The origin of Meniere's disease is presently controversial. While in the past, it was felt that plumbing problems (hydrops) in the ear were responsible for the. Driving up a canyon, taking off in an airplane, swimming completely submerged all of these things can make us take note of pressure in the inner ear. Are you sensitive to certain sounds? Hyperacusis is the perception of an unusual auditory sensitivity to some environmental noises or tones. The particular symptoms.
Vestibular Hyperacusis . The particular symptoms of cochlear hyperacusis and vestibular hyperacusis can help physicians and audiologists distinguish between the two disorders. The effects of hyperacusis can range from a mild sense of unease to a complete loss of balance or upright posture with severe ear pain. In serious cases, it can cause seizure- like activity in the brain. Hyperacusis can be associated with auto- immune disorders, traumatic brain injury, metabolic disorders, and other conditions. It has not been sufficiently studied in the adult population and is often ascribed to psychological conditions rather than being recognized as a physiologic symptom of cochlear or vestibular damage. The hearing and balance systems of the inner ear are interconnected. Both systems are filled with fluid whose movement stimulates tiny sensory cells. Sounds are detected as energy vibrations; the human cochlea can hear best the frequencies associated with speech. The balance system uses lower- frequency sensations to help maintain posture in relation to gravity. Hyperacusis is an abnormal condition in which the complex electrical signals generated by sound vibrations are misinterpreted, confused, or exaggerated. The signals coming in are identical to those that present to a normal ear, but the reaction in the abnormal system is markedly different: for example, the sounds in a quiet library may seem like a loud parade to a person with hyperacusis. ![]() Cochlear vs. Most people react by covering their ears or leaving the room. Severe emotional reactions may also occur; crying or panic reactions are not uncommon. In vestibular hyperacusis, exposure to sound can result in falling or a loss of balance or postural control. Such disturbances have been called by various names, including Tullio’s syndrome and audiogenic seizure disorder. Some of the same reactions as with cochlear hyperacusis can also occur, along with sudden severe vertigo or nausea. In some cases, vestibular hyperacusis can affect the autonomic system and cause problems such as loss of consciousness, mental confusion, nausea, or extreme fatigue. In both cochlear and vestibular hyperacusis, headache is common. In addition, many subjects with hyperacusis feel distinct cognitive changes during these exposures and will describe themselves as being “out of myself” or disassociated from reality, unable to take in other stimuli, having an immediate feeling of something being wrong or a sensation of being unwell, or experiencing severe confusion. What causes hyperacusis? The physiologic conditions underlying these symptoms cannot be identified with certainty because of difficulties involved with studying the very small inner ear structures without damaging them. A suspected cause of cochlear hyperacusis involves a loss of the regulatory function provided by the system that conducts impulses along the auditory neural pathways. In hyperacusis, the mechanism that regulates amplification erroneously magnifies the incoming sounds and noises instead of reducing them. For example, the sound of a passing car is interpreted as comparableto the roar of a jet engine! Other possible explanations of cochlear hyperacusis involve brain- chemistry dysfunction or head trauma that damages the chain of tiny bones in the middle ear that amplify sound and help transmit vibrations to the inner ear fluid. Changes in the transmission of electrical signals along complex neural pathways are also highly possible in cases of head injury. In vestibular hyperacusis, we suspect that the main pathology results from damage to the nerve cells in the balance system. These cells may suffer damage from trauma such as head injury, metabolic disruptions due to chemical ingestions (e. In addition, autoimmune disease, which can be triggered by many different causes, can harm the balance organ. Head trauma in a motor vehicle accident can set off an autoimmune reaction in the inner ear that can destroy the nerve cells, often weeks or months after the initial injury. In one clinic, several serious cases were evaluated where simple soft auditory stimulations of less than 3. All of these patients had suffered head and/or neck injuries in motor vehicle accidents that affected the brain stem and higher areas of the central nervous system. None of these patients had significant hearing loss or previous balance problems. One person loses balance and consciousness frequently and must use earplugs and earmuffs all of the time to avoid injury from falling. Testing and treatment innovations. Special audiologic tests can reveal the presence and severity of cochlear hyperacusis. Simple tests such as the Loudness Discomfort Level test (promoted for use in hyperacusis assessment by Drs. Pawel Jastreboff and Jonathan Hazell) and balance screening using an audiometer and observation take only a few moments and can yield significant information. Cochlear hyperacusis can be treated with acoustic therapies such as tinnitus retraining therapy (TRT). The Jastreboff TRT method is the treatment of choice and can result in recovery of normal or near- normal dynamic ranges of sound tolerance. Vestibular hyperacusis, however, continues to go untreated or unrecognized in many cases. When vestibular hyperacusis is recognized, the treatment protocols vary widely, depending on the level of expertise and interest of the treating physician. Treatment with a low- salt diet combined with anti- nausea drugs still dominates medical approaches, although there are some pioneers—such as John Epley, MD (Portland Otologic Clinic, Portland, Oregon)—who have had promising results introducing anti- inflammatory medicines directly into the cochlear/vestibular system using catheters. For individuals who complain of loss of balance with exposure to sound, thorough diagnostic testing should be completed in otology, neurology, and audiology offices. Innovative testing protocols could be devised to provoke or produce the response in a clinical setting. In the clinic, presenting a tone at 5. Hz and gradually increasing the loudness can often induce vestibular hyperacusis. It is important that clinicians present tests tailored to the individual patient’s situation. For example, if someone complains of falling when large vehicles pass by, identifying the specific problem area may require changing a test to include lower- frequency tones at very low volume levels, or narrow- band noise, or even white noise. A portable audiometer might be used in conjunction with a computerized dynamic posturography test so that various sounds can be presented to induce a balance response. Another possibility is to utilize electroencephalography (EEG) with an audiometer to present sound stimulation, so that shifts in brain- wave patterns in response to sound can be observed. We used this strategy in our clinic recently to produce clear evidence of brain- wave anomalies, providing proof to a patient that the source of her troubling symptoms was organic. Her constant falling and loss of consciousness were based on a physiologic condition, not a psychological one. These results provided a sense of relief to the patient, whose previous EEG results, without sound stimulation, had been normal. Adapting clinical assessment tools with the use of various stimuli and then making careful observations may allow medical providers to identify patients with vestibular hyperacusis and to devise better therapeutic strategies. Author: Marsha Johnson, MS, CCC- A, Oregon Tinnitus & Hyperacusis Treatment Clinic, Portland, Oregon. Click here to download a copy of our publication. Eustachian Tube Problems . The eustachian tube is approximately 1- . The narrowest portion is the area near the middle ear space. The eustachian tube functions as a pressure equalizing valve for the middle ear, which is normally filled with air. Under normal circumstances, the eustachian tube opens for a fraction of a second in response to swallowing or yawning. In so doing, it allows air into the middle ear to replace air that has been absorbed by the middle ear lining (mucous membrane), or to equalize pressure changes occurring with altitude changes. Anything that interferes with this periodic opening and closing of the eustachian tube may result in a hearing impairment or other ear symptoms. Eustachian Tube Dysfunction. Obstruction or blockage of the eustachian tube results in a vacuum in the middle ear (negative middle ear pressure), with resultant retraction (sucking in) of the eardrum. In an adult, this is usually accompanied by some discomfort, such as a fullness or pressure feeling, and may result in a mild hearing impairment and head noise (tinnitus). In children, there may be no symptoms. If the obstruction is prolonged, fluid may be sucked into the middle ear from the lining mucous membranes. If the fluid is unable to drain into the throat due to obstruction of the eustachian tube, a condition called serous otitis media (fluid in the middle ear) may develop. Serous otitis media is very common in young children due to immaturity of the eustachian tube, but can also occur in older children and adults. It occurs frequently in connection with upper respiratory infections or allergies. The limitation of mobility of the eardrum due to the presence of a vacuum or fluid in the middle ear accounts for the hearing impairment associated with eustachian tube dysfunction. Patulous Eustachian Tube. On occasion, the opposite of blockage occurs, and the eustachian tube remains excessively open for a prolonged period. This is called abnormal patency of the eustachian tube (patulous eustachian tube). This is less common than eustachian tube dysfunction and serous otitis media, and it occurs primarily in adults. It sometimes begins after a significant weight loss. Because the tube is constantly open, the patient may hear himself breath, and his voice may reverberate in the affected ear. Fullness and a blocked feeling are common sensations experienced by the patient. Abnormal patency of the eustachian tube can be extremely annoying but does not produce a hearing impairment. Treatment of an Abnormally Functioning Eustachian Tube. There are many alternatives to treat a poorly functioning eustachian tube. An abnormally narrow eustachian tube can sometimes be enlarged with medicines. Nasal steroid sprays are frequently tried, and in adults nasal and oral decongestants may be recommended. If an infection is thought to be present (otitis media), then antibiotics are appropriate. However, if middle ear fluid persists after more than one course of antibiotics, additional trials of antibiotics are much less efficacious in relieving the problem. If allergies are thought to be contributing to the eustachian tube dysfunction, allergy testing (which can be performed through our office) and allergy treatment may be indicated. When eustachian tube dysfunction persists despite maximal medical therapy, surgical procedures can be utilized. After the procedure, the recovery is very quick. For most adults and older children, the procedure can be performed in the office with the use of topical or local anesthetic. Younger children require the assistance of an anesthesiologist so that the delicate surgery can be safely completed. The procedure takes roughly 1. Pain is minimal to none. The tubes in the eardrum are designed to be temporary, and typically fall out 6 months to 3 years after placement (depending on type of tube selected). The hope is that the eustachian tube will have a chance to heal and resume normal function once the tube extrudes. At the Ear Institute of Texas, we are also performing a new procedure for treatment of chronic eustachian tube dysfunction in patients who have required more than one trial of tube placements in the eardrum. This procedure involves placing a tube in the eardrum overlying the opening to the eustachian tube, after the eustachian tube and middle ear have been visualized and inspected with an oto- endoscope (a small thin scope that allows the physician to visualize the middle ear structures with magnification and high resolution). A Micro. Wick is threaded through the tube and into the eustachian tube opening. The patient is then instructed to apply steroid drops to the ear canal, which allows delivery of a high concentration of steroids to the eustachian tube in a near- continuous fashion. The technique can be performed in the office or out- patient surgery center. Many patients have been found to respond to the treatment, with lasting improvement in their eustachian tube function and symptoms. Eustachian Tube Problems Related to Flying. Individuals with an eustachian tube problem may experience difficulty equalizing middle ear pressure when flying. When an aircraft ascends, the atmospheric pressure decreases. This results in a relative increase in the middle ear air pressure compared to the surrounding cabin pressure. When the aircraft descends, just the opposite occurs: atmospheric pressure increases in the cabin of the aircraft, and there is a relative decrease in the middle ear pressure compared to the surrounding cabin pressure. Either situation may result in discomfort in the ear due to pressure and stretching of the eardrum, when the eustachian tube is not functioning properly to equalize the pressure between middle ear and cabin pressure. Usually, this discomfort is experienced during descent of the aircraft. To avoid middle ear problems associated with flying, you should not fly if you have an acute upper respiratory problem such as a common cold, allergy attack, or sinus infection. Should you have such a problem, or a history of chronic eustachian tube problems, and must fly, you may help avoid ear difficulty by observing the following recommendations (if your physician agrees you can tolerate this therapy): Obtain from your drug store the following over the counter items: Sudafed tablets and a plastic squeeze bottle of Neo. Synephrine or Afrin decongestant nasal spray. One must be careful using these medications if you are not otherwise healthy and have conditions such as hypertension or heart rhythm disturbances. If you do have other medical conditions, you may discuss these recommendations with your primary care physician. Following the container directions, begin taking Sudafed tablets the day before your air flight. If you have experienced any problems equalizing your middle ear pressure during the flight, continue the medication for 2. Following the container directions, use the nasal spray shortly before boarding the aircraft. Should your ears “plug up” upon ascent, hold your nose and swallow while attempting to force air up the back of the throat. This will help suck excess air pressure out of the middle ear. Forty- five minutes before the aircraft is due to land, use the nasal spray every five minutes for fifteen minutes. Chew gum to stimulate swallowing. Should your ears “plug up” despite this, hold your nose and blow gently toward the back of the throat, while swallowing. This will blow air up the eustachian tube into the middle ear (termed Valsalva maneuver).***None of these recommendations or precautions need to be followed if you have a tube in your eardrum.
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