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Author: admin | 16.02.2015 | Category: Relieve Tinnitus

Tinnitus is the conscious, usually unwanted perception of sound that arises or seems to arise involuntarily in the ear of the affected individual. Bloodflow accelerates, or changes in bloodflow disrupt laminar flow, and the resulting local turbulence is audible.
Normal flow sounds within the body are perceived more intensely, either as a result of alterations in the inner ear with increased bone conduction or as a result of disturbance of sound conduction leading to loss of the masking effect of external sounds.
Pulsatile tinnitus is usually unilateral, unless the underlying vascular pathology is bilateral. This review article is based on a selective search of the literature and analysis of our patient records. The most common classification of tinnitus cases in the literature is subjective (heard by the patient only) versus objective (perceptible to the examiner also). Vascular stenoses: Arteriosclerotic plaques and stenoses in the vessels of the head and neck are the most common cause of pulsatile tinnitus in the elderly (1). Fibromuscular dysplasia, a segmental, nonatheromatous vascular disease that often leads to stenosis, can cause pulsatile tinnitus, particularly in younger persons. Elongations and loops in the arteries that supply the brain are occasionally described as a cause of pulsatile tinnitus (3). Aneurysms: Aneurysms of the internal carotid artery or the vertebral artery often lead to turbulent bloodflow, but it is surprisingly rare for them to become clinically manifest as pulsatile tinnitus. Anatomical variants and abnormalities of the arteries: The rare ectopic internal carotid artery, carotid-cochlear dehiscence, and persistent stapedial artery can be diagnosed using computed tomography (CT) (8–10).
Arteriovenous fistulas can cause unbearably loud pulsatile roaring sounds that can often be heard by the clinician too. With the exception of headaches, pulsatile tinnitus is the most common clinical symptom in dural arteriovenous fistulas and acquired arteriovenous short-circuits to the cerebral veins or sinuses (3).
As short-circuits lie within the dura mater, CT and MRI often yield only indirect evidence of them (15, 16). Direct arteriovenous fistulas result either from damage to major arteries that supply the brain or from the rupture of an extradural aneurysm into the surrounding venous plexus.
Typical tumors that are rich in blood vessels are paragangliomas (glomus tumors), benign tumors of the base of the skull. Pulsatile tinnitus can also be caused by other vessel-rich tumors of the base of the skull, particularly tumors of the temporal bone (metastases, basal meningiomas, hemangiomas, Heffner tumors) or Paget’s disease (21, 22). Capillary hyperemia: Throbbing sounds in the ear that are synchronous with the pulse in acute otitis is easy to clarify using the patient’s medical history and results of clinical examinations.
If there are no other venous abnormalities, venous tinnitus is perceived as right-sided more frequently than left-sided, because the right jugular vein is dominant in 70% to 80% of cases (23). Intracranial hypertension: Pulsatile tinnitus can be caused by an increase in intracranial pressure (24). It should never be forgotten that intracranial hypertension can also be caused by cerebral sinus thrombosis.
Other factors that should be mentioned as causes of increased intracranial pressure are cerebral neoplasias and other intracranial space-occupying lesions, craniocervical transition disorders, cranial stenoses, and hydrocephalic CSF flow disorders.
Anatomical variants and abnormalities of the veins and sinuses: Atypical formations of the jugular bulb favor the development of venous tinnitus. Diverticula of the sigmoid or transverse sinus are venous excrescences that bulge out through the internal bony cortex of the cranium into the diploe (Figure 3).
Signs of semicircular canal dehiscence are an absence of bone covering a semicircular canal, usually the anterior. Increased bone conduction with increased perception of sounds produced by the body itself (somatosounds) such as bloodflow sounds, autophony, eye movement sounds, and acoustic perception of the patient's own footsteps (32, 33). Treatment for semicircular canal dehiscence is surgery to cover the affected semicircular canal or obliteration of it.
Rare causes of pulsatile tinnitus include meningocele of the temporal bone (34), cholesterol granulomas (35), and perilymph fistulas (21).
In addition to questions concerning the duration and cause of tinnitus and any previous cerebrocranial trauma, the patient’s drug history is important, as some substances (ACE inhibitors, calcium antagonists) favor pulsatile tinnitus (24). Clinical warning signs are focal neurological symptoms, signs of intracranial pressure, and objective pulsatile tinnitus. As a symptom, pulsatile tinnitus has many, highly varied causes and involves several clinical disciplines.
Nussel F, Bradac GB, Schuierer G, Huk WJ: Klinische und neuroradiologische Aspekte bei Karotis- und Vertebralisdissektionen. Schrock A, Strach K, Kuhnemund M, Bootz F, Eichhorn KW: Seltene Ursache eines pulssynchronen Tinnitus. Dietz RR, Davis WL, Harnsberger HR, Jacobs JM, Blatter DD: MR imaging and MR angiography in the evaluation of pulsatile tinnitus.
Alatakis S, Koulouris G, Stuckey S: CT-demonstrated transcalvarial channels diagnostic of dural arteriovenous fistula. Park IH, Kang HJ, Suh SI, Chae SW: Dural arteriovenous fistula presenting as subjective pulsatile tinnitus. Waldvogel D, Mattle HP, Sturzenegger M, Schroth G: Pulsatile tinnitus – a review of 84 patients. Swartz JD: An approach to the evaluation of the patient with pulsatile tinnitus with emphasis on the anatomy and pathology of the jugular foramen.
Friedmann DR, Le BT, Pramanik BK, Lalwani AK: Clinical spectrum of patients with erosions of the inner ear by jugular bulb abnormalities. Russell EJ, De Michaelis BJ, Wiet R, Meyer J: Objective pulse-synchronous essential tinnitus due to narrowing of the transverse dural venous sinus. Koo JW, Hong SK, Kim DK, Kim JS: Superior semicircular dehiscence syndrome by the superior petrosal sinus.
Remley KB, Coit WE, Harnsberger HR, Smoker WRK, Jacobs JM, McIff EB: Pulsatile tinnitus and the vascular tympanic membrane. Vattoth S, Shah R, Cure JK: A compartment-based approach for the imaging evaluation of tinnitus. Send Home Our method Usage examples Index Contact StatisticsWe do not evaluate or guarantee the accuracy of any content in this site.
These will often pack the earwax down further into the ear canal, as well as to risk injury to the eardrum. Tinnitus is a ringing, swishing, or other type of noise that seems to originate in the head or ears. For more information on these and other ENT conditions visit the American Academy of Otolaryngology’s website.
How to cite this article Bittar RSM, Mezzalira R, Furtado PL, Venosa AR, Sampaio ALL, Oliveira CACP.
Benign Paroxysmal Positional Vertigo (BPPV) is one of the most prevalent clinical disorders in common Neurotology practice and accounts for approximately 17% of complaints of vertigo1.
Given the noteworthy prevalence of BPPV, its health care and societal impacts are tremendous8. Positional vertigo is defined as a spinning sensation produced by changes in head position relative to gravity. Significant improvements in the diagnosis and treatment of patients with BPPV may lead to significant health care quality improvements as well as medical and societal cost savings. The purpose of this paper is to review the available methods for diagnosis and treatment of BPPV intended for clinicians who are likely to diagnose and manage patients with BPPV, and applies to any setting in which BPPV would be identified, monitored, or managed. Of the two variants of BPPV, canalithiasis is the most common, and the posterior semicircular canal is the most affected because of its anatomical position (85-95% of cases of BPPV)8. Recently, Gacek21 proposed a neural theory for BPPV, in which there was degeneration of the saccular ganglion secondary to a latent viral reactivation.
Identifying the affected canal includes observation of the position that triggers the dizziness and the resulting type of nystagmus. When the patient gets in the position that triggers the dizziness, eye movement is observed resulting from the contraction of muscles related to the affected canal (slow component), followed by subsequent rapid correction in the opposite direction (fast component). In the vertical canals, there are excitatory connections to the ipsilateral superior oblique and contralateral inferior rectus to the posterior canal; ipsilateral superior rectus and contralateral inferior oblique to the superior canal, so that the arising movements are always rotational, but the nystagmus is vertical upward in the posterior canal and vertically downward in the superior canal23. The characterization of the nystagmus, allows the identification of the canal involved as well as the mechanism involved, and it is essential to choose the repositioning procedure. The Dix-Hallpike maneuver is considered the gold standard tool for the diagnosis of BPPV of posterior canal8. The Dix-Hallpike maneuver is performed by the clinician moving the patient through a set of specified head-positioning maneuvers to elicit the expected characteristic nystagmus of posterior canal BPPV (Figure 1). The maneuver begins with the patient in the upright seated position with the examiner standing at the patient's side. After resolution of the subjective vertigo and the nystagmus, if present, the patient may be slowly returned to the upright position. The particles present inside the semicircular canal undergo the effects of gravity and are shifted downward, and after a short latency, the liberating force created on the ampullar crista triggers the vertigo and nystagmus (Figure 2).
In the case of the superior semicircular canal, a torsional downbeating nystagmus is exhibited. If the patient has a history compatible with BPPV and the Dix-Hallpike test is negative, the clinician should perform a supine roll test to assess for lateral semicircular canal BPPV8.
Lateral canal BPPV (also called horizontal canal BPPV) is the second most common type of BPPV. In many instances, the presenting symptoms of lateral canal BPPV are indistinguishable from posterior canal BPPV. Due to an adaptation of the central nervous system8,26 or to the reversion of the direction of movement of the debris by the gravitational action26, it is not unusual that nystagmus spontaneously changes the direction without the head turning to the opposite side8,26.
Additional exams are essential to clarify the trigger and associated features of BPPV1,15, 23,35. Imaging is not useful in the routine diagnosis of BPPV because there are no radiological findings characteristic of or diagnostic for BPPV8.
Electronystmography has limited utility in the vertical canal BPPV diagnosis, since the torsional component of nystagmus cannot be registered by conventional techniques. Audiometry is not required for diagnosing BPPV, however it may offer additional information in cases where the clinical diagnosis of vertigo is unclear8.
The treatment of BPPV is based on the performance of liberatory maneuvers or canalith repositioning procedures, with the aim of returning the displaced particles to their original location: utricular macula. A standard protocol, that is described in Table 3, is used in our service, considering the better results for each maneuver indicated for each BPPV variant. Some patients manifest severe symptoms with dizziness, nausea, sweating and vomiting while undergoing diagnostic or therapeutic maneuvers. The Epley maneuver39 is the most frequently performed repositioning maneuver of the vertical canal.
According to the clinical practice guideline8, based on the review of the literature, it was not possible to determine the optimal number of cycles for the repositioning maneuvers. The maneuver described by Semont41 is indicated for the treatment of posterior canal cupulolithiasis.
Lempert42 described a maneuver (Barbecue Maneuver or Roll Maneuver) which is the most commonly employed maneuver for the treatment of lateral canal BPPV.
Forced prolonged position is another treatment maneuver, described by Vannuchi44, for the treatment of lateral canal BPPV. The Brandt-Daroff exercises were developed for home self-administration, as an additional therapy for patients who have been symptomatic, even after Epley or Semont maneuver40. Many patients complain of imbalance during and between vertigo attacks, as observed by Celebisoy45.
The otolithic dysfunction induced by unequal loads of the macular beds has been considered as the underlying mechanism46. The repositioning maneuvers are associated to mild and self-limited adverse effects in about 12 percent of the treated patients8.
During the course of repositioning maneuvers of vertical canals, the displaced particles could migrate into the lateral canal, in 6 to 7 % of the cases8. During the repositioning maneuvers, some patients develop severe, persistent vertigo, nausea, vomiting and nystagmus, which has the same features observed in the diagnostic maneuvers.
The treatment consists of performance of the reverse maneuver, to aim to eliminate the blockade.
By virtue of possible complications during the repositioning procedures, it is not a proper conduct to guide the patient self-treatment at home, without a physician. After repositioning procedures, it is important to keep the patient in sitting position, for 10 minutes, to avoid falls51.
Epley39, in his original paper, described the application of a bone conduction vibrator associated to repositioning maneuver, in order to release some adhered particles in the ampullar crista. The effectiveness of repositioning and liberatory maneuvers varies from 70% to 100%14,15,23,48.
It is important to be careful when performing diagnostic, repositioning and liberatory maneuvers in obese patients, with limited cervical range of motion or with unstable heart failure or carotid stenois8,25,58. Some authors believe in natural course of BPPV toward spontaneous relief48,59,60,61,62, which is possible in up to 89% of the patients in the first month, with subsequent recurrence in up to 33%, in three years37,38.
Thirty to 50 % of the patients have vestibular system dysfunction associated with initially treated BPPV, which can be demonstrated by caloric testing abnormalities. My understanding is that Facebook had been receiving complaints from the member base that business postings were causing their Main Page to scroll constantly, and they were missing their little nieces birthday, or baptism, or family stuff in general. We hope this will create a better Facebook experience for you, and here’s to us landing where you want us to land. Dale is the Practice Administrator for Family Hearing & Balance Center and Cardinal Hearing Centers.
I found this on my Facebook this morning, and in some over active thinking, the possible analogies were overwhelming. I can’t find this option on my mobile phone so it must only be able to be changed on a computer.
Healing is possible only if such diseases are examined very carefully and if the actual causes are taken into account during treatment on an individual and person-oriented basis. Therefore it is no surprise that a recently acclaimed treatment model remains to be challenged in public. NOW THEN: Whoever wants to heal tinnitus must first accept the fact that tinnitus itself does not exist in a vacuum without causal relationships. One model for understanding diseases within a specific context is traditional Chinese medicine (TCM). In my opinion (which is based upon practical experience), tinnitus can be retraced to this one source in at least 60 % of all cases. Traditional Chinese medicine offers the following explanation: Apart from reproductive capacities and regeneration, kidneys and their meridians govern the regulation of body fluids, the functioning of joints (hips and knees), hair growth, and functioning of the ears and brain. For example, tinnitus may also be caused by kidney weaknesses that have developed within an organism resulting from other diseases, or from stress, wrong nutrition and the abuse of alcohol and medical drugs. For instance, if kidneys suffer from a lack of warmth (which can actually be felt in this area!), then this condition signifies a lack of yang energy. A thorough medical history of the patient plus a clinical examination are necessary in order to recognise such patterns involving tinnitus. Iris diagnostics is one such procedure of analysing the eye in order to recognise diseases. Iris diagnostics goes back to the Hungarian physician von Peczely who presented his discovery to the public in 1881.
Basically, any functional disturbance can be appropriately treated within its own specific context. All pains (and all functional pains in particular) can be influenced, alleviated and often completely dissipated by treatment via the ear. Ear acupuncture is especially suited for use in emergency medical procedures due to its quick and precise access to biochemical interactions in the body.
Here it is very important to understand the principle that chronic illness is represented in the ear in the form of lineally organised points. My practical work with treatment lines has reconfirmed that indeed, when virulent, all points occurring on such lines can be assigned to a specific disease.
When recalling different areas of the ear plus the organs or organ-systems represented there, the innately profound meaning of this concept can be recognised.
Since the points found for reflexes or organ disturbances are always situated along a treatment line that runs from zero to the helix across the ear, a certain state of illness is always represented on each of the three germ layers, and all layers are affected by any given treatment. To illustrate this, I would like to describe two cases of tinnitus and their treatment via the ear. The patient is 56 years old, a gaunt, highly sensitive woman who has been suffering for years from roaring ear noises accompanied by light deafness. Her medical history reveals that she also has joint problems (clicking) and urine retention despite the urge to pass water.

A completely different problem is presented in the case of a younger woman who is 34 years old. Significant relaxation of the psychological situation occurred already after the first treatment and it stabilised after only a few treatments. I would like to emphasise that the symptoms exhibited in both cases also indicated the pathway to treatment. In addition to the patient’s medical history and targeted clinical examination, imaging procedures also play an important role in diagnosis. The search of the literature was performed using PubMed and included review articles, case series, and case studies, with no restrictions on date of publication. This distinction depends on how hard the clinician searches for the sound and does not reflect etiology.
It is perfectly possible for the cause of tinnitus to lead to contralateral symptoms: Closure of a vessel on one side of the body may lead to a compensatory acceleration in flow in the open vessel, which then becomes symptomatic as tinnitus.
Stenoocclusive vascular diseases found mainly in younger patient groups also include vascular dissection: The vascular lumen is narrowed by a hematoma on the vessel wall. However, because such findings are also common in asymptomatic patients, particularly the elderly, they must be evaluated cautiously and should not be grounds for not searching carefully for another cause. The frequency of vascular loops in the inner ear is higher in individuals with pulsatile tinnitus than chance alone would predict (11). Even on MRA (magnetic resonance angiography), alterations are usually subtle (see Case Study). The classic cause is a carotid-cavernous fistula in cases of fracture of the base of the skull.
In otosclerosis, arteriovenous microfistulas over the oval window lead to pulsatile tinnitus (1). In very general terms, it seems that venous tinnitus is often favored by anatomical predisposition and triggered by physiological conditions. One of the causes, particularly in young, overweight women, is pseudotumor cerebri, more accurately described as idiopathic intracranial hypertension. If there is a unilateral transverse sinus thrombosis, venous blood has to flow out through the open opposing side, where the increase in blood flow can lead to tinnitus.
These include a high-riding jugular bulb, a jugular bulb in an unusually lateral location, enlarged jugular bulb, and jugular bulb diverticulum. Patients with a dehiscent bulb may present with conductive hearing loss if the bulb is in contact with the ossicles and restricts their mobility. Naturally, it must be determined whether the tinnitus is actually synchronous with the pulse.
Magnetic resonance angiography (MRA) is useful in imaging arteries that supply the brain, while veins and sinuses are better represented by CT angiography (CTA) (36).
This gives rise to the interface problem: Diagnosis is often only possible if all clinical findings are collated and critically assessed in conjunction with imaging results. Objective tinnitus refers to noises generated from within the ear or adjacent structures that can be heard by other individuals. For most people home treatments with a few drops of hydrogen peroxide can aid in softening and removal of impacted earwax. The procedure, called a tympanoplasty, involves grafting skin tissue across the perforated eardrum to allow it to heal. The noises may be intermittent or an annoying continuous sound and the pitch can go from a low roar to a high squeal or whine. Nearly 36 million Americans suffer from this disorder, which may be caused by different parts of the hearing system, the outer ear, the middle ear, the inner ear or by abnormalities in the brain. This vestibular syndrome is characterized by transient attacks of vertigo, caused by change in head position, and associated with paroxysmal characteristic nystagmus.
It represents the most important peripheral vestibular impairment along the lifespan1,2,3, although the age at onset is commonly between the fifth and seventh decades of life4. It is estimated that it costs approximately US$2000 to arrive at the diagnosis of BPPV, and that 86 percent of patients suffer some interrupted daily activities and lost days at work because of BPPV8. Benign paroxysmal positional vertigo is defined as a disorder in the inner ear, characterized by repeated episodes of positional vertigo8, with typical paroxysmal nystagmus. Despite its significant prevalence, and quality of-life and economic impacts, considerable practice variations exist in the management of BPPV across disciplines8. Such improvements may be achievable with the reduction of the inappropriate use of vestibular suppressant medications, decreasing the inappropriate use of unnecessary tests such as radiographic imaging, and by increasing the use of appropriate cost effective therapeutic repositioning maneuvers.
Displaced particles from utricule otoliths float around in the endolymph (canalithiasis)11 or adheren to the cupulae (cupulolithiasis)12 and may change the density relation of the cupulae-endolymph system. The ampulla of the posterior semicircular canal is located in the lower region of the vestibule, both in the supine and standing position. Such reinfection could result in the loss of its antagonistic effect on the posterior semicircular canal. The classic complaint is vertigo in episodes, triggered by changes in the body position or head movements, lasting seconds and ceasing spontaneously. Each of the semicircular canals is directly connected to a pair of extrinsic muscles in the eye, having an excitatory and inhibitory influence, which determines the movement of the eyeball in the same plane as the canal24 (Table 1).
This biphasic movement, called nystagmus, is a standard direction that is known as being the same as the fast component. In Table 2, we can observe the main features of involvement of different semicircular canals. Before beginning the maneuver, the clinician should counsel the patient regarding the upcoming movements and warn that they may provoke a sudden onset of intense subjective vertigo, possibly with nausea, which will subside within 60 seconds. During the return to the upright position, a reversal of the nystagmus may be observed and should be allowed to resolve8. Mechanism of displacement of the debris from the dome of the canal at rest and under the action of gravity (g), indicated by the arrow.
The direction of the torsional component of the positioning nystagmus indicates which ear is the origin of nystagmus. Because this type of BPPV has received considerably less attention in the literature, clinicians may be relatively unaware of its existence and the appropriate diagnostic maneuvers for lateral canal BPPV8. The supine roll test is performed by initially positioning the patient supine with the head in neutral position, followed by quickly rotating the head 90 degrees to one side with the clinician observing the patient's eyes for nystagmus. In canalithiasis, the movement of the head toward the affected ear promotes the displacement of free particles in the direction of the ampulla, triggering a horizontal nystagmus whose fast component will be toward the tested ear, so geotropic (towards the ground). The mechanisms that initiate geotropic and apogeotropic eye movements can be seen in Figure 3. We can observe the mechanism of displacement of the ampullar crista that is responsible for the origin of geotropic nystagmus in canalithiasis(a), or for apogeotropic nystagmus in cupulolithiasis (b). De la Meilleure et al.26 reported the inversion of the horizontal nystagmus, in electronystagmography, in 75% of patients with BPPV of the lateral canal, always on the affected side. Further radiographic imaging may play a role in diagnosis if the clinical presentation is felt to be atypical, if the diagnostic maneuvers are unusual, or if additional symptoms aside from those attributable to BPPV are present, suggesting an accompanying modifying central nervous system or otological disorders8. On the other hand in horizontal semicircular canal BPPV diagnosis, the nystagmus is present in the positional testing23.
These are non-invasive procedures that have been found to be long term effective for BPPV2,14. In these cases, vestibular suppressant medications are recommended as adjuncts not only to relieve the vertigo after maneuver but also to control the clinical symptoms until the procedure can be repeated4.
The patient is placed in the upright position with the head turned 45 degrees to left when the left ear is affected. If the posterior canal is affected, the patient is seated in the upright position; then the patient's head is turned 45 degrees toward the unaffected side, and then is rapidly moved to the side-lying position.
Demonstration of Lempert Maneuver sequence - treatment of lateral semicircular canal BPPV (right ear in black). This maneuver involves rolling the patient 360 degrees in a series of steps to effect particle repositioning8.
The strategy consists of maintaining the forced lateral decubitus, with affected ear in the undermost position for 12 hours23,25. Some authors indicate them one week before the therapeutic maneuver, aiming to improve the patient's tolerability14. This observation lead to the investigation of postural balance in patients with lateral and posterior semicircular canal BPPV.
Other possibilities are the persistency of small amounts of residual debris in the canal, paresis of the ampullar receptors or the vestibular re-adaptation after peripheral disorder45. This phenomenon could result from a jamming of the otolithic debris (named jam) when migrating from a wider to narrower segment, such as from the ampulla to the canal or at the bifurcation of the commom crus50. The use of a cervical collar, positional avoidance, or other restrictions are not necessary52,53,54. However, studies found no benefit in the BPPV treatment, since it does not modify the results of repositioning or liberatory maneuvers2,55,56,57.
The successful treatment is based on the identification of the affected semicircular canal, the distinction between cupulolithiasis and canalithiasis, the right choice of the most indicated maneuver2. The spontaneous resolution is faster in the lateral semicircular canal BPPV than in posterior canal because the former spatial and anatomic orientation facilitates the return of the particles to their original place63,64. Therefore, even if symptoms are typical of BPPV, the diagnostic maneuver has been positive, the repositioning maneuver has been successful, it is important that complete neurotological evaluation is obtained to rule out other vestibular disorders. For the therapeutic maneuvers, correct diagnosis of the BPPV variant and affected semicircular canal is necessary.
Central etiologies must be investigated when atypical nystagmus is found and therapeutic maneuvers are unsucessfully. Bhattacharayya N, Baugh RF, Orvidas L, Barrs D, Bronston LJ, Cass S, Chalian AA, Desmond AL, Earll JM, Fife TD, Fuller DC, Judge JO, Mann NR, Rosenfeld RM, Schuring LT, Steiner RWP, Whitney SL, Haidari J.
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The sounds that drive patients nuts have been described by one patient as: growling, droning or roaring, ringing (similar to that of bells), pulsating, throbbing.
Some people become ill following sudden deafness, others become ill due to de-compensated renal metabolism, while a third group may experience blocked cervical vertebrae. Undoubtedly, these diseases cannot be considered as disturbances of the auditory system alone.
The actual problem then is simply that healing is difficult without knowing which factors are causing the disease.
I am aware that translating Asiatic understanding of illness into our ways of thinking is not an easy task.
Accordingly, the results are lumbago, cold and painful knees, dizziness, hypo-thyroidism and tinnitus (among other things). Naturally, differential diagnosis also includes the use of other empirical examinations to assist in establishing a sound opinion. Peczely originally taught (as is still being taught today) that certain symptoms within the iris could be associated with certain organic disorders. However, potential inherent in the ear for providing clues to the aetiology of diseases is often underestimated or even ignored.
NOGIER has therefore recommended this therapy for treatment of all complaints relating to the central nervous system such as anxiety conditions, agoraphobia, obsession, concentration deficiency, dizziness, stammering, etc. Various withdrawal programmes designed to manage alcohol abuse, other drug or medicinal drug abuse, smoking, and food craving, for example, enable therapists to confront individual situations of addicted patients. NOGIER had emphasised in his early publications that pertinent causal connections of a given disease were also visible within the energy lines of the ear in addition to the several respective organ or organ system points. This is the basis for the far-reaching therapeutic implications that exist in ear acupuncture. Virulent points are sought and treated along the treatment line that is indicated for the respective diseases and their corresponding points. During the day it is comprised of a whizzing sound connected with a feeling as though the ears were blocked. Virulent points here are stomach, an endogenous regulation point in the curve of the ant-helix, shoulder and nervous regulation points of shoulder and stomach. The ear noises still occurred but only sporadically after the second treatment and then stopped completely. We performed a retrospective search of our own patients’ radiology reports for 2003 to 2012 using the keywords “pulssynchron” or “pulsierend” (“pulsatile”) and “Ohrgerausch” or “Tinnitus” (“tinnitus”). The transfer of flow sounds to the inner ear by bone conduction may be a cause of pulsatile tinnitus (12).
However, the real risk of damage posed by fistulas lies not in short-circuit but in the anatomy of venous drainage.
However, vertebrovertebral fistulas (between the vertebral artery and the vertebral venous plexus) must also be considered (Figure 2).
Paraganglioma occurs bilaterally in 10% of cases; it can cause bilateral symptoms in these patients (20). They are heard only when they are so loud that they can no longer be suppressed by the hearing organs and auditory pathway, usually as venous tinnitus. However, there are huge variations between individuals, and these variants are common, asymptomatic incidental findings (26–28). If the bulb invades the bony labyrinth, a third window appears, through which sound waves escape.
Stenoses, strictures, and segmentation of the sinus (particularly the transverse sinus) are also associated with pulsatile tinnitus (31). Careful auscultation of the head and neck region and the heart should be performed in a completely quiet environment with no disrupting external sounds. A search for neurological symptoms of increased intracranial pressure (headache, visual disturbance with papilledema, double vision, and in the case of serious intracranial hypertension nausea and vomiting) should be performed, as should lumbar puncture measuring CSF pressure if required. If venous hum caused by anemia has been ruled out, an arteriovenous fistula must also always be considered. Imaging must never be considered in isolation: It must always be interpreted in the context of clinical findings.
Ideally, this should be performed by a multidisciplinary team with structured diagnostic pathways. The term subjective tinnitus is used when the sound is audible only to the affected individual. Excessive earwax, a foreign body in the external ear canal, fluid, infection or disease of the middle ear bones or eardrum can all cause tinnitus. The symptoms result from movement of the free floating otoconia particles in the endolymph or their attachment to the cupulae of the semicircular canal. These variations relate to both diagnostic strategies for BPPV and rates of utilization of various treatment options available for BPPV within and across the various medical specialties and disciplines involved in its management.
In this context, BPPV should be mentioned not only because of the high prevalence, but also because of the relative simplicity of the diagnosis and cost effectiveness of the treatment9. The semicircular canals change their gravitational orientation plane while the patients move their head.
The fragments in suspension inside the labirinth tend to be deposited in this region, by the action of gravity1,13,14,15. Typically, the vertigo arises in the lateral position of one or both sides, in hyperextension of the head, when standing up or lying down.
Because the patient is going to be placed in the supine position relatively quickly with the head position slightly below the body, the patient should be oriented so that, in the supine position, the head can "hang" with support off the posterior edge of the examination table by about 20 degrees. The examiner rotates the patient's head 45 degrees to the left and, with manual support, maintains the 45-degree head turn to the left during the next part of the maneuver8. The Dix-Hallpike maneuver should then be repeated for the right side, with the right ear arriving at the dependent position. If the upper pole of the eye beats away from the ground toward the uppermost ear, then it originates from the anterior canal of the uppermost ear. Patients with a history compatible with BPPV (ie, repeated episodes of vertigo produced by changes in head position relative to gravity) who do not meet diagnostic criteria for posterior canal BPPV should be investigated for lateral canal BPPV.
After the nystagmus subsides (or if no nystagmus is elicited), the head is then returned to the straight face-up supine position.
When the head is rotated to the healthy side, the particles displace and lead to a current moving in the opposite direction from the ampulla (also generating geotropic nystagmus), and the stimulation is less intense than that observed on the affected side.
Lee and colleagues27 described the spontaneous reversal of nystagmus bilaterally, and the primary phase of nystagmus was shorter and with greater velocity of the slow-phase.
Other possible causes are ovarian hormonal dysfunction, hyperlipidemia, hypoglycemia or hyperglycemia, hyperinsulinemia, migraine, cervical trauma, otological surgery, sedentary and prolonged bed rest2,15,32,33,34. Successful treatment depends mainly on the choice of the most appropriate maneuver for the case.

The patient is rapidly laid back in a supine head-hanging position, which is maintained for a period of 1 to 2 minutes. The patient is in supine position; the patient's head is turned 90 degrees slowly toward the unaffected side. The Brandt-Daroff exercises (Figure 8) are positioning exercises that, theoretically, promote habituation4. The treatment of each affected semicircular canal will be performed, in protocols according to the observed ocular movements and the correct identification of each affected semicircular canal. Patients with posterior BPPV had impaired static balance ability when visual and proprioceptive inputs were inadequate as described by Celebisoy45, Di Girolamo46.
The conversion to lateral canal BPPV (so called canal switch) and Canalith Jam are unusual conditions, however when present must be promptly diagnosed and treated47. In the Epley Maneuver, it happens when the head of the patient is turned to facedown position (Figure 5 - position c and d). If the patient develops important symptoms, vestibular suppressant medications may be considered to help in a later repositioning. Therefore, it is possible to propose to the patient to wait the spontaneous resolution, in cases where the maneuver can't be indicated.
Benign paroxysmal positional vertigo: 10 year experience in treating 592 patients with canalith repositioning procedure.
Neuro-otological features of benign paroxysmal vertigo and benign paroxysmal positioning vertigo in children: a follow-up study.
Free-floating endolymph particles: a new operative finding during posterior semicircular canal occlusion. Effectiveness of treatment techniques in 923 cases of benign paroxysmal positional vertigo.
Benign paroxysmal positional vertigo due to a simultaneous involvement of both horizontal and posterior semicircular canals.
Monitoring of caloric response and outcome in patients with benign paroxysmal positional vertigo. Diagnostic, pathophysiologic, and therapeutic aspects of benign paroxysmal positional vertigo. Reversal of initial positioning nystagmus in benign paroxysmal positional vertigo involving the horizontal canal. Eletronytagmographic (ENG) findings in paroxysmal positional vertigo (PPV) as a sign of vestibular dysfunction.
Canalith repositioning for benign paroxysmal positional vertigo: a randomized controlled trial. The canalith repositioning procedure for treatment of benign paroxysmal positional vertigo.
A positional maneuver for treatment of horizontal-canal benign paroxysmal positional vertigo.
Balance in posterior and horizontal canal type benign paroxysmal positional vertigo before and after repositioning maneuvers. Treatment efficacy of benign paroxysmal positional vertigo (BVVP) with canalith repositioning maneuver and Semont liberatory maneuver in 376 patients.
Treatment of benign paroxysmal ositional vertigo: necessity of postmaneuver patient restrictions.
Vibration with the canalith repositioning maneuver: a prospective randomized study to determine efficacy.
The canalith repositioning procedure with and without mastoid oscillation for the treatment of benign paroxysmal positional vertigo. Natural course of the remission of vertigo in patients with benign paroxysmal positional vertigo.
Natural history of benign paroxysmal positional vertigo and efficacy of Epley and Lempert maneuvers. Treatment of anterior canal benign paroxysmal positional vertigo by a prolonged forced position procedure. Diagnostic criteria for central versus peripheral positioning nystagmus and vertigo: a review. This procedure involves long-term treatment for which insurance companies spend a lot of money.
However, when it comes to tinnitus, such insights are invaluable resources that go even beyond the subject of the ear.
Formerly, iris diagnostics was a customary ingredient in the toolbox of all medical doctors until about the beginning of the 19th century. Based upon the topography of the eye, phenomena associated with the constitution of the iris plus the symptoms, structures and pigmentations included in eye diagnostics all serve to open the possibility of discovering causes of a particular disease and its probable course, and to recognise its disposition. Thus, disturbances are represented in the ear and such signs can be perceived (that is: touched, seen, measured). The balancing and relaxing effect of ear acupuncture is also welcomed in geriatrics and the treatment of older persons. It means that a whole segment reveals itself as a disease complex for both diagnosis and treatment. She is full of defences and is threatened by everything around her; everything is overwhelming.
They have merely been utilised in an exemplary fashion to illustrate how to arrive at decisions for treatment strategies.
Pulsatile tinnitus requires both a functional organ of hearing and a genuine, physical source of sound, which can, under certain conditions, even be objectified by an examiner.
A cause was found significantly less frequently in these cases of bilateral tinnitus than in unilateral tinnitus (42% versus 88%, Fisher’s exact test, p = 0.001). Damage to the cervical sympathetic trunk running alongside the vessels leads to ipsilateral Horner syndrome. Microscopic vascular abnormalities in the inner ear should be mentioned for the sake of completeness (13). This determines whether neurological complications (focal symptoms, elevated intracranial pressure, intracranial hemorrhage) may arise in addition to tinnitus (14). Compression of the occipital artery against the mastoid process therefore often reduces tinnitus.
Dural arteriovenous fistulas are the classic cause of objective pulsatile tinnitus, but not all arteriovenous fistulas cause tinnitus that can be heard by the clinician (17, 18). Tympanic paragangliomas are otoscopically visible as a reddish pulsating space-occupying lesion behind the tympanic membrane.
Venous hum, often overlooked, can be heard through a stethoscope and is thought to be caused by altered bloodflow behaviors, usually in anemia.
Ligature of the jugular vein, the first-line therapy, should therefore be reserved for persistent cases that cause a high degree of suffering.
This is also true of emissary veins (condylar or mastoid), which might be associated with tinnitus but are also found frequently. This also reduces sound conduction, in a similar way to semicircular canal dehiscence or cholesteatoma (29). Provocation and rotation maneuvers (Table 2) can be used to distinguish whether the tinnitus sounds are arterial or venous in origin. If no other causes can be identified for confirmed pulsatile tinnitus that is synchronous with the pulse, DSA is indicated. During this time, precaution should be taken to keep water from entering the ear, which could cause infection.
One of the most common causes of tinnitus is due to damage to the microscopic hair cells of the hearing nerve in the inner ear.
The diagnosis is essentially clinical and should be confirmed by performing diagnostic maneuvers.
Delays in the diagnosis and treatment of BPPV have both cost and quality-of-life implications for both patients and their caregivers8. The debris dislocates and promotes anomalous activation of the ampullar crista and may interfere with the neuronal output index that normally would be expected for that head and canal position. The lateral semicircular canal may be involved in 5 to 15% of patients8 and the anterior canal is rarely involved8; but there is still the possibility of simultaneous involvement of two canals18,19,20. The examiner should ensure that he can support the patient's head and guide the patient through the maneuver safely and securely, without the examiner losing support or balance himself8. Next, the examiner fairly quickly moves the patient (who is instructed to keep the eyes open) from the seated to the supine left-ear down position and then extends the patient's neck slightly (approximately 20 degrees below the horizontal plane) so that the patient's chin is pointed slightly upward, with the head hanging off the edge of the examining table and supported by the examiner. Again, the examiner should inquire about subjective vertigo and identify objective nystagmus, when present.
After any additional elicited nystagmus has subsided, the head is then quickly turned 90 degrees to the opposite side, and the eyes are once again observed for nystagmus. Thus, the resulting eye movement is always stronger when the affected ear is placed downward23. The arrows indicate the direction of displacement of the cupulae by gravity with the lateralization movement of the head. It has been proposed by Korres22 that the unilateral vestibular hypofunction is more common in cases secondary to head trauma or viral infection.
Next, the head is turned 90 degrees, to the right (usually necessitating the patient's body to move from supine position to the lateral decubitus position).
The jam generates a constant counter-attraction force in the cupulae, as result from negative pressure.
Possible explanations include some comorbidities and patient limitations during the maneuvers (for example: limited cervical range of motion or vascular failure)14.
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External origins such as traumas that have caused irreversible damage to the auditory system represent only minor problems to the therapist when investigating causal factors.
Furthermore, warts are present especially on the hands and in the face, which are hard, indented, and tend to burst open. In addition the inner ear points, Shen Men (blockages of the small pelvis), right hip and points on the line of sounds are treated. Pulsatile tinnitus can be classified by its site of generation as arterial, arteriovenous, or venous. Frequencies reported in the largest case series published to date vary enormously, as a result of both differing patient selection and different diagnostic pathways. There is a risk of cerebral infarction resulting from cerebral thromboembolism or hemodynamic instability of cerebral circulation. A vascular steal phenomenon involving the vessels that supply the brain poses an additional risk of damage. MRI often reveals empty sella syndrome, a prolapse of CSF-filled arachnoid membranes from the suprasellar cisterns through the sellar diaphragm and into the sella turcica. Essential examinations include taking blood pressure, determining body mass index, testing for anemia, and ruling out hyperthyroidism. The risk entailed in catheter angiography, which with an experienced clinician is low, must be weighed against the possibly risky spontaneous course of an undetected arteriovenous fistula.
Treatment is based on the identification of the affected semicircular canal and performance of liberatory maneuvers or repositioning of free floating particles of otoliths. Some other symptoms could be associated and often persist after the interruption of the episode, such as nausea, imbalance, or postural instability1,15.
The examiner observes the patient's eyes for the latency, duration, and direction of the nystagmus. Two potential nystagmus findings may occur with this maneuver, reflecting two types of lateral canal8. In cupulolithiasis, the fragments are adhered to the cupulae of the affected semicircular canal, which make them heavier than the endolymph. Some authors prefer to wait for the natural course towards a spontaneous relief, considering BPPV a self-limited condition. The patient is rapidly moved to the opposite side-lying position without pausing in the sitting position and without changing the head position relative to the shoulder. Then, the head is turned to the facedown position and the body is moved to the ventral decubitus.
The jam pressure induces cupulae displacement and consequent depolarization (vertical canals) or hyperpolarization (lateral canals).
Below are instructions that you can use to receive Notifications from our site, or other Business Facebook Sites, and what type of notifications. However, major causal relationships within the body’s system can result in sudden deafness and such interactions are not always easy to understand.
Pulsatile tinnitus requires hearing, as there is usually a genuine physical source of sound (3). Angiography reveals tears of the intima, with membranes and intimal cusps, or segmental narrowings of the lumen over longer distances, caused by the intramural hematoma. As with dural arteriovenous fistulas, endovascular surgery, the usual form of treatment, cannot be done without prior diagnostic DSA.
The Box provides an overview of the anatomical compartments and the imaging findings to be expected in each one. Besides the clinical history, the diagnosis of BPPV takes into account the type, direction and duration of nystagmus provoked by maneuvers that provide clues for identifying the affected canal and the pathophysiological mechanism involved (whether canalithiasis or cupulolithiasis). Again, the provoked nystagmus in posterior canal BPPV is classically described as a mixed torsional and vertical movement with the upper pole of the eye beating toward the dependent ear. When the head is rotated to one side, the action of gravity on the ampullar crista moves the debris into the opposite direction and it is possible to observe the nystagmus that is in the opposite direction from the tested ear (apogeotropic type)24,25.
Gradually the patient resumes the upright sitting position8.If the superior semicircular canal is affected, the movement is performed in the direction opposite to the procedure for posterior semicircular canal4,15,23,40. Later the patient's head is turned 90 degrees, and the body is placed on lateral decubitus. Common causes at the arteriovenous junction include arteriovenous fistulae and highly vascularized skull base tumors. Pulsatile tinnitus is therefore included under the umbrella terms “physical tinnitus” and “somatosounds” (4).
Magnetic resonance imaging (MRI) often reveals this intramural bleeding directly (Figure 1). In contrast, otoscopically visible paragangliomas may be only the tip of the iceberg if the main tumor mass is extratympanic. Blood vessels can become narrowed from outside as a result of intracranial hypertension, but the reverse is also true: A primary sinus stenosis can also be the cause of intracranial hypertension. Then the patient is asked to rest the chin on the shoulder and sit up slowly, completing the maneuver8 (Figure 4). Figure 6 demonstrates the Semont Maneuver for treatment of right-sided posterior semicircular canal cupulolithiasis.
They can worsen when listening to music, or on the contrary, they may even tend to improve. Common venous causes are intracranial hypertension and, as predisposing factors, anomalies and normal variants of the basal veins and sinuses.
Suspected paraganglioma is therefore always grounds for performing subtle cross-sectional imaging. In addition to clinical symptoms, lumbar puncture with measurement of CSF pressure, which imaging cannot reveal, can guide diagnosis. The head must stay in that position for some moments, before it returns to the normal position1,4,23,40. Each step is maintained for 15 seconds - for slow migration of the particles, in response to gravity. In our own series of patients, pulsatile tinnitus was most often due to highly vascularized tumors of the temporal bone (16%), followed by venous normal variants and anomalies (14%) and vascular stenoses (9%). Treatment consists of lumbar punctures to relieve CSF pressure or surgical CSF drainage (ventriculoperitoneal or lumboperitoneal shunt, optic nerve sheath fenestration). To complete the maneuver, the patient is brought into the upright sitting position with head bowed down at 30 degrees23,43,44.
Especially in the evenings she has bladder cramps and generally a slight burning in the urethra. Thorough history-taking and clinical examination are the basis for the efficient use of imaging studies to reveal the cause of pulsatile tinnitus. Tension pains in the left shoulder blade and pains in the thoracic spine become aggravated when walking for a longer periods of time.

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