The term refers to tinnitus sound heard by the patient in the absence of any external sound source. This can be ringing, ear ringing, crackling, the possibilities are endless.
For a dozen years this better understood pathology can effectively respond to the complaint of the patient. It affects several million people and in some cases can lead to a severe form with a major psychological impact.
The traumatic nature of a sound depends on two factors: intensity and duration of noise exposure. The ear receives the same amount of noise when exposed for 8 hours at 85 dB, 15 minutes and 27 seconds 100 dB to 112 dB.
acute and chronic tinnitus can be distinguished (Box 1).
Box 1. Main tinnitus
acute tinnitus
It accompanies acute diseases of the ear, sound trauma, stroke, eg
chronic tinnitus
Objective tinnitus: that any observer can hear by applying his ear against the patient or by moving a stethoscope in the area surrounding the ear.
Subjective tinnitus: that only the patient can hear.
DIAGNOSTIC:
Examination:
The examination allows:
– Specify since when the symptom is changing;
– Triggering circumstances: the most common is the acoustic trauma, but also research a period of stress or an emotional event;
– The uni- or bilateral or in the head, if tinnitus is bilateral and same intensity in both ears, it is perceived in the head;
– Specify what type is the sound;
– Look for associated signs: decreased hearing, ear bite sensation, headache, neck pain;
– Specify intermittent or permanent;
– Search for potential impact on sleep.
Physical examination:
Clinical examination of the ear or otoscopy:
Otoscopy research a possible local abnormality in the outer or middle ear.
Full otorhinolaryngological exam:
The review is complete ENT specifically focused on:
– Dental articulation;
– The search for a possible jump or a crack in the closure of the mouth;
– Auscultation of periauricular region in search of a vascular breath when pulsatile tinnitus.
Neurological examination:
Neurological examination search for its infringement VIII or other cranial nerves.
Taking blood pressure supplements the balance sheet.
Hearing assessment:
Basic hearing assessment:
The basic hearing assessment consists of an impedance and a tone and speech audiometry (see below, chapter Deafness). In the vast majority of cases, a hearing impairment associated with tinnitus. The audiogram specify the type and importance.
Tinnitus measure:
The tinnitus measure identifies tinnitus frequency and intensity.
In case of unilateral tinnitus, it is proposed to the patient in the contralateral ear with tinnitus sounds of different types and is asked to choose the one that is closest to his tinnitus. Once the frequency or frequency band, identified, adjusting the intensity for perfect equality between the two sounds. In case of bilateral or perceived tinnitus in the head, the procedure is the same for one ear, then the other. If tinnitus is multiple, the procedure is the same for the identification of individual components.
Some tinnitus are very stable, others, however, vary in intensity as in frequency. This identification has obviously the value of a photograph at a time.
In the vast majority of cases, tinnitus is pitched tone and it is between 5 and 10 dB above the hearing threshold. If tinnitus is identified with a much higher intensity of 20, 30 or even 40 dB above the threshold, this indicates a heavy psychological impact that amplifies sound perception.
In 90% of cases, tinnitus is associated with hearing loss to which it is correlated: for example, hearing loss at high frequencies and tinnitus located on the same area, identified on 4000 Hz to 5 dB threshold.
Other useful additional tests:
Auditory evoked potentials of the brainstem:
A review of the auditory evoked potentials of the brainstem (PEA) in case of unilateral hearing loss associated with tinnitus is helpful to remove an acoustic neuroma.
Radiological assessment of the cervical spine:
A radiological assessment of the cervical spine is necessary in the presence of call signs at this level.
Doppler cervicoencéphalique:
Doppler cervicoencéphalique or MRI angiography is useful in cases of pulsatile tinnitus.
ETIOLOGY:
Acute tinnitus:
In case of acoustic trauma:
Acute tinnitus is typically the accompanying noise trauma. It is a sign of suffering from the inner ear to be reckoned with, and any persistent tinnitus more than 12 hours after an intense sound exposure should lead to consult.
All individuals are equal before the acoustic trauma. Some are much more sensitive than others. This is a common finding among hunters: you can practice regularly hunting and retain good hearing and on the other hand, some people may hunt one weekend and have tinnitus and hearing loss.
In case of acoustic trauma, the early initiation of treatment with vasodilators high dose corticosteroids and allows in many cases to reduce or eliminate tinnitus and possibly retrieve the associated hearing loss.
The best action is prevention. There are now many diverse ear protection according to the traumatizing sound agent.
Some hunters meet specific needs, other than those of musicians.
They provide effective protection combined with comfort.
In case of acute ear pathologies:
Tinnitus can also accompany all acute diseases of the inner ear: sudden deafness, stroke or viral inner ear, the rock fracture, for example.
The treatment of tinnitus is then not specific, it is confused with that of the cause.
Chronic tinnitus:
Objective tinnitus:
Objective tinnitus are very rare. They are most often associated with a muscle clonus either at one of the ossicular muscles of the middle ear, either at the level of the Eustachian tube. They may be heard by a third party and be saved sometimes. The patient often has the perception of a mechanical phenomenon in the ear. They can be triggered by certain movements, such as walking.
Muscle relaxants treatments can mostly have a good effect. It is rare to be forced to intervene in the middle ear level for severing the muscle involved.
Pulsatile tinnitus:
In the particular case of pulsatile tinnitus, the ear that transmit sound from the blood in a blood vessel. The cervicoencéphalique Doppler or MRI angiography, its role is to detect any surgically treatable causes such as vascular malformation, aneurysm or arteriovenous fistula.
But in most cases, these tests are normal.
The pulsatile tinnitus may also appear during a blood pressure thrust.
He usually gives in to the blood pressure rebalancing.
If no cause is found, it uses vasorégulatrices therapeutic or a beta-blocker treatment to reduce or eliminate the tinnitus.
Chronic subjective tinnitus disabling:
Chronic disabling subjective tinnitus represents the majority of tinnitus patients.
They can be classified into two categories, those associated with normal hearing and those associated with hearing defi cit.
Many patients have tinnitus without feeling any discomfort. For that tinnitus becomes debilitating, you need a face-off the limbic system and cerebral cortex. This is sort of a processing error of the cognitive and emotional systems in place to eliminate this parasite sound without special meaning to maintain and give more importance to him than it has.
This drift can be observed especially in anxious patients, but is also favored by a stressful or emotional event found in three quarters of patients.
Chronic debilitating tinnitus in normal hearing:
Chronic tinnitus is disabling in normal hearing extraauriculaire find a cause.
* Dental malocclusion:
Dental malocclusion may follow non-replaced tooth extractions, the establishment of a poorly adapted denture, or a bruxism.
Careful maxillofacial clinical examination by a specialist stock of occlusal abnormalities.
Treatment aims to restore proper dental articulation grinding some dental areas, instead filling deficit contact points, gutter port, permanent or only night.
* Pathology of the temporomandibular joint:
The pathology of the temporomandibular joint is suspected when the tinnitus appears or accentuated by chewing or when it is associated with crunches or jaw pain.
Clinical examination search of tender points, areas of contracture, a deviation of the mandible to the closing or opening the mouth, or a jump. The review is completed by a static and dynamic radiological assessment of the joint. In the case of purely functional disorders, the use of a gutter can improve the situation but sometimes only surgery can restore satisfactory operation.
* Cervical osteoarthritis:
The role of cervical spondylosis can be evoked if tinnitus occurs or is increased during flares painful neck. Similarly, in the case of tinnitus installed after some untimely cervical manipulation or some trauma neck.
A radiological assessment takes stock of cervical lesions.
Unfortunately, the treatments referred to cervical, anti-inflammatories, physiotherapy soft neck, generally provide little improvement on the tinnitus itself.
Chronic debilitating subjective tinnitus associated with hearing impairment:
Chronic disabling subjective tinnitus associated with hearing decrease represents 90% of tinnitus patients. Tinnitus is then correlated to the auditory deficit area. The clinical examination and paraclinical will, of course, eliminated a treatable cause of deafness.
TREATMENT OF CHRONIC TINNITUS IDIOPATHIC:
In cases where the treatment of the cause is not enough, that the hearing is normal or poor, we must implement a directed specifically support against tinnitus.
Pharmacological treatment:
Pharmacologically, few molecules are able to have an action on a chronic disabling tinnitus. It is basically a benzodiazepine (Clonazépam®). Good results can be obtained with a morning and evening dose that is between 8 and 12 drops every time. A number of side effects, the importance of which varies from one subject to another, are possible drowsiness, memory loss, imbalance for example.
Electro stimulation:
The use of electro stimulation is derived from the management of chronic pain where the electrically restimulates the painful area. The same is done for the ear by providing both electrical stimulation and auditory stimulation recurring tinnitus.
Habituation therapies:
Recent years have mainly developed for supported which is referred to as habituation therapy. Healing referred is this time more silent, but indifference to tinnitus. It is obtained in 85% of cases, involving sound and psychological therapy.
Sound therapy:
Sound therapy uses white noise generators for normal hearing or hearing loss low. These devices deliver in the ear white noise, chosen for its stability. When the brain constantly hear the same sound, it becomes indifferent.
It is hoped, by coupling tinnitus white noise, get indifference to tinnitus.
This is obtained after 12 to 18 months of the noise emitters port. It is always bilateral noisemakers although tinnitus is unilateral.
The patient is asked to wear their noisemakers all day.
If cit auditory challenge, the conventional hearing aid solution is preferable. It allows to restore auditory patient comfort by compensating its defi cit and at the same time, work on the masking effects of tinnitus. These are obtained by specifically increasing the intensity of the sound environment on the acoustic area. It is then a natural mask, processed by the brain and particularly comfortable for the patient.
Psychological care:
In this sound therapy is associated with a psychological treatment. It consists of a step information on the functioning of the ear and tinnitus itself, the role of the limbic system in the management of emotions, the brain in sensory integration.
So that the patient understands the phenomena involved and in particular the increase in tinnitus perception under stress or anxiety.
Furthermore, the patient generally accumulated over time a number of negative ideas about tinnitus sound. It should dismantle gradually so as to clear tinnitus from any emotional connotation. This involves the fact to reassure the Benin character of tinnitus and the possibilities of control that can bring. All this work is completed the better by taking cognitive behavioral dependents, as well as in chronic pain, the patient learns to regain control of his symptoms.
It is therefore oppose chronic tinnitus invalidating a global care of all of the individual. This is best achieved by multidisciplinary teams that include around otologist, behaviorist psychologists, relaxation therapists and hearing aid practitioners.
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