Recommendation
BIAP 29/1
Tinnitus and Hyperacusis –
Diagnostic Procedures
Introduction
In the industrialised European countries ~20% of the population report
to have a tinnitus occasionally, ~4% seek further
diagnostics and 1-2% are affected by their tinnitus and/or hyperacusis to such
an extend that it has such a severe effect on their quality of life so that a
treatment is required.
The causes
of tinnitus and hyperacusis are various and the real etiopathology in most
cases is still unknown. So the diagnostic procedures, which are the focus of
this recommendation, must be quite broad to cover all possible causes and
demand quite often a multidisciplinary approach. Therapeutic procedures and
their multidisciplinary aspects will be dealt with in a second recommendation.
The term
"Tinnitus" covers all abnormal sounds in the ear in the absence of an
external sound sources. Only in a few cases these sounds are also audible by an
examiner.
Tinnitus
can be classified by its origin (a), its timely progression (b) and by its
effects on the patients (c).
a)
Objective Tinnitus, which has an physical
sound source inside the patient`s body (like a blood vessel) and subjective
Tinnitus, which originates in false information processing in the auditory
pathways without the existence of a physical sound source.
b)
Acute Tinnitus exists less than 3 months,
subacute tinnitus exists between 3 - 12 months and chronical
tinnitus exists more than 12 months.
c)
Compensated Tinnitus is noticed by the patient
but without or only with minor effects on his quality of life. The patient can
cope with the tinnitus. Decompensated Tinnitus has a major effect on the
life quality of the patient. The patient develops secondary mostly
psychosomatic symptoms. The patient cannot cope with the tinnitus without
external help.
Hyperacusis is used here in a broader sense of
any oversensitivity to sounds and noises that affects the patients well being.
Tinnitus and
Hyperacusis are symptoms based on various causes. Tinnitus of otogenic causes
is often intensified by other functional and/or psychological factors. All
possible causes have to be individually diagnosed or ruled out, as the results
of the examinations are the necessary
basis for counselling and eventual treatment. Quite often the doctor`s
explanations and the reassuring test results will overcome the patients fearful
attitude. This may lead to an acceptance of the tinnitus without any further
therapy.
Considering the
economically feasible and medical necessities, the diagnosic procedures should
not be done using a strict schedule for each patient, but to be adapted to the
individual case. Often the procedure will leads to the identification of a
hearing loss.
Case history
A thorough case
history presents the basis by which a sequence of relevant diagnostic procedures are identified. It also allows an
evaluation of the level of severity and annoyance as well as secondary
symptoms. It must be stressed that the examiner allocates enough time for the
anamnesis (for most tinnitus/hyperacusis patients 30 minutes must be regarded
as a minimum). The use of a questionnaire before or after the interview or as a
guideline for the examiner during the interview might be helpful but can never
substitute or cut short the amount of time allocated to the personal exchange.
During the
interview the following topics are especially relevant:
·
tinnitus/hyperacusis
persistence (development over time)
·
external
influences on the tinnitus/hyperacusis
·
additional
diseases / medical problems beside or connected to the tinnitus/hyperacusis
·
physical
and psychological effects on the well being of the patient
Necessary
diagnostic procedures (which should be done at least once)
·
ENT-evaluation
including tympanomicroscopy, nasopharyngoscopy an
·
function
of the eustachian tube
·
auscultation
of the a. carotis, cranial arteries and at the entrance of the ear canal when
tinnitus is pulse synchronic
·
puretone
audiometry (AC and BC), speech audiometry
·
loudness
discomfort level (LDL)
·
evaluation
of the tinnitus loudness with narrow band noise and evaluation of the frequency
characteristic by puretones
·
evaluation
of the minimal masking level with broadband and narrow band noise
·
tympanometry
and stapedius reflex measurement including monitoring of possible breathing- or
pulse synchronic changes.
·
OAE (Otoacoustic Emissions)
·
BERA
(Brainstem Evoked Response Audiometry)
·
test
of the vestibular function including caloric testing
·
manual
examination of the neck, searching for functional disorders
·
dental
and maxillary inspection
·
evaluation of the tinnitus/hyperacusis severity as
well as possible secondary symptoms, by the quantitative evaluation of the
level of annoyance using a standardised questionnaire or structured interview
possibly in combination with visual digital or analogue scales. (They can be
also used to monitor the treatment progress)
·
All test methods which use high loudness levels
(impedance audiometry, BERA, speech audiometry) should be performed with
precaution because of the danger of further damaging the inner ear.
Useful in special cases
After analysing
the results of the case history and the basic diagnostic evaluation further
and/or psychological diagnostic procedures might be necessary:
1.
medical
examinations like:
A gnathogical evaluation (when jaw disorders are
existing), a sonography of brain supplying arteries, an angiography of
cerebralvascular system, high resolution computer tomography of the petrosus
bones, MRI of the brain and the auditory pathways, internal medical
examination;
laboratory testing for: neurotropic bacteria or
viruses, immune system disorders, metabolic disorders, blood cell disorders
2.
psychological
evaluation:
A psychological evaluation should be considered, if the answers to the
questions ”Is tinnitus annoying? ”or
”Is tinnitus during the day enervating and always present?” are positive. (It
is not recommended, if the patient is hardly aware of the tinnitus during the
day or only aware of it in silence and if the level of annoyance is small). The
psychological assessment is crucial to diagnose accompanying disorders of
decompensated chronic tinnitus. This
assessment should take into account especially the patient`s actual disorders
which are directly related to tinnitus, seldom resulting into psychoanalysis.
The psychological evaluation should be made by a psychologist trained in
tinnitus diagnosis and therapy. In individual single cases this diagnosis may
lead to a psychotherapeutical approach.
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Literature:
1.
Lenarz T.:
Leitlinie Tinnitus der Dt. Ges. f. Hals-Nasen-Ohren-Heilkunde, Kopf- und
Hals-Chirugie, Konsensuspapier im Auftrag des Präsidiums. HNO Informationen 2,
40-45, (1999)
2.
Pilgramm M.,
Rychalik R. et al.: Tinnitus in der Bundesrepublik Deutschland – Eine
repräsentative epidemiologische Studie.
HNO-Aktuell 7; 261-265
(1999)
3.
Royal
National Institute for Deaf People (RNID) factsheet, Statistics on deafness; RNID
Helpline, PO Box 16464, London EC1Y 8TT