Vertigo2010

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Vertigo2010

  1. 1. Vertigo
  2. 2. วัตถุประสงค์ 1.ระบุอาการและอาการแสดงของกลุ่มอาการเวียนศีรษะที่ พบบ่อย ๆ ได้ 2.วินิจฉัยและวินจฉัยจำาแนกโรคได้จากประวัติและการ ิ ตรวจร่างกาย แยก peripheral vertigo ออกจาก central vertigo ได้ 3.อธิบายแนวทางการส่งตรวจทางห้องปฏิบัติการเพือให้ ่ ได้การวินิจฉัยโรคได้ 4.อธิบายหลักการและแนวทางในการรักษากลุ่มอาการ เวียนศีรษะได้ 5.ประเมินขีดความสามารถในการดูแลผู้ป่วย และส่งต่อ
  3. 3.  การรักษาการสมดุลย์ของการทรงตัวต้อง อาศัย visual system Proprioception  vestibular system
  4. 4. Vertigo Illusionor hallucination of movement Vestibular system
  5. 5. Vertigo History taking  Character of disorientation  Time course of vertigo , duration  Precipitating factors  Associated symptoms : hearing loss , tinnitus , nausea , vomiting , diplopia , CNS symptoms  Predisposing symptoms : general condition, trauma , drugs
  6. 6. Vertigo Physical examination  ENT examination  CNS examination  Vestibular system examination :  Unterberger test  Caloric test  Dix-Hallpike maneuver  Evaluation of pathologic nystagmus
  7. 7. Vertigo Investigation  Audiometry  ABR : Auditory Brainstem Response  ENG : Electronystagmography  Others : CBC,U/A,FBS,electrolyte,cholesterol, triglyceride,TFT,VDRL,CT scan ,MRI
  8. 8. Peripheral Central 1.Onset sudden insidious 2.Pattern episodic continuous 3.Sensation frequent infrequent of rotation 4.Severity often intense seldom intense 5.Duration min.,hr. mo. to yr.
  9. 9. Peripheral Central 6.Influence of marked slight or none head movement 7.Syncope never rare 8.Convulsion never rare 9.Tinnitus common rare 10.Deafness common rare
  10. 10. Peripheral Central 11.Spontaneous may be may be nystagmus present present 12.Type of horizontal horizontal, nystagmus vertical 13.Other CNS rare common involvement
  11. 11. Peripheral Cause of Vertigo BPPV Meniere’s disease Sudden hearing loss Vestibular neuritis Labyrinthitis
  12. 12. BPPV Benign paroxysmal positional vertigo The most common vestibular disorder Age range 11-84 yr. Mean age at onset 54 yr Cupulolithiasis Canalithiasis
  13. 13. BPPV Signs and Symptoms Vertigo and nystagmus  Latency of onset , usually 2-6 sec.  Short duration , usually less than 30 sec.  Reversibility  Fatigability Nausea , vomiting Dix-Hallpike maneuver
  14. 14. BPPV Cause  Idiopathic  Trauma  Otitismedia  Vestibular neuritis  Meniere’s disease  Otosclerosis
  15. 15. BPPV Cause  Sudden SNHL  CNS disease  Vertebral basilar insufficiency  Acoustic neuroma
  16. 16. BPPV Treatment  Reassurance  Medication : minor transquilizer  Vestibular rehabilitation Repositioning maneuver  Surgery
  17. 17. Meniere’s disease Idiopathic endolymphatic hydrop Signs and symptoms  Episodic vertigo lasting min to hr.  Fluctuating hearing loss  Tinnitus , fullness
  18. 18. Meniere’s disease Audiogram : low tone hearing loss ABR ENG Radiography
  19. 19. Meniere’s disease Treatment  Vasodilator  Cinnarizine , Dramamine  K-sparing diuretic drug  Stellate ganglion block  Intratympanic gentamicin therapy  Vestibular neurectomy
  20. 20. Sudden hearing loss Hearing loss : hr or day Vertigo Tinnitus Others : headache , URI symptoms Nystagmus Tuning fork Audiogram : unilateral SNHL
  21. 21. Sudden hearing loss Cause  Known cause : Syphilis, Meniere’s disease,multiple sclerosis , acoustic neuroma  Unknown : เชื่อว่าเกิดจากvirus,ความผิดปกติของหลอด เลือด autoimmune disease, labyrinthine membrane rupture ( LMR)
  22. 22. Sudden hearing loss Treatment  Bed rest  Repeat audiogram  Steroid  Vasodilator  Heparin
  23. 23. Vestibular neuritis Vertigo เป็นทันทีทนใดและเป็นอยู่นาน ั Spontaneous nystagmus มักมีไข้หวัดนำามาก่อน มักเดินเซข้างทีมี lesion ่ Audiogram : normal Caloric test : canal paresis or nonresponsive
  24. 24. Vestibular neuritis Treatment  Rest  Dramamine , diazepam  Steroid  Physical therapy : Cawthorne-Cooksey exercise
  25. 25. Labyrinthitis Virus : mump, measles, Herpes Bacteria : syphilis , OM ,meningitis  TB more often a complication of Tubercuolus meningitis than of Tuberculous otitis media.  Syphilis : congenital , acquire Fluctuating episodes of hearing loss and vertigo
  26. 26. Acoustic neuroma Acoustic schwannoma Schwann cell tumor of vestibular part of CN VIII มักเกิด บริเวณ Internal acoustic canal แล้วยื่นเข้าไปบริเวณ CP angle Initially,slowly progressive hearing loss and tinnitus . Postural imbalance or disequilibrium.
  27. 27. Acoustic neuroma Once the lesion compress the brainstem and vestibulocerebellum ,central compensation becomes impaired : vertigo , ataxia. Audiogram : unilateral SNHL ABR Caloric test : hypofunction MRI Treatment : surgery, radiation
  28. 28. Central cause of vertigo 1.Vertebrobasilar insufficiency  Elderly  Atherosclerosis  Vertigo  Nausea,vomiting  Ataxia  Visual illusion ,visual field defect, diplopia, headache
  29. 29. Central cause of vertigo 1.1Brainstem TIA 1.2Wallenberg’s syndrome ( Lateral medullary infartion ) 1.3Acute posterior cerebellar infarction 1.4Acute inferior cerebellar infarction
  30. 30. Central cause of vertigo 2.Cerebellar hemorrhage  Vertigo  Nausea, vomiting  Headache  Stiffness of neck, incoordination  50% loss of consciousness in 24 hr.
  31. 31. Central cause of vertigo 3.Vestibular migraine  Episodes of vertigo  Increased sensitivity to motion during the attack and increased susceptibility to motion sickness in between attacks  In 33% of pt episodic vertigo is not associated with headache.
  32. 32. Central cause of vertigo 3.Vestibular migraine  In 33% vertigo is associated with visual symptoms , dysarthria , tinnitus, decreased hearing , diplopia, ataxia, bilateral paraesthesia, bilateral paresis or decreased level of consciousness
  33. 33. Central cause of vertigo 3.Vestibular migraine  Treatment Acute attack : analgesic , antiemetic Prophylaxis for migraine attack : beta-blocker, calcium antagonist
  34. 34. Central cause of vertigo 4. Multiple sclerosis  Vertigo without hearing loss  Optic neuritis, transverse myelitis, others brainstem signs
  35. 35. Central cause of vertigo 5.Vestibular epilepsy  Dysequilibrium with rotational or linear vertigo  Accompany by body , head and eye rotation with or without nystagmus  May associated with mild nausea(vomiting not typical )
  36. 36. Medical treatment 1.Labyrinthine suppressant  Decreased vertigo , nausea, vomiting  1.1 Antihistamine : dimenhydrinate,meclizine  1.2 Antiemetic : prochlorperazine (Compazine), diphenidol  1.3 Anticholinergic : scopolamine  1.4 Minor tranquilizer : diazepam
  37. 37. Medical treatment 2.Vasodilator  B-histine , cinnarizine 3.Steroid

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