Hearing Loss, Tinnitus and Meniere

1
Hearing Loss, Tinnitus and Menieres Disease

• Harold N. Hollander, DO. FAAO-HNS
• Comprehensive Ear, Nose and Throat, PC.

2
(No Transcript)
3
Anatomy and Physiology

• Hearing is the complex interplay of three
  different components
• The Sound Conducting System
• The Sensory Organs
• The Neural Pathways

4
Anatomy and Physiology

• The Sound Conducting System
• Where sound energy from the external world is
  transmitted to the middle ear and amplified
• The External Ear
• Pinna and External Canal
• The Middle Ear
• Tympanic Membrane (ear drum)
  
• Ossicles (bones of hearing)

5
Anatomy and Physiology

• Ear Anatomy

6
Anatomy and Physiology

• Sound Transmission Pathway

7
Anatomy and Physiology

• Ossicular Amplifier System

8
Anatomy and Physiology

• The Sensory Organs
• Where mechanical sound energy is converted to
  electrical nerve energy
• Inner Ear
• Cochlea
• Organ of hearing
• Semicircular Canals
• Organ of balance

9
Anatomy and Physiology

• Inner Ear

10
Anatomy and Physiology

• Amplified sound energy enters the Inner Ear and
  creates fluid waves
• These fluid waves are transmitted to the Cochlea
  the organ of hearing
• The fluid waves deflect and move the Cochlear
  Hair Cells which change the mechanical fluid wave
  into millions of electrical nerve signals

11
Anatomy and Physiology

• Electron Microgram of Cochlea

12
Anatomy and Physiology

• Cochlear Hair Cells

13
Anatomy and Physiology

• The Neural Pathways
• Cranial Nerve VIII
• The Vestibulocochlear Nerve
• Cochlear branch combines all the information from
  the millions of hair cells into a complex single
  signal
• The Pons
• Information from both ears is sorted out
• The Midbrain
• Nerve pathways are directed to the correct
  cerebral hemisphere
• The Cerebral Cortex
• The processing centers of the auditory pathway
• Where electrical nerve signals are interpreted

14
Anatomy and Physiology

• Cranial Nerve VII and Central Auditory Pathways

Cochlea and Hair Cells
Cranial N. VIII
15
(No Transcript)
16
Types of Hearing Loss

• Conductive Hearing Loss
• Poor Sound Transmission
• Sensorineural Hearing Loss
• Poor cochlear or nerve function
• Mixed Hearing Loss
• Components of both conductive and sensorineural
  hearing loss

17
Types of Hearing Loss

• Hearing Can Be Lost At Any Point Along This
  Pathway!

18
(No Transcript)
19
Tinnitus

• Definition The perception of sound in the
  absence of external stimuli.
• Includes ringing, whining, buzzing, roaring,
  clicking or pulsatile sounds
• May be perceived as unilateral (one ear),
  bilateral (both ears) or nonlocalized.
• Estimated 40 million Americans affected with 10
  million at a severe level
• Most common in 40 to 70 years of age

20
Tinnitus

• There are a multitude of reasons for the various
  types of tinnitus!
• Pulsatile tinnitus
• Transmission from Carotid artery disease or heart
  murmurs
• Abnormal vascular lesions in the head and neck
• Tumors
• A-V malformations
• Brain aneurisms
• Benign Intracranial Hypertension

21
Tinnitus

• There are a multitude of reasons for the various
  types of tinnitus!
• Pulsatile tinnitus
• Muscular causes
• Palatal myoclonus
• Tensor tympani spasm
• Dehiscent Carotid artery in the middle ear
• Large or dehiscent Internal Jugular Bulb in the
  middle ear
• Severe hypertension

22
Tinnitus

• There are a multitude of reasons for the various
  types of tinnitus!
• Drug or diet related tinnitus
• NSAIDS (all aspirin-like products)
• Stimulants of any sort
• Nasal decongestants or diet pills
• Thyroid medicine
• Herbals
• Caffeine

23
Tinnitus

• There are a multitude of reasons for the various
  types of tinnitus!
• Conductive Hearing Loss
• Cerumen (wax) impaction
• Middle ear effusion (fluid)
• Poor Signal to Noise Ratio
• Similar to a poor quality stereo system
• Higher than average electrical noise in the
  cochlear amplifier
• Psychiatric Tinnitus

24
Tinnitus

• There are a multitude of reasons for the various
  types of tinnitus!
• Sensorineural Hearing Loss
• The most common cause for tinnitus
• Presbycusis ( the hearing loss of aging)
• We believe that this may be caused by gradually
  decreasing blood flow to the cochlear hair cells
  resulting in loss of the normal electrical
  actions.
• It is also possible that the cochlear hair cells
  simply have a certain life expectancy and begin
  to degenerate as some people age.
• In general, tinnitus is the result of spurious
  electrical signals produced by diseased or
  degenerated cochlear hair cells. The brain
  interprets these signals as tinnitus.

25
Tinnitus

• There are a multitude of reasons for the various
  types of tinnitus!
• Noise Induced Sensorineural Hearing Loss
• The second most common cause for tinnitus
• The result of severe noise exposure
• Long-term exposure (manufacturing and loud
  music)
• Short-term exposure single episodes of repeated
  exposure (loud concerts, gun shots, military
  service, fireworks, auto racing, chain saws)
• The noise exposure results in injury to the
  cochlear hair cells. We believe that the hair
  cells do not die, but are damaged causing
  production of spurious neuro-electrical signals
  that the brain interprets as tinnitus.

26
Tinnitus

• Noise Induced Sensorineural Hearing Loss Is
  Entirely Preventable!
• Hearing protection must be used
• Unfortunately, this type of hearing loss is
  becoming much more common in children due to
  headphone use with loud music.
• It is expected that within the next 20 years the
  number of young adults suffering from noise
  induced tinnitus will grow exponentially.

27
Tinnitus Treatments

• Unfortunately, there is no way to directly
  eliminate tinnitus unless it is related to
  specific medical conditions
• If a specific underlying cause can be found,
  corrective treatment can be very successful.

28
Tinnitus Treatments

• Medicines
• IV Lidocaine (local anesthetic that blocks nerve
  impulses) has worked , but cannot be used on a
  normal basis.
• Tocainamide (oral form of Lidocaine) has not been
  shown to be effective.
• Various antidepressants have been used with
  occasional, but inconsistent success.
• Benzodiazapines (like Valium or Xanax) are
  effective in up to 75 of patients, but the
  effect reduces with prolonged use. The risk of
  dependency is great, and long term use is not
  recommended.

29
Tinnitus Treatments

• Medicines
• Several seizure control medications are
  occasionally used, but with limited, occasional
  success.
• Ginko Biloba extract t 120-160mg per day has been
  shown to be effective in some trials and not in
  others.
• Inclusive evidence of effectiveness with more
  research to be done
• High-dose vitamin treatments have not been shown
  to be effective in any controlled study.

30
Tinnitus Treatments

• Hearing Aids
• Amplification of background sounds above the
  perceived level of tinnitus can be very effective
  during the day.
• If the tinnitus keeps the patient up at night
  this is a serious problem
• Masking with either a white noise generator, fan
  or programmed sound machine can be quite
  effective and is easy for bed partners to adjust
  to.
• TV or radio noise is not as effective and
  promotes poor sleep hygiene.

31
Tinnitus Treatments

• Surgery
• The use of Cochlear nerve section (cutting) has
  been reported. This results in deafness and is
  not effective in patients whose tinnitus is not
  related to the inner ear itself. Not an accepted
  treatment.
• Biofeedback
• Hypnosis
• Electrical or magnetic brain or cochlear
  stimulation
• Accupuncture
• All these treatments work for a small portion of
  patients, but have never been shown to be
  effective for the general population in any well
  controlled study.
• Continued research is ongoing.

32
(No Transcript)
33
Menieres Disease

• First described in 1861 by Prosper Meniere
• In 1935 studies of dissected human temporal bones
  demonstrated that endolympatic hydrops was
  present in the vast majority of affected patients.

34
Menieres Disease

• The criteria below Must Be Met
• Fluctuating sensorineural hearing loss
• Fluctuating ear fullness
• Fluctuating vertigo
• Fluctuating tinnitus
• Frequently misdiagnosed / over diagnosed
• May be more frequent in women
• Probably not hereditary

35
Menieres Disease

• The Cochlea is divided into 3 chambers with thin
  membranes dividing them.
• The 2 outer chambers are filled with Perilymph
  which is like Cerebrospinal Fluid that the brain
  is bathed in.
• The inner chamber is filled with Endolymph which
  is like the fluid found inside the bodys cells.

Perilymph
Endolymph
Perilymph
36
Menieres Disease

• Most otolaryngologists believe that Menieres
  Disease is the result of Endolymphatic Hydrops.
  (too much endolymph pressure in comparison to
  perilymph)
• Abnormal pressure/fluid dynamics in the cochlea
• Normal fluid balance Dilated Scala Media

37
Menieres Disease

• Many otolaryngologists believe that the increased
  pressure with Endolymphatic Hydrops may result in
  micro-ruptures of the Membranous Labyrinth.
• Ruptures have been seen in dissected and
  microscopically examined temporal bones in
  patients with Menieres Disease.
• This may be the reason for the episodic nature of
  the Menieres attacks
• Healing of these ruptures may account for the
  return of hearing and balance between episodes.

Membranous Labyrinth Ruptures
38
Menieres Disease

• We truly do not know why the apparent
  endolymphatic hydrops is present.
• Obstruction of the Endolymphatic Duct or Sac?
• (the area where excess Endolymph is absorbed)
• Increased production of Endolymph?
• Poor absorption of normally produced Endolymph?
• Some have suggested that allergies may play a
  role
• No convincing objective evidence to support any
  of these theories.

39
Menieres Disease Treatments

• Accurate diagnosis
• Reduced salt diet
• May reduce fluid shifts in the inner ear
• Consistent use of diuretics like Dyazide, Maxide
  or Aldactazide
• May reduce Endolymph fluid pressure in the inner
  ear
• Vestibular suppressant medications like Antivert,
  Benadryl or Transderm Scop
• Used to treat acute attacks
• Surgical treatment if medical therapy
  unsuccessful
• Vestibular rehabilitation to improve balance

40
Menieres Disease

• If left untreated
• Severe progressive hearing loss may result
• Severe, debilitating vertigo may result

41
(No Transcript)
42
The Future

• Ongoing research into the Inner Ear and
  Vestibulocochlear nerve physiology may eventually
  shed light on the actual mechanisms of hearing
  loss and vertigo.
• Further advances in treatment are currently
  awaiting research breakthroughs.