Tinnitus S. Greg Escue, MD June 12, 2008

Outline Overview Meniere’s Labyrinthitis Medications Acoustic Neuromas Objective Tinnitus

Definition Perception of sound without external stimulation Ringing, hissing, clicking Constant, pulsatile High or low pitch Subjective or Objective Examiner can hear objective

Epidemiology Estimated 10-15% of population Adults and children 30-40 million people Adults and children Incidence increases with age

Question What is the most common cause of tinnitus? A. AV Malformations B. Medication Side Effects C. Meniere’s D. Sensorineural Hearing Loss

Causes Subjective Sensorineural hearing loss – Most Common Loud Noise exposure Medications Meniere’s TMJ Disorders Depression, Stress Neurologic Disorders (Acoustic Neuroma, MS, ALS)

Objective Objective Toynbee Tube AV Malformations Arterial Bruits Enlarged Eustachian Tube Palatomyoclonus Stapedial Muscle Spasm Toynbee Tube Like a stethoscope with an olive shaped tip Used for listening to a patient’s ear to find objective tinnitus Things I found searching for picture of a Toynbee Tube (google – medical equipment Toynbee Tube)

History Unilateral vs. Bilateral Fluctuating tinnitus Description of Sound Pulsatile, Constant Associated symptoms Vertigo, hearing loss

Evaluation Examine head, ears, neck, torso Listen for carotid bruit or venous hum Examine ear canal for significant wax Examine TM for vesicles, tumors, fluid Perform CN exam

Rule Out Badness Tumors (acoustic neuroma) AV Malformations Often unilateral AV Malformations Pulsatile Sometimes audible to examiner (objective tinnitus) Meniere’s, Labyrinthitis Associated symptoms

Treatment Sensorineural Hearing Loss TCA’s/SSRI’s Hearing aids Electrical Stimulators Counseling, Biofeedback Tinnitus masking hearing aids Background noise for sleeping Bedside clock, radio Ginkgo biloba, niacin, acupuncture

Case 50yo female c/o sudden onset tinnitus for last 3 hours. It is a roaring tinnitus in left ear that is non-pulsatile. Also c/o vertigo and nausea. On exam, patient has reduced hearing from left ear. Our super detective emergency medicine resident suspects which as the most likely diagnosis? A. Benign Paroxysmal Positional Vertigo B. Head Trauma C. Medication Side Effect D. Meniere’s

Question What is the required triad for diagnosis of Meniere’s Disease?

Meniere’s Triad of Tinnitus, hearing loss, vertigo May also have nausea, vomiting, diaphoresis Hearing loss usually low frequencies Lasts 20 mins to 12 hours Can occur several times per week, or couple times a month Can be one ear or both

Meniere’s Pathophysiology uncertain Believed there is over accumulation of endolymph, causing increased cochlear duct size that pushes the Reissner membrane into the scala vestibuli

Meniere’s Also known as endolymphatic hydrops Refers to build-up of endolymph Beside’s Meniere’s, can also be: Post-Traumatic Post-Infectious Otosyphilis Cogan Syndrome Triad of nonsyphilitic interstitial keratitis, vestibuloauditory disease, and associated autoimmune vasculitis

Meniere’s Epidemiology 50-200 cases per 100,000 Peak Incidence age 40-60 Can be seen in children as young as 4 No gender preference Genetic predisposition 10-20% have bilateral

Meniere’s History Hearing loss, recurrent episodes vertigo, aural fullness, tinnitus Must have either aural fullness or tinnitus on affected side Must have history of at least 2 separate episodes of vertigo lasting at least 20 minutes Usually last several hours Nausea, vomiting, anxiety

Meniere’s History May have history of falls during episodes drop attacks or crises of Tumarkin Hearing loss may fluctuate More severe episodes superimposed on gradual deterioration Tinnitus Usually non-pulsatile whistle or roaring sensation May be continuous or intermittent

Meniere’s Physical Exam Horizontal or rotary nystagmus present during vertiginous attacks Nystagmus may be elicited by Dix-Hallpike test Should be fatigable Latency usually 2-5 seconds Occurs within 20 seconds May have positive Romberg

Meniere’s Physical Exam Hennebert sign Tullio phenomenon Nystagmus with pressure on external auditory canal Tullio phenomenon Sound induced vertigo or nystagmus

Meniere’s Testing Try to differentiate from other causes CBC, BMP, Sed rate/CRP, thyroid panel, and syphilis studies (RPR/VDRL) CT head, MRI head ENT referral for more extensive testing

Meniere’s Treatment Vertigo Nausea Antihistamines (Antivert, Dramamine) Anticholinergics (Scopolamine) Benzos (Valium) Others (Ephedrine, Prednisone) Nausea Phenergan, Compazine

Meniere’s Treatment for Severe Cases Surgical drainage of endolymph Intratympanic Injection of gentamicin, streptomycin, or corticosteroids Labyrinthectomy Vestibular nerve resection

Meniere’s Current Research Tympanic Wicks with Gentamicin Hypobaric chamber treatment Endolymphatic sac drainage with corticosteroid injection

Meniere’s Disposition Prognosis Discharge unless unable to control symptoms Follow-up with PCP or ENT if severe Prognosis Variable, with spontaneous remission in 50%, others have progressive symptoms with progressive hearing loss 5-10% require surgery

Case 45yo female presents to ED c/o sudden onset of tinnitus, vertigo, and hearing loss with history of recent fever and URI. What is the most likely diagnosis? A. Benign Paroxysmal Positional Vertigo B. Head Trauma C. Labyrinthitis D. Medication Side Effect

Labyrinthitis Occurs when infectious microorganisms or inflammatory mediators invade the membranous labyrinth causing damage to the vestibular and auditory end organs Similar to Meniere’s, but caused by infection instead of too much endolymph Symptoms Severe Tinnitus, hearing loss less likely Vertigo and disequilibrium more pronounced

Labyrinthitis Pathophysiology Epidemiology Inflammation of inner ear Usually infectious organism May be Viral (such as Ramsay-Hunt) or Bacterial Epidemiology Viral form most common One case per 10,000 people Age 30-60 most common, but can be any age

Labyrinthitis Viral Preceding viral URI in 50% of cases Sudden loss of hearing with onset of vertigo/loss of balance Patient may be bedridden due to severity Hearing loss usually high frequencies

Labyrinthitis Bacterial Usually secondary to Meningitis or Otitis Media Otitis Media related now uncommon Meningitis associated usually bilateral Can be due to toxins or inflammatory mediators (called serous labyrinthitis)

Labyrinthitis Physical Exam Nystagmus Balance difficulty Examine ear for otitis media, perforation, vessicles Examine patient for signs of meningitis, mastoiditis

Labyrinthitis Testing As indicated for suspected infections CT temporal bone for suspected mastoiditis LP if suspected meningitis MRI may be indicated if suspected acoustic neuroma, epidural hematoma, epidural/brain abscess

Labyrinthitis Treatment Antivert, Dramamine, Scopolamine, Phenergan, Compazine, Valium Corticosteroids may be beneficial Antivirals for Ramsay-Hunt Antibiotics for otitis media or meningitis

Labyrinthitis Disposition Prognosis Usually able to discharge viral associated Admit severe cases refractory to medications Fluids, bed rest, meds for vertigo and nausea Consider other meds as above Prognosis Most symptoms improve in days to weeks Hearing loss/disequilibrium permanent in small percentage

Case 22yo OD patient refuses to say which pills she took, though she does c/o tinnitus. The astute emergency medicine resident suspects an elevation of which toxicology level? A. Acetaminophen B. Aspirin C. Ethanol D. TCA

Medications Large list of medications can cause tinnitus Dose dependent Aminoglycosides (gentamicin, streptomycin, amikacin, tobramycin), ASA*, NSAIDS*, Chemotherapeutics Dose Independent Erythromycin*, Minocycline*, Fluoroquinolones*, Loop Diuretics, Antimalarials* Reversible indicated above with stars Loop Diuretics sometimes reversible, sometimes irreversible

Medications Most common medications ASA – as little as 1.5gm/day Standard dosing as much as 3900mg daily NSAIDS Aminoglycosides

Case 20yo male complaining of right side tinnitus. History also reveals frequent headaches and a family history of neurofibromatosis type II. Patient has also noted decreasing hearing in right ear over last several months. What is the likely diagnosis? A. Acoustic Neuroma B. AV Malformation C. Drug seeking D. Meniere’s

Acoustic Neuroma Pathophysiology Epidemiology Tumor of Vestibulocochlear nerve (CN VIII) Usually affect vestibular branch (95%) Arise from Schwann cell sheath Epidemiology One per 100,000 people Associated with Neurofibromatosis Type II (develop bilaterally)

Acoustic Neuroma History Unilateral Sensorineural Hearing Loss is Acoustic Neuroma until proven otherwise Unilateral Tinnitus should also be evaluated for Acoustic Neuroma Symptoms can fluctuate Headaches present 50-60% May also have facial numbness and/or weakness

Acoustic Neuroma Treatment Observation Elderly patients, high risk comorbidities, the only good ear is the one affected Stereotactic Radiotherapy (e.g. Gammaknife) Lower immediate morbidity/mortality, faster recovery More likely to cause facial or vestibular nerve damage Frequent imaging required for follow-up Surgical Resection Mortality of surgical resection 1-2% Reduced from 40% over last 80-90 years Facial nerve palsy 10-30% <10% for tumor <1.5cm

Acoustic Neuroma Prognosis Can have a variety of post-operative complications Aseptic meningitis, headache, CSF leak, nerve damage Tinnitus improved 25-60% Recurrence rate 5-10% Hearing preserved 30-80%

Objective Tinnitus Sound that an examiner can also hear Usually Muscular or Vascular Carotid artery or Jugular Vein Pulsatile or venous hum IF PULSATILE, THINK VASCULAR Patients with ALS or MS Myoclonus of stapedius or tensor tympani muscles Surgical excision is corrective

Important Points Sensorineural hearing loss most common Pulsatile equals vascular Review their medications Tinnitus, Vertigo, Hearing loss = Meniere’s Labyrinthitis – Vertigo, disequilibrium, recent URI Acoustic Neuroma – Tinnitus, hearing loss, headaches

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