Diagnosa Banding PUSING.docx

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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
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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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