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Tinnitus; diagnosis and imagingRutger Hofman, MD, PhD
NVA, NijmegenSeptember 30th, 2011
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Contents
Introduction Diagnosis Imaging Pathology; diagnosis and imaging Conclusion; algorithm
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Joseph Toynbee (1815-1866)
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Tinnitus
Definition: ‘a sound perceived for more than fiveminutes at a time, in absence of any externalacoustical or electrical stimulation of the ear and not occurring immediately after exposure to loudnoise’.
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Tinnitus
Objective Subjective Auditory hallucinations
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Diagnosis Medical history
Subjective description of tinnitus (uni-, bilateral) Annoyance daily life/sleep Synchrony of tinnitus with pulse Effect of neck movement Effect of neck compression Effect of respiration Associated auditory or vestibular symptoms Otological/general medial conditions Medication/Drugs Noise exposure, family history Stress conditions, psychological/psychiatrical disorders
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Medication
1. Salicylate, NSAID’s: aspirin (reversible)
2. Mycin-antibiotics3. Antimalaria medication: quinine (reversible)
4. Diuretics: furosemide5. Cytotoxic medication: cisplatin, methotrexate6. Tricyclic antidepressant, benzodiazepine
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Diagnosis
Physical examination Otoscopy Palpation Auscultation
Audiometry Pure tone audiometry Speech audiometry Tympanometry Stapedial reflexes (BERA, OAE’s)
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Otoscopy
External meatus acousticus Tympanic membrane, middle ear cavity
Tympanic sclerosis Glue Schwartze’s sign Myoclonus middle ear muscles Vascular tumours anomalies
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Physical examination
Palpation neck Thyroid gland
Auscultation Peri-auricular Neck (carotid souffle) Cor (transmittid souffle)
Oropharyngeal inspection Palatal myoclonus
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Diagnosis
(Vestibular assessment) (Neurological assessment)
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Imaging
Ultrasound neck (echo duplex) Superficial vascular structures
Computed Tomography (CT/CTA) Bony structures
Magnetic Resonance Imaging (MRI/ MRA) Soft tissue structures
Digital Substraction Angiography Profound vascular structures
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Tinnitus
Objective Subjective
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Objective tinnitus
Vascular (pulsatile) Vascular malformations
Arterioveneus malformationsAneurysmsFistulae
Carotid artery stenosis
Vascular tumours Paragangliomas
Glomus tympanicum
Glomus jugulare Haemangioma
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Arteriovenous malformations
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Arteriovenous malformations
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Stenosis carotid artery
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Paraganglioma
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Paraganglioma
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Paraganglioma
= glomustympanicum
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Haemangioma
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Haemangioma
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Objective tinnitus
Vascular (pulsatile) Increased intracranial pressure Transmitted cardiac murmurs Different hyperdynamic vascular states (‘veneus hum’)
Pregnancy Hyperthyreoidism
Anaemia
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Benign intracranial hypertension(‘pseudo-tumour cerebri’)
Unusual Raised intracranial pressure
headaches, dizziness, visual distubance, pulsatile tinnitus
Associated with obesity Lumbar puncture, MRI
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Objective tinnitus
Myogenic Palatal Middle ear muscles
m. tensor tympani m. stapedius m. levator palatini
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Objective tinnitus
Patulous Eustachian tube; ‘Tuba aperta’ Nasal respiration Tympanic membrane movements
Otocopy tympanometry
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Objective tinnitus
Temporomandibular joint abnormality
Spontanous otoacoustic emissions
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Subjective tinnitus
Conductive hearing loss Sensorineural hearing loss
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Conductive hearing loss
1. Otitis externa2. (chronic) Otitis media3. Otosclerosis
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Otitis externa
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Otitis media
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Otitis media
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Otosclerosis
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Otosclerosis
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Otosclerosis
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Otosclerosis
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Sensorineural hearing loss
1. Noise-induced2. Ménière’s disease3. Congenital/hereditary4. Vestibular schwannoma5. Presbyacusis6. Paget’s disease (osteodystrophia deformans)
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Vestibular schwannoma
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Vestibular schwannoma
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Vestibular schwannoma
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Paget’s diseaseosteodystrophia deformans
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Paget’s diseaseosteodystrophia deformans
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AICA
Anterior inferior carotid artery
Vascular loop with suggested compression orirritation of the auditory nerve equally present in symptomatic and non-symptomatic ears. Makinset al., 1998
Vascular loops significantly more common (p<0.0001) in patients with unilateral pulsatiletinnitus than non-pulsatile tinnitus. De Ridder et al., 2005
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AICA
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Typewriters tinnitus
Levine RA, 2006 n = 6 ‘…a staccato quality of their intermittent tinnitus
('like a typewriter in the background, popcorn, Morse code‘)’.
5 patients symmetric and consistent with theirages audiograms.
4 patients vascular compression of the auditorynerve on MR imaging.
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Typewriters tinnitus
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Conclusion
Extensive medical history Extensive physical examination Imaging Pulsatile tinnitus!
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Algorithm
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Acknowledgements
dr. R.H. Freedrs. J.A. Wachters
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References1. Ceranic B, Luxon LM. Tinnitus and other dyacuses. In: Gleeson
M et al.(eds) Scott-Brown’s Otorhinolaryngology, Head and NeckSurgery 7th edition. London: Hodder Arnold, 2008, 3594-3629
2. Andersson G et al. Tinnitus, a multidisciplinary approach. London, Philadelphia: Whurr publishers, 2005
3. Weismann JL, Hirsch BE. Imaging of tinnitus; a review. Radiology 2000, 216; 342-9
4. Levine RA. Typewriter tinnitus: a carbamazepine-responsivesyndrome related to auditory nerve vascular compression. ORL J Otorhinolaryngol Relat Spec 2006, 68; 43-6
5. De Ridder D et al. Pulsatile tinnitus and the intrameatal vascularloop; Why do we not hear our carotids. Neurosurgery 2005, 57; 1213-7
6. Mijangos SV et al. Case 171: Facial Nerve Hemangioma. Radiology 2011, 260; 296-301
7. Monsell EM. The mechanism of hearing loss in Paget's diseaseof bone. Laryngoscope 2004, 114; 598-606
8. Nam E-C et al. Carbamazepine responsive typewriter tinnitusfrom basilar invagination. J Neurol Neurosurg Psychiatry 2010, 81; 456-458
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City of Groningen