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VERTIGO AND TINNITUS

VERTIGO AND TINNITUS. Yard.Doc.Dr.Müzeyyen Doğan. Learning goal and objectives of the lesson. Learning goal of the lesson: Learning goal of the lesson: The learner should know the main clinical features and investigation of the tinnitus

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VERTIGO AND TINNITUS

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  1. VERTIGO AND TINNITUS Yard.Doc.Dr.Müzeyyen Doğan

  2. Learning goal and objectives of the lesson Learning goal of the lesson:Learning goal of the lesson: The learner should know the main clinical features and investigation of the tinnitus Learning objectives of the lesson the learner will be able to: • describe the tınnıtus, type of tinnitus • explain the evaluation methods for tinnitus • explain the rehabilitation methods for tinnitus

  3. Learning goal and objectives of the lesson Learning goal of the lesson: The learner should know the main clinical features and investigation of the vertigo Learning objectives of the lesson the learner will be able to: • take a directed history from patient with vertigo • list the evaluation methods for peripheral vestibular system • describe the peripheral causes of vertigo Skill objectives the learner will be able to • evaluate the patient’s nystagmus during acute attack of peripheral vertigo. • learn how to approach the patient with cochleovestibular pathology

  4. Vertigo

  5. Steps 1.History Taking 2.Clear definition (Vertiginous or Nonvertiginous dizziness) 3.Peripheral or Central Vertigo 4.Psychogenic Vertigo

  6. Differential diagnosis 1.Dizziness 2.Presyncope 3.Disequilibrium:Unsteady gait 4.Light-headedness

  7. Symptoms • Unconscious • Pallor • Sweating • Nausea/Vomiting • Auditory Symptoms :Hearing loss, Tinnitus, aural (ear) fullness • Diplacusis • Paracusis • Neurologic Symptoms: numbness, weakness, difficulty with swallowing or speech

  8. Definition a subjective sensation of movement May feel either that him involving in space or that objects in the environment are moving around him.

  9. History Taking • Description of the sensation (including associated symptoms) • Onset (acute, gradual) • Duration (date sensation was first noted, length of time it lasts) • Intensity (how troubling is it?) • Exacerbations (activities, positions, circumstances that worsen situation)

  10. Remissions (activities, positions circumstances that make sensation better) • Medications (prescription, herbal, over the counter) • Other medical problems (diabetes, hypertension, heart disease, etc) • Psychosocial (any stressors?)

  11. Physical Examinations • Mental conditions • Vital Signs: Bp,HR • Otoscopy • Ascultation of the neck for bruits • Rinne Test • Weber’s Test

  12. Rinne Test

  13. Weber’s Test

  14. Neurologic exams Nystagmus Romberg’s Gait Dix-Hallpike Maneuver

  15. Dix-Hallpike Maneuver

  16. Peripheral Vertigovs Central Vertigo

  17. Comparison of Common Diseases

  18. Peripheral Vertigo • Benign paroxysmal positional vertigo: most common in adults • Acute Labyrinthitis • Chronic Labyrinthitis (Meniere’s Syndrome) • Toxic Labyrinthitis • Vestibular Neuronitis • Acoustic Nerve Lesions • Labyrinthine Ischemia

  19. Central vertigo • Brainstem Lesions • Intravascular: Vertebrobasilar insufficiency • Tumors • Intracranial infection • Demyelinating diseases: Multiple Sclerosis, Syringobulbia

  20. Conclusions 1.History Taking 2.Physical Examinations 3.Psychogenic Vertigo must be consider 4.Labs for necessary

  21. Tinnitus

  22. Tinnitus • Definition • Classification • Objective tinnitus • Subjective tinnitus • Theories • Evaluation • Treatment

  23. 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.

  24. Tinnitus • 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

  25. Tinnitus • 40 million affected in the United States • 10 million severely affected • Most common in 40-70 year-olds • Roughly equal prevalence in men and women

  26. 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)

  27. Tinnitus • Pulsatile tinnitus – matches pulse or a rushing sound • Possible vascular etiology • Objective or subjective • Increased or turbulent blood flow through paraauditory structures

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

  29. 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

  30. Arteriovenous Malformations • Pulsatile tinnitus • Headache • Papilledema • Discoloration of skin or mucosa

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

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

  33. Venous hum • Benign intracranial hypertension • Dehiscent jugular bulb • Transverse sinus partial obstruction • Increased cardiac output from • Pregnancy • Thyrotoxicosis • Anemia

  34. 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

  35. Benign Intracranial Hypertension • Sismanis and Smoker 1994 • 100 patients with pulsatile tinnitus • 42 found to have BIH syndrome • 16 glomus tumors • 15 atherosclerotic carotid artery disease

  36. Benign Intracranial Hypertension • Treatment • Weight loss • Diuretics • Subarachnoid-peritoneal shunt • Gastric bypass for weight reduction

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

  38. Myoclonus • Palatal myoclonus associations: • Multiple Sclerosis and other degenerative neurological disorders • Small vessel disease • Brain stem tumors • Treatments: muscle relaxants, botulinum toxin injection

  39. Stapedius Muscle Spasm • Idiopathic stapedial muscle spasm • Rough, rumbling, crackling sound • Exacerbated by outside sounds • Brief and intermittent • May be able to see tympanic membrane movement • Treatments: avoidance of stimulants, muscle relaxants, sometimes surgical division of tensor tympani and stapedius muscles

  40. Patulous Eustachian Tube • Eustachian tube remains open abnormally • Ocean roar sound • Changes with respiration • Lying down or head in dependent position provides relief • Tympanogram will show changes in compliance with respiration • Associated with significant weight loss, radiation to the nasopharynx

  41. Otologic Hearing loss (presbycusis, noise exposure, otosclerosis, middle ear effusion) Meniere’s disease Acoustic neuroma Ototoxic drugs or substances Neurologic MS Head trauma Metabolic Thyroid disorders Hyperlipidemia B12 def Psych Depression/anxiety Infectious Syphilis Meningitis Subjective Tinnitus

  42. Conductive hearing loss • Conductive hearing loss decreases level of background noise • Normal paraauditory sounds seem amplified • Cerumen impaction, otosclerosis, middle ear effusion, otosclerosis, perforated TM, EAC swelling are examples • Treating the cause of conductive hearing loss may alleviate the tinnitus

  43. Sensorineural hearing loss • Indicates abnormality of the inner ear or cochlear portion of the 8th CN • NIHL and presbycusis most common

  44. Other subjective tinnitus • Poorly understood mechanisms of tinnitus production • Abnormal conditions in the cochlea, cochlear nerve, ascending auditory pathways, auditory cortex • Hyperactive hair cells • Chemical imbalance

  45. CNS Mechanisms • Reorganization of central pathways with hearing loss (similar to phantom limb pain) • Disinhibition of dorsal cochlear nucleus with increase in spontaneous activity of central auditory system

  46. Neurophysiologic Model • Proposed by Jastreboff • Result of interaction of subsystems in the nervous system • Auditory pathways playing a role in development and appearance of tinnitus • Limbic system responsible for tinnitus annoyance • Negative reinforcement enhances perception of tinnitus and increases time it is perceived

  47. Role of Depression • Depression is more prevalent in patients with chronic tinnitus than in those without tinnitus • Folmer et al (1999) reported patients with depression rated the severity of their tinnitus higher although loudness scores were the same • Which comes first, depression or tinnitus?

  48. Analgesic ASA, NSAIDs Antibiotics Aminoglycosides Erthyromycin Vancomycin Chloramphenicol Tetracycline Loop diuretics Chemotherapeutic agents Cisplatin Vincristine Methotrexate Bleomycin Others Chloroquine Heavy metals Quinine Heterocyclic antidepressants Ototoxic Drugs

  49. Evaluation - History • Careful history • Quality • Pitch • Loudness • Unilateral vs Bilateral • Constant/intermittent • Onset • Alleviating/aggravating factors

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