FK UPN Veteran Jakarta

Shindy Kurnia Putri

NRP: 1410221029
Pembimbing :
Letkol CKM dr.Heriyanto, SpS
 ABSTRACT

Based on the current literature treatment of vertigo and dizzines was

summarized depending on its origin. Attention was drawn to the most
common causes of vertigo and early differential diagnosis between central
and peripheral vertigo. There are three main methods of treatment for vertigo:
pharmacotherapy, rehabilitation and surgical treaatment. Pharmacotherapy in
the treatment of vertigo has its place mainly in the acute phase of attacks.
Rehabilitation is one of the most important methods of vestibular
compensation support, recommended in the vertigo treatment after the
resolution of acute symptoms in most cases. Benign paroxysmal positional
vertigo usually release after repositional maneuevers such as Epley
maneuver. In some diagnoses, such as Meniere’s disease or migraine
associated vertigo, appropriate diet can be able to preventing the attacks.
Surgery is used in some cases where there is no improvement after
pharmacotherapy and also in tumors, vascular and cervical spine lesions. In
some patients with vertigo, treatment success depends on multidisclipinary
cooperation: an otolaryngologist, a physiotherapist, an internist, a vascular
surgeon, a neurosurgeon or a psychiatrist.
 Most common causes of
vertigo and early differential
diagnosis between central and
peripheral vertigo.
Main methods treatments:
-Pharmacotherapy
-Rehabilitation
- Surgical treatment
 Step in dx. Vertigo

-Concomitant diseases and medications

- Getting information about duration and frequency of
symptoms
- Presence of triggering/alleviating factors
- Accompanying signs

Etiology

Most Common Less Common

Causes Causes
 According to the data published by
Tacikowska and Kubieczk-Jagielska,
50% of balance disorders is caused by
pathology of the inner ear, 5% is caused
by neurological disorders, 5% includes
orthostatic dizziness and adverse effects
of drugs, about 25% of vertigo and
dizziness etiology is unknown.
 Most Common Less Common
Causes Causes

BPPV
Acute vestibular neuritis or
labyrintitis Vertebrobasiler ischemia
Meniere disease Benign or malignant ear tumors
Migraine and cervical migraine
Anxiety disorders
Vertigo’s Diagnostics
 Taking into account different possible causes
of vertigo (especially in older patients), making
a correct diagnosis can be difficult. Data
collected in the anamnesis will be used to
perform the proper differential diagnostics
(Table 1).
Vertigo’s Diagnostics
 Physical examination should include
otoscopy and examination of the presence
of nystagmus. We should also perform
easy neurological examination known as
cerebellar tests –the finger-to-nose test,
the rapid alternating –movements tests for
dystaxia and dysmetria
(dysdiadochokinesia) and static dynamic
tests to assess the efficiency posture and
gait (Romberg’s test, Unterberger’s
stepping test).
 Trying Romberg’s test, the patient stands
with feet together and outstretched upper
limbs. Then the patient is observed to
become wobbly and possible direction of
incidence is noticed. In unterberger’s test
the patient is asked to walk on the spot
with his eyes closed. If the patient rotates
to one side he may have a vestibular
dysfunction on that side, but this test
should not be used to diagnose lesions
without the support of the other tests.
 Another test we should perform is a measurement of blood
pressure and pulse in horizontal position, sitting and standing
position (diagnostics of orthostatic hypotension)

 In order to differentiate between peripheral and central vertigo Hallpikes’s

manuever should be performed. The examination is carried out by rapid movement
of patient’s body, when his head is in a “hanging” position that is 10 degrees
deviation from vertical.

This test induces vertigo or nystagmus in a person suffering from BPPV. Delay in
the occurance of vertigo or nystagmus (by 2-40 seconds), high intensity of the
symptoms and rapid recovery after aboutt 60 seconds point to the peripheral
localization of the cause of vertigo. No delay in the occurance of vertigo and
nystagmus, mild intensity of the symptoms and their persistance of above 1 minute
indicate the central disorders.
 The diagnosis of central cause of vertigo
is also supported by walking difficulties
and the presence of other neurological
deficits beyond balance disorders.
Hypoacusis or tinnitus suggests
peripheral cause o vertigo.
Vertigo Treatment
 Symptomatic  Acute attack of vertigo accompanied by
vegetative symtomps (vertigo sock phase ex: nausea,
vomiting, heart palpitations, sweating and anxiety) and the
patient usually requires hospitalization.

 Neuroleptics
- Include chlopromazine (fenactile 25-50 mg every 6 h
them), promezine (50 mg every 6-8 h iv or im). This
medicines are potent anxiolytic because of effect on the
dopamine receptors (D2 receptor antagonists) in the
limbic system, hypotalamus and cortex. In addition they
work antiemetic and sedative. It is important to take into
account the occurance of adverse reactions of
neuroleptics possibility, such as convulsions, dyskinesia,
cardiac arrythmias, and hypotension.
 Benzodiazepines are the most commonly
used group of anxiolytics, including
diazepam (Relanium, valium 15-20 mg in
every 12 h), and rarely, collaboration with the
anesthesiologist, midazolam. Side effects,
which should be remembered, are quick
addiction possibility and memory disorders.

 In the symptomatic treatment of acute vertigo

prokinetics like Metoclopramide (MTC) may
be used, which also exerts Dopamine
receptor (D2) blockade in the central nervous
system and has a transquilizing and
antiemetic effect, inhibits nausea.
 Causal pharmacotherapy is used when there is strong evidence of the vertigo
etiology. We might dealing with such a situation in the case of the patient with
vertigo diagnosed as otitis media complication or inner ear inflammation,
where antibiotics are served.

 Currently, an important role in the treatment of chronic vertigo

has arelaitvely safe medicine of one of the best-documented
efficacy-betahistine. Betahsitine blocks presynaptic histamine
H3 receptors and stimulates weak postsynaptic H1, but does
not exhibit a significant affinity for H2. As a result, it increases
the release of histamine in the nerve endings. It exerts
relaxant effect on the precapilar sphingcters in the inner ear
microcirculation, which leads to improved stria vascularis
blood flow of labyrinth.
 It inhibits the activity of vestibular neurons.
Betahsitine reduces the frequency and intensity
of vertigo and tinnitus. It is approved for the
treatment of meniere disease.

 The optimal therapetic effects are visible only

after a few moths, so it is recommended to use
for 2-3 months, 24 mg 2 times a day. Another
advantage of betahistine is that it does not
reduce patient’s psychophysical activity. The
only contraindication to the use betahistine is a
pheochromocytoma. The medicine should be
used with caution in patients with asthma,
severe hypotension and peptic ulcer.
Meniere’s Disease
 Meniere disease (endolymphatic hydrops of
labirynth) is characterized by vertigo, tinnitus, low
frequency fluctuating hearing loss and feeling of
fullness of the ear. In this disease imbalance
between absorption and secretion of endolymph and
its improper composition leads to increase in volume
of endolmyph and in consequence to distention of
the membranous labirynth.

Treatment should lead to decreasing of the endolymph pressure.

Reduction of the vertigo symptoms can be achieved by implementing
low salt diet (less than 1-2 grams of salt per 24 hours) and diuretics
(hydrochlorothiazid 25-50 mg daily or acetazolamide 500 mg daily).
The effect of such treatment for hearing loss and tinnitus is significantly
smaller.
 In the suspected immune background of
Meniere’s disease (bilateral symptoms)
corticosteroids can be used (prednisone
in oral dose of 1 mg/kg/day for 5-10
days).
Migraine Associated Vertigo
(MAV)
 There are three main aspects of
migraine treatment: avoidance triggering
factors, acute symptomatic control, and
pharmacological prevention.
 Summary
Diagnostic and treatment of vertigo remains a
challange for many physicians. It is important to
remember about the possibilities of preventing
attacks of vertigo in some patients.
Rehabilitation sholud be recommended in most
patients in both peripheral and central balance
disorders. Important thing is a rational carefully
planned pharmacotherpay, avoiding
polypharmacy, individually adapted to the
patient. An improvement in a patient with
balance disorders after treatment does not
release the doctor from determining the cause of
symptoms.
Thank You