ENT Potpourri Tinnitus & Hiccups Jason L. Morris, MD

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ENT PotpourriTinnitus Hiccups

• Jason L. Morris, MD
• November 21, 2006

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Tinnitus

• Perception of sound in the absence of an external
  source.
• ringing gt hissing gt buzzing/whistling gt
  cricket-like gt humming
• 50 million people affected in U.S.
• Men gt Women
• Prevalence increases with age (most common in the
  elderly)
• Southern U.S. gt Northeastern U.S.

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Tinnitus

• Can be triggered anywhere along the auditory
  pathway
• Continuous or Intermittent
• Intermittent tinnitus can be normal/benign
• Exposure to loud noise (e.g. concerts)
• Drugs (e.g. aspirin)
• Persistent tinnitus usually the result of
  sensorineural hearing loss

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Tinnitus

• Chronic tinnitus defined as gt 6 months
• Unlikely to resolve completely, but often becomes
  less bothersome over time
• Unilateral or Bilateral
• Pulsatile or Non-Pulsatile
• Pulsatile tinnitus should raise concern for
  significant underlying pathology
• Usually the result of turbulent blood flow
• Objective Tinnitus

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Tinnitus - Impact

• May result in psychological distress
• Poor sleep
• Inability to concentrate
• Degree of disability can be measured
• Tinnitus Handicap Inventory
• Tinnitus Reaction Questionnaire
• Mood disorders and Insomnia may increase the
  degree of disability

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Tinnitus - Causes

• Auditory system dysfunction
• Most common etiology
• Medications ASA, aminogycosides, ACE-I, BZDs,
  CCBs, PPIs, TCAs
• Presbycusis sensorineural hearing loss w/aging
• Otosclerosis abnormal bone repair of the stapes
• Acoustic neuroma compress/stretch cochlear n.
• Chiari malformations low lying cerebellar
  tonsils place tension on auditory nerve

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Tinnitus - Causes

• Vascular Causes most common cause of pulsatile
  tinnitus
• Arterial bruits
• not usually associated with other otologic
  complaints (hearing loss, vertigo, etc)
• consider evaluation for underlying
  atherosclerotic dz
• AVMs

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Tinnitus - Causes

• Vascular Causes (cont.)
• Paraganglioma (a/k/a glomus tumors)
• Vascular tumor arising from paraganglia cells
  near carotid bifurcation
• Loud pulsating tinnitus that may interfere with
  hearing
• Mass effect may cause hearing loss or CN findings
• Venous hums
• Soft, low-pitched hum
• Assoc with HTN, increased ICP (e.g. pseudotumor
  cerebri)
• May stop with change in head position, pressure
  over Jugular vein, or with activity

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Tinnitus - Causes

• Neurologic disorders
• Pulsatile or clicking tinnitus from muscle spasm
• Local otologic disease, MS
• Eustachian tube dysfunction
• ocean roar which corresponds to respirations
• After significant weight loss or XRT
• Other somatic disorders
• TMJ, whiplash, c-spine disease

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Tinnitus - Evaluation

• History
• Episodic vs constant
• Pulsatile vs non-pulsatile
• Rhythm
• Pitch
• Quality
• Inciting/alleviating factors

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Tinnitus - Evaluation

• History
• Prior ear disease
• Noise exposure (machinists, veterans, etc.)
• Hearing loss
• Head trauma
• Ototoxic medications
• PMH (e.g. HTN, atherosclerosis, depression,
  insomnia)

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Tinnitus - Evaluation

• Exam
• Oral cavity muscle contractions
• Ears impacted cerumen, infection, glomus tumor
• Neck bruits
• Neuro especially CNs 8, 5, 7
• Provocative maneuvers eye mvmt, jaw clenching

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Tinnitus - Evaluation

• Suspect vascular etiology ?
• Audiogram
• Imaging (MRA, CT)
• Suspect auditory system etiology ?
• Prevent further hearing loss (noise, drugs)
• Audiogram
• Evaluate impact of tinnitus on quality of life

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Tinnitus - Evaluation
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Tinnitus Treatment

• No FDA-approved medication for the treatment of
  tinnitus
• Treat concurrent mood/sleep disorders
• Nortriptyline studied
• Hearing aids, Maskers
• Education
• www.ata.org
• Lessen the impact/disability

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Tinnitus Key Points

• Most common cause is sensorineural hearing loss
• Pulsatile tinnitus should raise suspicion for
  underlying pathology (think vascular)
• Refer for audiogram
• No good medical treatment goal is to lessen the
  impact/disability

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Hiccups
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Hiccup vs Hiccough vs Singultus?

• An abrupt inspiration as a result of a sudden
  contraction of the diaphragm. Closure of the
  glottis then halts the incoming air. The column
  of air strikes the closed glottis to produce the
  characteristic sound a hiccup.
• Hiccough later derivation of Hiccup
• Singultus medical term for hiccup
• Onomatopoeia a word that imitates the sound
  that it represents e.g buzz, meow, hiccup, etc

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Hiccups

• Common
• Usually benign and transient
• Function?
• Hiccup bout up to 48 hours
• Persistent Hiccups 48 hours 1 mo
• Intractable Hiccups - gt2 months
• World Record for hiccups ???

? gt ?
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Hiccups

• Exact mechanism not clearly defined, but
• Afferent limb phrenic n., vagus n., sympthetic
  chain
• Central mediator
• Efferent limb phrenic n. and accessory
  connections to glottis and intercostal muscles.

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Benign Hiccup Bouts - Causes

• Gastric distention
• Overeating
• Carbonated beverages
• Aerophagia
• Gastric insufflation (endoscopy)
• Sudden temperature changes (GI or ambient)
• Alcohol ingestion
• Tobacco use
• Sudden excitement or emotional stress

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Persistent/Intractable Hiccups Causes

• Vagus Phrenic nerve irritation
• Pharyngeal branches pharyngitis, laryngitis
• Thoracic branches pneumonia/bronchitis,
  esophagitis, LAD, etc
• Auricular branches hair/foreign body irritation
  of TM
• Recurrent Laryngeal nerve goiter/tumor in neck
• Abdominal branches gastric distention,
  gastritis, PUD, pancreatitis, IBS, etc
• Diaphragmatic branches GERD, subphrenic abscess

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Persistent/Intractable Hiccups Causes

• CNS disorders
• Head trauma, CVA, AVM
• Encephalitis, neurosyphillis, neoplasm
• Toxic-Metabolic disorders
• EtOH, uremia
• Hyponatremia, hypocalcemia
• Psychogenic factors
• Stress, excitement, conversion disorder,
  malingering
• Postoperative - anesthesia, intubation
• Drugs alpha methyldopa, diazepam, dexamethasone

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Hiccups - Evaluation

• History
• Duration, severity
• PMH
• Meds
• EtOH consumption?
• Hiccups while asleep?
• PE
• Focus on head, neck, chest, abd, neuro

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Hiccups - Evaluation

• Labs
• CBC (?occult infection, malignancy, etc)
• Electrolytes
• Renal function
• CXR (pulmonary or mediastinal abnormality?)
• Others
• LFTs, Calcium, ECG, EEG, PFTs, bronch, EGD

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Hiccups - Treatment

• Most therapies based on anecdotal info
• Treat underlying illness (e.g. PPI for GERD)
• If no cause identified, empiric therapy
• Non-pharmocologic (a/k/a home remedies)
• Breath holding
• Sugar
• Drinking from opposite side of glass
• Breathing into bag
• Fright

Interrupt vagal afferent limb
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Hiccups - Treatment

• Empiric therapy (cont)
• Pharmacologic
• Chlorpromazine IV most effective, but also PO
• Metoclopramide
• Baclofen
• Anticonvulsants phenytoin, VPA, carbamazepine
• Antidepressants amitryiptyline
• Marijuana

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Hiccups - Treatment

• Refractory hiccups
• Hypnosis
• Acupuncture
• Surgery
• Phrenic nerve crushing or block
• Implantable breathing pacemaker?
• Vagus nerve stimulator

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Hiccups World Record

• Charles Osborne (1894-1991)
• Anthon, Iowa
• Hiccups from 1922-1990 68 YEARS!!
• Guiness Book of World Records

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References

• UpToDate
• Kolodzik, PW, Eiers, MA. Hiccups (singultus)
  Review and approach to management. Ann Emerg Med
  1991 20565.
• Friedman, NL. Hiccups A treatment review.
  Pharmacotherapy 1996 16986.
• www.ata.org
• Fortune, DS, Haynes, DS, Hall, JW. Tinnitus.
  Current evaluation and management. Med Clin North
  Am 1999 83153.
• Lockwood, AH. Tinnitus. Neuro Clin 2005 23(3)
  893-900.