ISSN 1612-3352

Editors in Chief

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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Neurootological test profiles in tinnitus rehab-patients

Abstract

Introduction:

Tinnitus is an important complaint and/or disease within our population. The neurootologist is regularly dealing with many different disorders of the human cranial senses, like for instance tinnitus, as only sign, but also in combination with vertigo, dizziness, giddiness and hearing loss.

Together with the “Rehabilitation-Clinic Am Kurpark” in Bad Kissingen we have established a close cooperation towards the neurootometric analysis of tinnitus cases, which are treated there by means of a rehabilitation program, uptaking the patients for about a month of stationary treatment. For this paper we are evaluating 749 patient files. The patients have an average age of 50.70 +/- 8,61 years. 526 patients (70,23%) are male and 223 (29,77%) are female.

As the “Klinik Am Kurpark” at Bad Kissingen belongs to the LVA (Pension Fund of the state of Baden-Württemberg), most of the patients are, when being treated for the first time, workers and employees, suffering from a disabling tinnitus, which interferes with their working ability.

The spectrum of workers covers many professions, like advisor, assembly-worker, assistants, book-binders, book-keepers, brick-layers, brewers, building-service, bus-drivers, business-men, butchers, cable-workers, canteen-helpers, caretakers, carpenters, cleaners, chamber-maids, cooks, dental-technicians, dispatchers, dress-makers, drivers, electricians, electronic-workers, embroiderers, employees, equippers, factory-security men, farmers, firemen, fitters, flower-arrangers, foremen, forklift-drivers, garage-mechanics, gardeners, geriatric nurses, glass-blowers, grinders, hair-dressers, hatters, heating-engineers, hoteliers, hydraulic-engineering assistants, inspectors, insulation-workers, joiners, kitchen-helpers, labourers, lacquerers, landladies, lathe-workers, laundry-women, machine-workers, managers, mechanics, media-designers, metal-workers, milling-machine-operators, needle-women, neighbourhood-workers, nurses, painters, physicians, piano-builders, plasterers, plumbers, policemen, postmen, precision-mechanics, printers, punch-builders, quality-testers, rail-workers, retailers, road-builders, roofers, sawmill-workers, sellers, servicemen, solderers, steel-construction workers, tax-officers, technical experts, sextons, telecommunication-workers, test-drivers, tile-workers, timber-mechanics, tool-makers, tradesmen, truck drivers, type-setters, urban-employees, urban-workers, waiters, warehouse-managers, warehouse-workers, welders, workers, wrappers.

This is a broad spectrum of mainly industrial employees, who are receiving the benefit of a rehabilitation-cure at Bad Kissingen for giving them relief for to their complaint of tinnitus, so that they restore their working capacity

In the case of this study we are focussing on rehabilitation treatment especially for Tinnitus.

The present interest of the international community of researchers within the field of tinnitilogy is split into two directions:

A.) Improvement in objective and quantitative differential diagnosis of tinnitus.
B.) Evaluating, summarizing and improving the best ways for the regular treatment of the different kinds of tinnitus.

Since many centuries tinnitus was regarded to be one single disease. However, during the second half of the 20th century, the physicians have got the tools to discriminate at least 3 different kinds of tinnitus:

A.) Bruits
B.) Maskable tinnitus
C.) Non-maskable tinnitus

As the patients complained about tinnitus, we applied a series of audiometric methods for learning, whether they suffer for instance from an endogenous tinnitus, which can be functionally measured by masking. In modern audiometry we are using the masking procedure of tinnitus for measuring the pitch as well as the intensity of the tinnitus the modern air-conduction audiogram.

The easiest way for functionally localising tinnitus is the individual comparison of a sound, offered to the patient through ear-phones, which he subjectively has to compare with his subjective sound “in his ear” by sound frequency (measured in Hertz) and loudness of the sound (measured in dB). The comparative measures are drawn with a special triangular symbol into the pure tone audiogram, at its individual and indicative position. When using this audiometrical masking procedure, we easily can discriminate 3 categories of tinnitus within the hearing field of the pure tone audiogram, i.e.

a.) low-tone tinnitus
b.) middle-frequency tinnitus
c.) high-frequency tinnitus

The low-tone tinnitus mainly is found within the audiogram at and below 750 Hertz, the middle-tone tinnitus extends from 1 kHz until 2 kHz, the high-frequency tinnitus is seen at 3 kHz and above.

When submitting our 749 tinnitus patients to an audiometric tinnitus masking procedure, only 457 (61,01%) could prove a maskable tinnitus. Of these maskable tinnitus patients 232 (30,97%) suffered from a bilateral tinnitus, whereas 225 (30,04%) had a maskable tinnitus only within one ear.

Amongst all of our 749 tinnitus patients in 328 (43,79%) a maskable tinnitus was found in the right ear, with an average frequency pitch of 4059,60 Hertz and a standard deviation of 2384,78 Hertz. In the right ear the loudness of the tinnitus was in average 53,04 dB with a standard deviation of 21,99 dB.

In the left ear 351 patients (46,86%) suffered from a maskable tinnitus which had an average frequency of 4142,45 Hertz with a standard deviation of 2366,77 Hertz. The loudness of the tinnitus in the left ear in average was 54,86 dB with a standard deviation of 22,09 dB.

All in all we have submitted this sample of 749 tinnitus patients to the following audiometric investigations:

A.) Pure-tone audiometry with bone conduction.
B.) Pure-tone audiometry with air conduction.
C.) Measurement of the discomfort hearing level with air conduction.
D.) Tinnitus masking with respect to pitch (in Hertz) and loudness (in dB).
E.) Impedance audiometry, measuring the middle ear reflexes.
F.) Transitory evoked Oto-acoustic emissions (TEOAE).
G.) Acoustically evoked brainstem potentials (ABEP).
H.) Acoustically evoked late or cortical potentials (ALEP).

The last features of the list of investigations also serves for localizing the irritative focus within the stato acoustic pathways.

Clinical neurootology is depending much upon its sensory motor tests. These mainly belong into the neurootometrical field of equilibriometry.

Neurootological functional data acquisition provides us with a network of information about the sensorial status of our patients from the input at the level of the senses up to the central top most regulation on the surface of the brain.

Amongst the broad variety of equilibriometric investigations, the electronystagmographically recorded caloric nystagmus test has proved to be the most important clinical tool in neurootology. For the systematic and synoptical evaluation of this test Claussen has designed, as early as 1967, the so-called Butterfly-Scheme, which allows to combine the 4 caloric vestibular-ocular relational characteristics within a evaluation chart. Each of the quadrangles centrally contains a triangular chart field of normal behaviour. So any reactional characteristics can be classified as to whether it belongs to the normal, to the overactive or the inhibited part of the scheme. With simple digital figures of a 4-digit number, all the 4 positions of the caloric characteristics can be coded with a so-called arithmetic trinarely coded butterfly.

When submitting all of our patients of this tinnitus study to caloric butterfly testing, only 314 (41,92%) exhibit a normal monaural vestibular ocular test result.

At the same time many of our tinnitus patients also show disturbances within their stato-acoustic pathways, when these pathways are tested monaurally from the lateral semicircular canal in the inner ear towards the ocular nystagmus, as being released from the human mecancephalon.

As it is well known, that tinnitus also can be provoked from irritative lesions along the neck, we have also investigated the vestibular spinal pathway by means of cranio-corpo-graphy (USCCG).

In the workup of the single tinnitus cases we are using cranio-corpo-graphy for (CCG) for establishing an analysis of the gestural expression of our tinnitus patients besides of measuring their balance function in upright position. For performing ultrasound cranio-corpo-graphy (USCCG) the test person is equipped with a workman’s hardhat, containing small ultrasound loudspeakers above the forehead and the occiput. By means of a shoulder support two ultrasound loudspeakers are positioned above both the shoulders. All the 4 loudspeakers (markers) are connected through cablings to a data router, carried on a belt around the belly. The router box itself is connected to a PC. That PC also is connected to a geometrically arranged microphone board, which is positioned behind and above the test person. So we can use a local positioning system for digitally measuring the markers in space. Like a radar image the movement patterns of both the shoulders, the forehead and the occiput are traced on a chart on a PC-screen. We are mainly depending upon the Unterberger (1938) and Fukuda (1959) stepping test procedure, as this is the most sensitive vestibular spinal test. But we are also using Romberg’s standing test (1848).

When quantitatively evaluating the stepping test cranio-corpo-graphy, we have found amongst our 749 tinnitus cases in 212 cases (28,30%) normal CCG-patterns for the stepping test. This shows that amongst our tinnitus cases many also had problems within the regulation of the vestibular spinal sensory motor system. That also includes mechanisms from the neck.

The result and radar image of the patients’ USCCG pattern can be read and interpreted easily by an average physician.

Within our neurootological teams at Würzburg and at Bad Kissingen, we have facilitated the automatic evaluation and increased the amount of information at hand of the investigator by a well planed network of neurootometric tests on the one hand with respect to audiometry and on the other hand with respect to equilibriometry.

When using these equilibriometric tests we are estimating the following hierarchy of efficiency, which is listed below. The list is not yet complete:

1.) Vestibular ocular caloric test with Claussen Butterfly Chart evaluation;
2.) Stepping and standing test cranio-corpo-graphy with USCCG-recording;
3.) Acoustic brainstem evoked potentials (ABEP);
4.) Optokinetic pendular ocular tracking test,
5.) Vestibular stimulus response intensity comparison (VESRIC);
6.) Perrotatory nystagmus;
7.) Nystagmus coordination test;
8.) Visually evoked potentials (VEP);
9.) Postrotatory nystagmus;
10.) Complex equilibriometric tests;
11.) Spontaneous nystagmus test.

The above mentioned tests generally can well be used to establishing a topo-diagnosis along the stato acoustic pathways up and down.

The study of 749 rehabilitation patients with the aim of diagnosing, localizing and treating their tinnitus is quiet a challenge for our neurootological team and it unveils, that the tinnitus cases are not suffering from one single type of tinnitus, but that there is a major variation of different origins of the tinnitus complaints standing behind it.

All in all this study proves, that within our tinnitus patient group there is much of stato-accoustical interference with many positive findings in equilibriometry also.

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