As subjective tinnitus perception of sounds is called without acoustic stimulus, which is only audible to the patient. In most cases, the tinnitus is subjective.
At Tinnitus is noises in the ears. Around 10-15% of the population have experienced tinnitus. As subjective tinnitus perception of sounds is called without acoustic stimulus, which is only audible to the patient. In most cases, the tinnitus is subjective. An objective tinnitus is unusual and the result of noise produced by structures close to the ear. Sometimes tinnitus is loud enough to be audible to the examiner. Features Tinnitus can be described in the ears as buzzing, ringing, roaring, whistling or hissing sound, which sometimes changes and becomes more complex. An objective tinnitus is typically pulsating (in synchronism with the heartbeat) or intermittent. Tinnitus is most noticeable in a quiet environment and in the absence of disturbing stimuli, so he often gets worse before bedtime. It may be intermittent or continuous. Persistent tinnitus is at best only a nuisance, but often quite unnerving. Some patients get used to better the condition than others; occasionally can cause depression. Due to stress, the tinnitus generally reinforced. Pathophysiology from subjective tinnitus is believed that it is caused by abnormal neuronal activity in the auditory cortex. To such activity occurs when the input on the auditory pathway (cochlea, auditory nerve nuclei in the brain stem auditory cortex) is disturbed or altered in any way. This disorder can lead to loss of suppression of internal cortical activity and perhaps the creation of new neural connections. Some believe the phenomenon is similar to the development of phantom pain after amputation. A conductive hearing loss (eg. As caused by an Zeruminalpfropf, otitis media, or dysfunction of the Eustachian tube) may also be associated with subjective tinnitus by the noise input is changed to the central auditory system. An objective tinnitus represents the actual noise present, which is produced by physiological phenomena in the vicinity of the middle ear. In general, the noise from the blood vessels derived either from normal vessels under conditions of increased or turbulent flow (z. B. caused by arteriosclerosis) or abnormal vessels (z. B. in tumors or vascular malformations). Sometimes cause muscle spasms or myoclonus of palatal muscles or muscles in the middle ear (stapedius, tensor tympani) clicks. Etiology The causes can be classified according to whether they lead to a subjective or an objective tinnitus (see Table: Causes of tinnitus). Subjective tinnitus to a subjective tinnitus can carry almost any disturbance, the auditory pathway in question. Among the most common disorders are those that include a sensorineural hearing loss, in particular:. Acoustic trauma (noise-induced sensorineural hearing loss) presbycusis (with aging) ototoxic drugs Meniere’s disease infections and central nervous system lesions (eg caused by tumors, stroke, multiple sclerosis) that affect the auditory pathway can also be the cause. Including interference that cause conductive hearing loss can cause tinnitus. This includes installation of the ear canal by cerumen, a foreign body or an external otitis. Otitis media, barotrauma, dysfunction of the Eustachian tube and otosclerosis can also be associated with tinnitus. In some patients, a dysfunction of the temporomandibular joint with tinnitus gebracht.Objektiver in connection Tinnitus is an objective tinnitus usually includes the vascular flow noise, which cause a pulsating audible sound synchronous with the pulse. Causes include: turbulent flow through the carotid artery or jugular vein vascularized tumors in the middle ear arteriovenous malformations (AVM) of the dura mater muscle spasms or myoclonus of palatal muscles or that of the middle ear (stapedius, tensor tympani) can cause a noticeable noise in the usually a rhythmic clicking. Such spasms may (multiple sclerosis z. B.) be caused idiopathic or by tumors, head trauma as well as infectious or demyelinating diseases. A palatal myoclonus leads to a visible movement of the palate and / or the tympanic membrane, which matches the tinnitus. Causes of tinnitus cause suspicious findings Diagnostic procedure Subjective tinnitus * Acoustic trauma (eg. As noise-induced hearing loss) on business or leisure-related noise exposure, hearing loss Clinical evaluation barotrauma Unique exposure in the history Clinical evaluation * CNS tumors (eg. As acoustic neuroma, meningioma) and lesions (eg., Caused by multiple sclerosis or stroke) Unilateral tinnitus and hearing loss often Occasionally other neurological abnormalities gadolinium MRI audiometry drugs (eg. As salicylates, aminoglycosides, loop diuretics, some chemotherapeutic agents, including cisplatin ) the beginning of a bilateral tinnitus coincides with the use of the drug along the exception of salicylates, deafness also possible aminoglycosides possibly associated with bilateral vestibular function loss B. (eg. dizziness, incoordination) Clinical evaluation funct ionsstörungen of the Eustachian tube often continued deterioration of hearing, previous infections of the upper respiratory tract, problems with the ear cleaning, air travel or other pressure changes Severe allergies can aggravate one or both sides (often an ear a bigger problem than the other) audiometry tympanometry infections (such symptoms. As otitis media, labyrinthitis, meningitis, neurosyphilis) history of infection Clinical evaluation Meniere’s disease Episodic unilateral hearing loss, tinnitus, feeling of fullness in the ear and severe dizziness Typically fluctuating and eventually permanent low-frequency hearing loss audiometry Vestibular tests gadolinium-enhanced MRI for the evaluation of unilateral sensorineural hearing loss and to the exclusion of acoustic neuroma obstruction of the ear canal (z. B. caused durchZerume, foreign body or external otitis) on one side, with the visible abnormalities in the investigation of O hrs, including vaginal discharge with external otitis Clinical evaluation presbycusis (with aging) Progressive hearing loss, clinical often where a family history clarification Objective tinnitus Arteriovenous malformations of the dura mater sided, constant, pulsatile tinnitus Typically, no other symptoms may flow noise over the Skull The physical examination should always be a periaurikuläre auscultation include angiogram Myoclonus (palate muscles, tensor tympani, stapedius) Irregular click or mechanical-sounding noises may be other neurological symptoms (eg. B. Multiple Sclerosis) movement of the palate and / or the tympanic membrane in the study if symptomatic Neurological case conference MRT tympanometry Turbulent flow in the carotid artery or jugular vein vessel noise or venous sums in the neck Venous sums may stop with compression of the jugular vein or rotation of the head Clinical evaluation vascular middle ear tumors (z. B. glomus tympanic, jugular glomus) Single-sided, constant, pulsatile tinnitus occasionally bruit at auscultation of the ear tumor usually visible behind the eardrum as a very reddened, sometimes pulsating mass, di e may fades away (on the Pneumatoskopie) CT MRI angiogram (performed usually before surgery) * Usually a constant tone and accompanied by some degree of hearing loss. Most patients should receive audiometry. Typically intermittently or pulsed. TM = eardrum. Clarification history The history of the disease process should consider the duration of tinnitus, whether it occurs on or both sides, and whether it is a constant or intermittent sound. If intermittent, the physician should determine if it is regular and if it corresponds approximately to the pulse rate or sporadically occurring. Any exacerbation or mitigating factors (eg. As swallowing, head position) must be observed. Important associated symptoms include deafness, dizziness, earaches and ear discharge. In reviewing the organ systems you should look for symptoms of possible causes, including double vision and difficulty swallowing or speaking (lesions of the brain stem) and focal weakness and sensory changes (disorders of the peripheral nervous system). The effects of tinnitus on the patient should also be assessed. Whether the tinnitus is sufficiently onerous as to cause anxiety, depression or insomnia, should be noted. The history should for risk factors ask for tinnitus, including exposure to loud noise, sudden pressure change (diving or air travel), ear or CNS infections in prehistory or trauma, cranial irradiation and recently eingetretenem weight loss (risk of dysfunction of Tuba Eustachii). The use of drugs should be determined, especially salicylates, aminoglycosides or Schleifendiuretika.Körperliche investigation In the clinical studies, the ear and the nervous system are the focus. The ear canal should be inspected for leakage, debris and cerumen. The eardrum should be examined for signs of acute infection (z. B. redness, bulging), chronic infection (eg. B. perforation, cholesteatoma) and a tumor (or bluish red mass). At the bedside a hearing test should be performed. The cranial nerves, especially the vestibular function (lightheadedness (dizziness) and dizziness (vertigo)), are also checked as peripheral motor, sensory and reflexes. A stethoscope is used to a vascular noise in the course of carotid artery and jugular vein and on and off the ear festzustellen.Warnzeichen The following findings are of particular importance: bruit, particularly over the ear or the skull associated neurological symptoms or complaints (except for hearing loss) unilateral tinnitus interpretation of the findings in some cases, tinnitus can indicate a retrocochlear pathology such as an acoustic neuroma (benign but invasive tumor originating from the vestibular portion of the eighth cranial nerve in the internal auditory canal). It is important to determine if the tinnitus is unilateral, as an acoustic neuroma can manifest only with a unilateral tinnitus. This diagnosis is more likely at the same time when a unilateral sensorineural hearing loss exists or an asymmetrical hearing loss with worse hearing in the affected ear tinnitus. It is also important to distinguish the rare cases of objective tinnitus of the much more frequent cases of subjective tinnitus. A pulsating or intermittent tinnitus is almost always objective (albeit for the examiner not always detectable) is associated with a bruit, just like him. A pulsatile tinnitus is almost always benign. A constant Tinnitus is usually subjectively (perhaps with the exception that it is caused by a venous sums that can be due to the presence of a vascular noise and often identified by the change in Tinnitus upon rotation of the head or a compression of the jugular vein) , Specific causes can often be assumed results of these tests (see Table: Causes of tinnitus). In particular, noise exposure, barotrauma, or taking certain medications before the start put these factors as a cause nahe.Tests All patients with significant tinnitus should be referred for a comprehensive audiological evaluation to determine the presence, degree and type of hearing loss. In patients with unilateral tinnitus and hearing loss an acoustic neuroma should be ruled by a gadolinium MRI. In patients with unilateral tinnitus and normal hearing and unobtrusive physical examination an MRI is not necessary unless the tinnitus is> 6 months. The further procedure depends on the clinical picture (see Table: Causes of tinnitus). Patients with a visible vascular tumor in the middle ear need a CT, a gadolinium MRI and referral to a specialist if the diagnosis should be confirmed. In patients with a vibrant, objective tinnitus and no abnormalities on examination or audiology further studies of the vascular system (carotid, Vertebral- and cerebral vessels) are required. After the usual examination sequence starting with a magnetic resonance angiography (MRA). However, as the MRA is not very sensitive for arteriovenous malformations of the dura mater, many clinicians advise then an angiogram. Since arteriovenous malformations of the dura mater, however rare, the significant risks of angiography against the potential benefits for diagnostic and therapeutic embolization should be carefully considered this vascular anomaly. Patients who report that they hear clicking sound in one or both ears should be unersucht on tinnitus. This review can take place or by auscultation with a stethoscope by tympanometry to identify the clonus of the tensor tympani, the stapedius and / or palate muscles. A palatal myoclonus should be visible on physical examination of the oral cavity. Therapy Treatment of the underlying disease may also reduces the tinnitus. Around 50% of tinnitus patients it decreases when their hearing loss (z. B. with a hearing aid) is compensated. Since stress and other psychological factors (eg. As a depression) can worsen the symptoms, all efforts are helpful to recognize these factors and treat. Many patients can be calm with the assurance that their tinnitus does not constitute a serious medical problem. Tinnitus can be worsened by caffeine and other stimulants, and the patients should try to avoid the use of these substances. Although there is no specific medical or surgical therapy, many patients find that it helps them fall asleep when background noise to mask the tinnitus. Therefore, some patients benefit from a “tinnitus masker” which they wear like a hearing aid and can mask the tinnitus with its quiet noise level. A tinnitus retraining therapy, offered as part of programs that specialize in tinnitus treatment is helpful for some patients. Occasionally a Tinnitus can also be by electrical stimuli (eg. As a cochlear implant) in the inner ear weaken, but the method is only suitable for profound hearing loss (almost deaf) patients. Basics of geriatrics One of 4 persons> 65 years suffers from significant hearing loss. Since tinnitus is common among people with sensorineural hearing, tinnitus is a common disease among the elderly. Summary A subjective tinnitus is caused by an abnormality somewhere in the auditory pathway. An objective tinnitus is caused by an actual noise generated in a vascular structure in the vicinity of the ear. Loud noises, aging, Meniere’s disease, and drugs are the most common causes of subjective tinnitus. A unilateral tinnitus with hearing loss or dizziness / balance problems justifies a gadolinium MRI to rule out an acoustic neuroma. Each tinnitus, which is accompanied by a neurological deficit is cause for concern.