Tinnitus-slides-030122[1]

TinnitusGrandRoundsJanuary22,2003GordonShields,MDFrancisQuinn,MD“…onlymyearswhistleandbuzzcontinuouslydayandnight.IcansayIamlivingawretchedlife.”LudwigVonBeethoven-1801Tinnitus•Definition•Classification•Objectivetinnitus–pulsatile•Subjectivetinnitus•Theories•Evaluation•TreatmentIntroduction•Tinnitus-“Theperceptionofsoundintheabsenceofexternalstimuli.”•Tinnere–means“ringing”inLatin•IncludesBuzzing,roaring,clicking,pulsatilesoundsTinnitus•Maybeperceivedasunilateralorbilateral•Originatingintheearsoraroundthehead•Firstoronlysymptomofadiseaseprocessorauditory/psychologicalannoyanceTinnitus•40millionaffectedintheUnitedStates•10millionseverelyaffected•Mostcommonin40-70year-olds•MorecommoninmenthanwomenClassification•Objectivetinnitus–soundproducedbyparaauditorystructureswhichmaybeheardbyanexaminer•Subjectivetinnitus–soundisonlyperceivedbythepatient(mostcommon)Tinnitus•Pulsatiletinnitus–matchespulseorarushingsound–Possiblevascularetiology–Eitherobjectiveorsubjective–IncreasedorturbulentbloodflowthroughparaauditorystructuresObjective-Pulsatiletinnitus•Arteriovenousmalformations•Vasculartumors•Venoushum•Atherosclerosis•Ectopiccarotidartery•Persistentstapedialartery•Dehiscentjugularbulb•Vascularloops•Cardiacmurmurs•Pregnancy•Anemia•Thyrotoxicosis•Paget’sdisease•BenignintracranialhypertensionArteriovenousmalformations•Congenitallesions•Occipitalarteryandtransversesinus,internalcarotidandvertebralarteries,middlemeningealandgreatersuperficialpetrosalarteries•Mandible•Brainparenchyma•DuraArteriovenousmalformations•Pulsatiletinnitus•Headache•Papilledema•DiscolorationofskinormucosaVasculartumors•Glomustympanicum–Paragangliomaofmiddleear–Pulsatiletinnituswhichmaydecreasewithipsilateralcarotidarterycompression–Reddishmassbehindtympanicmembranewhichblancheswithpositivepressure–ConductivehearinglossVasculartumors•Glomusjugulare–Paraganliomaofjugularfossa–Pulsatiletinnitus–Conductivehearinglossifintomiddleear–CranialneuropathiesVenoushum•Benignintracranialhypertension•Dehiscentjugularbulb•Transversesinuspartialobstruction•Increasedcardiacoutputfrom–Pregnancy–Thyrotoxicosis–AnemiaBenignIntracranialHypertension•Young,obese,femalepatients•Hearingloss•Auralfullness•Dizziness•Headaches•Visualdisturbance•Papilledema,pressure200mmH20onLPBenignIntracranialHypertension•SismanisandSmoker1994–100patientswithpulsatiletinnitus–42foundtohaveBIHsyndrome–16glomustumors–15atheroscleroticcarotidarterydiseaseBIHSyndrome•Treatment–Weightloss–Diuretics–Subarachnoid-peritonealshunt–GastricbypassforweightreductionMuscularCausesofTinnitus•Palatalmyoclonus–Clickingsound–Rapid(60-200beats/min),intermittent–Contractureoftensorpalantini,levatorpalatini,levatorvelipalatini,tensortympani,salpingopharyngeal,superiorconstrictors–Musclespasmseenorallyortransnasally–RhythmiccompliancechangeontympanogramMyoclonus•Palatalmyoclonusassociations:–MultipleSclerosisandotherdegenerativeneurologicaldisorders–Smallvesseldisease–Tumors•treatments:musclerelaxants,botulinumtoxininjectionStapediusMuscleSpasm•Idiopathicstapedialmusclespasm–Rough,rumbling,cracklingsound–Exacerbatedbyoutsidesounds–Briefandintermittent–Maybeabletoseetympanicmembranemovement–Treatments:avoidanceofstimulants,musclerelaxants,sometimessurgicaldivisionoftensortympaniandstapediusmusclesPatulousEustachianTube•Eustachiantuberemainsopenabnormally•Oceanroarsound•Changeswithrespiration•LyingdownorheadindependentpositionprovidesreliefPatulousEustachianTube•Tympanogramwillshowchangesincompliancewithrespiration•Significantweightloss,radiationtothenasopharynx•Previoustreatments:caustics,mucosalirritants,saturatedsolutionofpotassiumiodide,TeflonorgelfoaminjectionaroundtorustubariusSubjectiveTinnitus•Muchmorecommonthanobjective•Usuallynonpulsatile•Presbycusis•Noiseexposure•Meniere’sdisease•Otosclerosis•Headtrauma•Acousticneuroma•Drugs•Middleeareffusion•TMJproblems•Depression•Hyperlipidemia•Meningitis•SyphilisConductivehearingloss•Conductivehearinglossdecreaseslevelofbackgroundnoise•Normalparaauditorysoundsseemamplified•Cerumenimpaction,otosclerosis,middleeareffusionareexamples•TreatingthecauseofconductivehearinglossmayalleviatethetinnitusOthersubjectivetinnitus•Poorlyunderstoodmechanismsoftinnitusproduction•Abnormalconditionsinthecochlea,cochlearnerve,ascendingauditorypathways,auditorycortex•Hyperactivehaircells•ChemicalimbalanceCNSMechanisms•Reorganizationofcentralpathwayswithhearingloss(similartophantomlimbpain)•DisinhibitionofdorsalcochlearnucleuswithincreaseinspontaneousactivityofcentralauditorysystemNeurophysiologicModel•ProposedbyJastreboff•Resultofinteractionofsubsystemsinthenervoussystem•Auditorypathwaysplayingaroleindevelopmentandappearanceoftinnitus•Limbicsystemresponsiblefortinnitusannoyance•NegativereinforcementenhancesperceptionoftinnitusandincreasestimeitisperceivedRoleofDepression•Depressionismoreprevalentinpatientswithchronictinnitusthaninthosewithouttinnitus•Folmeretal(1999)reportedpatientswithdepressionratedtheseverityoftheirtinnitushigheralthoughloudnessscoreswerethesame•Whichcomesfirst,depres