Tinnitus

Tinnitus
Presenatation by:Lianne Beck, MD
Assistant Professor
Emory Family Medicine

Tinnitus
* Definition
* Classification
* Objective tinnitus
* Subjective tinnitus
* Theories
* Evaluation
* Treatment

Introduction
* Tinnitus -“The perception of sound in the absence of external stimuli.”
* Tinnire – means “ringing” in Latin
* Includes buzzing, hissing, roaring, clicking, pulsatile sounds
* For some, an unbearable sound that drives them to contemplate suicide.
* May be perceived as unilateral or bilateral
* Originating in the ears or around the head
* First or only symptom of a disease process or auditory/psychological annoyance

Classification

* Objective tinnitus – sound produced by paraauditory structures which may be heard by an examiner, often pulsatile
* Subjective tinnitus – sound is only perceived by the patient (most common)
* Pulsatile tinnitus – matches pulse or a rushing sound
o Possible vascular etiology
o Objective or subjective
o Increased or turbulent blood flow through paraauditory structures

Objective tinnitus
* Vascular (pulsatile)
o A/V malformations
o Vascular tumors
o Venous hum (cardiac murmurs, anemia, BIH, thyrotoxicosis, pregnancy, dehiscent jugular bulb)
o Atherosclerosis
o Ectopic carotid artery
o Persistent stapedial artery
o Vascular loops
* Neuromuscular
o Palatomyclonus
o Stapedial muscle spasm
* Patulous eustachian tube

Arteriovenous Malformations
* Congenital lesions
* Occipital artery and transverse sinus, internal carotid and vertebral arteries, middle meningeal and greater superficial petrosal arteries
* Mandible
* Brain parenchyma
* Dura
* Pulsatile tinnitus
* Headache
* Papilledema
* Discoloration of skin or mucosa

Vascular tumors
* Glomus tympanicum
o Paraganglioma of middle ear
o Loud pulsatile tinnitus which may decrease with ipsilateral carotid artery compression
o Reddish mass behind tympanic membrane which blanches with positive pressure
o Conductive hearing loss

Vascular tumors
* Glomus jugulare
o Paraganglioma of jugular fossa
o Loud pulsatile tinnitus
o Conductive hearing loss if into middle ear
o Cranial neuropathies

Venous hum
* Benign intracranial hypertension
* Dehiscent jugular bulb
* Transverse sinus partial obstruction
* Increased cardiac output from
o Pregnancy
o Thyrotoxicosis
o Anemia

Benign Intracranial Hypertension
* Also called pseudotumor cerebri
* Young, obese, female patients
* Hearing loss
* Aural fullness
* Dizziness
* Headaches
* Visual disturbance
* Papilledema, pressure >200mm H20 on LP

Benign Intracranial Hypertension
* Sismanis and Smoker 1994
o 100 patients with pulsatile tinnitus
o 42 found to have BIH syndrome
o 16 glomus tumors
o 15 atherosclerotic carotid artery disease
* Treatment
o Weight loss
o Diuretics
o Subarachnoid-peritoneal shunt
o Gastric bypass for weight reduction

Neuromuscular Causes
* Palatal myoclonus
o Clicking sound
o Rapid (60-200 beats/min), intermittent
o Contracture of tensor palantini, levator palatini, levator veli palatini, tensor tympani, salpingopharyngeal, superior constrictors
o Muscle spasm seen orally or transnasally
o Rhythmic compliance change on tympanogram

Myoclonus
Stapedius Muscle Spasm
Patulous Eustachian Tube
Subjective Tinnitus
Conductive hearing loss
Sensorineural hearing loss
Other subjective tinnitus
CNS Mechanisms
Neurophysiologic Model
Role of Depression
Ototoxic Drugs
Evaluation - History
Evaluation – Physical Exam
Evaluation - Audiometry
Laboratory studies
Imaging
Glomus Tympanicum
Glomus jugulare
Acoustic Neuroma
ENT Referral
Treatments
Treatments - Medicines
Treatments
* Hearing aids – amplification of background noise can decrease tinnitus
* Maskers – produce sound to mask tinnitus
* Tinnitus instrument – combination of hearing aid and masker
Conclusions
References

Tinnitus.ppt