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Vestibular Disorders, Vestibular Disorders, Tinnitus and OtotoxicityTinnitus and Ototoxicity
Dr Satvinder Singh BakshiDr Satvinder Singh Bakshi28.03.201628.03.2016
22
IntroductionIntroductionBasic inputs - vision, proprioception, and Basic inputs - vision, proprioception, and
vestibular systemvestibular systemProvide ocular stability, gait control, and Provide ocular stability, gait control, and
balancebalanceDisorders of vestibular system are major Disorders of vestibular system are major
disruptors causing spatial disorientationdisruptors causing spatial disorientationMany causes of dizziness, vertigo when Many causes of dizziness, vertigo when
caused by a loss of vestibular functioncaused by a loss of vestibular functionManagement strategies for vestibular Management strategies for vestibular
disorders has continued to evolvedisorders has continued to evolve
33
PathophysiologyPathophysiologyVestibular labyrinth - detects linear and Vestibular labyrinth - detects linear and
angular head movementsangular head movementsSemicircular canals - angularSemicircular canals - angular
Hair cells organized under cupulaHair cells organized under cupulaOtolithic organs (utricle, sacule) - linearOtolithic organs (utricle, sacule) - linear
Hair cells attached to a layer of otoconiaHair cells attached to a layer of otoconiaVestibular nerve - superior, inferior branchVestibular nerve - superior, inferior branchAfferent nerve fibers are bipolar - cell Afferent nerve fibers are bipolar - cell
bodies lie within Scarpa’s ganglionbodies lie within Scarpa’s ganglion
44
PathophysiologyPathophysiology Balance requires –Balance requires –
Normal functioning vestibular systemNormal functioning vestibular system Input from visual system (vestibulo-ocular)Input from visual system (vestibulo-ocular) Input from proprioceptive system (vestibulo-spinal)Input from proprioceptive system (vestibulo-spinal)
Central causes compromise central circuits that Central causes compromise central circuits that mediate vestibular influences on posture, gaze mediate vestibular influences on posture, gaze control, autonomic fxcontrol, autonomic fx
Disruption of balance between inputs results in Disruption of balance between inputs results in vertigovertigo
Goal of treatment: restore balance between Goal of treatment: restore balance between different inputsdifferent inputs
55
PathophysiologyPathophysiologyVestibular system influences autonomic Vestibular system influences autonomic
systemsystem Intimate linkage in brainstem pathways Intimate linkage in brainstem pathways
between vestibular and visceral inputsbetween vestibular and visceral inputsAlteration of vestibular inputs results in:Alteration of vestibular inputs results in:
nausea, vomitingnausea, vomitingPallorPallorRespiratory/circulatory changesRespiratory/circulatory changes
66
Medical TreatmentMedical TreatmentSymptomaticSymptomaticSpecific therapySpecific therapyVestibular rehabilitationVestibular rehabilitation
77
Symptomatic PharmacotherapySymptomatic Pharmacotherapy Predominant targeted vestibular Predominant targeted vestibular
neurotransmitters:neurotransmitters: CholinergicCholinergic HistaminergicHistaminergic GABA neurotransmitters - negative inhibitionGABA neurotransmitters - negative inhibition
Vomiting center transmitters:Vomiting center transmitters: Dopaminergic (D2)Dopaminergic (D2) Histaminergic (H1)Histaminergic (H1) SeratonergicSeratonergic
Multiple classes of drugs effectiveMultiple classes of drugs effective
88
Symptomatic PharmacotherapySymptomatic PharmacotherapyAntihistaminergic - dimenhydrinateAntihistaminergic - dimenhydrinateAnticholinergics - scopolamine, meclizineAnticholinergics - scopolamine, meclizineAnti-dopaminergic - droperidolAnti-dopaminergic - droperidol(gamma)-aminobutyric acid enhancing (gamma)-aminobutyric acid enhancing
(GABA-ergic) agents - lorazepam, valium(GABA-ergic) agents - lorazepam, valium
99
Symptomatic PharmacotherapySymptomatic PharmacotherapySome drugs of the antihistamine class are Some drugs of the antihistamine class are
useful for symptomatic control of vertigouseful for symptomatic control of vertigoHave anti-motion sickness properties in large Have anti-motion sickness properties in large
part due to inhibition of vestibular system H1 part due to inhibition of vestibular system H1 histaminergic neurotransmittershistaminergic neurotransmitters
Examples include dimenhydrinate (Dramamine) Examples include dimenhydrinate (Dramamine) and promethazine (Phenergan)and promethazine (Phenergan)
Also suppress the vomiting centerAlso suppress the vomiting center
1010
Symptomatic PharmacotherapySymptomatic Pharmacotherapy
1111
Symptomatic PharmacotherapySymptomatic Pharmacotherapy Two recent ER clinical trialsTwo recent ER clinical trials
Marill et al. 2000Marill et al. 2000 50mg IV dimenhydrinate vs. 2mg IV Ativan50mg IV dimenhydrinate vs. 2mg IV Ativan Benadryl more effective for symptomsBenadryl more effective for symptoms
Irving et al. 2002Irving et al. 2002 50mg IM dimenhydrinate vs. 2.5mg IM droperidol50mg IM dimenhydrinate vs. 2.5mg IM droperidol Equally effectiveEqually effective
Response is dose-dependentResponse is dose-dependent All medications are sedating All medications are sedating Newer non-sedating antihistamines do not cross Newer non-sedating antihistamines do not cross
blood-brain barrier - little therapeutic valueblood-brain barrier - little therapeutic value
1212
Specific PharmacotherapySpecific PharmacotherapyVestibular Neuritis *Vestibular Neuritis *Meniere’s Disease *Meniere’s Disease *Benign Paroxysmal Positional Vertigo *Benign Paroxysmal Positional Vertigo *OtosyphilisOtosyphilisVertebrobasilar InsufficiencyVertebrobasilar InsufficiencyMigraine (with vertigo)Migraine (with vertigo)
* * more common more common
1313
Vestibular NeuritisVestibular NeuritisSudden onset of peripheral vertigoSudden onset of peripheral vertigoUsually without hearing lossUsually without hearing lossPeriod of several hours - severePeriod of several hours - severeLasts a few days, resolves over weeksLasts a few days, resolves over weeks Inflammation of vestibular nerve - Inflammation of vestibular nerve -
presumably of viral originpresumably of viral originSpontaneous, complete symptomatic Spontaneous, complete symptomatic
recovery with supportive treatmentrecovery with supportive treatmentTreatment aimed at stopping inflammationTreatment aimed at stopping inflammation
1414
Vestibular NeuritisVestibular NeuritisAriyasu et al.Ariyasu et al.
20 patients: double-blinded, crossover20 patients: double-blinded, crossoverMethylprednisolone vs. placeboMethylprednisolone vs. placebo90% decrease in vertigo within 24 hours vs. 90% decrease in vertigo within 24 hours vs.
30% of placebo group30% of placebo groupPlacebo switched to steroid after 24 hours Placebo switched to steroid after 24 hours
with decrease in vertigo over next 24 hourswith decrease in vertigo over next 24 hours16 patients receiving steroid with resolution 16 patients receiving steroid with resolution
had normal ENG within one monthhad normal ENG within one month
1515
Meniere’s DiseaseMeniere’s DiseaseHallpike and Cairns - 1938 found Hallpike and Cairns - 1938 found
endolymphatic hydrops by histologyendolymphatic hydrops by histology Implicated a disturbance of salt and water Implicated a disturbance of salt and water
as pathologyas pathologyClassic triadClassic triad
Recurrent vertigoRecurrent vertigoFluctuating SNHLFluctuating SNHLTinnitusTinnitus(aural fullness very common)(aural fullness very common)
1616
Meniere’s DiseaseMeniere’s DiseaseWidely accepted medical treatmentWidely accepted medical treatment
Dietary salt restrictionDietary salt restrictionDiureticsDiuretics
Thiazide diureticsThiazide diureticsDecrease Na absorption is distal tubuleDecrease Na absorption is distal tubuleSide effects - hypokalemia, hypotension, Side effects - hypokalemia, hypotension,
hyperuricemia, hyperlipoproteinemiahyperuricemia, hyperlipoproteinemiaCombination potassium sparing agentsCombination potassium sparing agents
Maxzide, DyazideMaxzide, DyazideAvoids hypokalemiaAvoids hypokalemia
1717
Meniere’s DiseaseMeniere’s DiseaseAt least 3 months of diuretic therapy At least 3 months of diuretic therapy
recommended before discontinuingrecommended before discontinuingSulfa allergies - can try loop diuretics or Sulfa allergies - can try loop diuretics or
alternate therapiesalternate therapies
1818
Meniere’s DiseaseMeniere’s DiseaseCarbonic anhydrase inhibitors Carbonic anhydrase inhibitors
(acetazolamide)(acetazolamide)““inner ear glaucoma”inner ear glaucoma”Decreased Na-H exchange in tubuleDecreased Na-H exchange in tubuleDecreased CSF productionDecreased CSF productionDiuretic effect not as long-lastingDiuretic effect not as long-lastingSide effects - nephrocalcinosis, mild Side effects - nephrocalcinosis, mild
metabolic acidosis, GI disturbancesmetabolic acidosis, GI disturbances
1919
Meniere’s DiseaseMeniere’s DiseaseVasodilatorsVasodilators
Based on hypothesis - pathogenesis results Based on hypothesis - pathogenesis results from ischemia of stria vascularisfrom ischemia of stria vascularis
Rationale - improve metabolic functionRationale - improve metabolic functionIV histamine, ISDN, cinnarizine (CA agonist), IV histamine, ISDN, cinnarizine (CA agonist),
betahistine (oral histamine analogue)betahistine (oral histamine analogue)Anecdotal successAnecdotal successNo demonstrated beneficial effects in studiesNo demonstrated beneficial effects in studies
2020
Meniere’s DiseaseMeniere’s DiseaseNewer theoriesNewer theories
Multifactorial inheritanceMultifactorial inheritanceImmune-mediated phenomenaImmune-mediated phenomenaAssociation of allergiesAssociation of allergies
Study by Gottschlich et al.Study by Gottschlich et al.50% meeting criteria have antibodies to 70-kD 50% meeting criteria have antibodies to 70-kD
heat-shock proteinheat-shock protein70-kD HSP implicated in AI-SNHL70-kD HSP implicated in AI-SNHL
2121
Meniere’s DiseaseMeniere’s Disease Immunosuppressive agents gaining favorImmunosuppressive agents gaining favor
Systemic and intra-tympanic glucocorticoidsSystemic and intra-tympanic glucocorticoidsCyclophosphamideCyclophosphamideMethotrexateMethotrexate
Shea study - intractable Meniere’sShea study - intractable Meniere’s48 patients IT dexamethasone 48 patients IT dexamethasone 66.7% elimination of vertigo66.7% elimination of vertigo35.4% improvement in hearing (>10dB and/or 35.4% improvement in hearing (>10dB and/or
15% change in word recognition score) 15% change in word recognition score)
2222
Meniere’s DiseaseMeniere’s DiseaseChemical labyrinthectomyChemical labyrinthectomy
Disabling vertigoDisabling vertigoAfter trial of adequate medical therapyAfter trial of adequate medical therapy
Intratympanic aminoglycoside (ITAG)Intratympanic aminoglycoside (ITAG)Allows treatment of unilateral diseaseAllows treatment of unilateral diseaseGentamicinGentamicin
Primarily vestibulotoxicPrimarily vestibulotoxic may impair vestibular dark cells (endolymph)may impair vestibular dark cells (endolymph)
Inherent hearing loss risk - 30%Inherent hearing loss risk - 30%
2323
ITAGITAGStock solution - 40mg/mL gentamicinStock solution - 40mg/mL gentamicin10 to 20 mg injected over round window10 to 20 mg injected over round windowPatient supine, ear up for 30 minutesPatient supine, ear up for 30 minutes Instructed not to swallowInstructed not to swallowBolus injections - weekly or bi-weeklyBolus injections - weekly or bi-weeklyEnd point variable - vestibular hypofunctionEnd point variable - vestibular hypofunctionAudiometry monitoring between injectionsAudiometry monitoring between injectionsTotal vestibular ablation not necessaryTotal vestibular ablation not necessary
2424
ITAGITAGMinorMinor
91% control of vertigo91% control of vertigo3% rate of profound SNHL (usually sudden)3% rate of profound SNHL (usually sudden)22% recurrence rate22% recurrence rate
Continuous deliveryContinuous deliveryMicrowickMicrowickRound Window MicrocatheterRound Window Microcatheter
Direct injection (labyrinthotomy)Direct injection (labyrinthotomy)Significant hearing lossSignificant hearing lossOut of favorOut of favor
2525
BPPVBPPV Most common causeMost common cause Dysfunction of posterior SCCDysfunction of posterior SCC Cupulolithiasis vs. CanalithiasisCupulolithiasis vs. Canalithiasis CupulolithiasisCupulolithiasis
Calcium deposits embedded on cupulaCalcium deposits embedded on cupula PSCC becomes dependent on gravityPSCC becomes dependent on gravity
CanalithiasisCanalithiasis Calcium debris (otoconia) displaced into PSCCCalcium debris (otoconia) displaced into PSCC Does not adhere to cupulaDoes not adhere to cupula
2626
BPPVBPPV Head movementsHead movements
Looking upLooking up Lying downLying down Rolling onto affected earRolling onto affected ear
Result in displacement of “sludge” / otoconiaResult in displacement of “sludge” / otoconia Vertigo lasting a few secondsVertigo lasting a few seconds Treatment approachesTreatment approaches
Liberatory maneuversLiberatory maneuvers Particle repositioningParticle repositioning Habituation exercisesHabituation exercises
2727
BPPVBPPV Semont et alSemont et al CupulolithiasisCupulolithiasis Liberatory maneuverLiberatory maneuver Single treatmentSingle treatment Cure ratesCure rates
84%-one treatment84%-one treatment93%-two treatments93%-two treatments
2828
BPPVBPPV EpleyEpley CanalithiasisCanalithiasis Canalith repositioningCanalith repositioning Move into vestibuleMove into vestibule Cure ratesCure rates
80% - one treatment80% - one treatment 100% - multiple100% - multiple
2929
BPPV - EpleyBPPV - Epley
3030
BPPVBPPV Brandt and DaroffBrandt and Daroff Habituation techniqueHabituation technique Move to provoking Move to provoking
position repeatedlyposition repeatedly 98% success rate 98% success rate
after 3 to 14 days of after 3 to 14 days of exercisesexercises
3131
BPPVBPPVBlakelyBlakely
Compared repositioning techniques with no Compared repositioning techniques with no treatmenttreatment
89% of all patients improved after 1 month89% of all patients improved after 1 monthNo statistical significance between groupsNo statistical significance between groups50% spontaneous remission after 1 month50% spontaneous remission after 1 month
3232
OtosyphilisOtosyphilisPenicillin established treatmentPenicillin established treatment IM and IV routes acceptableIM and IV routes acceptable IM - 2.4 million units benzathine PCN IM - 2.4 million units benzathine PCN
weekly x 3 consecutive weeks is minimal weekly x 3 consecutive weeks is minimal treatment (some advocate up to 1 year)treatment (some advocate up to 1 year)
IV - 10 million units PCN G qD in divided IV - 10 million units PCN G qD in divided doses x 10 days, followed by 2.4 million doses x 10 days, followed by 2.4 million units benzathine PCN x 2 weeksunits benzathine PCN x 2 weeks
3333
Vertebrobasilar insufficiencyVertebrobasilar insufficiencyVertigo, diplopia, dysarthria, gait ataxia Vertigo, diplopia, dysarthria, gait ataxia
and bilateral sensory & motor disturbanceand bilateral sensory & motor disturbanceTransient ischemia - low stroke riskTransient ischemia - low stroke riskAntiplatelet therapy - aspirin 325mg qDAntiplatelet therapy - aspirin 325mg qDTiclid Ticlid
Platelet aggregate inhibitorPlatelet aggregate inhibitorRisk of life-threatening neutropeniaRisk of life-threatening neutropeniaOnly in patients unable to tolerate aspirinOnly in patients unable to tolerate aspirin
3434
MigraineMigraineConcomitant vertigo and disequilibriumConcomitant vertigo and disequilibriumHeadache control improves vertigoHeadache control improves vertigoDiagnostic criteriaDiagnostic criteria
Personal/family historyPersonal/family historyMotion intoleranceMotion intoleranceVestibular symptoms - do not fit other causesVestibular symptoms - do not fit other causes
Theories - vascular origin, abnormal Theories - vascular origin, abnormal neural activity (brainstem), abnormal neural activity (brainstem), abnormal voltage-gated calcium channel genesvoltage-gated calcium channel genes
3535
MigraineMigraineTreatmentTreatment
Modifying risk factorsModifying risk factorsExercise and dietExercise and dietAvoid nicotine, caffeine, red wine and chocolateAvoid nicotine, caffeine, red wine and chocolate
Abortive medical therapyAbortive medical therapyErgotsErgotsSumatriptinSumatriptinMidrinMidrin
Prophylactic medical therapyProphylactic medical therapyB blockers, Ca channel blockers, NSAIDs, B blockers, Ca channel blockers, NSAIDs,
amitryptiline, and lithiumamitryptiline, and lithium
Testing Vestibular FunctionTesting Vestibular FunctionOtolaryngologist is considered balance Otolaryngologist is considered balance
specialistspecialistOften PCP for dizzy patientsOften PCP for dizzy patientsPrivate practice physicians often quoted Private practice physicians often quoted
“I wish I knew more about dizzy patients”“I wish I knew more about dizzy patients”
ObjectivesObjectivesDescribe office examinations of dizzy Describe office examinations of dizzy
patientspatientsDescribe vestibular function studiesDescribe vestibular function studiesReview indications for vestibular function Review indications for vestibular function
studies studies Review efficacy of office and vestibular Review efficacy of office and vestibular
function studies function studies
Office Examination of the Dizzy Office Examination of the Dizzy PatientPatient
Dix-Hallpike ManeuverDix-Hallpike ManeuverUsed to provoke nystagmus and vertigo Used to provoke nystagmus and vertigo
commonly associated with BPPVcommonly associated with BPPVHead turned 45 degrees to maximally Head turned 45 degrees to maximally
stimulate posterior semicircular canalstimulate posterior semicircular canalHead supported and rapidly placed into head Head supported and rapidly placed into head
hanging positionhanging positionFrenzel glasses eliminate visual fixation Frenzel glasses eliminate visual fixation
suppression of responsesuppression of response
Dix-Hallpike ManeuverDix-Hallpike Maneuver
Dix-Hallpike ManeuverDix-Hallpike ManeuverPositive testPositive test
Up-beating nystagmusUp-beating nystagmusNystagmus to the stimulated sideNystagmus to the stimulated sideRotary component to the affected earRotary component to the affected earLasts 15-45 secondsLasts 15-45 secondsLatency of 2-15 secondsLatency of 2-15 secondsFatigues easilyFatigues easily
Pneumatic OtoscopyPneumatic OtoscopyPositive and negative pressure applied to Positive and negative pressure applied to
middle earmiddle earHennebert’s sign/symptom – nystagmus Hennebert’s sign/symptom – nystagmus
and vertigo with pressure, alternates with and vertigo with pressure, alternates with positive and negative pressurepositive and negative pressure
Can be present in patients with Can be present in patients with perilymphatic fistula, syphilis, Meninere’s perilymphatic fistula, syphilis, Meninere’s disease, SCC dehiscence syndromedisease, SCC dehiscence syndrome
Romberg TestRomberg TestPatient asked to stand with feet together Patient asked to stand with feet together
and eyes closedand eyes closedFall or step is positive testFall or step is positive testEqual sway with eyes open and closed Equal sway with eyes open and closed
suggests proprioceptive or cerebellar sitesuggests proprioceptive or cerebellar siteMore sway with eyes closed suggests More sway with eyes closed suggests
vestibular weaknessvestibular weakness
Romberg TestRomberg Test
Fukuda Stepping TestFukuda Stepping Test Originally described by Fukuda using 100 steps Originally described by Fukuda using 100 steps
on a marked floor.on a marked floor. Patients are asked to step with eyes closed and Patients are asked to step with eyes closed and
hands out in fronthands out in front Rotation by more than 45 degrees is abnormalRotation by more than 45 degrees is abnormal Rotation usually occurs to the side of the lesionRotation usually occurs to the side of the lesion Rotation often found in asymptomatic patientsRotation often found in asymptomatic patients
Dysdiadochokinesia TestingDysdiadochokinesia TestingMost commonly tested with the hand Most commonly tested with the hand
slapping testslapping testAbnormalities seen in patients with Abnormalities seen in patients with
cerebellar dysfunctioncerebellar dysfunctionPoor sensitivity and specificityPoor sensitivity and specificity
Tandem Gait TestTandem Gait TestPatients are asked to walk heal to toe in a Patients are asked to walk heal to toe in a
straight line or in a circlestraight line or in a circleComplex function evaluates many aspects Complex function evaluates many aspects
of balanceof balancePoor performance seen in cerebellar Poor performance seen in cerebellar
lesions, but can be seen in many disorderslesions, but can be seen in many disordersPoor sensitivity and specificityPoor sensitivity and specificity
Orthostatic HypotensionOrthostatic HypotensionMost often in patients on BP meds with Most often in patients on BP meds with
“light headedness” on sitting to standing“light headedness” on sitting to standingDefined as drop of SBP 20mm HG or DPB Defined as drop of SBP 20mm HG or DPB
10mm HG within 3 minutes of standing10mm HG within 3 minutes of standingTilt exams offer objective measurements Tilt exams offer objective measurements
with well established normswith well established normsPatients with no symptoms will often “Tilt”Patients with no symptoms will often “Tilt”
Voluntary HyperventilationVoluntary HyperventilationPatients asked to over breathe for 90 Patients asked to over breathe for 90
seconds to 3 minutesseconds to 3 minutesHyperventilation causes symptoms in Hyperventilation causes symptoms in
some anxiety disorderssome anxiety disordersMay provoke symptoms in normalMay provoke symptoms in normalPoor test for vestibular diagnosisPoor test for vestibular diagnosis
Quantitative Vestibular TestingQuantitative Vestibular TestingDiagnosis unclearDiagnosis unclearProlonged symptoms unresponsive to Prolonged symptoms unresponsive to
conservative treatmentconservative treatmentScreen for central disordersScreen for central disordersEvaluate prior to surgical ablation Evaluate prior to surgical ablation
proceduresproceduresDocumentation of vestibular deficitsDocumentation of vestibular deficits
Electronystagmography (ENG)Electronystagmography (ENG)Divided into oculomotor tests, positional Divided into oculomotor tests, positional
and positioning tests, and caloric testsand positioning tests, and caloric testsOnly vestibular test with the ability to test Only vestibular test with the ability to test
individual labyrinths separatelyindividual labyrinths separatelyRelies on the vestibulo-ocular reflex (VOR) Relies on the vestibulo-ocular reflex (VOR)
to test the peripheral vestibular functionto test the peripheral vestibular functionMostly a test of HSCC function Mostly a test of HSCC function
Optokinetic TestsOptokinetic TestsVestibular system and optokinetic Vestibular system and optokinetic
nystagmus allow steady focus on objectsnystagmus allow steady focus on objectsTarget is rapidly passed in front of subject Target is rapidly passed in front of subject
in one direction, then the otherin one direction, then the otherEye movements are recorded and Eye movements are recorded and
compared in each directioncompared in each directionAsymmetry suggestive of CNS lesionAsymmetry suggestive of CNS lesionHigh rate of false positive resultsHigh rate of false positive results
Caloric TestingCaloric TestingEstablished and widely accepted method Established and widely accepted method
of vestibular testingof vestibular testingMost sensitive test of unilateral vestibular Most sensitive test of unilateral vestibular
weaknessweaknessPatient positioned 30 degrees from prone Patient positioned 30 degrees from prone
(HSCC vertical allowing max stim)(HSCC vertical allowing max stim)Cold and warm water/air flushed into EACCold and warm water/air flushed into EAC
Caloric TestingCaloric TestingCOWS (cold opposite, warm same) – COWS (cold opposite, warm same) –
direction of the nystagmusdirection of the nystagmusStimulation in 0.002-0.004 Hz range Stimulation in 0.002-0.004 Hz range
(Head movements in 1-6 Hz range)(Head movements in 1-6 Hz range)Visual fixation should reduce strength of Visual fixation should reduce strength of
caloric responses 50-70%caloric responses 50-70%% caloric paresis = 100 * [(LC + LW) – % caloric paresis = 100 * [(LC + LW) –
(RC + RW)/(LC + LW + RC + RW)](RC + RW)/(LC + LW + RC + RW)]
Rotational Chair TestingRotational Chair Testing ““Gold standard” in identifying bilateral vestibular Gold standard” in identifying bilateral vestibular
lesionslesions Used to monitor for progressive bilateral Used to monitor for progressive bilateral
vestibular loss (gentamicin toxicity)vestibular loss (gentamicin toxicity) Used to quantify bilateral vestibular loss – Used to quantify bilateral vestibular loss –
vestibular rehab vs. balance trainingvestibular rehab vs. balance training Useful in testing children that will not allow Useful in testing children that will not allow
caloric irrigationscaloric irrigations Used with borderline caloric tests when water Used with borderline caloric tests when water
calorics cannot be used calorics cannot be used
Rotational Chair TestingRotational Chair Testing
Rotational Chair TestingRotational Chair TestingSinusoidal Harmonic Acceleration TestSinusoidal Harmonic Acceleration Test
Most commonly performedMost commonly performedRotates patients at frequencies from 0.01-Rotates patients at frequencies from 0.01-
1.28 Hz1.28 HzUnilateral lesions have gain and phase Unilateral lesions have gain and phase
asymmetries to the affected sideasymmetries to the affected sideReduced gain across all frequencies or phase Reduced gain across all frequencies or phase
leads suggests bilateral vestibular lesionsleads suggests bilateral vestibular lesions
PosturographyPosturographyUsed to tests integration of balance Used to tests integration of balance
systemssystemsUseful in quantification of fall riskUseful in quantification of fall riskMost useful in following conditions:Most useful in following conditions:
Chronic disequilibrium and normal examsChronic disequilibrium and normal examsSuspected malingeringSuspected malingeringSuspected multifactorial disequilibriumSuspected multifactorial disequilibriumPoorly compensated vestibular injuriesPoorly compensated vestibular injuries
PosturographyPosturography
5959
Vestibular RehabilitationVestibular RehabilitationPromoting vestibular compensationPromoting vestibular compensationHabituationHabituationEnhancing adaptation of VOR & VSREnhancing adaptation of VOR & VSRMay have initial exacerbationMay have initial exacerbation
6060
Vestibular RehabilitationVestibular RehabilitationCawthorne - CookseyCawthorne - Cooksey
Developed in 1940sDeveloped in 1940sHead movementsHead movementsBalance tasksBalance tasksCoordination of eyes with headCoordination of eyes with headTotal body movementsTotal body movementsEyes open & closedEyes open & closedNoisy environmentsNoisy environments
6161
Vestibular RehabilitationVestibular RehabilitationHabituation of pathologic responsesHabituation of pathologic responsesPostural control exercisesPostural control exercisesVisual-vestibular interactionVisual-vestibular interactionConditioning activitiesConditioning activitiesB.I.D., most improve after 4-6 weeksB.I.D., most improve after 4-6 weeks
6262
VRT - ElderlyVRT - ElderlyMultifactorial causes of balance difficultyMultifactorial causes of balance difficulty
Need 2 of 3 systems functionalNeed 2 of 3 systems functionalvestibular, visual, proprioceptivevestibular, visual, proprioceptive
Good outcome measures with longer timeGood outcome measures with longer time Impact on complications of fallsImpact on complications of falls
6363
ConclusionsConclusionsVestibular complaints common to ENTVestibular complaints common to ENTThorough evaluation and understandingThorough evaluation and understandingDx and treat acute symptomsDx and treat acute symptomsWean vestibular suppressantsWean vestibular suppressantsSpecific pharmacotherapy institutedSpecific pharmacotherapy institutedChronic, uncompensated disease benefits Chronic, uncompensated disease benefits
from early VRTfrom early VRT
OtotoxicityOtotoxicity
IntroductionIntroduction DefinitionDefinition
Damage to the cochlea or vestibular apparatus from Damage to the cochlea or vestibular apparatus from exposure to a chemical sourceexposure to a chemical source
Many sourcesMany sources MercuryMercury HerbsHerbs Streptomycin (1944)Streptomycin (1944)
Dihydrostreptomycin (1948)Dihydrostreptomycin (1948) Gentamicin (1965)Gentamicin (1965) OthersOthers
AminoglycosidesAminoglycosidesStreptomycin, kanamycin, neomycin, Streptomycin, kanamycin, neomycin,
amikacin, gentamicin, tobramycin, sisomycin, amikacin, gentamicin, tobramycin, sisomycin, netilmicinnetilmicin
Enter into inner ear by unknown mechanismEnter into inner ear by unknown mechanismSecreted into the perilymph by spiral ligament Secreted into the perilymph by spiral ligament
or endolymph by stria vascularisor endolymph by stria vascularisDiffuse through round window membraneDiffuse through round window membrane
Eliminated by kidneyEliminated by kidney
AminoglycosidesAminoglycosidesCochlear toxicityCochlear toxicity
Amikacin, kanamycin, neomycin, netilmicinAmikacin, kanamycin, neomycin, netilmicinVestibular toxicityVestibular toxicity
Streptomycin, gentamicin, sisomycinStreptomycin, gentamicin, sisomycinCan occur simultaneouslyCan occur simultaneously
AminoglycosidesAminoglycosidesCochlear toxicityCochlear toxicity
Increase of 10-20 dB in thresholds of one or Increase of 10-20 dB in thresholds of one or more frequenciesmore frequencies
Incidence (6-13%), netilmicin lowestIncidence (6-13%), netilmicin lowestRisk factorsRisk factors
Diuretics, renal failure, prolonged treatment, old Diuretics, renal failure, prolonged treatment, old age, preexisting SNHLage, preexisting SNHL
Infants less affected, once daily dosingInfants less affected, once daily dosing
AminoglycosidesAminoglycosides Cochlear toxicityCochlear toxicity
Outer hair cell loss first Outer hair cell loss first in basal turn then to in basal turn then to apexapex
Inner hair cell loss Inner hair cell loss laterlater
AminoglycosidesAminoglycosidesCochlear toxicity presentationCochlear toxicity presentation
High frequency SNHL first, then lower High frequency SNHL first, then lower frequencies to profound lossfrequencies to profound loss
Not reversibleNot reversibleDamage usually heralded by tinnitusDamage usually heralded by tinnitus
AminoglycosidesAminoglycosidesVestibular toxicityVestibular toxicity
Assessment is difficultAssessment is difficultDynamic posturography can detectDynamic posturography can detectPathologicallyPathologically
Type I hair cells more sensitiveType I hair cells more sensitiveCristae ampullaris then utricle and sacculeCristae ampullaris then utricle and saccule
Clinically (ambulatory vs. bedridden)Clinically (ambulatory vs. bedridden)Ataxic gait, lose balance when turningAtaxic gait, lose balance when turningBobbing oscillopsiaBobbing oscillopsia
AminoglycosidesAminoglycosidesPreventionPrevention
PharmacologicalPharmacologicalClinicalClinical
Consider less ototoxic drugs (netilmicin)Consider less ototoxic drugs (netilmicin)Identify “high-risk” patientsIdentify “high-risk” patients
Audiogram before and weekly after startingAudiogram before and weekly after starting ENG prior if possibleENG prior if possible History and physical exam daily (Romberg, VA)History and physical exam daily (Romberg, VA) Adjust doses or switch drugs if toxicAdjust doses or switch drugs if toxic
MacrolidesMacrolides Discovered erythromycin 1952 (McGuire)Discovered erythromycin 1952 (McGuire) Mintz (1972) first report of ototoxicityMintz (1972) first report of ototoxicity
Reversible 50-55 dB losses in two casesReversible 50-55 dB losses in two cases ClinicallyClinically
Hearing loss with/without tinnitus– 2 daysHearing loss with/without tinnitus– 2 daysAll frequencies, recovery after stoppingAll frequencies, recovery after stoppingRarely permanent (hepatic)Rarely permanent (hepatic)Incidence unknownIncidence unknown
Other antibioticsOther antibioticsVancomycinVancomycin
Believed to be ototoxic (no data)Believed to be ototoxic (no data)Penicillin, sulfonamides, cephalosporinsPenicillin, sulfonamides, cephalosporins
May have topical toxicity in middle earMay have topical toxicity in middle earNucleoside analog reverse transcriptase Nucleoside analog reverse transcriptase
inhibitorsinhibitorsPoor studyPoor study
Loop DiureticsLoop DiureticsEthacrinic acid, furosemide, bumetasideEthacrinic acid, furosemide, bumetasideClinically (6-7%)Clinically (6-7%)
Usually tinnitus, temporary and reversible Usually tinnitus, temporary and reversible SNHL, rare vertigo within minutesSNHL, rare vertigo within minutes
High doses can cause permanent SNHLHigh doses can cause permanent SNHLHighest risk– coadministration of Highest risk– coadministration of
aminoglycosidesaminoglycosides
Loop DiureticsLoop Diuretics PathologicallyPathologically
Edema of stria Edema of stria vascularisvascularis
Ionic gradient changesIonic gradient changes Inhibition of adenylate Inhibition of adenylate
cyclase and G-cyclase and G-proteinsproteins
Salicylates and NSAIDSSalicylates and NSAIDSMost common OTC drugs in USMost common OTC drugs in USMechanismMechanism
Normal histology (no hair cell loss)Normal histology (no hair cell loss)Decreased blood flow, decreased enzymesDecreased blood flow, decreased enzymes
ClinicallyClinicallyTonal, high frequency tinnitus (7-9 kHz)Tonal, high frequency tinnitus (7-9 kHz)Reversible mild to moderate SNHL (usually Reversible mild to moderate SNHL (usually
high frequency)– rarely permanenthigh frequency)– rarely permanent
QuinineQuinine Similar clinical findings with aspirinSimilar clinical findings with aspirin Usage up for leg crampsUsage up for leg cramps ClinicallyClinically
High-pitched tinnitusHigh-pitched tinnitus Reversible, symmetric SNHLReversible, symmetric SNHL Occasional vertigoOccasional vertigo
MechanismMechanism Decreased perfusion, direct damage to outer hair Decreased perfusion, direct damage to outer hair
cells, biochemical alterationscells, biochemical alterations
Antineoplastic AgentsAntineoplastic AgentsCisplatinCisplatin
Incidence is high (62%-81%)Incidence is high (62%-81%)PathologicallyPathologically
Outer hair cell degenerationOuter hair cell degenerationClinicallyClinically
Bilateral symmetric SNHL, usually high frequency– Bilateral symmetric SNHL, usually high frequency– not reversible, cumulativenot reversible, cumulative
Risks factors– age extremes, cranial irradiation, Risks factors– age extremes, cranial irradiation, high dose therapy, high cumulative dosehigh dose therapy, high cumulative dose
Antineoplastic DrugsAntineoplastic DrugsCisplatinCisplatin
PreventionPreventionProbenecid, WR 2721, DDTC, diuretics, calcium Probenecid, WR 2721, DDTC, diuretics, calcium
supplements– not effectivesupplements– not effectiveL-N-acetyl-cysteine– protective in vitroL-N-acetyl-cysteine– protective in vitro
Topical AntimicrobialsTopical AntimicrobialsCommonly prescribed for otorrhea after Commonly prescribed for otorrhea after
tubes and CSOMtubes and CSOMControversial subjectControversial subject
Agents may enter middle ear and gain access Agents may enter middle ear and gain access to membranous labyrinthto membranous labyrinth
Animal testing reveals irrefutable evidence of Animal testing reveals irrefutable evidence of severe ototoxicitysevere ototoxicity
Topical AntimicrobialsTopical AntimicrobialsPolymixin B (Brummett)Polymixin B (Brummett)Chloramphenicol (Patterson)Chloramphenicol (Patterson)Neomycin (Brummett)Neomycin (Brummett)Gentamicin (Webster)Gentamicin (Webster)Ticarcillin (Jakob)Ticarcillin (Jakob)Vasocidin (Brown)Vasocidin (Brown)Ciprofloxacin (Lenarz)Ciprofloxacin (Lenarz)
Topical AntimicrobialsTopical Antimicrobials Differences in humansDifferences in humans
Round window is not Round window is not exposedexposed
Round window thickerRound window thicker Mucosal membrane Mucosal membrane
protectiveprotective Mucosal edema with or Mucosal edema with or
without exudates without exudates typically presenttypically present
Widespread usage with Widespread usage with few side effectsfew side effects
One in ten thousandOne in ten thousand
Topical AntimicrobialsTopical AntimicrobialsRemains a possibility in humansRemains a possibility in humansPatient education importantPatient education importantPrescribe for only necessary durationPrescribe for only necessary durationAvoid in healthy earAvoid in healthy earCaution with prexisting vestibular defectsCaution with prexisting vestibular defects
TINNITUSTINNITUS
“…“…only my ears whistle and buzz continuously day and only my ears whistle and buzz continuously day and
night. I can say I am living a wretched life.”night. I can say I am living a wretched life.”
Ludwig Von Beethoven - 1801Ludwig Von Beethoven - 1801
IntroductionIntroduction
Tinnitus -“Conscious experience of a sound Tinnitus -“Conscious experience of a sound that originates in an involuntary manner, in the that originates in an involuntary manner, in the head of it’s owner, or may appear to do so.head of it’s owner, or may appear to do so.[Mac Fadden] [Mac Fadden] Tinnere Tinnere – means “ringing” in Latin– means “ringing” in Latin
Includes Buzzing, roaring, clicking, pulsatile Includes Buzzing, roaring, clicking, pulsatile soundssounds
TinnitusTinnitus
May be perceived as unilateral or bilateralMay be perceived as unilateral or bilateralOriginating in the ears or around the headOriginating in the ears or around the headFirst or only symptom of a disease process or First or only symptom of a disease process or
auditory/psychological annoyanceauditory/psychological annoyance
TinnitusTinnitus
May occur at any ageMay occur at any ageMost common in 40-70 year-oldsMost common in 40-70 year-oldsMore common in men than womenMore common in men than womenU/L 50 %U/L 50 %B/L 50 %B/L 50 %Left ear more than Right earLeft ear more than Right earPrevalence in children with SOM is up to Prevalence in children with SOM is up to
43.9%.43.9%.
ClassificationClassification
Objective tinnitusObjective tinnitus – sound produced by – sound produced by paraauditory structures which may be heard by paraauditory structures which may be heard by an examiner. The term has been replaced by an examiner. The term has been replaced by somato-sounds.somato-sounds.
Subjective tinnitusSubjective tinnitus – sound is only perceived – sound is only perceived by the patient (most common)by the patient (most common)
TinnitusTinnitus
Pulsatile tinnitus – matches pulse or a rushing Pulsatile tinnitus – matches pulse or a rushing sound sound Possible vascular etiologyPossible vascular etiologyEither objective or subjectiveEither objective or subjectiveIncreased or turbulent blood flow through Increased or turbulent blood flow through
Para auditory structuresPara auditory structures
Vascular Pulsatile tinnitusVascular Pulsatile tinnitus
Arteriovenous Arteriovenous malformationsmalformations
Vascular tumorsVascular tumors AtherosclerosisAtherosclerosis Ectopic carotid arteryEctopic carotid artery Persistent stapedial Persistent stapedial
arteryartery Vascular loopsVascular loops
Benign intracranial Benign intracranial hypertensionhypertension
Venous humVenous hum Dehiscent jugular bulbDehiscent jugular bulb Cardiac murmursCardiac murmurs PregnancyPregnancy AnemiaAnemia ThyrotoxicosisThyrotoxicosis
Nonvascular Pulsatile TinnitusNonvascular Pulsatile Tinnitus
Palatal myoclonus.Palatal myoclonus.Stapedius muscle spasm.Stapedius muscle spasm.Tensor tympani spasm.Tensor tympani spasm.Patulous eustachian tube.Patulous eustachian tube.
Subjective TinnitusSubjective Tinnitus Much more common than Much more common than
objectiveobjective Usually nonpulsatileUsually nonpulsatile
PresbycusisPresbycusis Noise exposureNoise exposure Meniere’s diseaseMeniere’s disease OtosclerosisOtosclerosis Head traumaHead trauma Acoustic neuromaAcoustic neuroma DrugsDrugs Middle ear effusionMiddle ear effusion TMJ problemsTMJ problems DepressionDepression HyperlipidemiaHyperlipidemia MeningitisMeningitis SyphilisSyphilis
Drugs that cause tinnitusDrugs that cause tinnitus
AntinflammatoriesAntinflammatoriesAntibiotics Antibiotics
(aminoglycosides)(aminoglycosides)Antidepressants Antidepressants
(heterocyclines)(heterocyclines)
AspirinAspirinQuinineQuinineLoop diureticsLoop diureticsChemotherapeutic Chemotherapeutic
agents (cisplatin, agents (cisplatin, vincristine)vincristine)
MANAGEMENT OF TINNITUSMANAGEMENT OF TINNITUS
HISTORYHISTORYCLINICAL EXAMINATIONCLINICAL EXAMINATIONLABORATORY INVESTIGATIONSLABORATORY INVESTIGATIONSTREATMENTTREATMENT
Evaluation - HistoryEvaluation - History Careful historyCareful history Onset and durationOnset and duration Subjective or objectiveSubjective or objective Unilateral or bilateralUnilateral or bilateral Constant/intermittentConstant/intermittent Pitch: Meniere’s disease – low frequency ; NIHL – Pitch: Meniere’s disease – low frequency ; NIHL –
high frequencyhigh frequency QualityQuality LoudnessLoudness Alleviating/aggravating factorsAlleviating/aggravating factors
Evaluation - HistoryEvaluation - History InfectionInfection Trauma or prior ear surgeryTrauma or prior ear surgery Noise exposureNoise exposure Medication usageMedication usage Medical historyMedical history Hearing lossHearing loss VertigoVertigo PainPain Family historyFamily history Impact on patientImpact on patient Social history : alcohol, caffeine, tobacco, illegal drugs usageSocial history : alcohol, caffeine, tobacco, illegal drugs usage
Evaluation – Physical ExamEvaluation – Physical Exam
Complete head & neck examComplete head & neck examGeneral physical examGeneral physical examOtoscopy (glomus tympanicum, dehiscent Otoscopy (glomus tympanicum, dehiscent
jugular bulb)jugular bulb)Search for audible bruit in pulsatile tinnitusSearch for audible bruit in pulsatile tinnitus
Auscultate over orbit, mastoid process, skull, neck, Auscultate over orbit, mastoid process, skull, neck, heart using bell and diaphragm of stethoscopeheart using bell and diaphragm of stethoscope
Toynbee tube to auscultate EACToynbee tube to auscultate EAC
Evaluation – Physical ExamEvaluation – Physical Exam
Light exercise to increase pulsatile tinnitusLight exercise to increase pulsatile tinnitusLight pressure on the neck (decreases venous Light pressure on the neck (decreases venous
hum)hum)Valsalva maneuver (decrease venous hum)Valsalva maneuver (decrease venous hum)Turning the head (decrease venous hum)Turning the head (decrease venous hum)
Evaluation - AudiometryEvaluation - Audiometry
PTA, speech descrimination scores, tympanometry, PTA, speech descrimination scores, tympanometry, acoustic reflexesacoustic reflexes
Acoustic reflexes should not be performed in tinnitus Acoustic reflexes should not be performed in tinnitus patient with hyperacusis, as can worsen the tinnituspatient with hyperacusis, as can worsen the tinnitus
Vascular or palatomyoclonus induced tinnitus – graph Vascular or palatomyoclonus induced tinnitus – graph of compliance vs. timeof compliance vs. time
Patulous Eustachian tube – changes in compliance with Patulous Eustachian tube – changes in compliance with respirationrespiration
Asymmetric sensorineural hearing loss or speech Asymmetric sensorineural hearing loss or speech discrimination, unilateral tinnitus suggests possible discrimination, unilateral tinnitus suggests possible acoustic neuroma - MRIacoustic neuroma - MRI
Laboratory studiesLaboratory studies
As indicated by history and physical examAs indicated by history and physical examPossibilities include:Possibilities include:
HematocritHematocritFTA absorption testFTA absorption testBlood chemistriesBlood chemistriesThyroid studiesThyroid studiesLipid profileLipid profileAutoimmune panelAutoimmune panel
ImagingImaging
Pulsatile tinnitusPulsatile tinnitusContrast enhanced CT of temporal bones, Contrast enhanced CT of temporal bones,
skull base, brain, calvaria as first-line studyskull base, brain, calvaria as first-line studyCT for retrotympanic mass, MRI/MRA if CT for retrotympanic mass, MRI/MRA if
normal otoscopynormal otoscopyGlomus tympanicum,glomus Glomus tympanicum,glomus
jugulare,arteriovenous malformations,acoustic jugulare,arteriovenous malformations,acoustic neuromaneuroma
ImagingImaging
Other contrast enhanced CT diagnosesOther contrast enhanced CT diagnosesAberrant carotid arteryAberrant carotid arteryDehiscent carotid arteryDehiscent carotid arteryDehiscent jugular bulbDehiscent jugular bulbPersistent stapedial arteryPersistent stapedial artery
Soft tissue on promontorySoft tissue on promontoryEnlargement of facial nerve canalEnlargement of facial nerve canalAbsence of foramen spinosumAbsence of foramen spinosum
Treatment of tinnitusTreatment of tinnitus
Mnemonic : Five Ps and Three Ss.Mnemonic : Five Ps and Three Ss.The management of tinnitus should be The management of tinnitus should be
individualized according to patient problems.individualized according to patient problems.
Management option 1 : PreventiveManagement option 1 : Preventive
Prevention of maternal rubella and Prevention of maternal rubella and noise exposure.noise exposure.
Treatment of cause of underlying Treatment of cause of underlying disorder.disorder.
Management option 2 : PathologicalManagement option 2 : Pathological
In 5-10% of cases there is a cause for which In 5-10% of cases there is a cause for which treatment may result in abolition or reduction of treatment may result in abolition or reduction of tinnitus.tinnitus.
1)1) Conductive hearing loss :Treatment of it help Conductive hearing loss :Treatment of it help tinnitus by restoring the normal masking and tinnitus by restoring the normal masking and distracting effects of ambient noises.e.g. includedistracting effects of ambient noises.e.g. include
Cerumen removalCerumen removal Surgery for middle ear effusionSurgery for middle ear effusion Otosclerosis : doubtful value and post-Otosclerosis : doubtful value and post-
stapedectomy tinnitus is often particularly stapedectomy tinnitus is often particularly troublesome and resistant to treatment.troublesome and resistant to treatment.
2)2) Meniere’s disease : Vertigo is usually most Meniere’s disease : Vertigo is usually most distressing symptom but in later stages distressing symptom but in later stages constant tinnitus usually develops. Treatment constant tinnitus usually develops. Treatment regimen includes-regimen includes-
Cochlear vasodilator , preferably betahistine Cochlear vasodilator , preferably betahistine hydrchloride.hydrchloride.
Diuretic , e.g. bendrofluazide.Diuretic , e.g. bendrofluazide. Reduced salt intake.Reduced salt intake. Stress reduction.Stress reduction. Relaxation training therapy.Relaxation training therapy.
3)3) Drugs , Foods and LiquidsDrugs , Foods and Liquids Avoidance of ototoxic drugs viz. quinine, Avoidance of ototoxic drugs viz. quinine,
aspirin, NSAID’s, aminoglycosides and aspirin, NSAID’s, aminoglycosides and cytotoxic drugs.cytotoxic drugs.
Avoidance of certain foods e.g. chocolate, Avoidance of certain foods e.g. chocolate, certain cheeses and milk products if certain cheeses and milk products if suspected to cause tinnitus.suspected to cause tinnitus.
Avoidance of liquids e.g. tea, coffee, red Avoidance of liquids e.g. tea, coffee, red wines, ports if suspected to cause tinnitus.wines, ports if suspected to cause tinnitus.
Avoidance of smoking and alcohol.Avoidance of smoking and alcohol.
4) Benzodiazepine Reinstatement 4) Benzodiazepine Reinstatement Too rapidly withdrawal of addictive drugs can Too rapidly withdrawal of addictive drugs can
lead to tinnitus.lead to tinnitus.Most common drug causing tinnitus in this Most common drug causing tinnitus in this
way is benzodiazepines.way is benzodiazepines.Quite often reinstatement of the drug followed Quite often reinstatement of the drug followed
by very gradual withdrawal results in much by very gradual withdrawal results in much reduced or abolished tinnitus.reduced or abolished tinnitus.
5) Anaemia , Hypertension , Atherosclerosis5) Anaemia , Hypertension , Atherosclerosis EiEither anaemia or hypertension may lead to ther anaemia or hypertension may lead to
pulsatile tinnitus, especially when combined pulsatile tinnitus, especially when combined with atherosclerosis in carotid circulation.with atherosclerosis in carotid circulation.
Correction of underlying cause may reduce Correction of underlying cause may reduce tinnitus.tinnitus.
Occasionally, carotid circulation may be so Occasionally, carotid circulation may be so reduced (<80%) that endarterectomy may be reduced (<80%) that endarterectomy may be justified.justified.
Management option 3 : PsychologicalManagement option 3 : Psychological
Professional CounsellingProfessional CounsellingCounselling by LiteratureCounselling by LiteratureLay CounsellingLay CounsellingRelaxation training therapyRelaxation training therapyPsychological counselling and treatmentPsychological counselling and treatment
Management option 4 : ProstheticManagement option 4 : Prosthetic
1.1. Tinnitus retraining therapyTinnitus retraining therapy
2.2. Tinnitus MaskingTinnitus Masking
Tinnitus Retraining TherapyTinnitus Retraining Therapy It is a combination of prosthetic and psychological It is a combination of prosthetic and psychological
avenues.avenues. Long-term reduction in tinnitus intrusiveness is the aim.Long-term reduction in tinnitus intrusiveness is the aim. It uses a constant low level of noise, which is independent It uses a constant low level of noise, which is independent
of tinnitus, so that its presence is soon forgotten.of tinnitus, so that its presence is soon forgotten. The first instrument to consider is a Hearing Aid. It has to The first instrument to consider is a Hearing Aid. It has to
be worn for many hours a day, particulary in the quieter be worn for many hours a day, particulary in the quieter periods.periods.
In other cases Tinnitus Maskers , as therapeutic noise In other cases Tinnitus Maskers , as therapeutic noise generators is triedgenerators is tried
Exact mechanism of benefit seems to be combination of Exact mechanism of benefit seems to be combination of repeated counseling, prosthesis itself and normal tendency repeated counseling, prosthesis itself and normal tendency to habituate to tinnitus with time.to habituate to tinnitus with time.
1.1. TRT is applicable for all types of tinnitus, as TRT is applicable for all types of tinnitus, as well as for decreased sound tolerance.well as for decreased sound tolerance.
2.2. Success rate more than 80?%.Success rate more than 80?%.3.3. TRT can provide cure for decreased sound TRT can provide cure for decreased sound
tolerance.tolerance.4.4. It does not require frequent clinic visits.It does not require frequent clinic visits.5.5. It has no side effects.It has no side effects.
Management Option 5 : Management Option 5 : PharmacologicalPharmacological
Drugs to reduce tinnitus per se :Drugs to reduce tinnitus per se :1.1. Intravenous lignocaine : 50% success rate. Relief is Intravenous lignocaine : 50% success rate. Relief is
for few hours only.for few hours only.2.2. Clonazepam : 33% success rate.Clonazepam : 33% success rate.3.3. CarbamazepineCarbamazepine4.4. NimodipineNimodipine5.5. TocainideTocainide6.6. Intravenous frusemideIntravenous frusemide TranquilizersTranquilizers AntidepressantsAntidepressants
Management Option 6 : SurgeryManagement Option 6 : Surgery
• Used for treatment of arteriovenous Used for treatment of arteriovenous malformations, glomus tumors, otosclerosis, malformations, glomus tumors, otosclerosis, acoustic neuromaacoustic neuroma
• Some authors have reported success with cochlear Some authors have reported success with cochlear nerve section in patients who have intractable nerve section in patients who have intractable tinnitus and have failed all other treatments, this is tinnitus and have failed all other treatments, this is not widely acceptednot widely accepted
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