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Neurootological test profiles in tinnitus rehab-patients | ASN
Archives for Sensology and Neurootology in Science and Practice
Prof. Dr. Claus F. Claussen, Neurootological Research Institute of te 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,
Te editors welcome authors to submit articles for publications in te ASN.
Read te Information for Authors.
Neurootological test profiles in tinnitus rehab-patients
Prof.Dr.med. Claus F. Claussen (Bad Kissingen, Germany)
XXXI Congress of te NES - Bad Kissingen - Germany
Together with te “Rehabilitation-Clinic Am Kurpark” in Bad Kissingen we have established a close cooperation towards te neurootometric analysis of tinnitus cases, which are treated there by means of a rehabilitation program, uptaking te patients for about a month of stationary treatment. For this paper we are evaluating 749 patient files. Te patients have an average age of 50.70 +/- 8,61 years. 526 patients (70,23%) are male and 223 (29,77%) are female.
As te “Klinik Am Kurpark” at Bad Kissingen belongs to te LVA (Pension Fund of te state of Baden-Württemberg), most of te patients are, when being treated for te first time, workers and employees, suffering from a disabling tinnitus, which interferes with their working ability.
Te 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 te 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 te case of this study we are focussing on rehabilitation treatment especially for Tinnitus.
Te present interest of te international community of researchers within te field of tinnitilogy is split into two directions:
A.) Improvement in objective and quantitative differential diagnosis of tinnitus.
B.) Evaluating, summarizing and improving te best ways for te regular treatment of te different kinds of tinnitus.
Since many centuries tinnitus was regarded to be one single disease. However, during te second half of te 20th century, te physicians have got te tools to discriminate at least 3 different kinds of tinnitus:
As te 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 te masking procedure of tinnitus for measuring te pitch as well as te intensity of te tinnitus te modern air-conduction audiogram.
Te easiest way for functionally localising tinnitus is te individual comparison of a sound, offered to te 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 te sound (measured in dB). Te comparative measures are drawn with a special triangular symbol into te pure tone audiogram, at its individual and indicative position. When using this audiometrical masking procedure, we easily can discriminate 3 categories of tinnitus within te hearing field of te pure tone audiogram, i.e.
Te low-tone tinnitus mainly is found within te audiogram at and below 750 Hertz, te middle-tone tinnitus extends from 1 kHz until 2 kHz, te 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 te right ear, with an average frequency pitch of 4059,60 Hertz and a standard deviation of 2384,78 Hertz. In te right ear te loudness of te tinnitus was in average 53,04 dB with a standard deviation of 21,99 dB.
In te 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. Te loudness of te tinnitus in te 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 te following audiometric investigations:
A.) Pure-tone audiometry with bone conduction.
B.) Pure-tone audiometry with air conduction.
C.) Measurement of te discomfort hearing level with air conduction.
D.) Tinnitus masking with respect to pitch (in Hertz) and loudness (in dB).
E.) Impedance audiometry, measuring te middle ear reflexes.
F.) Transitory evoked Oto-acoustic emissions (TEOAE).
G.) Acoustically evoked brainstem potentials (ABEP).
H.) Acoustically evoked late or cortical potentials (ALEP).
Te last features of te list of investigations also serves for localizing te irritative focus within te stato acoustic pathways.
Clinical neurootology is depending much upon its sensory motor tests. These mainly belong into te neurootometrical field of equilibriometry.
Neurootological functional data acquisition provides us with a network of information about te sensorial status of our patients from te input at te level of te senses up to te central top most regulation on te surface of te brain.
Amongst te broad variety of equilibriometric investigations, te electronystagmographically recorded caloric nystagmus test has proved to be te most important clinical tool in neurootology. For te systematic and synoptical evaluation of this test Claussen has designed, as early as 1967, te so-called Butterfly-Scheme, which allows to combine te 4 caloric vestibular-ocular relational characteristics within a evaluation chart. Each of te quadrangles centrally contains a triangular chart field of normal behaviour. So any reactional characteristics can be classified as to whether it belongs to te normal, to te overactive or te inhibited part of te scheme. With simple digital figures of a 4-digit number, all te 4 positions of te 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 te same time many of our tinnitus patients also show disturbances within their stato-acoustic pathways, when these pathways are tested monaurally from te lateral semicircular canal in te inner ear towards te ocular nystagmus, as being released from te human mecancephalon.
As it is well known, that tinnitus also can be provoked from irritative lesions along te neck, we have also investigated te vestibular spinal pathway by means of cranio-corpo-graphy (USCCG).
In te workup of te single tinnitus cases we are using cranio-corpo-graphy for (CCG) for establishing an analysis of te gestural expression of our tinnitus patients besides of measuring their balance function in upright position. For performing ultrasound cranio-corpo-graphy (USCCG) te test person is equipped with a workman’s hardhat, containing small ultrasound loudspeakers above te forehead and te occiput. By means of a shoulder support two ultrasound loudspeakers are positioned above both te shoulders. All te 4 loudspeakers (markers) are connected through cablings to a data router, carried on a belt around te belly. Te router boks itself is connected to a PC. That PC also is connected to a geometrically arranged microphone board, which is positioned behind and above te test person. So we can use a local positioning system for digitally measuring te markers in space. Like a radar image te movement patterns of both te shoulders, te forehead and te occiput are traced on a chart on a PC-screen. We are mainly depending upon te Unterberger (1938) and Fukuda (1959) stepping test procedure, as this is te most sensitive vestibular spinal test. But we are also using Romberg’s standing test (1848).
When quantitatively evaluating te stepping test cranio-corpo-graphy, we have found amongst our 749 tinnitus cases in 212 cases (28,30%) normal CCG-patterns for te stepping test. This shows that amongst our tinnitus cases many also had problems within te regulation of te vestibular spinal sensory motor system. That also includes mechanisms from te neck.
Te result and radar image of te 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 te automatic evaluation and increased te amount of information at hand of te investigator by a well planed network of neurootometric tests on te one hand with respect to audiometry and on te other hand with respect to equilibriometry.
When using these equilibriometric tests we are estimating te following hierarchy of efficiency, which is listed below. Te 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);
7.) Nystagmus coordination test;
8.) Visually evoked potentials (VEP);
10.) Complex equilibriometric tests;
11.) Spontaneous nystagmus test.
Te above mentioned tests generally can well be used to establishing a topo-diagnosis along te stato acoustic pathways up and down.
Te study of 749 rehabilitation patients with te aim of diagnosing, localizing and treating their tinnitus is quiet a challenge for our neurootological team and it unveils, that te tinnitus cases are not suffering from one single type of tinnitus, but that there is a major variation of different origins of te 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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Balance Balance control Balance disorders Betahistine BPPV Brain electrical tomography Brain electric tomography Brain mapping Brainstem evoked potential Children Cochlear implant Cochlear implantation Craniocorpography Diagnosis Dizziness Doppler Sonography Electronystagmography Equilibrium Hearing loss LORETA Low Resolution Brain Electric Tomography Meniere Migraine Multiple sclerosis Ménière's disease Neurootological examination Neurootological tests Neurootometric tests P300 Paroxysmal positional vertigo Platform Posturography Rehabilitation Stabilometry Therapy Tinnitus Tinnitus topodiagnostic Treatment Ultrasound Vertigo Vestibular evoked myogenic potential Vestibular evoked potentials Vestibular Rehabilitation Virtual Reality Whiplash Injury
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