SSS Alasan mengapa diperlukan pemeriksaan penunjang tersebut, ditulis dengan lengkap Pemeriksaan laboratorium : darah lengkap ( bila ditemukan leukositosis berarti terdapat tanda infeksi)

7/29/2019 SSS Alasan mengapa diperlukan pemeriksaan penunjang tersebut, ditulis dengan lengkap Pemeriksaan laboratori

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WEEK 3

LECTURE DR. RENO HARDOYO KELAN (LECTURE 3 & 4)

Anatomy & Physiology of balance apparatus

1. Understand the anatomy and embryological of the labyrinthine structureThe vestibular apparatus is located in the inner ear and comprises of 3 semi-circular canals and

vestibule which contain these sensor organs:

a. The utricleb. The sacculec. 3 ampulla

These organs contain the sensory hair receptors:

d. the maculae (for the utricle & saccule)e. and cristae (ampullae).

2. Describe the anatomy of the temporal bone and the vestibular apparatus


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3. Describe central pathway for balanceStatic equilibrium: is concerned with the orientation of the body relative to the ground ( Linear

acceleration) which interprets the position of the head permitting the CNS tomaintain stability

and posture when the head and body are not moving.

Receptors for static Equilibrium are the maculae. The Maculae are in the

Saccule : is responsible for vertical acceleration Utricle: Is responsible for horizontal acceleration

Dynamic equilibrium is concerned with the maintenance of posture,

especially in the head (Rotational movement) which interprets balance when

one is moving, or at least the head is moving.

The receptors for Dynamic equilibrium are the ampulla which is found in thesemicircular canals.

The ampulla is responsible for the change in rotational movement.

5. Explain how receptors in the semicircular canals detect rotational acceleration and how thereceptor in the saccule and utricle detect linear acceleration


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The Visual System

The 2nd system that plays an important role in equilibrium is the visual system. The effect of the visual system is best noticed when there is a conflict between the messages

that reach the brain.

The train illusion. When sitting in a fixed train, you look by the window and seeanother train starting to move. You then do feel like you are moving .

Propreceptive system

Nerve endings that respond to muscle and tendon stretch are calledproprioceptors (ex. Muscle spindle). They send signals to the brain, giving it

information about the posture of the body.

The proprioceptors are available in the muscles, ligaments, tendons, andjoints. It which they can detect the initiation and termination of body

movement.

Note: In a sitting situation the system that is responsible for equilibrium in thePRORIORECEPTOR

4. Understand the physiology of equilibrium6. List the major sensory inputs that provide the information which is

synthesized in the brain into the sense of position in space

A peripheral sensory apparatus (located in the inner ear, macula and crista

ampulla) The 8th (vestibulocochlear) cranial nervecentral processing

system (located in the vestibular nuclear complex in the brain stem and

the cerebellum)...

and a motor output system (mediated through the vestibulo-ocular reflex

[VORl and the vestibulospinal reflex [VSR]).

The vestibule-ocular reflexhelps maintain fixation of the eyes on an object with movement ofthe head. Both angular and linear acceleration signals are use in the vestibule-ocular reflex.

Projections from the vestibular nuclei to the extraocular muscle nuclei allow for eye movements

that counteract head movements for gaze stabilization.

The vestibulospinal reflex allows for input from the vestibular organs to be use for posture andstability in a gravity environment. Ex. a head tilt to one side stimulates both the otoliths and

semicircular canals. Stimulation of the otoliths results in the transmission of impulses to the

spinal cord increase in extensor activity on the side of the body and increase in flexor activity

on the contralateral side.


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7. Gangguan yang dapat terjadi pada sistem keseimbangan (balance apparatus)Dizziness

Dizziness is a common description for many different feelings Dizziness : unsteadiness, motion intolerance, imbalance, floating, a tilting sensation, Vertigo,

Lightheadedness, Pre syncope

Dizziness may be attributed to a wide variety of causes (non vertigo)Vertigo

Vertigo is the true rotational movement of self or the surroundings. True vertigo is often due to inner-ear disease, whereas symptoms of nonvertigo may be due to

CNS, cardiovascular, or systemic diseases.

FALSE SENSE OF MOTION, usually rotational. Feeling that you or your environment is moving or spinning Illusion of movement :

When you feel as if you yourself is moving, it's called subjective vertigo, The perception that your surroundings are moving is called objective vertigo

2 TYPES 1- CENTRAL VESTIBULAR CAUSES (Brain stem or cerebellum) 2- PERIPHERAL VESTIBULAR CAUSES ( Labyrinth or vestibular nerve

PERIPHERAL (ear) CENTRAL (brain)

Vestibular Neuronitis Benign Positional Vertigo Meniere's Disease Ear Trauma Labyrinthitis Drugs (aminogycosides, quinine, ASA) Perilymph fistula Degenerated Otoconia (cupololithiasis) Autoimmune ear disease cholesteatoma

Stroke in Brainstem Tumor in brainstem Multiple Sclerosis Encephalitis Migraine (rare) Drugs (esp. sedatives) Seizures (rare) Anxiety and Panic Motion Sickness Acoustic Neuroma Head trauma

8. Cara mendiagnosis Physical Exam and Otoscopic

examination,

Neurologic Exam Dix-Hallpike Maneuver (central vs

Peripheral)

Complete Audiometric Testing No LAB testing! Brain imaging : MRI , MRA
http://www.pneuro.com/publications/dizzy/bppv.htmlhttp://www.pneuro.com/publications/dizzy/bppv.html


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a. Dix-Hallpike :BPPV Pemeriksaan keseimbangan dengan lebih obyektif : Posturografi Elektronistagmografi

b. Pemeriksaan keseimbangan sederhana : Examinations of coordination and gait are used for testing

cerebellar function (the cerebellum coordinates muscle

actions to produce organized activities such as walking).

Past pointing

c. Tes Romberg d. Stepping test e. Epley Maneuver

Vestibular neuritis (viral infection suspected)

the most common cause of acute vertigo, with an incidence of 170 cases per 100,000 people. is believed to result from a reactivation of herpes simplex virus that affects the patient's

vestibular ganglion and vestibular nerves.

A prodromal upper respiratory tract illness may or may not be present. Vertigo is without auditory or other CNS symptoms and lasts for several days. One third of patients have chronic vestibular symptoms and develop BPPV. Sudden, incapacitating, severe vertigo with no hearing loss or other findings Lasts up to 1 wk, with gradual lessening of symptoms
http://emedicine.medscape.com/article/218580-overviewhttp://emedicine.medscape.com/article/218580-overviewhttp://emedicine.medscape.com/article/218580-overview


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Clinical evaluation Gadolinium-enhanced MRI Besides symptomatic treatment methylprednisolone has been found to provide relief of vertigo

with normalization of the ENG at one month.

BPPV / Vertigo posisi paroksismal jinak

Gangguan vertigo perifer yg sering dijumpai Gejalanya : keluhan vertigo yg tiba2 pada perubahan posisi Penyebabnya kanalolithiasis partikel2 kalsium karbonat dari fragmen otokonia (otolith) yang

terlepas dari macula utriculus masuk ke KSS

Otokonia dari utrikulus terlepas dan masuk ke dalam salah satu KSS dan tersangkut,menimbulkan rangsangan semu pada saat bergerak

Otokonia dalam Sakulus tidak punya kemampuan utk bermigrasi ke KSS Otokonia yang terlepas dan bermigrasi dapat disebabkan trauma kepala, infeksi atau kelainan

lain di telinga dalam atau proses degenerasi karena usia

Severe, brief (< 1 min) spinning triggered by moving head in a specific direction Nystagmus is fatigable, and is torsional, beating toward the undermost ear Hearing and neurologic examination intact Dix-Hallpike maneuver to assess characteristic positional nystagmus Pengobatan :

1/CRT (canalis repositioning treatment) misal Epley manouvre, perasat liberatory dan latihan

brand daroff to teach vestibular habituation exercises (repeated adoption of the position

causing vertigo )

2/Reduce alcohol intake,if patient is alcoholic.

3/Drugs histamine analogues(betahistine), vestibular sedatives(prochlorperazine),

antidepressants.

4/Last choice is posterior semicircular canal denervation and obliteration by transmastoid laser

(deafness may follow )


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vestibular exercises

Penyakit Meniere

Adanya gangguan keseimbangan cairan endolimf, hidrops endolimf pada koklea danvestibulum secara mendadak dan tiba2

Penyebab diduga o/k :1.Naiknya tekanan hidrostatik diujung arteri

2. berkurangnya tekanan osmotik didalam kapiler

3. Meningkatnya tekanan osmotik ekstrakapiler

4. Jalan keluar sakus endolimfatikus tersumbatpeningkatan cairan endolimf

Kelainan bilateral pada 1/3 kasus Kemungkinan penyebab : herediter, autoimun, infeksi atau idiopatikne, infectious, or idiopathic Gejala klinik : trias, vertigo yang hilang timbul,tinitus dan tulisensorineural terutama nada

rendah yang berfluktuasi

Pengobatan : Lebih dari 80% meberikan respons baik dengan pengobatan konservatif simptomatik,

anti muntah, sedatif dll, vasodilatansia perifer utk mengurangi tekanan, pembatasan

garam dan diuretikd to conservative therapy with salt restriction and diuretics.

Kortikosteroid oral atau intra timpani dapat menstabilkan penyakit ini Penyuntikan Gentamisin intra timpani digunakan untuk mengurangi gejala vestibuler

tetapi hanya diberikan pada penderita dengan pendengaran yg buruk

Documents

SSS Alasan mengapa diperlukan pemeriksaan penunjang tersebut, ditulis dengan lengkap Pemeriksaan laboratorium : darah lengkap ( bila ditemukan leukositosis berarti terdapat tanda infeksi)