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Jenny Bashiruddin

Otorhinolaryngology Head&Neck Surgery Department


Medical Faculty University of Indonesia
Jakarta


Vestibular system interacts with many other
parts of the nervous system
Symptoms may also be experienced as
problems with vision, muscles,thinking, and
memory.

Maintaining balance is dependent on input
from a number of sources
Goebel JA. Otolaryngol Clin North Am 2000;33:483-93
Shepard NT, Solomon D. Otolaryngol Clin North Am 2000;33:455-69
Vertigo can be of central or peripheral origin
Baloh RW. Lancet 1998;352:18416. Mukherjee A et al. JAPI 2003;51:1095-101. Puri V, Jones E. J Ky Med Assoc
2001;99:31621. Salvinelli F et al. Clin Ter 2003;154:3418. Strupp M, Arbusow V, Curr Opin Neurol 2001;14:1120.
Peripheral
Involving structures not
part of the central
nervous system, most
frequently the inner ear
Central
Involving structures in the
central nervous system
(e.g., cerebrum,
cerebellum, brainstem)
Vascularisation


Demographics of Dizziness / Vertigo


1/3 population by age of 65 years ( Roydhouse 1974 )
48% women and 37% men by 80 years ( Pemberton 1956 )
5/1000 consult GP for vertigo ( RCMOP /OPCS 1986 )
10/1000 consult GP for dizziness ( RCMOP /OPCS 1986 )
1 in 4 adults in community report dizziness ( Yardley et al
1998 )


Symptoms
The most frequently reported symptoms of vestibular
disorders are dizziness, unsteadiness or imbalance
when walking, vertigo, and nausea.
These symptoms may be quite mild, lasting minutes,
or quite severe, resulting in total disability.

Symptoms
In addition, may suffer headache and muscular aches
in the neck and back,
increased sensitivity to noise and bright lights.
fatigue and loss of stamina and an inability to
concentrate.
may be accompanied by irritability, loss of self-esteem,
and/or depression.

Symptoms
Balance disorders increase in frequency in the older
age groups and increased by age 75 years
In general, the more violent and spinning the
sensation of vertigo, the more likely the lesion if
peripheral.
Central lesions tend to cause less intense vertigo and
more vague symptoms.

Some studies
Pyykko et all age influence balance problem,
Starude et all balance disturbance in elderly
80% Balance problem was periferal vestibuler
disturbance
Nevitt et al. (1989), falls in elderly 60-70% were
falls in the next 12 months.
Balance problem will increase frequency of falls in
elderly
Balance problem in elderly was based on
changes in vestibular, visual, somatosensoris organ




Falls in Elderly
Tabel 2. Prevalens Falls in elderly

Age Presentation Reseacher

65 + 28 35 % Campbell et al. 1989
Prudham & Evans, 1981
Blake et al. 1988
70 + 35% Campbell et al. 1989
75 + 32 42 % Tinetti et al. 1988
Downton & Andrrews.
1991



Falls makes scared self limitation
Nevitt et al. (1989) falls in elderly 60-70% will fall in the next 12 months
Changes in elderly
Neurologis changes
- nerve conduction system
- Cognitive function
- disturbances Brain cell
- Vibration sensation loss

Eyes degeneration
- thickening of Lens
decrease accommodation flexibility
- Changes in retina decrease ability to catch the light


Changes in elderly
- Eyes diseases :
cataract, glaucoma,
macular senile degeneration

Organ vestibular in elderly process
- limitation in moving to compensated changes
movement
- Process degeneration canalolithiasis and
cupulolithiasis in BPPV

Changes in elderly
Musculoskeletal degeneration
- less muscles mass
- Cardiovascular less ability for nutrition
supply
- Other Degeneration process

Falls influences condition
Peripheral Neuropathy, disturbances input Wrong
interpretation
Diabetes, hypoglycemia, Mycroangiopathy Weak
condition
Myopathy, extremity muscles weakness
Falls influences condition
Spondyloarthrosis, discus vertebralis degeneration,
osteofit, a. vertebralis oclusion propioseptif
disturbances


Falls influences condition
Hypercoagulation, increased 8,67 time as a risk of
vertigo
Hypoksia, Morinaka 22 patiens with balance problem
decrease in O2 saturation



Vertebrobasilar arterial insufficiency, Cervical
arthritis, Carotid artery stenosis can cause vertigo,
usually with associated nausea, vomiting. It is
commonly diagnosed in dizzy patients who are
older than 50.

Meniere's is labyrinthine hydrops. The
endolymphatic fluid pressure increases
symptoms.
High doses or long-term use of certain antibiotics
can also cause permanent damage to the inner ear.

Other drugs, such as aspirin, caffeine, alcohol,
nicotine, sedatives, and tranquilizers, as well as
many illegal drugs, can cause temporary dizziness
but do not result in permanent damage to the
vestibular system. [Ototoxicity].


Diagnosis & Examination
Anamnesis/History of
the problem
- Onset,Intensity,
Duration
- Changes potitions
- Episodic/continues

- Other disease
- Ototoxic drug
- Trauma

Cerebelum exam
- Past pointing test
- Finger noseTest

Diagnosis & Examination
Neurotologi exam
- General ENT - N. III,IV,VI,VII,IX
- Otoscopy - Neck
- Audiometri - Hallpike Manoever
- Posturography - Potitional Nistagmus
- Caloric Nistagmus - ENG

Propioseptif exam
- Romberg Test
- Stepping test
Eye movements often hold
clues to vestibular
dysfunction. To record eye
movements, physicians use a
technique called
electronystagmography
(ENG).
Rehabilitation
Treatment for vestibular disorders varies according to the
diagnosis, rehabilitation should be comprehensif
In mild cases, the symptoms may go away on their own as
the vestibular apparatus heals or the nervous system learns
to compensate for the disorder.

3 principal therapy :
1. Adaptation,
2. Substitution, compensation mechanism,
3. Canal Reposition, for BPPV

VRT (Vestibular Rehabilitation Treatment)





easy & static Difficult & Dinamic


Adaptation
VRT
Substitution
1. Repeated stimulation could
improved vestibular system
2. Exercise to improve vestibular
function
VRT








Benign Paroxysmal Position Vertigo (BVPV)
This disorder is caused when some very small crystals of
calcium carbonate, located in the inner ear, become
dislodged.
When a person lies down, these crystals can float down
into one of the three canals that are located in the inner
ear.
A head injury is the most common cause of BPPV in
people under the age of 50. In older people the most
common cause is degeneration of the vestibular system
of the inner ear.



Canal Reposition, for BPPV

Where symptoms persist, some patients can be cured
completely. In other persistent cases, the symptoms
can only be controlled and not eliminated entirely.
Treatments may consist of drugs, diets, physical
therapy, or in severe cases, surgery.

Disability
Although most vestibular disorders are treatable,
some people with the disorders find they are
temporarily or permanently unable to work or
carry on normal activities.
Social Security disability as well as many employee
disability plans cover chronic, severe disability
caused by vestibular disorders
Prevention
Primer Prevention
> Identification high risk people.
> Identification environment risk.
> Screening factor as potential risk.


Prevention
Secondary Prevention
> Identified cause of falls in elderly and try
to managed it
> Managed environment risk
> Minimized the trauma if fall.
It is often useful to have a care giver, social worker, or
friend help with the record-keeping and paperwork.



Conclusion
Technical modification in examination should be
consider for limitation patients in movement
Balance problem in elderly should be managed
properly cause of increasing the morbidity and
mortality
Need proper teamwork from several department and
family