Tidak dijumpai perasaan berputar

Pasien mengeluhkan merasa melayang,

mengambang, bergoyang, mengayun

Biasanya pada saat berdiri

Merasa enak kalau duduk

Mual dan muntah biasanya tidak ada

Ggn organ penglihatan atau somatosensorik

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Ver t igo Non Ves t ib u la r


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Neurok imia Ver t igo

NEUROTRANSMITTER P E R I F E R S E N T R AL

Glutamat Eksitatori Synap Afferen Eksitatori

Acethylcholine (ACH) Eksitatori Synap Efferen Eksitatori

GABA Inhibitori Inhibitori

Glycine Belum Jelas Inhibitori

Dopamine Belum Jelas Eksitatori

Norepinephrine Belum Jelas Modulator

5-Hydroxytryptamine Belum Jelas Eksitatori

Histamine Belum Jelas Inhibitori ?


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Glutamat neurotransmitter eksitatori utama

Acethylcholine (ACH) agonis perifer dan

sentral reseptor muskarinik

Di perifer ACH terlibat pada eferent

brainstem sinaps sel rambut

Di sentral 5 subtipe reseptor ACH

di pons dan medulla berhubungan

dgn dizziness(subtipe M2)

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GABA dan glycine neurotransmitter

inhibitori pada koneksi antara second

order neuronvestibular dan neuron

okulomotorius

Pengaruh reseptor glycine


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Norepinefrin terlibat secara sentral dalam

memodulasi intensitas reaksi stimulasi

vestibular dan memfasilitasi kompensasi

Dopamin memfasilitasi kompensasi

vestibular

Agen selektif utk subtipe reseptor serotonin

memodulasi nausea

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Histamin dijumpai pada struktur vestibular

sentral secara difus

Terdapat 3 subtipe reseptor histamin

(H1, H2, H3) respons vestibular

Agonis H3 menginhibisi pelepasan

histamin, dopamin dan ACH

Pada vertigo meningkatnya Histamin reseptor

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Anamnesis

Pemeriksaan Fisik & Neurootologi

Pemeriksaan Penunjang

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Diagno sa Ver t igo


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Effect ive management requ ires ident i f icat ion of

vert igo type and cause.

Aim of treatment :

1. Treat the underly ing cause :

Pharmacotherapy

Part ic le repos i t ioning pro cedure

Surgery

2. Manage symptom s :

Pharmacotherapy

3. Promote long -last ing neural reorganisat ion :

Vestibu lar rehabi l i tat ion exercises

P e n a t a la k s a n a a n


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TIPE VERTIG O PENGOBATAN

PERIFER :

BPPV Canal i th reposi t ioning manoeuvre

Labyr inthine con cuss ion Vest ibular rehabi l itation

Menieres disease Low -sal t diet , diuret ic , surg ery, transtymp anic gentamic in

Labyr inth i t is Ant ib io t ics, removal of infected t issue, vest ibular rehabi l ita t ion

Peri lymph f istula Bed rest, avoidance of straining

Vest ibular neur i t is Br ief cours e of high-dose steroids, vest ibular rehabi l ita tion

SENTRAL :

Migraine Beta-blockers, calc ium channel block ers, tr icyc l ic amines

Vascu lar disease Contr ol of vasc ular risk factors , e.g., antiplatelet agents

Cerebel lopont ine tumours Surgery



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TERAPI SIMPTOMATIK VERTIGO :

SUPRESAN

VESTIBULARANTI EMETIKUM



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1) Supresan vestibular :

a) Antihistaminantikholinergik :

Dimenhydrinate

50 mg/4-6 jam

Diphenhydramine

Meclizine

12,5-50 mg/4-6 jam

b) Benzodiazepine :Lorazepam

0,5 mg 2x sehari

Diazepam

2 mg 2x sehari

Clonazepam

0,5 mg 2x sehari

Hain TC and Yacovino D. Pharmacologic Treatment for Persons with Dizziness. Neurol Clin2005;23:831-853



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1) Supresan vestibular :

c) Calcium channelblocker :

Flunarizine

10 mg 1x sehari

Cinnarizine

25 mg 3x sehari

d) Obat lainnya :Betahistine

Ginkgo biloba

Baclofen

Amantadine




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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) Domperidoned) Sulpiride

e) Ondansetron (4-8 mg 3x sehari)




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Bekerja pd neuron histaminergik

tuberomamilaria dan nukleus vestibularis

Betahistine memainkan peranan penting dalam

memperbaiki aliran darah telinga tengah

Meningkatnya oksigenasi telinga tengah ,

mencegah kerusakan reseptor sensorik dan

memperbaiki fungsi normal sel rambut yang

sensitif gerakan

B e t a h is t in e


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Diroleransi dgn baik dan efek samping minimal

Dosis tinggi (36-48 mg/hr) lebih efektif dari pada

dosis rendah (18-24 mg/hr)Efektif untuk vertigo vestibuler perifer terutama

yg rekuren

B e t a h is t in e


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0

2

4

6

8

10

12

6 mg 12 mg 6 mg 12 mg

BPPV MV

Numberofc

asesonHighStimulatingRateABR

ABR: Auditory Brainstem Response, BPPV: Benign Positional Paroxysmal Vertigo, MV: Migrainous Vertigoadministered for 1 month, n: 37

Merislon 12mg t.i.d is more effectivethan Merislon6mg t.i.d1

pre

post

1. Graph adapted from Zi-ming W, et al. The effect of betahistine mesylate as a treatment to vertigo induced by inner ear ischemia. Chinese Scientific Journal of Hearing and Speech Rehabilitation 2007; 5: 26-29.

2. Japanese Package Insert, July 2009; 8th version

p


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0

20

40

60

80

100

120

6 mg 12 mg 6 mg 12 mg

BPPV PCI

DHIScore

DHI: Dizziness Handicap Inventory, DHI Score: 0-30 is mild, 31-60 is medium, 61-100 is severe, BPPV:Benign Positional Paroxysmal Vertigo, PCI: Posterior Circulation Ischemia,

administered 1 month, n:60

Improves Quality of LifeVertigo patient1

pre

post



IN-MRFI-14C-02


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0

20

40

60

80

100

3 7 14 30 60 90

Imp

rovementrate(%)

Days

LM: Liberatory Manoeuvre, BE: Betahistine mesylate, BPPV: Benign Positional Paroxysmal Vertigo.32mg/day administered until complete recovery, n=52

Addition of Merislon providesfaster recovery of BPPV patients1

LM

LM-BE

**

1. Cavaliere M, et al. Benign Paroxysmal Positional Vertigo: a study of two manoeuvres with and without betahistine. Acta Otorhinolaryngol Ital 25, 107-112, 2005.


*p


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1. Cavaliere M, et al. Benign Paroxysmal Positional Vertigo: a study of two manoeuvres with and without betahistine. Acta Otorhinolaryngol Ital 25, 107-112, 2005.


0

20

40

60

80

100

3 7 14 30 60 90

Imp

rovementrate(%)

Days

BD: Brandt Daroff Exercises, BE: Betahistine mesylate, BPPV: Benign Positional Paroxysmal Vertigo,32mg/day administered until complete recovery, n=51

Addition of providesfaster recovery of BPPV patient1

BD

BD-BE

*

*

*p


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0

0.5

1

1.5

2

2.5

Before therapy 1 3 6 12

Meanscore

ofvertigosymptoms

Week

No Statistically significant difference between the therapy group

t.i.d has similar efficacy withcombination of two Anti vertigo drugs1

Dimenhydrinate + Cinnarizine (n=40) Betahistine (n=40)

1. Adopted from Novotny, et al., Fixed combination of cinnarizine and dimenhydrinate versus betahistine dimesylate in the treatment of Menieres disease, International Tinnitus Journal, Vol.8, No.2: 115-123 (2002)2. Japanese Package Insert, July 2009; 8th version

IN-MRFI-14C

-05


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99%Total Adverse

Reaction :26 patients

1%

Merislon is well tolerated2No Adverse Reaction Adverse Reaction

Total Patient:2.254



Doses: 18mg 36mg /dayCommon Adverse Reaction:

Nausea (0.44%), Skin Eruption (0.13%)

IN-MRFI-14C-06


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Mesylate salt 5x more soluble, and 2.6x morebioavailable than the hydrochloride salt

Mean plasma concentrations in male beagleEngel GL, et al. Salt form selection and characterization of LY333531 mesylate monohydrate. International Journal of Pharmaceutics 198 (2000): 239-247

IN-M

RFI-14C-07


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1. Konfirmasi Vertigo ?

2. Tentukan Jenis

3. Tentukan Letak Lesi

4. Cari Kausa

5. Pilih Terapi :

Kausal

Simtomatik

Rehabilitasi

Vertigo Vestibular Vertigo Non Vestibular

Perifer Sentral Visual Somatosensorik

(Proprioseptif)

Algor i tma Ver t ig o36


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TERIMA KASIH

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slide management vertigo in daily practice

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