Cristina Brandolini

Prevalence of tinnitus in patients withhypertension and the impact of different anti hypertensive drugs on the incidence of tinnitus: A prospective, single-blind, observational study.

BACKGROUND Tinnitus is a common symptom in audiology and neurologypatients. Controversial data have been reported in the literature about the prevalence of tinnitus in hypertensive patients, whereas its relationship with the extent of blood pressure (BP) control has not been substantially explored. OBJECTIVE The aim of this study was to determine the prevalence of tinnitus in hypertensive patients, and the impact of different antihypertensive drugs on the incidence of tinnitus in these patients. METHODS This prospective, single-blind, observational study was conducted at the Hypertension Clinic, St. Orsola-Malpighi Hospital, Bologna, Italy. Patients aged 18 to 75 years with uncontrolled hypertension and receiving antihypertensive therapy were enrolled. Patients were asked to complete a standardized questionnaire to assess the presence, frequency, and duration of tinnitus and the apparent effect of their antihypertensive treatment on it. Patients considered by the investigator to have tinnitus, regardless of their audiologic condition, underwent a complete clinical cardiovascular examination, including supine systolic BP (SBP) and diastolic BP measurement and standard 12-lead electrocardiography. Twelve-hour ambulatory BP monitoring was also performed, and patients were asked to record, using patient diaries, times of the onset and resolution of tinnitus that occurred during those 12 hours. From these data, correlations between the onset of tinnitus and BP were calculated. RESULTS A total of 476 patients participated in the study (283 men, 193 women). Of these, 84 (17.6%) patients reported occasional or prolonged spontaneous tinnitus, whereas 392 (82.4%) reported no tinnitus. The incidence of tinnitus was significantly higher in patients receiving diuretics (72/265 [27.2%]) compared with those receiving angiotensin lI receptor blockers (5/37 [13.5%]), α-blockers (12/55 [21.8%]), or 3-hydroxy-3-methylglutaryl coenzyme A reduc tase inhibitors (9/73 [12.3%]) (all, P < 0.05). Mean (SD) SBP was significantly higher in patients without tinnitus compared with those with it (143.2 [11.1 ] vs 140.6 [10.3] mm Hg; P < 0.005). In 10 (11.9%) patients with tinnitus, the onset was correlated with a sudden decrease in SBP (<140 mm Hg). CONCLUSIONS In this study of tinnitus in patients receiving antihypertensivetherapy, tinnitus was found in 17.6% of patients. Tinnitus was associated with the use of diuretics and with low SBP. Further studies are needed.

Superior semicircular canal dehiscence : A series of 13 cases

Increasingly more detailed imaging techniques have recently highlighted the frequent occurrence of bony labyrinthine dehiscence. Among them, superior canal dehiscence (SCD) has been described in a number of cases presenting different features. Here, we report a series of 13 cases, in which the detection of vestibular evoked myogenic potentials (VEMPs) in response to stimuli of abnormally low intensity as compared to normal responses led us to suspect the presence of a ‘third window effect’. An accurate HRCT investigation allowed the diagnosis of SCD. Anamnestic and symptomatologic differences seem difficult to explain, although in our opinion a dural rupture could be at the basis of the onset of pathologic manifestations after many years of silence of a probably malformative condition.

MENIERE’S DISEASE: UPDATE OF ETIOPATHOGENETIC THEORIES AND PROPOSAL OF A POSSIBLE MODEL OF EXPLANATION

Abstract Meniere’s Disease (MD) is an affection consisting of an association of sensorineural hearing loss, tinnitus and vertigo initially presenting by crises. A review of the most considered possible causative factors and pathophysiologic interpretations allows us to underline the uncertainties which still exist about the genesis of this illness. We propose a mechanistic model based on the effect of a haemodynamic imbalance leading to transient ischaemia which could have an effect on the pH of the inner ear as well as on the work of the inner ear proton pumps. It is hypothesized that under ischaemic conditions and consequent metabolic acidity a preserved proton pump activity can generate an overload of anions in the endolymphatic partition, which is a closed system, thus resulting in an enhancement of osmolarity and consequently in the formation of a hydrops resulting in the development of fluctuating hearing loss, tinnitus and vertigo which characterize Meniere’s Disease.

Tinnitus in elderly patients and prognosis of mild-to-moderate congestive heart failure: a cross-sectional study with a long-term extension of the clinical follow-up

BackgroundThe complex mechanism responsible for tinnitus, a symptom highly prevalent in elderly patients, could involve an impaired control of the microcirculation of the inner ear, particularly in patients with poor blood pressure control and impaired left ventricular (LV) function.MethodsIn order to define the relationship between the presence of tinnitus and the severity and clinical prognosis of mild-to-moderate chronic heart failure (CHF) in a large population of elderly patients (N = 958), a cross-sectional study was conducted with a long-term extension of the clinical follow-up. Blood pressure, echocardiographic parameters, brain natriuretic peptide (BNP), hospitalization, and mortality for CHF were measured. Multivariate logistic regression analysis was used to assess the association between the presence of tinnitus and some of the prognostic determinants of heart failure.ResultsThe presence of tinnitus was ascertained in 233 patients (24.3%; mean age 74.9 ± 6 years) and was associated with reduced systolic and diastolic blood pressure (123.1 ± 16/67.8 ± 9 vs 125.9 ± 15/69.7 ± 9; P = .027/P = .006), reduced LV ejection fraction (LVEF%; 43.6 ± 15 vs 47.9 ± 14%, P = .001), and increased BNP plasma levels (413.1 ± 480 vs 286.2 ± 357, P = .013) in comparison to patients without symptoms. The distribution of CHF functional class was shifted toward a greater severity of the disease in patients with tinnitus. Combined one-year mortality and hospitalization for CHF (events/year) was 1.43 ± 0.2 in patients with tinnitus and 0.83 ± 0.1 in patients without tinnitus, with an adjusted hazard ratio (HR) of 0.61 (95% confidence interval (CI): 0.37 to 0.93, P <.002).ConclusionsOur preliminary data indirectly support the hypothesis that tinnitus is associated with a worse CHF control in elderly patients and can have some important clinical implications for the early identification of patients who deserve a more aggressive management of CHF.

Gastric type proton pump of the inner ear: Its possible involvement in labyrinthine disorders

It was recently suggested that the favourable effect of proton pump inhibitors on gastric reflux could threaten the homeostasis of the inner ear in several different ways. Moreover, when it is considered that a gastric type proton pump has been found in the inner ear, it could be hypothesized that this treatment has a direct effect. As ischaemia threatens gastric mucosa even by acid secretion, thus implying resistance of the proton pump to damaging factors, a similar kind of mechanism could be imagined in the inner ear, where it could even cause the osmotic changes possibly involved in Ménières disease hydrops. This hypothesis, if proved, could open new perspectives on some not fully understood phenomena and lead to finding more satisfactory therapeutic options.

Could vestibular evoked myogenic potentials (VEMPs) also be useful in the diagnosis of perilymphatic fistula

The role of vestibular evoked myogenic potentials (VEMPs) is at this time indisputable in the study of vestibular disorders. Furthermore, VEMPs are widely accepted as a diagnostic tool when a superior semicircular canal dehiscence (SCD) is suspected, presenting in such cases a lowering of threshold values able to raise a recordable response due to increased inner ear immittance. According to the same principle, the possibility of another kind of alteration having the same effect on the inner ear might be considered when high-resolution computed tomography has excluded the presence of an SCD. In this paper four cases are described in which high-resolution computed tomography showed normal features without any labyrinthine dehiscence and VEMP threshold values were lowered; the appropriateness of suspecting a perilymphatic fistula in such cases and resorting to VEMPs in detecting a perilymphatic fistula is discussed.

Inner ear symptoms: can we use them to approach cardiovascular diseases?

Sensory organs are programmed to detect external stimuli, and inform about possible threats. In general, they are characterized by a complex architecture, a highly energy-requiring function, a peripheral location and a vascular supply depending on a terminal circulation usually under systemic control. Their function may be highly sensitive to more general disorders primarily involving other organs or physiological systems. Consequently, the onset of transient or persistent symptoms of impairment of sensory organs might be the expression of abnormalities in the integrity of more general systems, especially in the elderly population. In the otologic area, despite the availability of evidence supporting the negative impact of some systemic conditions negatively affecting the local blood supply at the labyrinth level, the possibility that the inner ear can reveal the presence of sub-clinical, non-otologic disorders has never been the topic of a constructive investigation. The present review summarizes the preliminary available evidence suggesting a possible negative impact of early systemic hemodynamic changes on the function of the inner ear, as well as the possibility that some audiological symptoms may play some role in the early detection of cardiovascular diseases. In particular, we hypothesize that some cardiovascular diseases may cause an impairment in correct labyrinthine function as a result of a negative interaction between systemic hemodynamic changes, a reflex activation of the autonomic nervous system, and a local vascular response. A multidisciplinary approach to the interpretation of inner ear disorders may increase the possibility of an earlier recognition and understanding of systemic dysfunctions in clinical practice.

Dehiscence of the superior semicircular canal: a review of the literature on its possible pathogenic explanations

The dehiscence of superior semicircular canal is a well-known affection which is able to explain some cases of hearing loss, tinnitus and/or vertigo unexpectedly presenting in adults without previous otologic affections. Although a diagnostic algorithm has been assessed and a surgical therapy has been indicated, the review of the literature shows that a completely satisfactory explanation for the reason why symptoms of a supposed congenital condition only occur in adulthood is still lacking. A pathogenic hypothesis based on the slow metabolism of the bony labyrinth, which could in time result in a prevalence of bone re-absorption on new bone formation leading to a dehiscence, despite some controversial findings could represent a the most reliable explanation for the question.

Haemodynamic profile of young subjects with transient tinnitus

Abstract Objective: Our objective was to contribute to drawing a haemodynamic profile of healthy subjects prone to labyrinthine disorders of functional origin. The aim was to determine if some haemodynamic aspects could characterize young people with a history of transient tinnitus, considered as an early symptom of cochlear damage possibly derived from hypoperfusion. In one year we studied 60 consecutive subjects (28 ± 5.2, range 18–40 years): 24 who experienced transient tinnitus, and 36 without tinnitus. Exclusion criteria were a history of audiological and otological impairment, ear surgery, and known cardiac abnormalities. A clinical and echographic cardiac evaluation was performed, with assessment of blood pressure, heart rate, and left ventricular structure and function. Results: All results were within the normal range in both groups. The tinnitus group had a slightly lower body mass index (BMI) (p = 0.05) and body surface area (BSA) (p <0.05), while age, blood pressure and heart rate were similar in the two groups. Tinnitus subjects showed reduced diastolic and systolic left ventricular internal dimensions (p = 0.01 and 0.02, respectively) and left ventricular end-diastolic volume (p = 0.02). Left ventricular mass (LVM) related to height 2.7 and observed LVM were reduced in tinnitus subjects (both p = 0.02), while LVM related to BSA had a less marked reduction (p = 0.04), and predicted LVM and appropriate LVM showed only a borderline statistically significant reduction (p = 0.05). Functional systolic left ventricular aspects were similar in the two groups apart from a lower stroke volume in tinnitus subjects compared with the no-tinnitus group (p = 0.03), and no differences were observed in diastolic function indexes between the two groups. Conclusion: Subjects with a history of transient tinnitus, although presenting normal echocardiographic parameters, seem to have smaller somatic and cardiac structural characteristics, which could be less adequate in maintaining peripheral perfusion. In particular, a terminal circle district such as the cochlear one could thus show its stress through tinnitus. This observation indirectly supports the theory of a cochlear origin of tinnitus in a number of cases and is reminiscent of what happens in hypertension and heart failure.

The possible role of proton pump inhibitors of the homeostasis of the inner ear.

The possibility of a benefit in some cases of inner ear sufferance by using proton pump inhibitors has been considered after a casual observation. The hypothesis is advanced considering the adverse effect of reflux on the eustachian tube function, the possible influence of the latter on inner ear symptoms and, from a more general point of view, the trigger effect which a gastric dysfunction requiring proton pump inhibitors could exert on the sympathetic system. These considerations, deserving a further study, seem to be based on logical assessment and therefore in our opinion deserve to be kept in mind in trying to define inner ear disorders of uncertain origin.