ISSN 1612-3352

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Prof. Dr. Claus F. Claussen, Neurootological Research Institute of the Research Society for Smell, Taste, Hearing and Equilibrium Disorders at Bad Kissingen (4-G-F). Bad Kissingen, Germany.
Dr. med. Julia M. Bergmann,
Dr. med. Guillermo O. Bertora,
Otoneuroophthalmological Neurophysiology,
Buenos Aires, Argentina.

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Dr. med. Julia M. Bergmann,
Dr. med. Guillermo O. Bertora,
Otoneuroophthalmological Neurophysiology,
Buenos Aires, Argentina.


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Medical classification of tinnitus between bruits, exogenous and endogenous tinnitus and other types of tinnitus

Abstract

Introduction:

Tinnitus is a common complaint of modern patients. In an epidemiologic survey on the population of Cardiff, Glasgow, Nottingham and South Hampton (1984) it has been reported that between 33,8% up to 39% of the persons answered positively to the general questions: “Have you ever noticed noises on your head or ears?”

Within the same study it was reported that moderate to severe annoyance of tinnitus is reported by 5,7% to 8,7% of the persons within this investigation.
According to studies of the US-American Tinnitus Association about 36 Mil. Americans suffer from tinnitus.
Nowadays tinnitus belongs to the most important symptoms in neurootology besides of vertigo, nausea and hearing loss.

The term “tinnitus” does not describe a very concise entity of symptomatology. At least the complaint tinnitus classically has to be differentiated into: Bruits, tinnitus aurium and tinnitus cranii sive cerebri or also the “syndrome of the hypersensitive ear”.
The term “bruits” stands for a physically objectively measurable noise, created in the upper part of the body, which can be listened to by an external investigator through his stethoscope for instance.
Tinnitus aurium indicates a subjective experience of a noise, which seemingly is originated in the inner ears of the patients. However, this noise can not be heard by an external investigator, for instance by the help of a microphone or a stethoscope.

A subjective noise, which the patient cannot localize in one or the other or both the ears, but which is somewhere in the head, but still not objectively measurable, is called tinnitus cranii sive cerebri. The latter, for instance, occurs also as an aura of an epileptic seizure. Also psychogenic causes for tinnitus cranii sive cerebri are discussed in the classical literature.

During the recent decade we have further developed the systematics of tinnitus. Besides the above mentioned bruits we are now differentiating between an endogenic tinnitus and an exogenic tinnitus and other special forms.

Amongst our tinnitus patients we regularly find a group, who is reporting, that their tinnitus subjectively can be localized in the right, or in the left, or in both ears. They further report, that they feel relieved to a certain extent, when they are staying in a noisy environment. These patients generally also demonstrate that their tinnitus can be masked with audiometry, using a narrow band noise, which they then define to be equivalent to their subjective noise according to frequency and loudness intensity. So the patients with an endogenous tinnitus who now are amounting to around 48% of all the tinnitus cases whom we have investigated are named by us “endogenous tinnitus”.

Another group of our tinnitus patients describes that the personal disturbances due to their tinnitus can be decreased when being exposed to maximal silence for instance in a cellar, or when using a comfortable and shielding hearing aid.

In about 52% of our tinnitus patients we could prove, that the tinnitus could not be masked. For them the noise existed somewhere diffusely distributed within their heads. When being exposed to too much noise within their surrounding or within a party and between many talks and shielding from other people, they feel more or less much disturbed by their tinnitus. Therefore they try to escape from such a loudness.

When audiometrically measuring the hearing threshold, as well as the threshold of audiometric discomfort, we are regularly finding a shrinking of the distance between the two thresholds, which we call the reduction of the audiometric dynamics or hearing capacity. This type of tinnitus we are calling “the syndrome of the hypersensitive ear”.

Other special groups have been discovered in our sophisticated neurootometric laboratories, where we submit our patients to a network analysis of the stato-acoustic pathways. Besides audiometry we also apply vestibulometry. In a first instance we discovered, that some of our tinnitus patients show normal maximal activities of the caloric responses, however, the nystagmus culmination latency was too much enlarged. When in these cases with tinnitus where we also performed the acoustic brainstem evoked potentials (ABEP), we also found an increase in the latencies of wave-5. We called this the “syndrome of the slow brainstem”.

Many of these patients, mostly older patients, when being submitted to a pharmacological therapy with a compound therapy of Conium and Coculus together with Ambra and Petrol Oil (Vertigo Heel), lost their undiscerned tinnitus from their head. Usually this syndrome is presented in combination with vertigo and giddiness. Also vertigo and giddiness comes under control with this therapy.

Generally speaking there is no tinnitus in a sleeping or unconscious patient. With respect to our most recent investigations we know, that the cortex of the human brain, especially the superior gyrus of the temporal lobe, plays a most important role for the release of tinnitus.

However, tinnitus can be triggered throughout the whole distance of the acoustic pathways from the cochlea in the inner ear, following the 8th nerve into the brainstem towards the acoustic nuclei, following their further direction through the olivary nuclei, passing the inferior geniculate body running through the thalamus and the basal ganglia towards the cortical projections in the temporal lobe.

As we have the possibility to functionally diagnose disturbances at various levels of the stato-acoustic pathways by for instance applying the caloric butterfly test and the vestibular stimulus response intensity comparison (VESRIC) by also adding the perrotatory nystagmus characteristics to the characteristics of the Claussen Butterfly Chart, then we can discriminate the height of the irritative focus between the inner ear, the 8th nerve, the brainstem and the temporal lobe functionally.

Using the combination of acoustic brainstem evoked potentials together with acoustic cortically evoked potentials and the neurootometric functional localisation scheme, we nowadays come to a conclusion, that about 20% of all the tinnitus cases have their irritative focus in the acoustic periphery, i.e. inner ear and/or 8th nerve. About 25% have their irritative focus leading to tinnitus within the central structures of the hearing pathways in the posterior fossa.

For the rest of 55% we are estimating that objectively measurable functional irritations in the upper brain above the posterior fossa, psychogenic, iatrogenic or pharmacologic reasons have the main influence upon the existence of tinnitus within these patients.

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