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Vestibular Disorders, Vestibular Disorders, Tinnitus and OtotoxicityTinnitus and Ototoxicity

Dr Satvinder Singh BakshiDr Satvinder Singh Bakshi28.03.201628.03.2016

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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

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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

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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

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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

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Medical TreatmentMedical TreatmentSymptomaticSymptomaticSpecific therapySpecific therapyVestibular rehabilitationVestibular rehabilitation

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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

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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

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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

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Symptomatic PharmacotherapySymptomatic Pharmacotherapy

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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

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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

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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

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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

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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)

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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

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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

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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

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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

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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

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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)

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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%

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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

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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

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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

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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

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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

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BPPVBPPV EpleyEpley CanalithiasisCanalithiasis Canalith repositioningCanalith repositioning Move into vestibuleMove into vestibule Cure ratesCure rates

80% - one treatment80% - one treatment 100% - multiple100% - multiple

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BPPV - EpleyBPPV - Epley

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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

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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

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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

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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

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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

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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

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Vestibular RehabilitationVestibular RehabilitationPromoting vestibular compensationPromoting vestibular compensationHabituationHabituationEnhancing adaptation of VOR & VSREnhancing adaptation of VOR & VSRMay have initial exacerbationMay have initial exacerbation

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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

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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

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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

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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

Thank YouThank You