Inner Ear Conditions: Tinnitus & Vertigo PDF

Inner ear Tinnitus & Vertigo) Heba_Allah Abu Rumman Noor Thaljy  Tinnitus:.- Any sound that is perceived by the listener that does not originate from an external sound source for more than five minutes at a time, in the absence of any external acoustical or electrical stimulation of the ear...

Inner ear Tinnitus & Vertigo) Heba_Allah Abu Rumman Noor Thaljy  Tinnitus:.- Any sound that is perceived by the listener that does not originate from an external sound source for more than five minutes at a time, in the absence of any external acoustical or electrical stimulation of the ear and not occurring immediately after exposure to loud noise. - Disturbing tinnitus occurs in 3% to 5% of individuals with tinnitus. - Two types of tinnitus are described: 1. Subjective, which can only be heard by the patient. 95% 2. Objective, which can even be heard by the examiner with the use of a stethoscope. Usually pulsatile (in sync with heartbeat). - Subjective > objective tinnitus. Causes: - MC caused by some sort of change to the auditory system: * 80% of patients with SNHL have tinnitus. * Hearing loss results in changes in the neural activity of the auditory system, which the auditory cortex interprets as sound. * Much like phantom limb syndrome.] Areas of the cochlea where there is hair cell damage can no longer amplify sounds where damage has occurred so a phantom sound is interpreted by the brain. History: * Important features include: - Sound quality (tonal, hissing, buzzing, clicking, ringing). - Unilateral Vs. Bilateral localization in the head. - Localization (left, right, in the head, outside of the head). - Temporal features (episodic, fluctuating, constant, pulsatile). - Interaction with external sounds, including masking, inhibition, and exacerbation. - Pitch (high pitch à inner ear / crackling à middle ear / pulsating à vascular). - Loudness. Physical Examination: - Palpation and light compression of the jugular vein may diminish tinnitus of venous origin (a similar effect can be achieved by the Valsalva manoeuvre, during which an increased intrathoracic pressure and decreased venous return, may also reduce tinnitus). - Auscultation of the neck and cranium for the presence of carotid bruit or blood turbulence due to arteriovenous malformation. - Otoscopy/Otomicroscopy may reveal glomus tumors or tympanal hemangioma. - Oropharyngeal examination could reveal contraction of the soft palate in palatal myoclonus. Investigations: - Tympanometry may demonstrate myoclonic activity and Patulous Eustachian tube. - Pure tone audiometry may indicate conductive hearing loss secondary to vascular lesions affecting the middle ear. - Imaging with gadolinium-enhanced computed tomography CT) and magnetic resonance imaging MRI) is necessary in most cases * Patulous Eustachian tube PET) is the name of a physical disorder where the Eustachian tube, which is normally closed, instead stays intermittently open. When this occurs, the person experiences autophony, the hearing of self-generated sounds. Management: - Tinnitus is a symptom not a disease, so the cause of the tinnitus should be sought and treated. When no cause could be found, the management would be: * Reassurance and psychotherapy. Many times the patient has to learn to live with tinnitus. * Techniques of relaxation and biofeedback. * Sedation and tranquillizers. They may be needed in initial stages till patient has adjusted to the symptom. * Masking of tinnitus - Use of noise to temporarily mask or "cover up" the tinnitus so it cannot be perceived - This is often successfully accomplished when patients with hearing loss use traditional hearing aids. The amplification of environmental noises often reduces or completely masks tinnitus. - The newest generation hearing aids have optional tinnitus maskers built-in for when hearing aids arenʼt enough to mask tinnitus. - The use of a sound machine or external noise source (i.e. ceiling fan) can be very helpful at night. Vertigo: - Defined as the illusion of movement of the patient or the surroundings. - Chief complaint of patients with injury to the vestibular system is usually dizziness not vertigo. - Never permanent, continuous symptom. Even when the vestibular lesion is permanent, the central nervous system adapts to the defect so that vertigo subsides over days or weeks. - Constant dizziness lasting months is not vestibular. - Some patients describe it as constant due to frequent episodic dizziness.  Causes based on duration: - Seconds: - Weeks: * Benign paroxysmal positional vertigo BPPV * CNS disorder. - Minutes: * Multiple sclerosis. * Migraine-associated vertigo. * Acoustic neuroma. “Associated with hearing lossˮ * Vertebrobasilar insufficiency. * Autoimmune. “Associated with hearing lossˮ - Hours: - Variable duration: * Meniere's disease (endolymphatic hydrops). * Inner ear fistula. “Associated with hearing lossˮ “Associated with hearing lossˮ * Lyme disease. * Otic syphilis. * Labyrinthine concussion.* Blast trauma or - Days: Barotrauma. * Vestibular neuritis. * Superior semi-circular canal dehiscence syndrome. * Labyrinthitis. “Associated with hearing lossˮ Types : Diagnosis: - The diagnosis depends mostly on history, much on examination and little on investigation. - History: Onset of vertigo, Character of vertigo (real vertigo vs dizziness), Duration, Relationship to movements of the head, Other associated symptoms (tinnitus, hearing loss…etc.) - Neurological symptoms: loss of consciousness, weakness, numbness, dysarthria, diplopia. History: - Before any diagnosis we have to exclude central causes first because most of the inner ear diseases are diagnosis by exclusion. - True vertigo, any sensation of motion. - Any nausea, vomiting, sweating, and abnormal eye movements. - Occur when moving or changing positions. - Duration. - Constant or come and go. - Any new medications. - Recent head trauma. - Other hearing symptoms (ringing or hearing loss). - Other neurological symptoms such as weakness, visual disturbances, altered level of consciousness, difficulty walking, abnormal eye movements, or difficulty speaking.  Examination: - Romberg's test: Relies on the brain (cerebellum) receiving 3 sensory inputs: * Joint position sense (proprioception), carried in the dorsal columns of the spinal cord, Vision, Vestibular apparatus. * If the visual pathway is removed by closing the eyes but the other 2 systems are intact balance will be maintained however if proprioception is not intact, two of the sensory inputs will be absent and the patient will sway and lose balance when his eyes are closed. * Itʼs not a test of cerebellar function, it is a test of the proprioception receptors and pathwayʼs function. * A positive Romberg's test has been shown to be 90%. sensitive for lumbar spinal stenosis. - Unterberger test: Used to help assess whether a patient has a vestibular pathology. It is not useful for detecting central disorders of balance. * If the patient rotates to one side, they may have a labyrinthine lesion on that side (not enough alone). - Walking with eyes closed: repeat three times, if vestibular deficit is present the patientʼs gait is deviated or unsteady towards the same side  Turning test: close eyes, walk straight and turn quickly 180 stops, the patient tends to fall toward the side of vestibular weakness (perilymph fistula). - The head thrust test: an examination for chronic peripheral vestibular loss, to diagnose as well as identify the side of the hypo-functioning labyrinth. based on the dollʼs eye phenomenon - Fistula test: done when perilymph fistula is suspected by pressing on tragus and checking for nystagmus and symptoms * Nystagmus: Involuntary, rhythmical oscillation of the eyes away from the direction of gaze, followed by a return of the eyes to their original position named after the fast component of the nystagmus.  Investigations: - CT scan if a brain injury is suspected. - Blood tests to check blood sugar levels. - ECG to look at heart rhythm may also be helpful. BPPV Benign paroxysmal positional vertigo): Essentials of Diagnosis: 1. Sudden vertigo lasting seconds with certain head positions. 2. No associated hearing loss. 3. Characteristic nystagmus (latent, geotropic/toward -the ground, fatigable) with Dix- Hallpike test. - Statistics: * The posterior semi-circular canal PSC) was affected in the majority of cases of BPPV 93% of cases), with 85% being unilateral, and 8% Bilateral. * The average age of presentation is in the 5th decade * No gender bias. * Nearly 20% of patients seen at vertigo clinics are given the diagnosis of BPPV. * The rate of recurrence may be 1015% per year. - Arising as a result of mostly due to Canalithiasis.  Predisposing factors: Dix Hallpike Test: 1. Circumstances in which the head is placed - A positive test is indicated by a latent period of 15 or seconds during which the patient is minimally maintained in an inverted orientation (eg, dental symptomatic. procedures, visits to the hairdresser). - Followed by the acute onset of vertigo and rotatory 2. Age, Inactivity, Family history. nystagmus with a rapid component toward the 3. Trauma and vestibular neuritis. affected side. A typical duration of symptoms and visible nystagmus is 1040 seconds. 4. Other ear disease; Meniereʼs syndrome. - Repeated to the same side; with each repetition, the 5. The triggering positions: rolling over in bed into a lateral position, getting out of bed, intensity and duration of nystagmus will diminish looking up and back, and bending over. (fatigability).  Treatment of PSC BPPV - Treatment with Repositioning: First-line therapy for BPPV, use gravity to move canalith debris out of the affected semi- circular canal and into the vestibule. - Epley manoeuvre, gravity is the stimulus that moves the particles within the canal. The manoeuvre is repeated until no nystagmus is elicited. In this way, the Epley manoeuvre is effective in more than 90% of cases in eliminating BPPV. Meniere disease: - Endolymphatic hydrops: excessive build-up of endolymph. * Primary idiopathic endolymphatic hydrops Meniereʼs disease) is of unknown etiology. * Secondary endolymphatic hydrops: head trauma or ear surgery, and it can occur with other inner ear disorders, allergies, or systemic disorders (such as diabetes or autoimmune disorders). - Essentials of diagnosis Meniere's disease): * Episodic vertigo lasting hours. * Fluctuating hearing loss. * Tinnitus. * Aural pressure (fullness). * Usually starts unilateral, but in 25% of cases bilateral. Management: - Stabilizing the body's fluid and electrolyte levels. - A hydrops diet regimen HDR minimizing the use of solutes (salts and sugars); Adequate fluid intake 68 glasses/day; Caffeine and alcohol restriction. - Physicians may prescribe diuretics as part of treatment - identifying and treating the underlying conditions. - Creating a safe physical environment. - Managing persistent symptoms and changes. * Aminoglycoside therapy: intratympanic gentamicin therapy. generally, 10% risk of worsening the hearing loss. * Surgical measures: Endolymphatic sac decompression; Vestibular neurectomy; Labyrinthectomy. Vestibular neuritis: - Essential for diagnosis: * Vertigo lasting days after an upper respiratory infection. * No hearing loss. * No other neurologic signs or symptoms - The proposed etiologies for vestibular neuritis include viral infection, vascular occlusion, and immunologic mechanisms. - The patient may have postural instability toward the injured ear but is still able to walk without falling. Labyrinthitis: - characteristically is viral-induced Endolabyrinthitis and is not potentially fatal. - However, labyrinthitis secondary to middle ear infection can be fatal if suppurative labyrinthitis and, subsequently, meningitis occur. - Suppurative labyrinthitis = Vertigo + SNHL permanent.- Therefore, each call from the emergency department to see a patient in whom severe vertigo and hearing loss occur simultaneously requires the clinician to determine whether the middle ear is normal. - Route of spread into the labyrinth: * In AOM - Weakened oval window membrane: post stapes surgery. * Dehiscent oval window membrane: as occurs in congenital labyrinthine deformities. - In COM Direct bacterial invasion of the labyrinth through a cholesteatomatous lateral semi-circular canal fistula.  Diffuse Suppurative Labyrinthitis: Other disorders: - Cause: suppurative otitis media. * Herpes zoster oticus Ramsay hunt syndrome): - this syndrome is believed to represent activation - Pathogens: S. pneumoniae (most common), of latent herpes zoster infection of the geniculate H. influenzae, and Neisseria meningitides. ganglion. - Management: admission, IV antibiotic (to - In addition to acute vertigo and/or hearing loss, prevent further bacterial invasion ipsilateral facial paralysis, ear pain, and vesicles in intracranially, not to reverse SNHL or the auditory canal and auricle are typical features. vestibular damage). * Acoustic Neuroma: - A type of tumor of the nerve tissue. - Symptoms include: vertigo, one-sided ringing, hearing loss.