How to Make Diagnosis of Vertigo

       How to diagnose Vertigo? How to make diagnosis vertigo use anamnesis and physical examination. Anamnesis includes clinical manifestations, family history, and treatment history. There is a family history of migraine, seizures, meniere disease, or deaf at a young age need to be asked and some medications can induce vertigo include ototoxic drugs, anti-epilepsy drugs, antihypertensives, and sedatives.
The physical examination includes a neurologic examination, Head and neck examination also the cardiovascular system.

A. Neurologic examination
Neurologic examination include:
a. Cranial nerve examination
    Cranial nerve examination for finding signs of nerve paralysis, neuralsensoric deafness, and nystagmus. Vertical nystagmus 80% sensitive for vestibular nucleus lesions or cerebellar vermis. Horizontal nystagmus spontaneous nystagmus with or without rotator consistent with acute vestibular neuronitis.
b. Gait test
    1. Romberg's sign
       Patients with peripheral vertigo have impaired balance, but still able to walk, while patients with central vertigo have the severe instability and often unable to walk. Although Romberg's sign is consistent with vestibular problems or propioceptive, this can not be used to diagnose vertigo. In one study, only 19% sensitive for vestibular disorders and is not associated with more serious causes of dizziness (vertigo is not limited to) such as drug-related vertigo, seizures, arrhythmia, or cerebrovascular event.
      The patient stands with both feet were docked, first with eyes open and then closed. Leave in this position for 20-30 seconds. It must be ensured that the patient is not able to determine its position (eg with the aid of a light or sound a certain point). In vestibular disorders, only the eyes closed, the body swaying, moving away from the center line and then back again, whereas when the eyes open, the patient remains upright. While the loss of cerebellar disorder sufferers will sway, both eyes open and the eyes closed.

2. Heel-to-toe walking test

3. Unterberger's stepping test
       (Patients are asked to walk on the spot with  eyes closed - if the patient is turned to one side, the patient has a lesion in the labyrinth on that side).  Stand straight with  arms horizontally forward and stepped on the spot, lifting  knees as high as possible for one minute. In vestibular disorders, the patient's position would deviate / spiraled toward the lesion with moves such as throwing the discus and the head and body rotate in the direction of the lesion, both arms moving in the direction of the lesion with the arm on the side of the lesion is down and the other up. This condition is accompanied by the slow phase nystagmus toward the lesion.

4. Past-pointing test (Test Point Bárány).
       With index finger extension and arm straight forward, the patient was told to lift his arm up, then lowered to touch the hand index examiner. This is done repeatedly with eyes open and closed. In vestibular disorders will look deviations patient's arm toward the lesion

Examination to determine whether the location of the lesion is central or peripheral.
1. Vestibular function
a. Dix-Hallpike manoeuvre
  From a sitting position on the bed, the patient laid back quickly, so that his head hung 45 º below the horizontal, then the head is tilted 45 ° to the right and to the left. Notice when incurred and loss, vertigo and nystagmus, the test can distinguish whether peripheral or central lesions.
Peripheral : Vertigo and nystagmus occur after a latent period of 2-10 seconds, gone in less than 1 minute, will diminish or disappear when the test is repeated several times (fatigue).
Central : No latency period, nystagmus and vertigo lasted more than 1 minute, if repeated reactions remain as they are (non-fatigue)

b. Test hyperventilation
     This test is performed if other tests were normal. Patients were instructed to breathe strong and in 30 times. Then examined whether there nystagmus and ask the patient if such procedure induce vertigo. If patients experience vertigo without nystagmus then diagnosed as hyperventilation syndrome. If nystagmus occurs after hyperventilation indicate a tumor in the nerve VIII.

c. Test Calories
      This test requires simple tools. People appointed to head back (looking up) as much as 60 º. (The goal is to have lateral vessels in the labyrinth is in a vertical position, thereby maximally affected by the convection flow due endolymf). Syringe size 20 mL with needle tip is protected by a rubber size No. 15 is filled with a water temperature of 30 º C (approximately 7 º below body temperature) water is sprayed into the ear canal with a speed of 1mL / sec, thus the tympanic membrane soaked in water for approximately 20 seconds. Eyeball patients readily observed, the presence of nystagmus. Direction of nystagmus is to the side opposite to the side of the ear were fed (Because the injected water is colder than body temperature). Motion direction  is recorded, the frequency (usually 3-5 times / second) and the duration of nystagmus lasted, were recorded. The duration of nystagmus have proceeded differently in each patient. Usually, between ½ - 2 minutes. After break for 5 minutes, the second ear tested. It is important is to compare the duration of nystagmus on both sides, which in normal circumstances are similar. In such patients with 5ml of ice water is injected into the ear, slowly, so that the length of the injection lasted was 20 seconds. In normal circumstances this would trigger nystagmus that lasts 2 to 2.5 minutes. If not arise nystagmus, can be injected 20 mL of ice water for 30 seconds. If this also does not cause nystagmus, it can be considered that the labyrinth is not working. This test allows us to determine whether the state of normal labyrinth, hypoactive or not functioning.

d. Electronystagmogram.
This check is only done at the hospital, in order to record eye movements in nystagmus, nystagmus thus can be analyzed quantitatively.

e.  Posturography
In order to maintain a balance there are three elements that have an important role: the visual, vestibular, and somatosensory.
The test is done in 6 phases:
a. At this point patients fixated standing room, and the view even in normal conditions (normal)
b. obstructed view (eyes closed) and stood fixated (similar to the Romberg test)
c. view of an object seen swaying, and it stood on the fixated. With its pace that is seen, then input acuity can not be used as a mold for orientation space.
d. fixed object that is seen, but the focus to stand shaken. With a shaky footing, the somatosensory input from the bottom of the body can be disturbed.
e. eyes closed and shaken beachhead.
f. glance view of the swaying and stepping focus shaken.
With a shake then become ambiguous sensory information (stirring, not accurate) so patients must use other sensory systems to input (information)

2. Hearing Function
a. The tuning fork test: Rinne, Weber, Swabach. To distinguish conductive deaf and dumb, perceptive
b. Audiometry: Loudness Balance Test, SIDE, Bekesy Audiometry, ToneDecay.

B. Head and Neck Examination
Inspection of the head and neck include:
a. Examination of tympanic membrane, to discover the vesicles (eg auticus herpes zoster (Ramsay Hunt Syndrome)) or colesteatoma
b. Hennebert sign (vertigo or nystagmus that occurs when prompted tragus and acusticus meatus externus on the problematic side) indicated a perilymph fistula.
c. Valsava maneuver (exhalation with mouth and nose closed to increase pressure against eusthacius tube and inner ear) can cause vertigo in patients with perilymph fistula or dehiscence anterios Canalis semicircularis. But based on clinical diagnostic value is still limited.
d. Head impulses test
 Patient sitting upright with eyes fixated on the object distance of about 3 m and instructed to continue to see the object when the inspector menolehkan patient's head. Begins with the patient's head menolehkan examiner to one side after the plans examiner menolehkan other side of the patient's head 20 degrees horizontally quickly. In normal people do not have their eyes fixated saccades indicate the object. If no saccades afterwards then indicate that there are lesions on the side of the peripheral vestibular

Cardiovascular examination
 Orthostatic changes in systolic blood pressure (eg, decreased 20 mmHg or more) and pulse (eg increased 10 beats per minute) in patients with vertigo can determine dehydration problems and autonomic dysfunction

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