1. Tinnitus
S. Greg Escue, MD
June 12, 2008

2. Outline Overview Meniere’s Labyrinthitis Medications Acoustic Neuromas
Objective Tinnitus

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

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

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

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

7. 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)

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

11. 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

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

13. 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

15. 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

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

17. 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

18. 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

21. 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

22. 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

23. 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

24. 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

25. 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

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

27. 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

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

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

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

32. 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

35. 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

36. 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

38. 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 most common, but can be any age

39. 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

40. 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)

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

42. 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

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

44. 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

46. 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

47. 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

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

50. 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

51. 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)

54. 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

55. 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 years
Facial nerve palsy 10-30%
<10% for tumor <1.5cm

56. 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%

58. 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

60. 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

61. One Last Announcement