Exam 1 (Tinnitus Causes & Types) Flashcards
Which models contributed to the development of Cognitive Behavioral Therapy (CBT)
and Tinnitus Retraining Therapy (TRT).
Foundation for TRT (tinnitus retraining therapy) = Jasterboff’s
McKenna cognitive behavioral model of tinnitus = CBT
what is subjective tinnitus
Only heard by the PT
Most common
Source is complex or difficult to determine since a variety of factors are involved
Unique to each PT
Can be bothersome (significantly impacting quality of life) or nonbothersome (minimal impact on quality of life)
One PT can have multiple sounds
what are causes of subjective tinnitus
ototoxicity
meniere’s
nIHL
OTSC
cerumen blockage
autoimmune diseases
TMJ
tumor
IE viral infections
SSNHL
presbycusis
whiplash
what is objective tinnitus
Can be heard by the examiner and the PT
Rare
Can be vascular or mechanical in origin
Usually due to vascular disturbances or muscular spasms in the head/neck
Sounds generated within the body & can be audible to another person
Always a somatosound with an internal acoustic source
Not all somatosounds are detectable by the examiner and may not qualify as objective
true
causes of objective tinnitus
ME muscle spasms
Glomus tumors
head/neck trauma/injury
Changes in blood flow in vessels near the ear
ETD
Palatal myoclonus
what is acute tinnitus
short duration, less than 3 mos
Associated w/ recent exposure triggers (e.g. loud noise, ear injury, meningitis etc.)
Higher chance of spontaneous recovery
what is chronic tinnitus
persistant, 3-6 mos or longer
Involves sustained neurobiological changes & may require ongoing management
HL
Less chance of spontaneous recovery
persistant, 3-6 mos or longer
Involves sustained neurobiological changes & may require ongoing management
HL
Less chance of spontaneous recovery
chronic
short duration, less than 3 mos
Associated w/ recent exposure triggers (e.g. loud noise, ear injury, meningitis etc.)
Higher chance of spontaneous recovery
acute
bothersome tinnitus
distressing and negatively affects quality of life and/or health status
non bothersome
little to no impact on quality of life or health status
bothersome is broken down into
Mild
Moderate
Severe
primary tinnitus
Tinnitus that is idiopathic & may or may not be associated with SNHL (source is unknown)
If we do not know the cause or disorder that caused it
secondary tinnitus
Tinnitus that is associated with a specific underlying cause (other than SNHL) or an identifiable organic condition
If we do know the cause of the tinnitus
auditory causes of secondary tinnitus
impacted cerumen, ME diseases, cochlear abnormalities, auditory nerve pathology
non auditory causes of secondary tinnitus
vascular anomalies, myoclonus, intracranial hypertension, tonic tensor tympani syndrome, TMJ disorder
what is pulsatile tinnitus
Tinnitus is characterized by sound that is rhythmic and resembles the heartbeat
what is somatic tinnitus
tinnitus caused or influenced by sensory input in the body
apply pressure or clench jaw etc. and they notice the tinnitus
Somatic and pulsatile could be classified as ______ because we know what is causing it
secondary
3 categories we can use to classify tinnitus
temporal characteristics
duration
impact
Temporal characteristics
how often do they experience it
Do you always here the tinnitus? How often do you hear it (every week, every month etc.)
what are the classifications under temporal characteristics
spontaneous
temporary
occassional
intermittent
constant
spontaneous
sudden sound, usually unilateral lasting 2-3 min
sudden sound, usually unilateral lasting 2-3 min
spontaneous
temporary
lasts minutes to days often after noise exposure or medications and can accompany TTS
lasts minutes to days often after noise exposure or medications and can accompany TTS
temporary
occassional
occurs les than weekly (e.g., every few weeks, months or every few months) and lasts at least 5 minutes
occurs les than weekly (e.g., every few weeks, months or every few months) and lasts at least 5 minutes
occasional
occurring regularly (daily or weekly) and lasts at least 5 minutes
intermittent
intermittent
occurring regularly (daily or weekly) and lasts at least 5 minutes
constant
continuous sound
continuous sound
constant
duration classification
how long you had it
recent/acute: experienced less than 6 months
persistent/chronic: experienced for >/= 6 months
experienced less than 6 months
recent/acute
experienced for >/= 6 months
persistent/chronic
impact classification
how does it affect their life or interfere
Is it bothersome? Do you feel like you are distracted when you have it? Does it keep you u? Can you sleep?
Classifications:
Bothersome: distressing and negatively affects quality of life and/or health status
Non-bothersome: little to no impact on quality of life or health status
classifications under impact
Classifications:
Bothersome: distressing and negatively affects quality of life and/or health status
Non-bothersome: little to no impact on quality of life or health status
HL & tinnitus
Most common cause of severe tinnitus - deprivation of sensory input to CANS
Tinnitus is 2x as common in older adults than young adults - potential link to age-related HL and other health issues
tinnitus causes HL
FALSE
HL can lead to tinnitus BUT tinnitus doesn’t cause HL
NIHL & tinnitus
Second most common of HL
Exposure to hazardous levels of occupational or recreational noise
Severity of NIHL: influenced by duration, intensity and energy content of the noise
At risk: military personnel & industrial/recreational noise
who are at risk for NIHL & tinnitus
military personnel & industrial/recreational noise
serverity of NIHL
influenced by duration, intensity and energy content of the noise
possible cuases of menieres disease
ncreased endolymph pressure, rupture of Reissner’s membrane, & loss of hair cells
management of meniere’s
primarily focused on vertigo and HL with less attention on tinnius
what is experienced in menieres
Tinnitus often LF tone (125-250 Hz)
common symptoms of vestibular Schwannoma & Cerebellopontine Angle Lesions
Common symptoms
unilateral/assymetric HL
Loss of balance
Dizziness
Facial numbness
Tinnitus here has higher severity and annoyance levels
OTSC and tinnitus
Tinnitus is common
High-pitched or resembles white noise
First symptom
Can initially be pulsatile
how does OTSC cause tinnitus
CHL = deafferentation
Reduction of masking effect
Rich blood supply = pulsatile
Arteriovenous malformations
Cochlear tinnitus caused by toxic enzymes produced by otosclerotic bone, bony invasion of the cochlea and damage to the cochlear blood supply
ototoxicity & tinnitus sound
Continuous high-pitched sound
what drugs is tinnitus a side effect for
Salicylates (e.g., Aspirin), non-steroidal anti-inflammatory drugs (NSAIDs), Quinine, Aminoglycoside antibiotics, loop diuretics (e.g., Furosemide), chemotherapeutic agents (e.g., Cisplatin and Carboplatin)
examples of ototoxic drugs
Salicylates (e.g., Aspirin), non-steroidal anti-inflammatory drugs (NSAIDs), Quinine, Aminoglycoside antibiotics, loop diuretics (e.g., Furosemide), chemotherapeutic agents (e.g., Cisplatin and Carboplatin)
Most drug-induced tinnitus is reversible if drug is discontinued
true
what drugs cause permanet hl
aminoglycoside antibiotics, cisplatin, carboplatin) or prolonged high-dose use of salicylates.
describe synergistic effects
significant increase to the risk of hearing damage beyond what either factor would cause alone
A combined exposure to noise & aminoglycosides = greater auditory damage
More than either of them alone
stress & tinnitus
High stress = severe tinnitus
Stress can worsen tinnitus in those that already have it OR it can induce tinnitus on its own
what is pulsatile tinnitus
In sync with the heartbeat
Rhythmical noise usually the same beat as the heart
Usually caused by bloodflow changes near the ear or by a change in awareness of the blood flow
Whooshing sound with a constant rhythm
what is heard with pulsatile tinnitus
Whooshing sound with a constant rhythm
causes of pulsatile tinnitus
Venous hums
Stenosis of carotid arteries
Heart murmur
Hypertension
Hyperthyroidism
Vascular stenosis
Aneurysms
Coronary artery disease
Unilateral head or neck pain with abrupt tinnitus onset
carotid dissection
Tinnitus intensity changes with head movement
venous source
what hx is important for pulsatile tinnitus
Ask about meds related to blood pressure & hx of heart disease or BP issues
If they are taking meds is their BP under control or variable?
Ask about previous imaging studies
carotid/vertebral ultrasound, MRA, CTA
PTs hx can give clues to the source of pulsatile tinnitus
Abrupt onset with unilateral neck or head suggests a carotid dissection
Changes in tinnitus intensity with head turning suggests venous source for tinnitus
what evaluations should be done for pulsatile tinnitus
Complete audio testing - comprehensive audio, tymps, reflexes
DPOAEs
Find pulse to determine if pulsing matches tinnitus
Tinnitus of venous origin can be suppressed by compressing the jugular vein
Use 2 fingers to press firmly on SCM muscle & carotid artery for 10 sec. On the right and left sides of the neck
Ask PT if pulsing changes in any way (may stay, go away or change to a different sound)
If it does change, refer for medical workout of vascular pathways
Glomus jugulare Symptoms
Slow growing, late diagnosis until tumor is extensive (avg around 6 years from first symptom)
HL is main presenting feature due to ME invasion
Pulsatile tinnitus, ME mass, CN involvement, vertigo, otorrhea
Rising sun appearance in otoscopy; red ™
Pulsatile tinnitus & decrease amp with carotid pressure
PTA - unilateral CHL or mixed HL
what is clicking tinnitus
Rare
Can be objective; somatosounds
Not all are detectable by the examiner
This appears to be due to contractions of the tensor tympani or the nasopharyngeal muscles controlling the patency of the ET
Clicking can be a symptom of
ME myoclonus (jerking of a muscle group)
Bilateral clicking is usually associated with
palatal myoclonus
things to ask for case hx for clicking tinnitus
What does it sound like? Clicking of a pen?
When did it start? Is it progressing?
One or both ears? (usually one ear)
Random or does it coincide with some movement they do
Does it get better or worse with position changes or changing head movements
what testing can be done for clicking tinnitus
Can see abnormalities during impedance testing
Can be detectable using ARTs or reflex decay; will occasionally see it on tymps
Sometimes reflexes are too short in duration so you can capture it during reflex decay testing
Have PT tap leg when clicking is heard and look for corresponding results to te PT tap
True clicking is likely caused by ME muscle spasms
REFER to ENT
characteristic features of somatosensory tinnitus
Closely associated with factors related to the head or upper neck
Tinnitus always perceived in the ear ipsilateral to the somatic event
High pitched and constant ringing
No other hearing or vestibular complaints & neurological exams show no abnormalities
Hearing sensitivity is normal
causes of somatosensory tinnitus
muscle tension
tmj/jaw issues
dental disorders
head injuries
cervical spine issues
chronic stress
case hx questions to ask
Any jaw issues currently or in the past
Any clenching or grinding teeth
Any jaw pain/poppin gon either side
Any tightness in jaw or fatigue while chewing
diagnostic criteria/characteristics for somatic tinnitus
tinnitus increases with bad psture
pitich, loudness and/or location vary
teeth clenching
dental diseases
TMJ
tinnitus preceded by head or neck trauma
what are clinical assessments that can be done for somatic tinnitus
TMJ - Have PT clench jaw for 10 s. Any change in tinnitus?
Have PT open jaw wide/protrude jaw for at least 5s. Any change in tinnitus?
neck maneuvers: Active neck movements - with and without resistance
Passive muscular palpation in order to search for myofascial trigger points (MTP) or tender points
what are some red flags of tinnitus and should you refer
REFER for all
Pulsatile tinnitus
Tinnitus in association with vertigo
Unilateral tinnitus or hearing loss
Examination showing abnormalities of the ears
Tinnitus in association with asymmetric hearing loss
Psychological distress
Significant associated sleep / concentration problems
Anxiety regarding possible underlying pathology
Distressing tinnitus not improving, despite initial treatment
Patient request for ENT/audiological assessment
Tinnitus in association with significant neurological symptoms
An 87 year old woman had a year of intermittent severe hissing tinnitus that could be left ear only or bilateral. It followed a cyclical pattern. Following a day or two of no tinnitus, it would begin softly in the left ear but over the next two days become progressively louder as it spread to both ears. It would then lessen over the next two days or so, until the tinnitus was heard only in the left ear and ultimately would disappear completely. She had a long history of bruxism and muscle contraction headaches (tightness over her temples and jaw). When her tinnitus was severe her headaches were severe.
Her audiogram showed symmetric mild sloping to moderately severe SNHL, bilaterally.
At a visit when her tinnitus was extremely loud (10/10) and bilateral, somatic testing was performed.
Her tinnitus loudness decreased to 4/10 and became unilateral (left ear only).
These changes in her tinnitus persisted for the remainder of that visit (20 minutes).
By the next day her tinnitus had disappeared completely, but the usual cycle then returned within a day or two.
Type: somatosensory (changes intensity when things change - she has jaw problems, clenching causes migraines and comes and goes with certain things)
Maneuver relaxed the muscle which is why it could’ve decreased the intensity
A 33 year old man was seen because of non-lateralized tinnitus. His mother had been diagnosed with terminal lung cancer about three weeks earlier, and he had been closely involved with her care. Two days before her death as he was trying to sleep, his tinnitus began. It was described as a high-pitched ringing similar in pitch but much louder than transient tinnitus he had previously experienced following loud sound exposure. Clenching or turning his head would aggravate his tinnitus. His exam and audiogram were normal. Despite four years of a variety of treatments, his tinnitus has persisted, and he remains distressed.
Type: dishabituation because he experienced tinnitus before and it was gone (occurred due to some change, he habituates and then he is fine and it comes back and brain perceives it as a new stimulus)
Value of digging into history of PT
He has normal hearing
What referral should be considered for this PT?
Mental health services to deal with the stress and this might change the vicious cycle
Most common sound a patient will report for tinnitus is
ringing
pushing/whoosing
Does it match your heartbeat
Count the beats you feel and at the same time ask the PT to count the number of tinnitus beats they hear
pulsatile
Confirmed with tone decay because it provides a larger time window where as a reflex is shorter (can se there too) and gives a better chance to see it
Every time you hear the clicking sound tap your foot and watch decay and changes confirm the clicking
clicking tinnitus
Related to muscle spasms, etc.
Do maneuvers to confirm this
somatosensory
