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A 64-year-old man with left-sided tinnitus since September 2003 underwent left atrial catheter ablation for atrial flutter that he had been experiencing since 1999. Owing to its multifactorial origin (Table 1) [1], tinnitus presents a treatment challenge [2]. For his paroxysmal atrial flutter, the patient had undergone right atrial catheter ablation in spring 2002, with a short-lived effect. Immediately after waking from anesthesia, the patient recognized that the left-sided tinnitus had completely disappeared. Clinical neurological investigation revealed ptosis on the left side, hypoacusis on the left side, slight wasting of the tongue edges, generally absent deep-tendon reflexes, slight wasting of the thighs, a deficit of elbow extension of 5 degrees bilaterally, postural tremor, gynecomastia, and turning to the right by 45 degrees on Unterberger's treadmill test. To reproduce the curative effect of propofol or fentanyl on the tinnitus, the patient was scheduled to undergo a second injection with propofol and fentanyl.
The causes of left-sided ptosis, fasciculations, muscle cramps, easy fatigability, the generally reduced deep-tendon reflexes, or elevation of some muscle enzymes in this patient remain speculative, as results from nerve conduction studies, electromyography, and creatine-kinase analysis were repeatedly normal. This case study shows that high-dose intravenous fentanyl and propofol may transiently discontinue unilateral, idiopathic tinnitus. Importance Can be a sign of serious diseases Can be seen in other specialties Hard to diagnose because it integrates several organs and systems together and the underlying cause is not clear. INTRODUCTION Dizziness is a common symptom that accounted for more than 5.6 million clinic visits in the United States 15% to 30% of patients, most often women and the elderly, will experience dizziness severe enough to seek medical attention at some time in their life. Physiology Function of vestibular system: “Input” resulting from a stimulus that needs to be corrected through the vestibular system such as falling down.
It is not surprisingly that vestibular lesion cause: Imbalance posture and gait imbalance visual distortion (oscillopsia ). VERTIGO The word "vertigo" comes from the Latin "vertere", to turn + the suffix "-igo", a condition = a condition of turning about). Vestibular Neuritis Viral infection of vestibular organ Affect all ages but rare in children – mostly adults Affected patient presents acutely with spontaneous nystagmus,vertigo and nausea &vomiting stays for hours and sometimes days.
BPPV The most common cause of vertigo in patient > 40 years Repeated attacks of vertigo usually of short duration less than a minute. BPPV Diagnosis History Dix-Halpike maneuver : putting the patient in a certain position to stimulate the attack, and to look at the eye (causes nystagmus) to see which canal is mostly affected by trying to push the particles inside the canal and inducing the sense of dizziness.
Migraine associated vertigo (MAV): common in females between the ages of 20 to 35 Classical presentation, preceded by aura or without aura then headache followed by couple of hours of dizziness. Acoustic tumor Benign tumor Arise from vestibular division of VIII Clinical presentation: Unilateral tinnitus Hearing loss Dizziness The only way to differentiate between Meniere's disease and the Acoustic tumor is by MRI.
This study evaluated the interference of tinnitus on the quality of life for noiseexposed workers enrolled in a hearing conservation program. Most tinnitus research has focused on effective treatments and the mechanisms of the cause, detection, and perception of tinnitus. In addition to its medical and audiological aspects, the psychosocial consequences of tinnitus can be of significance and have also been investigated. Tinnitus is a common complaint among noise-exposed workers, and in some countries it is even recognized as a work-related condition for compensation purposes.
The objective of our study is to evaluate the impact of tinnitus on the quality of life of workers who are exposed to noise and enrolled in a corporate hearing conservation program. We enrolled participants from a meat-packing facility in the state of Rio Grande do Sul, Brazil. We administered a questionnaire to all the employees of the company (N = 372) at the beginning of the training sessions of their hearing conservation program. To assess the workers' hearing status, we performed otoscopy and pure-tone audiometry, according to the requirements of the Brazilian legislation [10]. We administered to the 52 participants the Brazilian version of the Tinnitus Handicap Inventory (THI) questionnaire, elaborated by Newman et al. We calculated Pearson coefficients of linear correlation and tested their significances via the Student's t -test and Fisher's exact test, using a significance level of 5%.
Eighty-two workers (22%) of the total population of 372 workers in the studied company reported tinnitus in the first interview of this study. Company records also indicated that 15% of the participants who were exposed to noise were also exposed to other hazards. The results of the relationship between tinnitus and the three THI scales are presented in Figure 2. Table 2 displays the correlations between the functional, emotional, and catastrophic scales and medical history. Table 3 presents the correlations of the THI results with the health problems described by the participants (n = 52).
We separated the participants into two groups: The first was composed of 37 participants with normal hearing (71%), and the second included 6 participants (12%) with a bilateral high-frequency notch. Twenty-two percent of the noise-exposed participants complained of tinnitus, a finding comparable to rates of 25% reported by Sahley and Nodar [14] and 15.5% reported by Zimmermann [15]. Seventy-one percent of the participants with tinnitus complaints presented normal audiometric results, which suggests that tinnitus can be an early indicator of auditory risk from exposure to noise. The application of the Brazilian version of the THI was both easy and expedient, as indicated by Newman et al.
In Table 2, we found significant results involving the functional scale results with the use of prescription drugs and the catastrophic scale results with consumption of coffee. Concerning the degree of severity of tinnitus, 44% presented degree 1 or "slight" tinnitus according to the classification by McCombe et al. We observed a significant correlation between tinnitus severity and exposure to noise and chemical pollutants, predominantly CO. We observed a significant correlation between the duration of noise exposure and the emotional scale for the participants with high-frequency notches, suggesting an extra-auditory effect of noise. The results of this study demonstrated that the prevalence of tinnitus was high (22%) in this population, despite the fact that study participants were young individuals who had a short duration of noise exposure. The Brazilian version of the THI proved to be an easy instrument to use for evaluating the impact of tinnitus on the quality of life of noise-exposed workers. Transient Interruption of Unilateral Tinnitus by Fentanyl and Propofol in a Patient with Neuromuscular Disorder. In cases in which its cause can be identified, the success rate is higher than in idiopathic cases [3].
The man's hearing was subjectively not affected, but initial audiometry revealed impaired hearing for lower frequencies on the left side. However, at follow-up, five months after the second ablation, the tinnitus had already decreased to such a degree that it no longer affected the patient's well-being.
Possible causes were arterial hypertension, increased tone of the cervical muscles, stress or cardiac rhythm abnormality, and mitochondriopathy (see Table 1).
These negative results, however, do not exclude a neuromuscular disorder, such as a laminopathy or metabolic myopathy. An “output” results from responses of the vestibular system to the input such as the eyes, cerebellum..

B) central vestibular loss – above the level of the vestibular nerve and towards the brain.
Patient requires only symptomatic treatment It takes 3 weeks to recover from vestibular neuritis Diagnosis – no other tool other than history. Pathophysiology: Calcium carbonate particles shear off and enter the canal leading to brief episodes of vertigo.
Provoked by cert" title="BPPV The most common cause of vertigo in patient > 40 years Repeated attacks of vertigo usually of short duration less than a minute. Treatment: repositioning of the head to get particles out of the canal (Epley or particle repositioning maneuver). Noise measurements, a questionnaire, a Brazilian version of the Tinnitus Handicap Inventory (THI), and pure-tone audiometry were conducted with 52 participants (mean age, 29 years) who suffered from tinnitus. Among the risk factors for tinnitus, the most prominent are age, gender, various diseases (otological, metabolic, neurological, and vascular alterations and dental factors), hearing loss, and exposure to noise, ototoxic drugs, caffeine, nicotine, and alcohol [1-4]. Tinnitus can alter an individual's ability to function in professional, social, and leisure activities and in family relationships, hence affecting the quality of life [5,6].
In addition to being beneficial for clinical applications, the tinnitus questionnaires are valuable for understanding the relationship between personality and the psychopathology of tinnitus, its impact on the daily life of persons who suffer from tinnitus, the difficulties and the perception of social support in relation to the problem, and the incapacities and the difficulties produced by tinnitus that can seriously affect quality of life [7-9]. Occupational hearing loss prevention initiatives rarely focus on the prevention and management of tinnitus. The company employs 372 workers (120 female, 252 male) working in two fixed 8-hour and 48-minute shifts. The questionnaire gathered information on demographics and occupational and medical histories for each worker.
We also used Spearman's rank correlations to examine the results of exposure information versus the outcome. Because of attrition, we were able to study only 52 workers (14% of total population of the plant). Of those, 62% were exposed to carbon monoxide (CO), 13% to CO and vibration, 12% to hydrochloric acid, and 13% to sodium hydroxide.
We observed that of the 52 participants, 71% had normal audiometric results, whereas 12% presented a bilateral high-frequency notch and 17% presented audiometric configurations of hearing loss due to causes other than noise, such as unilateral losses and flat audiometric configuration. Median of hearing thresholds for the groups with normal hearing (all thresholds 25 dB hearing level [HL]), hearing loss configurations suggestive of noise-induced hearing loss (NIHL), and hearing loss from various causes. The distribution of poorest scores across scales of the Tinnitus Handicap Inventory, in percent (n = 52). We observed a significant correlation between headaches (p = .0458) and the duration of tinnitus. We did not include the remaining 9 individuals (17%), who displayed other audiometric configurations of hearing loss in the statistical analysis. The prevalence of tinnitus complaints in male subjects was 16% and in female subjects was 9%, similar to what has been reported [16-18]. Schleuning [2] explained that caffeine and nicotine could aggravate tinnitus because they are stimulants and can induce the constriction of blood vessels. The participants of the study who had such combined exposure had a higher degree of tinnitus severity. Moreover, a negative impact of tinnitus on the subjects' quality of life could de detected. The 22% tinnitus rate among workers, most of whom nonetheless had normal hearing, suggests a need to address tinnitus in occupational hearing loss prevention initiatives. Rick Davis and Robert Randolph (National Institute for Occupational Safety and Health, USA) and Alberto Behar (University of Toronto, Canada) provided helpful critiques of the manuscript.
At that time, the patient was receiving metoprolol, ramipril, allopurinol, pentoxifylline, and betahistine. Nerve conduction studies and electromyography revealed a carpal tunnel syndrome exclusively. Arguments against propofol are that no anti-tinnitus effect of the substance has been previously reported and that it may cause muscle rigidity [6].
More frequently the patient might complain of nausea when smelling something in the car or while driving around.
THI results indicated that tinnitus had the greatest influence in the functional scale (54%). We used the overall result to identify the degree of severity of tinnitus for each individual and for completing an analysis of the total scores by scales. Of all noise-exposed female workers in the plant, 11 (9%) reported having experienced tinnitus, and 41 (16%) of the noise-exposed male workers reported the condition. Spearman's rank correlation coefficient results indicated a significant correlation between noise levels and how often workers experience tinnitus (p = .01). We also observed a significant correlation between the duration of noise and the functional scale (p = .039).
It is important to notice that the average age of the population of our study (29.2 years) is younger than in other studies, which reported results from groups whose mean ages varied from 40 to 50 years and who had a short duration of noise exposure (average, 7 years)[18-21] . According to that author, doctors believe that 50% of patients with complaints of tinnitus improve significantly when they stop smoking or reduce caffeine intake. In recent decades, studies have demonstrated that simultaneous chronic exposure to CO and noise represents a potential risk to hearing, but reports of tinnitus exist only for cases of intense poisoning from CO [24]. This supports the inclusion of tinnitus prevention initiatives alongside workplace hearing loss prevention initiatives because of shared causal factors. Information on tinnitus prevention and treatment could have a measurable, positive impact on a person's quality of life. The authors thank all those who participated in the study for their time, interest, and cooperation.
Guidelines for the grading of tinnitus severity: The results of a working group commissioned by the British Association of Otolaryngologists. Discontinuation of tinnitus after administration of fentanyl and propofol has not been reported in the literature thus far.
At the beginning of the procedure, the patient received local anesthesia with lidocaine, which the treating physician carefully avoided to inject intraarterially.
Ten days after the intervention, left-sided, highfrequency tinnitus recurred, associated with vertigo, nausea, and vomiting. A magnetic resonance imaging scan of the brain showed multiple, small white-matter lesions in the parietal region bilaterally. A cervicogenic cause was largely excluded, as physiotherapy of the cervical spine was ineffective.
Our study was limited in that the cause of tinnitus could not be definitively discovered and we could not determine whether fentanyl, propofol, or both were responsible for the therapeutic effect.
People need hard surfaces to get the full effect of their proprioception or it will feel like they are walking on sand “ shaky grounds”.
The physical stimulus (input) will be transformed into a biological stimulas in the brain stem which will in turn be sent afterwards to the corresponding areas in the vestibular system.

Eighty-two individuals (22% of the total population) had experienced tinnitus and were invited to participate in the study. The equipment used was an Interacoustics audiometer, model AD 229, with TDH-39 earphones, calibrated according to ISO 8253. The average age of the sample was 29.2 years, and the average duration of noise exposure was 7 years. Moreover, significant results were found for the degree of tinnitus and exposure to chemical pollutants (p = .02).
The THI indicated that even the degree 1 "slight" tinnitus experienced by most of the participants who reported tinnitus nevertheless had an impact on their quality of life. For instance, lesions in the neck and the middle ear and sinusitis and headaches increase the risk of tinnitus from 28% to 35%.
The findings underscore the need for noise control and other effective strategies to mitigate causal factors. The use of an instrument designed to evaluate the impact of tinnitus on a person's life, such as the THI, can contribute to a greater understanding of the needs of a specific person or group (or both). Experiencia do hospital das clinicas da faculdade de medicina da Universidade de Sao Paulo. In conclusion, high-dose intravenous fentanyl and propofol transiently discontinue unilateral, idiopathic tinnitus. Initially, the sound was a low-frequency permanent noise evoking the feeling of a water-filled left ear. Results of ultrasonographic investigation of the carotid arteries, otolaryngologic investigation, and audiometry all were normal. The cardiac rhythm abnormality was excluded because it had persisted for 4 years, whereas the tinnitus had persisted for only 3 months.
Arguments against fentanyl are that it increases the intracranial pressure and causes muscle rigidity.
Transform of the forces associate with head acceleration and gravity into a biological signals that the brain can use to develop subjective awareness of head position in space (orientation) produce motor reflexes that will maintain posture and ocular stability to prevent the feeling of dizziness. Twenty (24%) of the 82 were not able to participate because they lost their jobs before collection of data, 5 (6%) declined to participate saying that they no longer had symptoms of tinnitus, and 5 (6%) were on vacation at the time of data collection.
We performed puretone audiometry for all subjects at frequencies of 0.5, 1, 2, 3, 4, 6, and 8 kHz. The functional subscale, composed of 11 questions, evaluates the limitations that tinnitus induces in the mental, social, occupational, and physical areas. Table 1 displays the findings pertaining to the health problems and auditory and medical histories described by the participants. In the THI, tinnitus was shown to have the greatest relationship to the functional scale (54%), indicating that its impact is more noticeable in social, daily, and reading activities involving concentration, auditory acuity, attention, and rest. The analysis of the THI results along with the audiometric results indicated that a considerably greater number of significant correlations were verified in the group with altered hearing, which was expected because the two conditions-compromised hearing and tinnitus-are often associated. Information dissemination on the risks and prevention alternatives is of great importance, as is the management of tinnitus. Finally, it could be used in the design of appropriate strategies to manage tinnitus in the workplace.
Later on, the frequency changed and evoked an unpleasant feeling on reaching higher frequencies. Additionally, the tinnitus recurred even though atrial flutter had been successfully stopped after the second ablation. Assuming a cervicogenic origin, one can speculate that muscle relaxation during an- esthesia relieved hypertension of the cervical muscles. Being pushed from behind will lead to all the previous systems to work together to maintain balance. If there is a defect in the input and output processes the patient will present with vertigo, defects in the gait or ocular distortions. Therefore, the final sample of the study consisted of 52 participants: 11 females (9% of the total of 120 noiseexposed female workers in the studied plant) and 41 males (16% of the total of 252 noise-exposed male workers in the studied plant). The emotional subscale, composed of 9 questions, includes affective answers for tinnitus (anger, frustration, irritability, and depression). All participants exposed to noise levels greater than 85 dB are required to use ear muffs, and information on their use and maintenance are given when workers are hired.
The emotional scale was the second most affected and is related to manifestations of nervousness, frustration, irritation, depression, anxiety, insecurity, and difficulty in relationships with family and friends. Estabelece diretrizes e parametros minimos para avaliacao e acompanhamento da audicao dos trabalhadores expostos a niveis de pressao sonora elevados. Mitochondriopathy was considered because of the patient's individual and family history and the clinical neurological examination results and because tinnitus has been reported to occur in 7% of patients with mitochondriopathy [5].
However, this assumption does not explain why the effect lasted for 10 days, although the muscle-relaxant effect of anesthesia had disappeared already. We also performed daily biological calibration checks on the audiometer immediately before testing subjects. Last, the catastrophic subscale is composed of 5 questions and examines the most severe reactions from tinnitus (desperation, loss of control, inability to face problems, inability to escape tinnitus, and fear of having a serious ailment)[12].
Walkthrough observations suggest that use of the hearing protection is high, but no information exists on the consistency of hearing protection use.
The catastrophic scale demonstrated alterations related to desperation, intolerance to tinnitus, and loss of control in situations when experiencing tinnitus (see Fig.
His family history was informative for diabetes mellitus (father, sister), renal failure (brother), heart failure and tetanus (mother), short stature (mother, sister), and liver cell carcinoma (father). Other possible causes of tinnitus (see Table 1) were excluded by a perusal of the patient's history and through appropriate investigations. Additionally, a cervical cause of the tinnitus could not be excluded definitively, as no magnetic resonance imaging scan of the cervical spine had been performed.
In our study, factors such as gender, age, tobacco, and exposure to firearms were not significantly associated with tinnitus. That discontinuation of tinnitus was caused by unintentional intraatrial administration of lidocaine is rather unlikely, given the particular care with which the local anesthesia was placed, the fact that the tinnitus did not disappear immediately after injection of the local anesthetic, and the longstanding therapeutic effect (10 days).
Coles [26], among several authors, reported that the worse the hearing is, the more probable is the occurrence of tinnitus. Approximately 20% of the patients with hearing loss present complaints of tinnitus, whereas 90% of those with severe tinnitus had hearing loss.

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