Spring 08 Week 6

This week I recruited a patient that described symptoms of Tullio's, which is dizziness due to loud sounds. He complained of feeling dizzy only at concerts. The patient has a high frequency ringing in both ears. Often the ringing causes problems with his sleeping patterns. He reported having many noisy hobbies including: playing in a band, power tools, and listening to music. No other abnormal history was accounted.

Otoscopy revealed normal ear canals and intact tympanic membranes bilaterally. Normal type A tympanograms were measured. Pure tone audiometry revealed hearing within normal limits bilaterally. SRTs were in agreement with PTA. Word recognition scores were 100% bilaterally.

An informal test for Tullio's was administered using a audiometer set to 90-100 dB HL and Frenzel lenses. The warble tones were played for about 2-4 seconds. During this time, the clinician was looking for nystagmus. However, the absence of nystagmus suggests that the patient does not have Tullio's at least with the presentation of only 2-4 seconds. He discussed how dizziness usually only occurs when he has been exposed to sounds for an extended period of time. For example, a rock concert will last about an hour with sounds reaching 140 dB HL. An article was found that discussed ways to test for Tullio's. This study used VEMPs (vestibular evoked myogenic potentials) which is the essential tool for testing Tullio's. The study examined 20 normal subjects, using a 500 Hz tonal stimulus of 105 dB HL, applied monoaurally. Each subject was studied under 4 different conditions: 1) head facing forwards, eyes open; 2) head facing forwards, eyes closed; 3) head rotated :90° to the right, eyes closed; and 4) head rotated :90° to the left, eyes closed. The results of the study suggest that the click-evoked
vestibulocollic reflex, can be considered a physiological Tullio phenomenon and VEMPs can be used for evaluation.

Russolo, M. (2002). Sound-evoked postural responses in normal subjects. Acta Otolaryngol, 122: 21–27

http://web.ebscohost.com.www.libproxy.wvu.edu/ehost/pdf?vid=1&hid=114&sid=9de4686a-25e8-4e9a-9556-62a5954941a3%40sessionmgr104

Calorics were also performed for practice. The patient agreed to participate in the test. Both cool and warm calorics were administered bilaterally. Nystagmus was observed much sooner than expected (~ 15-25 seconds after first presenting). We usually see nystagmus after 30 seconds. Also, the patient had normal but robust responses. Although the patient had some unusual responses to calorics, everything was within normal limits.

Spring 08 Week 5

An elderly woman came in who was previously diagnosed with BPPV and was given Meclizine to help with her symptoms upon diagnosis. She has had recurring symptoms in the last two weeks. She reported symptoms of lightheadedness especially when she first wakes up and has fallen previously. The duration of symptoms vary. She also has tingling and a sharp pain on the left side of her face particularly her eye. However, these symptoms do not always occur with the dizziness. The client noted having glaucoma and high blood pressure. She is currently taking Celebrex, a diuretic, and blood pressure medicine. She reported no problems with hearing during her vestibular symptoms or any other time. The client was instructed to not take any medication before having her vestibular evaluation.

An article that was found gives typical responses and symptoms of BPPV. It included 59 patients, 19 men and 40 women, with benign paroxysmal positional vertigo (BPPV). The patients filled in a questionnaire concerning their symptoms, earlier diseases, accidents and tobacco and alcohol use. None of the patients had hearing loss. The mean duration of the vertigo attacks ranged from a few seconds to 5 min, and they were fairly mild. The attacks were perceived as more intense if vertigo was rotational or if it was accompanied by nausea. The vertigo attacks occurred in spells; patients had several attacks a week (23%) or during the course of 1 day (52%). The vertigo was rotational in 80% of patients, and 47% experienced a floating sensation.


Kentala, E. & Pyykko, I. (2000). Vertigo in Patients with Benign Paroxysmal Positional Vertigo. Acta Otolaryngology, 543, 20-22.

http://web.ebscohost.com.www.libproxy.wvu.edu/ehost/pdf?vid=4&hid=15&sid=9a94e1ac-652f-424e-9d24-5f8185d7d5bf%40sessionmgr8

The Dix-Hallpike maneuver was performed to evaluate the presence or absence of nystagmus. Upon testing very strong rotary nystagmus was seen on the right side. Additionally, she reported feeling dizzy. These symptoms were positive for BPPV. No nystagmus was seen on the left side. Two rotations of the Epley maneuver were performed to the right side in order to successfully treat her BPPV. The client's results revealed positive signs of BPPV and the Epley was performed to reduce and treat the symptoms of BPPV. Reduction of symptoms and absent rotational nystagmus was observed during the second Dix-Hallpike maneuver. It was recommended that the client rest for a few days since the testing can cause some unsteadiness.

Spring 08 Week 4

A female student came to clinic to seek help for a fluctuating hearing loss. She describes her hearing as intermittent and fluctuating. Approximately four years ago, she had mononucleosis symptoms; however, test results were negative. She reports a constant feeling of aural fullness and tinnitus only with the decrease in hearing ability.

Clear ear canals and intact tympanic membranes were observed bilaterally. Normal, Type A tympanograms were measured. Pure tone thresholds using insert earphones were found to be within normal limits, less than 25 dB HL across all frequencies bilaterally. Speech recognition thresholds (SRT) were in excellent agreement with the pure tone averages. SRT scores were 5 dB bilaterally. Speech discrimination was 100% bilaterally. On the day of testing, her hearing is considered to be normal.

Although diagnosis can not be made just from the results, the patient described a case history that suggest multiple sclerosis. The report was sent to her primary care physician with a side note of fluctuating hearing loss is a symptom of MS. Which you can find a list of symptoms here:

http://www.nationalmssociety.org/about-multiple-sclerosis/symptoms/index.aspx

The article that I found tested one female with known MS. The participant was in later stages of MS and had more severe symptoms than that of the patient seen. However, it gives valuable information about the use of audiological assessment used for diagnosing MS. The participant had sudden bilateral sensorineural hearing loss and vertigo. She was tested with audiometry, AEPs, bithermal calorics, and MRI.

Young-Mi Oh et al. (2008). Sequential bilateral hearing loss in multiple sclerosis.
Annals of Otolarngology, 117: 186-191.

http://web.ebscohost.com/ehost/pdf?vid=1&hid=104&sid=ff919d2a-aafa-4afc-9cfe-7225021250c1%40sessionmgr107

Spring 08 Week 3

I saw an adult man who stated that he notices a hearing loss especially in his left ear with occasional tinnitus. A previous surgery for the removal of a neuroma of the pituitary gland was reported. However, he noted that his hearing loss did not coincide with the surgery. He also reported having served in the military and he target shoots annually.

Otoscopy revealed normal ear canals and tympanic membranes bilaterally. Immittance results were normal type A tympanograms bilaterally. Pure tone audiometry using insert earphones revealed a normal sloping at 1000 Hz to severe sensorineural hearing loss in the left ear. The right ear is normal sloping at 500 Hz to severe sensorineural hearing loss with an abnormal air-bone gap at 1000 Hz. Pure tone averages were in good agreement with the speech recognition thresholds of 30 dB in the right ear and 55 dB in the left ear. Speech discrimination was 84% in the right ear and 60% in the left ear. According to the results, the client has a sensorineural hearing loss bilaterally with an unexplained, unusual air-bone gap at 1000 Hz that was retested with active assistance of the supervisor.

After this finding, several other patients had strange masking responses in our clinic. When searching for an article about calibration and the effects on bone conduction scores, I found this article which discusses random and systematic errors made when performing BC audiometry. When two different sites were observed, bone conduction thresholds at 2 kHz revealed a notch or 'inflection'. The authors described, "part of the problem appears to be related to excessive air borne sound from the bone vibrator at these high frequencies. Regarding lower frequencies, several audiology professionals in the UK have expressed some concern about the accuracy of bone conduction at 1 kHz and 2 kHz". As a result, the authors suggest a complete review of technology of bone vibrators and also precise placement of the bone vibrators. This was a very strange finding since I've never heard of it. This may be a useful piece of information for all clinics.


O'Neill, G. et al. (2000). Systematic errors in bone conduction audiometry. Clinical Otolaryngology, 25, 357-369.

http://web.ebscohost.com/ehost/pdf?vid=1&hid=104&sid=3d17ea14-0ffe-465b-a833-cd2aaebebedf%40sessionmgr102

Spring 08 Week 2

A woman from the local group home came in for a hearing evaluation. The caregiver reported that the client had bilateral perforated tympanic membranes (TM), due to ear infections as a child, and a longstanding history of significant hearing loss. However, she can verbalize some words but chooses to do so with her mother only. A previous surgical attempt to repair the right TM was reportedly made but was unsuccessful. The caregiver also stated that she had a recent ear infection that was being treated with antibiotics. She has a history of mental retardation and seizure disorder.

Otoscopy revealed a perforated left TM. A potentially infected green substance was observed in both auditory canals. Immittance testing revealed flat, Type B, tympanograms bilaterally. The volume of the right ear was normal at 1.92 mL while the left ear was large at 2.76 mL. Visual reinforcement audiometry (VRA), using insert earphones, revealed fairly consistent behavioral responses to narrow band noise in the moderate to severe hearing loss range at 1000 and 2000 Hz. Additional testing could not be tested due to client noncompliance. Speech awareness thresholds were found for the right ear at 70 dB HL and for the left ear at 60 dB HL. Speech recognition thresholds could not be obtained. Otoacoustic emissions were not attempted due to abnormal Type B tympanograms bilaterally. Although specific thresholds could not be obtained, behavioral results revealed a bilateral moderate to severe hearing loss in the mid frequency range. Communication strategies were discussed with the caregiver.

I found an article that discussed the prevalence of viruses and bacteria after PE tubes were placed. In this instance, the patient had subsequent perforated tympanic membranes which allows more bacteria to build. In the study, at least 1 respiratory tract pathogen was noted in 76 children (96%). Bacteria were found in 73 cases (92%), and viruses were found in 55 (70%). In 52 patients (66%), both bacteria and viruses were found. Bacteria typical of AOM were detected in 86% of patients. Picornaviruses accounted for 60% of all viral findings.

Ruohola, A. et. al (2006) Microbiology of acute otitis media in children with tympanostomy tubes: Prevalences of bacteria and viruses. Clinical Infectious Diseases; 43.

http://web.ebscohost.com/ehost/pdf?vid=1&hid=104&sid=66bae850-ccf5-4eb8-9475-4aea16cc1f3a%40sessionmgr109

Spring 08 Week 1

I saw an elderly man this week who reported a gradual decline in hearing throughout his life. He reported noise exposure from power tools, construction, and hunting. In addition, he confirmed a personal and family history of diabetes. He is not currently a hearing aid user; however, the purpose of his visit was to determine hearing aid candidacy and discuss amplification options. The client's wife, a long time hearing aid user, accompanied him. Otoscopy revealed normal, clear ear canals and tympanic membranes bilaterally. Tympanometry revealed normal, Type A, tympanograms bilaterally. Pure tone audiometry revealed a mild sensorineural loss in the low frequencies sloping at 2000 Hz to a severe loss bilaterally. Fairly reliable responses were found for bone conduction testing due to inconsistencies in masked responses and client fatigue. Speech recognition thresholds (SRT) were found to be 45 dB HL, in both ears. Pure tone averages were in agreement with the SRT bilaterally. Speech discrimination testing, performed at 40 dB SL, resulted in 76% in the right ear and 52% in the left ear. According to the results, he displays a mild sloping to severe sensorineural hearing loss and is an excellent candidate for bilateral amplification. Several hearing aid options, including behind-the-ear (BTE) hearing aids, were discussed; however, he chose an in-the-ear (ITE) hearing aid comparable to his wife’s current aid. Ear impressions were made, Oticon Tego LP hearing aids were ordered, and a follow up appointment will be scheduled when the hearing aids arrive.

I found an article that discusses speech recognition assessments and their ability to measure objective and subjective outcome of wearing hearing aids. The SPIN, HINT, and QuickSin were administered to 21 hearing aid users. All tests were administered with and without hearing aids to see if the participants speech understanding improved. Subjective matter was measured using the Hearing Aid Performance Inventory. The results suggest a great benefit in speech recognition with all tests while using hearing aids. When comparing objective and subjective results, the HAPI ratings improved as the performance on the tests improved.

http://web.ebscohost.com.www.libproxy.wvu.edu/ehost/pdf?vid=4&hid=15&sid=9a94e1ac-652f-424e-9d24-5f8185d7d5bf%40sessionmgr8

Mendel, L.L. (2007) Objective and Subjective Hearing Aid Assessment Outcome. American Journal of Audiology, 16