Hearing & Balance Conditions (Tinnitus, Vertigo, Meniere's) PDF

8/25/2023 Hearing and Balance Conditions: Tinnitus, Vertigo, Meniere’s Disease NURS641 FNP1 Prepared and Presented by Lori -Jeanne West ©Lori-Jeanne West, 2023 Reproduction of this material is prohibited without the author...

8/25/2023 Hearing and Balance Conditions: Tinnitus, Vertigo, Meniere’s Disease NURS641 FNP1 Prepared and Presented by Lori -Jeanne West ©Lori-Jeanne West, 2023 Reproduction of this material is prohibited without the author’s consent. Posting or sharing of these materials without the author’s consent is a copyright violation. Tinnitus 1  8/25/2023 Overview and Presentation Perception of persistent sound in the ear, most often caused by changes in peripheral auditory nerve function, ranges from minor irritation to completely debilitating – Ear fullness, itching, hearing loss, headache, numbness, N/V, vertigo, nystagmus Primary (idiopathic) vs secondary (underlying cause) Symptom not a disease, important to identify underlying cause Can be subjective or objective Risk factors: hearing loss, hearing and balance disorders, ear infections, ear canal blockage, blood pressure changes, head trauma, thyroid disorder, allergies, chronic exposure to noise, anemia, medications Physical Exam Head, Neck, and Ear exam – Gross hearing tests – Weber and Rinne tuning fork tests – Rule out ear infections, cerumen impaction, TMJ Cardiovascular Evaluation (pulsatile tinnitus) – Heart, carotid arteries, thyroid to assess for murmurs, venous hums, bruits – Rule out intracranial HTN, vascular disorders Neurological Exam – Rule out neoplasms, nervous system deficits Diagnostics Refer to audiologist for comprehensive evaluation CBC, CMP, thyroid labs, lipid panel, B12, zinc Culture drainage from the ear Imaging for unilateral or pulsatile tinnitus (CT, MRI) – MRI in patients with asymmetric hearing loss or sudden SNHL to detect tumors 2  8/25/2023 Differentials Determine underlying cause – Diagnoses: Dunphy: Table 22.1, page 319 – Medications: Dunphy: Box 22.3, page 319 Treatment Treat underlying disease – Avoid ototoxic antibiotics and medications Avoid risk factors: – Excessive noise – Insomnia – Medications (especially aspirin products and NSAIDs) – Alcohol White nose, tinnitus masking devices, hearing aids Biofeedback Refer to audiologist Patient Education Reassure that tinnitus is a symptom and not a disease and focus is to treat underlying cause Play background music, or white noise Stop smoking Decrease intake of caffeine, alcohol, salt Proper sleep hygiene Chew gum, swallow, pop ears on airplanes 3  8/25/2023 Benign Paroxysmal Positional Vertigo Overview and Presentation Disorder of inner ear with symptoms of repeated short episodes of v ertigo induced by changes in head position – Caused by loose canalith in the semicircular canals – Usually lasts 30-60 seconds, max of 2 minutes – Range mild to intense, may have N/V, disequilibrium, nystagmus – Typically caused by head nodding, rolling over, turning head side to side, sudden head movement Not accompanied by hearing loss, aural fullness, tinnitus, migraines Patient describes: – Room is spinning or patient is spinning or whirling, unsteadiness Physical Exam Neurological exam to assess cranial nerv es Head, Neck, and Ear exam If patient has BPPV → no neural def icits and normal ear exam Dix Hallpike Maneuv er- check f or ny stagmus – Contraindicated for recent neck surgery, severe RA, carotid sinus syncope, cervical myelopathy/radiculopathy, vascular dissection syndrome Supine Head Roll- perf orm if no ny stagmus noted on Dix Hallpike to ev aluate lateral semicircular canal 4  8/25/2023 Diagnostics Diagnosis is based on history, physical exam, and positive result on Dix-Hallpike or Supine Head Roll test No imaging or lab tests to assist diagnosis Vestibular testing not recommended if patient meets criteria for BPPV Differentials Differentiate from dizziness – Orthostatic hypotension – Cerv ical vertigo (degenerative cervical spine disease) – Medication induced vertigo Medical conditions that cause vertigo: – Dunphy , Table 22.4, page 324 Treatment Canalith repositioning procedures (CRPs) and treatment: Dunphy, Table 22.5, page 325 Dunphy, Table 22.6, page 326 Check out the following demos by Dr. Christopher Chang: Dix Hallpike Maneuver: https://www.youtube.com/watch?v=wgWOmuB1VFY Epley Maneuver: https://www.youtube.com/watch?v=o4GV-EbnMfI Lempert Maneuver: https://www.youtube.com/watch?v=mwTmM6uF5yA Refer to provider with expertise if needed Reevaluate in one month for resolution of symptoms 5  8/25/2023 Patient Education Reassure patient this is not life threatening and usually self limited Safety is important- educate on fall precautions Avoid vestibular suppressants (meclizine, benzos) Educate on performing canalith repositioning procedures at home Meniere’s Disease Overview and Presentation Def ined as two or more episodes of spontaneous vertigo lasting 20 minutes – 12 hours along with fluctuating hearing loss, roaring tinnitus, and aural f ullness in affected ear – May also have sudden attack of N/V, pallor, diaphoresis, dizziness Etiology unclear: associated with increased endolymphatic fluid in the cochlea Risk factors: stress, allergies, high salt intake, caffeine, alcohol, hormonal changes, barometric pressure changes, exposure to loud noise ov er several years 6  8/25/2023 Physical Exam and Diagnostics Head, Neck, and Ear exam – Ear exam typically normal Neurological Assessment No specific diagnostic testing exists – Diagnostic criteria: Two distinct episodes of rotational vertigo lasting at least 20 minutes – 12 hours each Along with: Low frequency fluctuating SNHL, roaring tinnitus, or a perception of aural fullness Differentials Diagnosis of exclusion and is based on symptoms Rule Out: – Otitis media, vestibular neuritis, secondary or tertiary sy philis, neurologic tumors, acoustic neuromas, degenerative nerve disorders (MS, Alzheimer’s), hy pothyroidism, BPPV, hypoglycemic disorders, lipid disorders, drug toxicity, psychiatric disorders Treatment Rule out other causes Carefully monitor for hearing loss Bedrest during acute episodes with eyes closed and protection from falling Vestibular suppressants (effective only during acute attacks): Meclizine, Dramamine, Benadryl, Valium, Ativan, Klonopin, Scopalamine, Atropine Medications to prevent attacks: Betahistine 16mg PO 3x/day Dietary modifications (restrict sodium, caffeine, alcohol) Diuretics Intratympanic dexamethasone Streptomycin/Gentamycin inner ear ablation therapy Surgical interventions for disabling symptoms 7  8/25/2023 Patient Education Monitor carefully for hearing loss and report worsening symptoms/frequency Stop smoking Monitor stress levels, encourage relaxation techniques Dietary restrictions Vestibular rehabilitation Avoid ototoxic medications Safety during acute attacks References Buttaro, T.M., Polgar-Bailey, P., Sandberg-Cook, J., & Trybulski, J. (2021). Primary care: Interprofessional collaborative practice (6th ed.). Elsevier. Chang, Christopher. (2014, September 21). Dix hallpike maneuver to diagnose BPPV dizziness [Video]. YouTube. https://www.youtube.com/watch?v=wgWOmuB1VFY Chang, Christopher. (2021, February 17). Epley maneuver to treat BPPV dizziness [Video]. YouTube. https://www.youtube.com/watch?v=o4GV-EbnMfI Chang, Christopher. (2014, November 14). Lempert maneuver to treat BPPV vertigo [Video]. YouTube. https://www.youtube.com/watch?v=mwTmM6uF5yA Dunphy, L. M., Winland-Brown, J. E., Porter, B. O., & Thomas, D. J. (2022). Primary care: The art and science of advanced practice nursing and interprofessional approach (6th ed.). F. A. Davis Company. 8