slide management vertigo in daily practice
TRANSCRIPT
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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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Neurok imia Ver t igo
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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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Neurok imia Ver t igo
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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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Neurok imia Ver t igo
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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
P e n a t a la k s a n a a n
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TERAPI SIMPTOMATIK VERTIGO :
SUPRESAN
VESTIBULARANTI EMETIKUM
P e n a t a la k s a n a a n
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TERAPI SIMPTOMATIK VERTIGO :
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
P e n a t a la k s a n a a n
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TERAPI SIMPTOMATIK VERTIGO :
1) Supresan vestibular :
c) Calcium channelblocker :
Flunarizine
10 mg 1x sehari
Cinnarizine
25 mg 3x sehari
d) Obat lainnya :Betahistine
Ginkgo biloba
Baclofen
Amantadine
Hain TC and Yacovino D. Pharmacologic Treatment for Persons with Dizziness. Neurol Clin2005;23:831-853
P e n a t a la k s a n a a n
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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) Domperidoned) Sulpiride
e) Ondansetron (4-8 mg 3x sehari)
Hain TC and Yacovino D. Pharmacologic Treatment for Persons with Dizziness. Neurol Clin2005;23:831-853
P e n a t a la k s a n a a n
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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
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
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.
2. Japanese Package Insert, July 2009; 8th version
*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.
2. Japanese Package Insert, July 2009; 8th version
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
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
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
37
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