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.