Tinnitus unilateral causas 2014,tenis new balance 880 v2,sudden sensorineural hearing loss labs - Reviews

How to cite this article Mendes RCCG, Ribas A, Macedo IP, Buschle M, Ataide AL, Pereira R, Kochen AP, et al. Several studies have shown that cochlear implants may reduce or even eliminate tinnitus in patients with bilateral profound hearing loss. Keywords: cochlear implants, deafness, language and hearing sciences, speech, speech perception, tinnitus.
Tinnitus means perceiving a sound that is not being generated in the environment at that time. Considered one of the most common symptoms of profound sensorineural hearing loss, tinnitus can significantly affect the quality of life of individuals2. The latest international publications7,8 suggest that patients with unilateral hearing loss, or even severe hearing loss, presenting ipsilateral tinnitus with hearing loss, unresponsive to several treatments, may also benefit from electrical stimulation of the auditory nerve through the CI.
The beneficial effect of a CI on tinnitus can be explained by acoustic masking, by electrical stimulation directly to the auditory nerve, and especially by the reorganization of the central auditory system and associative brain areas that occurs after activation of the implant. The aim of this study was to describe the audiological results of a patient with asymmetric hearing loss with ipsilateral disabling tinnitus, who was underwent the CI procedure. Throughout the ENT care, various treatments were performed without success, for the reduction or remission of tinnitus, which led the patient at the time to have suicidal thoughts. The patient underwent cochlear implant surgery to the right ear in an attempt to improve auditory acuity, but mainly as a last resort in tinnitus treatment. Before the CI, results were compatible with profound hearing loss to the right ear and severe loss to the left.
After the CI, thresholds compatible with normal hearing on the right ear were observed, as shown in Figure 1. We used the Glendonald Auditory Screening Procedure (GASP test)12 which classifies the category of hearing on a scale of zero to six, where zero means no detection of speech sounds and six means open-set speech recognition. The protocol for assessing tinnitus was applied at the following times: before surgery, 45 days after surgery (activation of CI), two months later, six months later and one year after CI surgery.
The literature11 states that the CI is configured as an alternative treatment of deafness and constitutes a multifactorial process with proven effectiveness. The Brazilian study17 indicates that the hearing assessment obtained six months after the first implant programming demonstrates that English-speaking patients get excellent results in tests of recognizing words and sentences in open presentation, regaining useful hearing. Despite these satisfactory and known findings by physicians and audiologists, the primary complaint by the subject, which is the focus of this study, was the tinnitus.
Di Nardo et al.6 reported that the CI provides effective results in reducing the perception of tinnitus intensity. Statistically significant reduction in THI overall indices and sub-indices, pre and post CI, were demonstrated in scientific studies8,11 showing lower levels of discomfort and a decrease in the intensity of tinnitus as a result of direct electrical stimulation of the auditory nerve and reorganization of the central auditory pathways and cortical association areas, leading to the use of tinnitus as a criterion for choosing the ear to be implanted. The results related to the concentration (66%), emotional (100%), sleep (26%) and hearing (96%) obtained by preoperative TAQ converged at a rate of 72% indicating strong interference of tinnitus, especially in the emotional and hearing states of the patient. Factor 3, life prospects, went from a preoperative score of 100% to 50% after activation of the CI, 25% after two months of use, 75% after six months and reduction to 25% after 1 year of CI use.
The consulted study11 shows that the CI generates maximum benefit in remission buzz around seven months after the performed procedure. The reduction in the intensity and degree of tinnitus annoyance confirms the improvement in the quality of life of individuals, a fact that must be considered in preoperative counseling of patients with tinnitus as candidates for cochlear implants. CI as a treatment for post-lingual profound hearing loss is highly effective, there is improvement seen in hearing thresholds in performance and perception of speech sounds, as in the case presented. Although the literature describes the indication of CI for patients with tinnitus, the initiative is still not being widely accepted by physicians and speech-language pathologists, especially when hearing loss is unilateral or asymmetric. Paper submitted to the ITJ-SGP (Publishing Management System) on May 21, 2013; and accepted on June 21, 2013.
In tinnitus associated with inner ear damage, and especially that due to noise, it seems reasonable to expect that deficits in inner ear function should be present at the same frequency as the tinnitus. For the left ear (top), OAEs (the difference between the top and bottom trace) are excellent up to roughly 11,000 Hz. Tinnitus has been reported for nearly 80% of patients referred to the otolaryngology services.
Tinnitus may be defined as an auditory illusion, a sound sensation related to an external source of stimulation.
National research conducted by the Public Health Agency of America in 1984-1985 showed that severe tinnitus is perceived as the third worst symptom in humans, owing to the pain and untreatable dizziness with which it is associated. Complete audiological and clinical evaluations are an important initial step in the diagnosis and treatment of tinnitus, because tinnitus is a symptom related to several diseases.
Some authors consider that vestibular evaluation in tinnitus cases is useful to indicate the image test that will be adequate to make the diagnosis, and it could be enough to establish the diagnosis without the use of any other tests [6,7]. The aim of our study was to analyze the results of a proposed method called otoneurological evaluation in patients with tinnitus as a main complaint and to assess this evaluative method's contribution to establishing the etiology of tinnitus.
Patients complaining of tinnitus, regardless of its association with other symptoms, were selected and divided into two groups.
We analyzed the patients' clinical history (the most important factor), the otolaryngologic physical examination results, the cranial nerve evaluation results, and results of tonal and vocal audiometry, tympanometry, and vestibular tests to establish the probable etiological diagnosis of tinnitus. In this study, we used a method called otoneurological evaluation in which vestibular tests are included in the tinnitus evaluation. Then, in this study, otoneurological evaluation was performed on the patients in the two groups. Some authors [6,7] reported that the use of otoneurological evaluation is important in defining the disorder's site and in determining the appropriate imaging study for a patient with tinnitus. In our study, the otoneurological evaluation suggested vestibular schwannoma in two patients in group 2; the findings were unilateral hyporeflexia and areflexia on caloric tests and corneal hypoesthesia and sensorineural hypoacusia on high frequencies at the affected side. In cases of central disease, otoneurological evaluation localized the lesion on the cortical level in two patients in group 2.
Some other studies proposed the use of otoneurological tests in the evaluation of patients with tinnitus associated with headache [23,24]. In our study, analysis of patients in both groups indicated 24 patients with a history of noise exposure, and the otoneurological evaluation results were conclusive in 15; 11 of the 15 had diagnosed acoustic trauma. Eustachian tube dysfunction may also cause tinnitus synchronous to nasal breathing, usually associated with reverberation and autophonia. Regarding odontogenic causes of tinnitus, nearly 45% of patients with severe tinnitus had temporomandibular joint dysfunction and, of these, 38% reported worsening both of tinnitus and the dysfunction [2]. Vestibular neuronitis is not considered a cause of tinnitus because of its definition as a sudden dizziness in the absence of audiological symptoms.
In inconclusive cases in both patient groups, we found vestibular test results were incompatible with patients' complaints or we found examination results to be of poor quality, causing difficulty in interpreting graphics. On the basis of these data, we noted that on vestibular examinations, caloric test results showed the most common alterations in both patient groups. Specifically, vestibular alterations were significantly present in metabolic, vascular, and cervical diseases in patients in group 1. Our study allows us to conclude that otoneurological evaluation is an efficient method of studying tinnitus and must be included in tinnitus assessment. However, there are not consistent references regarding ipsilateral tinnitus compared to unilateral profound hearing loss. It is a very frequent symptom, which may affect around 17% of the population in some countries.
Several studies claim that the cochlear implant (CI) can diminish or even eliminate the perception of tinnitus in patients with bilateral profound hearing loss and that, although a risk of tinnitus perception that increases after implantation exists, it is very small3-6. With the support of these findings researchers suggest that tinnitus should be a selection criterion in choosing which ear to implant and that patients with severe unilateral hearing loss associated with severe tinnitus can be considered CI candidates9-11. The comparison between the responses obtained before and after the CI verify the benefits achieved with this therapy. The tests were conducted in a soundproof booth, with the Madsen Itera - GN Otometrics audiometer. The test was applied prior to the CI, five months later, eight months later, and finally, after a year. This fact was borne out in this case report, where the pre and postsurgical audiometric tests showed improvement in tone thresholds with CI use. In this study, by applying the VAS, we observed a significant reduction in the intensity of tinnitus perception, and that after activation of the CI, the rating went from four to one after 60 days of using the device. In our study, after activation of the CI, there was a reduction in the THI total index (six) and sub-indices (functional 2, catastrophic 0, and emotional 4) to a score of one.


A total reduction of assessed scores on aspects of sleep and concentration with a reduction of greater than 20%, significant data regarding the emotional and hearing aspects, was observed after activation of the CI. In our study there was a significant reduction in the percentage of THQ (Table 3) after activation of the CI and the subsequent evaluations (two and six months of CI use) mainly in factors 1 and 2. In addition, it can be seen that the CI was critical to the reduction of tinnitus perception. Speech, Language and Hearing Sciences - Universidade Tuiuti do Parana - Curitiba - PR - Brasil. Department of Otolaryngology - Hospital Infantil Pequeno Principe - Curitiba - PR - Brasil. Speech, Language and Hearing Sciences - Hospital Infantil Pequeno Principe - Curitiba - PR - Brasil.
This conjecture offers a possible for adding objective evidence to substantiate the existance of what would otherwise be an intrinsicially subjective phenomenon. Usually, its evaluation is based on tonal and vocal audiometry, tympanometry, brainstem-evoked potentials, electrocochleography, and otoacoustic emissions. It may be the main or even the only symptom in many kinds of disease, compromising many individuals and their relatives.
The same research estimated that 36 million adult Americans have some kind of tinnitus and that 7.2 million have severe tinnitus.
The analysis of clinical history, physical examination, and audiological tests helps to identify the main site of lesion.
Other authors relate that vestibular tests are part of screening for suspected vestibular schwannoma [8,9] or other tumors in the cerebellopontine angle, such as meningioma [10], which could be altered in up to 95% of cases [11] or normal in one-half of small tumors [12]. Group 1 was composed of 64 patients with tinnitus in one or both ears (without specified location of the complaint).
Examinations usually employed to evaluate a patient complaining of tinnitus include tonal and vocal audiometry, tympanometry, electrocochleography, and brainstem evoked potential response. In group 1 (with tinnitus as an isolated complaint), the probable etiology was conclusive in 75% of cases.
Hyperthyroidism may cause tinnitus by increasing cardiac debit, and hypothyroidism may cause tinnitus by increasing inner-ear pressure. In our study, these alterations were most frequent in group 2 patients, possibly because vertigo is a significant complaint and the most common findings are caloric test result alterations and cervical nystagmus related to stimulation on the neck.
Alternatively, even the exclusive use of audiological and vestibular tests may sometimes be enough to establish a diagnosis.
However, in one patient, the otoneurological evaluation was inconclusive (normal vestibular tests) but related to important complaints, so an imaging examination was proposed and showed a vestibular schwannoma. We did not find vestibular alteration in either group, the diagnosis being based only on history of noise exposure and audiometric findings.
In our study, only one patient had diagnosed head injury as the etiology of tinnitus, and we found caloric hypoexcitability on the affected side after the trauma. In our study, Eustachian tube dysfunction occurred in three patients in group 1 and in one patient in group 2. The relation of this joint to tinnitus seems to stem from a group of ligaments that extends from the joint disk to the malleus.
However, a similar alteration was seen in different diseases, which demonstrates that it is not just one part of an examination that may provide a diagnosis but the analysis of all different steps of the otoneurological evaluation in both groups.
In patients in group 2, vestibular alterations were likewise present in metabolic, vascular, and cervical diseases but additionally in presbycusis, Meniere's disease, sudden hearing loss, otosclerosis, cranioencephalic trauma, vestibular neuritis, acoustic neuroma, and central cortical lesions.
We also concluded on the basis of this study that otoneurological evaluation allowed the establishment of the probable etiological diagnosis in a significant number of patients with tinnitus and vestibular symptoms but also in patients complaining of tinnitus only. The aim of this paper is to describe audiological results of a patient with asymmetrical hearing loss with incapacitating ipsilateral tinnitus in the ear subjected to cochlear implant surgery. We do not know its prevalence in Brazil, but if we extrapolate the data from our international population, it is possible that some 28 million Brazilians have already had some form of tinnitus1.
Chart 1 shows the comparison between the results where it can be verified that the patient progressed from category zero to six in the 12-month study. The patient went from category zero to six, where there is open-set recognition of words and phrases together. The degree of discomfort, intolerance or failure often are not related to the intensity of tinnitus, says a consulted study1, but mood disorders (depression, dysthymia) and anxiety often present, exerting strong influences on the worsening of the tinnitus. After 180 days of use, the patient did not perceive any ringing with the CI turned on and noticed only mild tinnitus with the CI off.
Influence of evoked compound action potential on speech perception in cochlear implant users. Incapacitating unilateral tinnitus in single-sided deafness treated by cochlear implantation. Stimulation by cochlear implant in unilaterally deaf rats reverses the decrease of inhibitory transmission in the inferior colliculus. Techniques for assessing auditory speech perception and lipreading enhancement in young deaf children. Resultados auditivos com o implante coclear multicanal em pacientes submetidos a cirurgia no Hospital das Clinicas da Faculdade de Medicina da Universidade de Sao Paulo. Because tinnitus can be a single tone, at nearly any pitch, one really needs to quantify inner ear function at all frequencies.
This suggests that there was outer hair cell damage at the same location using an objective test as had already been localized using a subjective test (audiometry). However, as the cochleovestibular system works as a unit, the use of vestibular tests has been proposed to evaluate tinnitus. This site may be the cochlea, the cochlear nerve, the cochlear nuclei, the brainstem, or the auditory cortex.
Some practitioners conclude that no reliable vestibular tests can confirm the suspicion of a tumor and that magnetic resonance imaging is indicated for all cases [13,14]. All patients submitted to otoneurological evaluation that consisted of a clinical history directed at tinnitus, otolaryngologic physical examination, cranial nerve evaluation, tonal and vocal audiometry, tympanometry, and vestibular tests as described in 1991 by Rubin and Brookler [28,29] and in 1999 by Maudonnet [30].
However, vestibular tests have been proposed for use in this evaluation because of the anatomical and functional relation of vestibular and cochlear systems.
In group 2 (tinnitus associated with other symptoms), the probable etiology was conclusive in 72%.
Reports in the literature cite the use of otoneurological evaluation in cases of tinnitus related to metabolic disorders, mainly hypothyroidism [21,22]. Some authors [8,9] cited otoneurological evaluation as part of a screening in suspected cases of vestibular schwannoma or others tumors of the cerebellopontine angle [10]. This approach is justified because the otoneurological study results may be normal in up to one-half of small tumors [12]. Both patients had pulsed Romberg test results, altered optokinetic nystagmus, and important alterations on the fixation index. The most common finding on caloric testing was directional preponderance to the affected ear related to endolymphatic hydrops. Migraine is a vascular syndrome, and the most frequent findings in the literature are pathological nystagmus and disorder displayed on caloric tests [23]. Affected patients may present with neurosensory hearing loss at high frequencies associated with noise exposure or with presbycusis. The pendular test showed vestibular compensation, which is compatible with the literature [34]. In the latter case, the vestibular test results did not contribute to diagnosis, because they had no value during middle-ear disease. Its incidence in our evaluation was four cases in group 2, and the main finding was caloric hyporerlexia on the affected side secondary to cochlear or neural lesion [35]. The anatomical and functional union of cochlear and vestibular systems could explain this disorder. Vestibular tests did not contribute to diagnosis in temporomandibular joint dysfunction, Eustachian tube dysfunction, acoustic trauma, and migraine, but they were useful to rule out the possibility of association with other diseases. Efficiency of tests used to screen for cerebello-pontine angle tumours: A prospective study. Assessment of auditory and vestibular functions after vestibular neurectomy for Meniere's disease. Progressive sensorineural hearing loss, subjective tinnitus and vertigo caused by elevated blood lipids.


Sudden unilateral deafness and geotropic positional nystagmus -a special form of acute cochleovestibular disorders? Audiological exams and responses to perception protocols for tinnitus before and after surgery were analyzed.
Without a personal sound amplification device (PSAP) during the application of the GASP, the patient reported that he felt only a slight vibration in the right ear to the presented sound stimuli. In our study, the patient reported he had considered suicide due to the discomfort caused by tinnitus.
Experiencia do Hospital das Clinicas da Faculdade de Medicina da Universidade de Sao Paulo. Unfortanately, it is impractical to test hearing in a continuous fashion because each single frequency takes roughly a minute to test. This technique might be useful for medico-legal situations where there is noise trauma and tinnitus. Many patients with tinnitus have altered vestibular test results even in the absence of vestibular symptoms. This symptom is especially marked in patients with some kind of audiological problem and sometimes may be very severe and incapacitating. Some studies demonstrated the use of vestibular tests for evaluating (1) vestibular function during the use of ototoxic drugs [15,16], (2) vestibular function in Meniere's disease after intratympanic gentamicin use [17], or (3) the effect of diphenidol [18], or for following up vestibular compensation after vestibular neurectomy [19]. Tinnitus was unilateral in 31%, 29% had tinnitus bilaterally, and the remaining 40% could not identify the side of their malady. It may be considered a significant symptom when its intensity exceeds normal behavioral sounds. Moreover, many patients complaining of tinnitus have altered vestibular test results even in the absence of such vestibular symptoms as vertigo.
However, several studies [4-10,20-27] have proposed the use of vestibular tests in evaluating patients with tinnitus even in the absence of vestibular symptoms because the cochleovestibular system works as a unit. In 1981, Schleuning [31] stated that the most common disorder is the reduced caloric output due to an occlusion of capillaries of stria vascularis, leading to biochemical alterations on endolymph. Some other authors [13,14] concluded that no reliable vestibular tests can determine a suspected tumor and that magnetic resonance imaging is indicated for all cases. In our study, we obtained normal results with a consistent history of migraine from most of the patients in both groups. The most frequent findings were spontaneous and positional nystagmus and reduced caloric output. We found presbycusis in only five patients in group 1 and in five in group 2; in group 1, all patients produced normal vestibular test results. Diagnosis was based on audiometry and tympanometry, relating to otoscopy and patient clinical history. The incidence of temporomandibular joint dysfunction in our series was two cases in group 1 and one case in group 2.
The tests showed improvements in the hearing threshold on the side with the implant, improvements in speech perception and a significant reduction in tinnitus perception, which consequently led to an improvement in the patient's quality of life.
Shortly after activation of the CI he began to recognize open-set word and auditory performance, improving at each evaluation. This finding accounts for the indication of complete vestibular and audiological evaluation of tinnitus.
The characteristics of tinnitus are investigated: type, intensity, duration, frequency, improvement factor, and associated symptoms. Also in regard to Meniere's disease, vestibular tests are used to evaluate the stage of disease [20].
This fact should signal the need for a complete evaluation of audiological and vestibular systems in patients with tinnitus [4,5]. Thus, in our research we used vestibular tests together with audiological tests (audiometry and tympanometry), physical examination, and recording of patients' history.
This outcome is compatible with the literature and demonstrates the possibility of normal examination results in some phases of the disease (or progressive hyporeflexia), but areflexia is rare [32]. On caloric testing, our most common finding in altered examination results was directional preponderance of the nystagmus, as is usual in vascular syndromes. The low incidence of clinical symptomatology might be explained by the central nervous system's ability to compensate for peripheral vestibular malfunction. Vestibular test results are usually normal, so diagnosis is based on patient history and physical examination of the articulation. The finding was secondary to neural lesion with vestibular compensation shown on rotational tests. The aim of this study is to analyze the contribution of otoneurological evaluation in the diagnosis of tinnitus. The examinations usually involved in the diagnosis of tinnitus are tonal and vocal audiometry, tympanometry, electrocochleography, and the brainstem evoked potential response. Others studies propose their use in investigating tinnitus related to metabolic disorders [21,22], headache [23,24], or alcohol abuse [25].
In this way, the vestibular tests do not establish the diagnosis alone but work in conjunction with all the information obtained by this complete method. We too found reduced caloric results (mainly directional preponderance of the nystagmus) in both groups. However, as the cochleovestibular system works as a unit, the use of vestibular tests has been proposed for the evaluation of patients with tinnitus even in the absence of vestibular symptoms. Vestibular tests have also been put to use in evaluating tinnitus caused by noise exposure; the altered test results proved that noise also affects vestibular function [26].
Table 5 shows previous diseases or symptoms cited by patients, the most frequent being hypertension and pain at the nape of the neck. Approximately one-third of patients with severe tinnitus have one or more cardiovascular disorders, the most frequent of which is hypertension [2]. Group 1 was composed of patients complaining about tinnitus only, whereas group 2 was composed of patients with tinnitus associated with dizziness, hearing loss, and fullness.
A study by Goldstein and Shulman [27] summarized the use of vestibular tests as part of the evaluation of a patient with tinnitus and emphasized the importance of audiologists and otologists working as a team to establish the correct diagnosis and treatment of affected patients. Table 2 shows the results of otoneurological evaluation, and Table 3 shows the results of vestibular tests of these conditions.
Table 6 shows the results of otoneurological evaluation, and Table 7 shows findings of vestibular tests of these different conditions. In our study, we found a history of hypertension in 14 patients in group 1 and 22 in group 2.
Vestibular test findings are usually normal or they may show reduced caloric output and positional nystagmus. All submitted to otoneurological evaluation based on directed clinical history, physical examination, tonal and vocal audiometry, tympanometry, and vestibular examination.
This fact must signal the indication for a complete evaluation of audiological and vestibular systems in patients with tinnitus [4,5].
The analysis of these results could lead to a probable etiological diagnosis in 48 cases (75%), and the results were not conclusive in the others 16(25%). The probable etiological diagnosis obtained from these data was conclusive in 94 cases (72%) and inconclusive in 37 cases (28%).
The most frequent alterations were reduced caloric results due to transitional ischemia of the inner ear. This finding may be related to vascular and biochemical alterations on the liquids of the internal ear [33].
The otoneurological evaluation was conclusive in the diagnosis in 48 cases (75%) in group 1 and in 94 cases (72%) in group 2.
The present study showed that otoneurological evaluation contributes to the etiological diagnosis of tinnitus.




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