Inleiding
Fysiologie vestibulo-oculaire reflex ...................................................................................................................... 3
Anatomie ................................................................................................................................................................. 3
Centraal vestibulaire pathway................................................................................................................................... 4
BPPD/BPPV ............................................................................................................................................................. 4
Beroerte of neuronitis vestibularis ............................................................................................................................. 7
Duizeligheid/ vertigo ............................................................................................................................................ 9
Anatomie / fysiologie ...............................................................................................................................................10
Diagnostische evaluatie ..........................................................................................................................................13
Differentiële diagnose .............................................................................................................................................16
Behandeling ...........................................................................................................................................................24
Klinische praktijk .....................................................................................................................................................25
Casuïstiek ..............................................................................................................................................................28
Pediatrische NKO ............................................................................................................................................... 31
Permanent gehoorverlies.........................................................................................................................................31
Otitis media en ventilatiebuisjes ..............................................................................................................................37
Adenotonsillectomie ...............................................................................................................................................41
Stridor en heesheid .................................................................................................................................................47
Vreemde voorwerpen ..............................................................................................................................................54
Rhinologie: anatomie & fysiologie !! .................................................................................................................... 57
Anatomie neus & sinussen ......................................................................................................................................57
Fysiologie van neus & sinussen ................................................................................................................................58
Rhinologie: pathologie en therapie ...................................................................................................................... 60
Onderzoek neus & sinussen.....................................................................................................................................60
Aandoeningen van neus & sinussen .........................................................................................................................61
Rhinosinusitis .........................................................................................................................................................68
Traumatische neusafwijkingen .................................................................................................................................73
BELANGRIJK ...........................................................................................................................................................75
Epistaxis ............................................................................................................................................................ 76
Oorzaken ................................................................................................................................................................77
Epistaxis bij kinderen ...............................................................................................................................................78
Behandeling ...........................................................................................................................................................78
Audiologische begrippen, hoortoestellen & tinnitus ............................................................................................ 81
Audiologische (gehoor)testen ..................................................................................................................................81
Gehooroplossingen .................................................................................................................................................90
Gehoorsymptomen bij gehoorverlies ........................................................................................................................92
1
,Oor en gehoor .................................................................................................................................................... 96
Basics ....................................................................................................................................................................98
Aandoeningen van het uitwendige oor ......................................................................................................................99
Middenoor ............................................................................................................................................................ 100
Binnenoor en verder .............................................................................................................................................. 104
Symptoom-gebaseerd ........................................................................................................................................... 106
Screening > management ...................................................................................................................................... 108
Hearing rehabilitation ............................................................................................................................................ 108
Oor chirurgie ......................................................................................................................................................... 109
Keel en pharynx ................................................................................................................................................113
Anatomie en fysiologie .......................................................................................................................................... 113
Diagnostiek, pathologie en behandeling ................................................................................................................. 114
SLAAP-GERELATEERDE ADEMHALINGSSTOORNISSEN .......................................................................................117
Slaapgerelateerde Ademhalingsstoornissen........................................................................................................... 117
Centraal vs. Obstructief apnea/hypopnea .............................................................................................................. 119
Risicofactoren ...................................................................................................................................................... 120
Diagnostiek........................................................................................................................................................... 121
Behandeling ......................................................................................................................................................... 123
Conclusies ........................................................................................................................................................... 128
Heesheid ..........................................................................................................................................................129
de Stem ................................................................................................................................................................ 129
Diagnose .............................................................................................................................................................. 129
Heesheid .............................................................................................................................................................. 131
Stemstoornissen...............................................................................................................................................134
Stemonderzoek..................................................................................................................................................... 134
Casussen ............................................................................................................................................................. 137
Take home messages ............................................................................................................................................ 140
Slikstoornissen – Orofaryngeale dysfagie ...........................................................................................................141
Slikken ................................................................................................................................................................. 141
Fysiologie, pathofysiologie & kenmerken van dysfagie ............................................................................................. 141
Prevalentie & consequenties ................................................................................................................................. 144
Screening & detectie ............................................................................................................................................. 145
Onderzoeken van de slikfunctie ............................................................................................................................. 145
Behandeling van de slikfunctie............................................................................................................................... 147
Proefexamen ....................................................................................................................................................148
Vragen .................................................................................................................................................................. 148
Antwoorden .......................................................................................................................................................... 150
2
, FYSIOLOGIE VESTIBULO-OCULAIRE REFLEX
Chapter 40 / The Vestibular System 921
The Otolith Organs Sense Linear Accelerations vestibular nerve to signal linear acceleration owing
to translational motion or gravity. The orientations
The vestibular system must compensate not only for of the otolith organs and the directional sensitivity of
head rotations but also for linear motion. The two oto- individual hair cells are such that a linear accelera-
lith organs, the utricle and saccule, detect linear motion tion along any axis can be sensed. For example, with
as well as the static orientation of the head relative to the head in its normal position, the macula of each
gravity, which is itself a linear acceleration. Each organ utricle is approximately horizontal. Any substantial
consists of a sac of membranous labyrinth approxi- acceleration in the horizontal plane excites some hair
mately 3 mm in the longest dimension. The hair cells cells in each utricle and inhibits others, according to
of each organ are arranged in a roughly elliptical patch their orientations (Figure 40–6).
called the macula. The human utricle contains approxi- In some instances the vestibular input from a
mately 30,000 hair cells, whereas the saccule contains receptor may be ambiguous. For example, accelera-
some 16,000. tion signals from the otolith organs do not distinguish
The hair bundles of the otolithic hair cells extend between linear acceleration owing to translation and
into a gelatinous sheet, the otolithic membrane, that cov- acceleration owing to gravity (Figure 40–7). The brain,
ers the entire macula (Figure 40–5). Embedded on the however, integrates inputs from the semicircular
surface of this membrane are fine, dense particles of canals, otolith organs, and visual and somatosensory
calcium carbonate called otoconia (“ear dust”), which systems to properly interpret head and body motions.
give the otolith (“ear stone”) organs their name. Oto- The operation of the paired saccules resembles
conia are typically 0.5 to 10 µm long; millions of these that of the utricles. The hair cells represent all possi-
particles are attached to the otolithic membranes of the ble orientations within the plane of each macula, but
utricle and saccule. the maculae are oriented vertically in nearly para-
Gravity and other linear accelerations exert sagittal planes. The saccules are therefore especially
shear forces on the otoconial matrix and the gelati- sensitive to vertical accelerations including gravity.
nous otolithic membrane, which can move rela- Certain saccular hair cells also respond to accelera-
tive to the membranous labyrinth. This results in a tions in the horizontal plane, in particular those along
deflection of the hair bundles, altering activity in the the anterior–posterior axis.
ANATOMIE
5 receptororganen Midsagittal line
- 3 semicirculaire kanalen (rotationeel)
o Horizontaal Cochlear nerve
Cochlea
o Anterior
o Posterior Vestibular nerve
- 2 otolith organen (translationeel) Semicircular canals:
Anterior vertical
o Utricle Vestibulocochlear
nerve (VIII)
Horizontal
Posterior vertical
o Saccule
Foramen magnum
Internal acoustic
meatus
Angle at which the plane of
the anterior vertical semicircular
canal crosses the midsagittal line
Figure 40–4 The bilateral symmetry of the semicircular vertical canals have a more complex relationship. The anterior
canals. The horizontal canals on both sides lie in approximately canal on one side and the posterior canal on the opposite side
the same plane and therefore are functional pairs. The bilateral lie in parallel planes and therefore constitute a functional pair.
HET VESTIBULAIR SYSTEEM
- Benig labyrint – vliezig labyrint
- Endolymfe (< vliezig labyrint)
o Na arm
o K rijk
- Perilymfe (tussen
benig en vliezig
labyrint)
o Na rijk
o K arm
o ~cerebrospinaal
vocht
3
, CENTRAAL VESTIBULAIRE PATHWAY
2 evenwichtsorganen
- In oor
- 3 halfcirkelvormige kanaaltjes per oor
- Als we ons hoofd bewegen → altijd 2 kanten aan het stimuleren
o Kan niet slechts 1tje testen
- Als je in constante rotatie bent → merkt in de eerste fase dat je draait, maar als je uw ogen sluit ga je dat niet meer
door hebben → als je dan stopt met draaien: merkt dat terug op
o = acceleratie en descelleratie
o Stimulatie zorgt voor toename in afvoerfrequentie: vanaf het moment
dat je beweegt → toename in stimulatie
o Aansturing ogen gaat naar de tegenovergestelde richting
ð Vestibulo-oculaire reflex zorgt ervoor dat als je je hoofd beweegt, toch uw
ogen kan scherpstellen
Werking
- Hoofd in rust:
o Spontane tonische afscheiding in de nervus VIII: gelijk aan beide zijden
- Bijv. naar links draaien
o Horizontaal kanaal links opgewonden, horizontaal kanaal rechts
geremd
o N VIII links: toename van het schieten
o N VIII rechts: afname van het bakken
o De hersenen interpreteren dit als naar links bewegen
ROTATIONELE VESTIBULO-OCULAIRE REFLEX
Nystagmus
- Nystagmus: richting bepaald door de snelle fase
o Nystagmus is naar de snelle kant = snelle fasen van oogbewegingen: snelle oogbeweging naar bv links van
de patient → stimulatie in acceleratie
- Rechtsdraaiende nystagmus naar rechts (langzame fase naar links voor een gecompenseerde oogbeweging)
- Linksdraaiende nystagmus naar links (langzame fase naar rechts voor een gecompenseerde oogbeweging)
ð Stel je hebt een overstimulatie van uw rechterkant omv aandoening → hersenen denken dat je beweegt naar rechts
→ ogen gaan mee maar kunnen niet 360° draaien → ogen doen correctie: nystagmus naar rechts
ð Stel links valt uit in de eerste fase → hersenen denken rechterkant werkt meer → denkt dat we draaien naar rechts →
nystagmus naar de gezonde kant
o Als je links een uitval hebt: nystagmus gaat het hardst aanwezig zijn aan de aangedane zijde → snelle fase gaat
altijd naar de niet aangedane zijde omdat die beter werkt
o Als links is uitgevallen en je beweegt met uw vinger naar links → oog beweegt snel naar rechts en traag naar
links + als je vinger naar rechts beweegt: oog zal ook snel naar rechts bewegen
BPPD/BPPV
= Benigne Paroxismale Positie Duizeligheid/Vertigo
INLEIDING
- Degelijk evenwichtskristallen in het centrale gedeelte van het evenwichtsorgaan
o Zorgen normaal voor zwaartekracht detectie (zitten vast)
o Als ze loskomen kunnen ze op de foute plaats komen → sluit de ampulla af
§ Omv zwaartekracht vnl naar posterior kanaal
o Elke keer als je gaat bewegen → dwarrelen ze op → stimulatie duurt aantal seconden tot ze terug stilvallen
4
Fysiologie vestibulo-oculaire reflex ...................................................................................................................... 3
Anatomie ................................................................................................................................................................. 3
Centraal vestibulaire pathway................................................................................................................................... 4
BPPD/BPPV ............................................................................................................................................................. 4
Beroerte of neuronitis vestibularis ............................................................................................................................. 7
Duizeligheid/ vertigo ............................................................................................................................................ 9
Anatomie / fysiologie ...............................................................................................................................................10
Diagnostische evaluatie ..........................................................................................................................................13
Differentiële diagnose .............................................................................................................................................16
Behandeling ...........................................................................................................................................................24
Klinische praktijk .....................................................................................................................................................25
Casuïstiek ..............................................................................................................................................................28
Pediatrische NKO ............................................................................................................................................... 31
Permanent gehoorverlies.........................................................................................................................................31
Otitis media en ventilatiebuisjes ..............................................................................................................................37
Adenotonsillectomie ...............................................................................................................................................41
Stridor en heesheid .................................................................................................................................................47
Vreemde voorwerpen ..............................................................................................................................................54
Rhinologie: anatomie & fysiologie !! .................................................................................................................... 57
Anatomie neus & sinussen ......................................................................................................................................57
Fysiologie van neus & sinussen ................................................................................................................................58
Rhinologie: pathologie en therapie ...................................................................................................................... 60
Onderzoek neus & sinussen.....................................................................................................................................60
Aandoeningen van neus & sinussen .........................................................................................................................61
Rhinosinusitis .........................................................................................................................................................68
Traumatische neusafwijkingen .................................................................................................................................73
BELANGRIJK ...........................................................................................................................................................75
Epistaxis ............................................................................................................................................................ 76
Oorzaken ................................................................................................................................................................77
Epistaxis bij kinderen ...............................................................................................................................................78
Behandeling ...........................................................................................................................................................78
Audiologische begrippen, hoortoestellen & tinnitus ............................................................................................ 81
Audiologische (gehoor)testen ..................................................................................................................................81
Gehooroplossingen .................................................................................................................................................90
Gehoorsymptomen bij gehoorverlies ........................................................................................................................92
1
,Oor en gehoor .................................................................................................................................................... 96
Basics ....................................................................................................................................................................98
Aandoeningen van het uitwendige oor ......................................................................................................................99
Middenoor ............................................................................................................................................................ 100
Binnenoor en verder .............................................................................................................................................. 104
Symptoom-gebaseerd ........................................................................................................................................... 106
Screening > management ...................................................................................................................................... 108
Hearing rehabilitation ............................................................................................................................................ 108
Oor chirurgie ......................................................................................................................................................... 109
Keel en pharynx ................................................................................................................................................113
Anatomie en fysiologie .......................................................................................................................................... 113
Diagnostiek, pathologie en behandeling ................................................................................................................. 114
SLAAP-GERELATEERDE ADEMHALINGSSTOORNISSEN .......................................................................................117
Slaapgerelateerde Ademhalingsstoornissen........................................................................................................... 117
Centraal vs. Obstructief apnea/hypopnea .............................................................................................................. 119
Risicofactoren ...................................................................................................................................................... 120
Diagnostiek........................................................................................................................................................... 121
Behandeling ......................................................................................................................................................... 123
Conclusies ........................................................................................................................................................... 128
Heesheid ..........................................................................................................................................................129
de Stem ................................................................................................................................................................ 129
Diagnose .............................................................................................................................................................. 129
Heesheid .............................................................................................................................................................. 131
Stemstoornissen...............................................................................................................................................134
Stemonderzoek..................................................................................................................................................... 134
Casussen ............................................................................................................................................................. 137
Take home messages ............................................................................................................................................ 140
Slikstoornissen – Orofaryngeale dysfagie ...........................................................................................................141
Slikken ................................................................................................................................................................. 141
Fysiologie, pathofysiologie & kenmerken van dysfagie ............................................................................................. 141
Prevalentie & consequenties ................................................................................................................................. 144
Screening & detectie ............................................................................................................................................. 145
Onderzoeken van de slikfunctie ............................................................................................................................. 145
Behandeling van de slikfunctie............................................................................................................................... 147
Proefexamen ....................................................................................................................................................148
Vragen .................................................................................................................................................................. 148
Antwoorden .......................................................................................................................................................... 150
2
, FYSIOLOGIE VESTIBULO-OCULAIRE REFLEX
Chapter 40 / The Vestibular System 921
The Otolith Organs Sense Linear Accelerations vestibular nerve to signal linear acceleration owing
to translational motion or gravity. The orientations
The vestibular system must compensate not only for of the otolith organs and the directional sensitivity of
head rotations but also for linear motion. The two oto- individual hair cells are such that a linear accelera-
lith organs, the utricle and saccule, detect linear motion tion along any axis can be sensed. For example, with
as well as the static orientation of the head relative to the head in its normal position, the macula of each
gravity, which is itself a linear acceleration. Each organ utricle is approximately horizontal. Any substantial
consists of a sac of membranous labyrinth approxi- acceleration in the horizontal plane excites some hair
mately 3 mm in the longest dimension. The hair cells cells in each utricle and inhibits others, according to
of each organ are arranged in a roughly elliptical patch their orientations (Figure 40–6).
called the macula. The human utricle contains approxi- In some instances the vestibular input from a
mately 30,000 hair cells, whereas the saccule contains receptor may be ambiguous. For example, accelera-
some 16,000. tion signals from the otolith organs do not distinguish
The hair bundles of the otolithic hair cells extend between linear acceleration owing to translation and
into a gelatinous sheet, the otolithic membrane, that cov- acceleration owing to gravity (Figure 40–7). The brain,
ers the entire macula (Figure 40–5). Embedded on the however, integrates inputs from the semicircular
surface of this membrane are fine, dense particles of canals, otolith organs, and visual and somatosensory
calcium carbonate called otoconia (“ear dust”), which systems to properly interpret head and body motions.
give the otolith (“ear stone”) organs their name. Oto- The operation of the paired saccules resembles
conia are typically 0.5 to 10 µm long; millions of these that of the utricles. The hair cells represent all possi-
particles are attached to the otolithic membranes of the ble orientations within the plane of each macula, but
utricle and saccule. the maculae are oriented vertically in nearly para-
Gravity and other linear accelerations exert sagittal planes. The saccules are therefore especially
shear forces on the otoconial matrix and the gelati- sensitive to vertical accelerations including gravity.
nous otolithic membrane, which can move rela- Certain saccular hair cells also respond to accelera-
tive to the membranous labyrinth. This results in a tions in the horizontal plane, in particular those along
deflection of the hair bundles, altering activity in the the anterior–posterior axis.
ANATOMIE
5 receptororganen Midsagittal line
- 3 semicirculaire kanalen (rotationeel)
o Horizontaal Cochlear nerve
Cochlea
o Anterior
o Posterior Vestibular nerve
- 2 otolith organen (translationeel) Semicircular canals:
Anterior vertical
o Utricle Vestibulocochlear
nerve (VIII)
Horizontal
Posterior vertical
o Saccule
Foramen magnum
Internal acoustic
meatus
Angle at which the plane of
the anterior vertical semicircular
canal crosses the midsagittal line
Figure 40–4 The bilateral symmetry of the semicircular vertical canals have a more complex relationship. The anterior
canals. The horizontal canals on both sides lie in approximately canal on one side and the posterior canal on the opposite side
the same plane and therefore are functional pairs. The bilateral lie in parallel planes and therefore constitute a functional pair.
HET VESTIBULAIR SYSTEEM
- Benig labyrint – vliezig labyrint
- Endolymfe (< vliezig labyrint)
o Na arm
o K rijk
- Perilymfe (tussen
benig en vliezig
labyrint)
o Na rijk
o K arm
o ~cerebrospinaal
vocht
3
, CENTRAAL VESTIBULAIRE PATHWAY
2 evenwichtsorganen
- In oor
- 3 halfcirkelvormige kanaaltjes per oor
- Als we ons hoofd bewegen → altijd 2 kanten aan het stimuleren
o Kan niet slechts 1tje testen
- Als je in constante rotatie bent → merkt in de eerste fase dat je draait, maar als je uw ogen sluit ga je dat niet meer
door hebben → als je dan stopt met draaien: merkt dat terug op
o = acceleratie en descelleratie
o Stimulatie zorgt voor toename in afvoerfrequentie: vanaf het moment
dat je beweegt → toename in stimulatie
o Aansturing ogen gaat naar de tegenovergestelde richting
ð Vestibulo-oculaire reflex zorgt ervoor dat als je je hoofd beweegt, toch uw
ogen kan scherpstellen
Werking
- Hoofd in rust:
o Spontane tonische afscheiding in de nervus VIII: gelijk aan beide zijden
- Bijv. naar links draaien
o Horizontaal kanaal links opgewonden, horizontaal kanaal rechts
geremd
o N VIII links: toename van het schieten
o N VIII rechts: afname van het bakken
o De hersenen interpreteren dit als naar links bewegen
ROTATIONELE VESTIBULO-OCULAIRE REFLEX
Nystagmus
- Nystagmus: richting bepaald door de snelle fase
o Nystagmus is naar de snelle kant = snelle fasen van oogbewegingen: snelle oogbeweging naar bv links van
de patient → stimulatie in acceleratie
- Rechtsdraaiende nystagmus naar rechts (langzame fase naar links voor een gecompenseerde oogbeweging)
- Linksdraaiende nystagmus naar links (langzame fase naar rechts voor een gecompenseerde oogbeweging)
ð Stel je hebt een overstimulatie van uw rechterkant omv aandoening → hersenen denken dat je beweegt naar rechts
→ ogen gaan mee maar kunnen niet 360° draaien → ogen doen correctie: nystagmus naar rechts
ð Stel links valt uit in de eerste fase → hersenen denken rechterkant werkt meer → denkt dat we draaien naar rechts →
nystagmus naar de gezonde kant
o Als je links een uitval hebt: nystagmus gaat het hardst aanwezig zijn aan de aangedane zijde → snelle fase gaat
altijd naar de niet aangedane zijde omdat die beter werkt
o Als links is uitgevallen en je beweegt met uw vinger naar links → oog beweegt snel naar rechts en traag naar
links + als je vinger naar rechts beweegt: oog zal ook snel naar rechts bewegen
BPPD/BPPV
= Benigne Paroxismale Positie Duizeligheid/Vertigo
INLEIDING
- Degelijk evenwichtskristallen in het centrale gedeelte van het evenwichtsorgaan
o Zorgen normaal voor zwaartekracht detectie (zitten vast)
o Als ze loskomen kunnen ze op de foute plaats komen → sluit de ampulla af
§ Omv zwaartekracht vnl naar posterior kanaal
o Elke keer als je gaat bewegen → dwarrelen ze op → stimulatie duurt aantal seconden tot ze terug stilvallen
4
