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Pertimbangan diagnostik
Atas dasar sejarah dan fsik temuan pasien, dokter yang memeriksa harus mampu
merumuskan diagnosis dierensial dan menentukan apakah gejala cenderung
perier atau sentral (lihat Tabel di bawah).
eja. !itur embedakan perier dari "entral #ystagmus ($pen Table di jendela
baru)
%istem atau &e'e Peripheral esi "entral esi
$kulomotorius spontan nystagmus dengan mata tertutup saccades (kecepatan,akurasi), internuclear otalmoplegia, saccadic mengejar, tatapan menimbulkan
nistagmus
*estibulo+okular re'eks (*$&) #ystagmus tanpa fksasi, nystagmus setelah kepalagemetar, ketidakcocokan mata+kepala, unilateral dan kehilangan estibular bilateral
-iperakti *$&, !!%, nistagmus posisional, kehilangan estibular bilateral
*estibulospinal re'eks (*%&) kiprah+hati gerakan spontan normal /erakan normal,spontan, dan benar berdasarkan 0ide+gaya berjalan, gerakan spontan minimal
1iagnosis 2anding
2enign Paroysmal Positional *ertigo
Penyakit telinga dalam imun
Penyakit eniere (3diopathic endolymphatic -idrops)
%akit kepala sebelah
estibular neuronitis
schwannoma estibular
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1i44iness5 A 1iagnostic Approach
P1!
P&3#T
"$6#T%
%-A&6
&$26&T 6. P$%T, 1, *irtua !amily edicine &esidency, *oorhees, #ew 7ersey
$&3 . 13"86&%$#, Pharm1, edical 9niersity o %outh "arolina, "harleston,%outh "arolina
Am Fam Physician.:;
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intratympanic dexamethasone or gentamicin for Meniere disease, and
steroids for vestibular neuritis. rthostatic hypotension that causes
presyncope can be treated ith alpha agonists, mineralocorticoids, or
lifestyle changes. Disequilibrium and lightheadedness can be alleviated by
treating the underlying cause.
1iagnosing the cause o di44iness can be diBcult because symptoms are otennonspecifc and the diCerential diagnosis is broad. -oweer, a ew simple Duestionsand physical eamination tests can help narrow the possible diagnoses. 3t is
estimated that primary care physicians care or more than one hal o all patients
who present with di44iness.
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The initial description o di44iness can be diBcult to obtain because patientresponses are not always consistent. Thereore, the history should frst ocus on
what type o sensation the patient is eeling. &able *includes descriptors or the
main categories o di44iness.?,=,E,>3t is important to note that some causes odi44iness can be associated with more than one set o descriptors.
/ie0!rint Table
Table
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"ardiac medications
Alpha blockers (e.g., doa4osin H"arduraI, tera4osin)
AlphaJbeta blockers (e.g., caredilol H"oregI, labetalol)
Angiotensin+conerting en4yme inhibitors
2eta blockers
"lonidine ("atapres)
1ipyridamole (Persantine)
1iuretics (e.g., urosemide HasiI)
-ydrala4ine
ethyldopa
#itrates (e.g., nitroglycerin paste, sublingual nitroglycerin)
&eserpine
"entral nerous system medications
Antipsychotics (e.g., chlorproma4ine, clo4apine H"lo4arilI, thiorida4ine)
$pioids
Parkinsonian drugs (e.g., bromocriptine HParlodelI, leodopaJcarbidopa
H%inemetI)
%keletal muscle relaants (e.g., bacloen HioresalI, cycloben4aprine H!leerilI,
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methocarbamol H&obainI, ti4anidine HKana'eI)
Tricyclic antidepressants (e.g., amitriptyline, doepin, tra4odone)
9rologic medications
Phosphodiesterase type = inhibitors (e.g., sildenafl H*iagraI)
9rinary anticholinergics (e.g., oybutynin H1itropanI)
+n"ormation "rom re"erences *4and **.
/ie0!rint Table
Table @.
1elected auses of Dizziness
CAUSE
CATEGORY
OF
DIZZINESS PATHOPHYSIOLOGY
DIAGNOSTIC
CRITERIA
2enign
paroysmal
positionalertigo
*ertigo oose otolith in
semicircular canals
causing a alse senseo motion
Positie fndings
with 1i+-allpike
maneuerepisodic ertigo
without hearingloss
-yperentilati
on syndrome
ightheadedn
ess
-yperentilation
causing respiratory
alkalosis underlying
aniety may prookethe hyperentilation
%ymptoms
reproduced with
oluntary
hyperentilation
eniere
disease
*ertigo 3ncreased
endolymphatic 'uid in
the inner ear
6pisodic ertigo
with hearing loss
igrainous *ertigo 9ncertain one 6pisodic ertigo
http://www.aafp.org/afp/2010/0815/p361.html#afp20100815p361-b10http://www.aafp.org/afp/2010/0815/p361.html#afp20100815p361-b11http://www.aafp.org/afp/2010/0815/p361.html#afp20100815p361-b10http://www.aafp.org/afp/2010/0815/p361.html#afp20100815p361-b11 -
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CAUSE
CATEGORY
OF
DIZZINESS PATHOPHYSIOLOGY
DIAGNOSTIC
CRITERIA
ertigo
(estibularmigraine)
hypothesis is that
trigeminal nucleistimulation causesnystagmus in persons
with migraine
with signs o
migraine, plusphotophobia,phonophobia, or
aura during at
least two episodeso ertigo
$rthostatichypotension
Presyncope 1rop in bloodpressure on position
change causing
decreased blood 'owto the brain, aderse
eCect o multiple
medications (seeTable:)
%ystolic bloodpressure decrease
o :; mm -g,
diastolic bloodpressure decrease
o
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inner ear).E,
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least one aniety disorder.:3n another study, one in our patients with di44inessmet criteria or panic disorder.:EA study o patients with chronic di44iness showed
that those with panic disorder were more likely to hae neurotologic fndings than
those without panic disorder.:>9p to ; percent o patients with chronic subjectiedi44iness hae been reported to hae an aniety disorder.:F1epression and alcohol
intoication hae also been ound to oerlap with di44iness.
:
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8igure =.
1i+-allpike maneuer. 0hile the patient is in a seated position, thephysician 0A2turns the patientMs head ?= degrees to one side, then 0B2rapidly lays
the patient into a supine position with the head hanging about :; degrees oer the
end o the table, obsering the patientMs eyes or approimately @; seconds. Themaneuer is repeated or the opposite side. #ystagmus is diagnostic o estibular
debris in the ear that is acing down, closest to the eamination table. A ideo
demonstration o this maneuer is aailable at http5JJwww.youtube.comJwatchN
O&pw:m3@%9.
+n"ormation "rom re"erences 5and *6.
esions o the labyrinth and cranial nere *333 (estibulocochlear) commonly
produce spontaneous nystagmus. %accadic eye moements associated with apatientMs smooth ocular pursuit o the physicianMs fnger as it moes slowly let,
right, up, and down may be associated with a central cause, such as brainstem or
cerebellar disease. The head impulse test inoles asking the patient to remainocused on a target while the physician moes the patientMs head back and orth
rapidly. 6ye moement to one side with a refation saccade (rapid oscillatory eye
moement that occurs as the eye fes on an object) is indicatie o a lesion on theside to which the eyes moe. 2ilateral refation moements commonly occur with
ototoicity. Another test that can elicit nystagmus inoles the patient leaning
orward @; degrees while the physician shakes the patientMs head back and orth
igorously or :; seconds. The presence o nystagmus indicates a peripheral cause
in the ipsilateral direction o the nystagmus.F
$ther physical eamination tests include the &omberg test and obseration o gait.
%waying toward one side with the &omberg test is indicatie o estibulardysunction in the ipsilateral side. Also, a patientMs gait will lean toward the side o a
estibular lesion. Ataia is indicatie o cerebellar dysunction, and the patientMs gait
is usually slow, wide+based, and irregular.F,:;$bseration o gait is also important todetect symptoms suggestie o parkinsonism in patients presenting with
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diseDuilibrium.?3n early Parkinson disease, gait is usually slower with smaller stepsand reduced arm swing, and progresses to ree4ing and hesitation in later stages o
the disease.:;%creening or peripheral neuropathy is also important in patients
presenting with diseDuilibrium.?
3 hyperentilation syndrome is suspected, the diagnosis can be confrmed by
haing the patient rapidly take :; deep inhalations and ehalations, in an attemptto reproduce symptoms.F,
A thorough cardioascular eamination should be perormed in all patients with
di44iness. -oweer, tests such as electrocardiography, -olter monitor testing, and
carotid 1oppler testing should be perormed only i an underlying cardiac cause is
suspected based on other fndings or known cardiac disease.E
'dditional Testing
3n general, laboratory testing and radiography are not benefcial in the work+up o
patients with di44iness when no other neurologic abnormalities are
present.@ patients (;. percent) had laboratoryabnormalities that eplained their di44iness.E
6lectronystagmography tests estibular unction by using electrodes to detect
nystagmus. The test has a reported sensitiity o F to E? percent and specifcity o>< to >@ percent or peripheral estibular disorders. !or central estibular disorders,
sensitiity has been reported as high as >< percent and specifcity as high as F@
percent.E
'pproach to the !atient
Ater obtaining the patient history, the physician can tailor the physical eamination
to best ft the diCerential diagnosis. $ne approach to the initial ealuation opatients with di44iness is presented in Figure 1.
/ie0!rint 8igure
'pproach to the !atient ith Dizziness
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8igure ).
Algorithm or the initial ealuation o a patient with di44iness.
The initial history can help place the diagnosis into one o the our major categories
o di44iness. Then, Duestions specifc to that category can urther narrow thepossible diagnoses. A thorough neurologic and cardioascular eamination should
be perormed in all patients, as well as targeted components o the physical
eamination based on suspicion o the underlying diagnosis. !urther testing, such as
cardiac and radiologic testing, is only needed when specifc causes are suspected.
Treatment o ertigo has been addressed.@@ &able summari4es the treatment o
selected causes o di44iness,
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Treatment for 1elected auses of Dizziness
CAUSE TREATMENT COMMENTS
*ertigo
2enignparoysm
al
positionalertigo
ecli4ine (Antiert),:= to =; mg orally
eery our to si
hours
"ommonly used to reduce symptoms oacute episodes o ertigo, although
there are no &"Ts to support its use use
o estibular suppressants can lead tobrainstem compensation and prolong
ertiginous symptoms
6pley maneuer
(canalith
repositioningsee Figure 3)
ain benign paroysmal positional
ertigo treatment sae and eCectie
compared with placebo ideodemonstration is aailable
athttp5JJwww.youtube.comJwatchN
OKDokK&b7wamp#&O.
6pley maneuer (canalith repositioning). The techniDue inoles a series o
moements. 0A2The maneuer begins with the patient sitting with the head rotated?= degrees to the right. 0B2The physician lays the patient into a supine positionwith the head hanging oer the end o the table. 0!2The head is then rotated F;
degrees to the let, 082and the head and body are rotated together an additional F;
degrees until the patient is
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be repeated until no nystagmus is present at any position. The maneuer can alsobegin with the patient in the supine position. A ideo demonstration o this
maneuer is aailable athttp5JJwww.youtube.comJwatchN
OKDokK&b7wamp#&O
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/ie the full table of contents @@
Pusing menyumbang sekitar = persen dari kunjungan klinik perawatan primer.
%ejarah pasien umumnya dapat mengklasifkasikan pusing menjadi salah satu dari
empat kategori5 ertigo, ketidakseimbangan, presinkop, atau ringan. Penyebabutama dari ertigo jinak ertigo paroksismal positional, penyakit eniere, neuritis
estibular, dan labyrinthitis. 2anyak obat dapat menyebabkan presinkop, danrejimen harus dinilai pada pasien dengan jenis pusing. Penyakit Parkinson dan
neuropati diabetes harus dipertimbangkan dengan diagnosis diseDuilibrium.
gangguan kejiwaan, seperti depresi, kecemasan, dan sindrom hiperentilasi, dapat
menyebabkan pusing yang samar+samar. 1iagnosis pusing dapat dipersempitdengan tes pemeriksaan fsik mudah melakukan, termasuk ealuasi untuk
nystagmus, yang 1i+-allpike, dan pengujian tekanan darah ortostatik. pengujian
laboratorium dan radiograf memainkan sedikit peran dalam diagnosis. 1iagnosisakhir tidak diperoleh di sekitar :; persen kasus. Pengobatan ertigo termasuk 6pley
manuer (canalith reposisi) dan rehabilitasi estibular untuk benign paroysmalpositional ertigo, deksametason intratympanic atau gentamisin untuk penyakiteniere, dan steroid untuk neuritis estibular. hipotensi ortostatik yang
menyebabkan presinkop dapat diobati dengan agonis alpha, mineralocorticoids,
atau perubahan gaya hidup. 8etidakseimbangan dan ringan dapat diatasi denganmengobati penyebab yang mendasari
PERIPHERAL ETIOLOGIES
Benign paroxysmal positional vertigo
Vestibular neuritis
Herpes oster oti!us
"eniere #isease
Labyrint$ine !on!ussion
Perilymp$ati! %istula
Semi!ir!ular !anal #e$is!en!e syn#rome
Vestibular paroxysmia
&ogan's syn#rome
Re!urrent vestibulopat$y
Ot$er #isor#ers
( Vestibular s!$)annoma *a!ousti! neuroma+
( Aminogly!osi#e toxi!ity
( Otitis me#ia
&E,TRAL ETIOLOGIES
Vestibular migraine
Brainstem is!$emia
( TIA
( Rotational vertebral artery syn#rome
( -allenberg syn#rome
( Ot$er stro.e syn#romes
&erebellar in%ar!tion an# $emorr$age
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Epilepti! vertigo
&$iari mal%ormation
"ultiple s!lerosis
Episo#i! ataxia type /
0isembar.ment *mal #e #ebar1uement+ syn#rome
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