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Ear problems

In the first of a two-part article, consultant otologist Professor Tony Wright answers questions from GP Dr Melanie Wynne-Jones

In the first of a two-part article, consultant otologist Professor Tony Wright answers questions from GP Dr Melanie Wynne-Jones

1 Is there anything new in tinnitus? Who should be investigated ?

Subjective tinnitus, or phantom auditory perception, is the individual's perception of sound when none exists in the environment. Objective tinnitus occurs when an outsider can also detect the sound by listening to the patient's ear. Objective tinnitus is uncommon but is usually due to a mechanical problem such as a carotid stenosis, a muscle in fibrillation giving a rapid clicking noise or a vascular hum due to a venous anomaly such as a glomus tumour. These need investigation, and treatment (if indicated) usually resolves the problem.

Subjective tinnitus, which occurs in at least 10% of the population for a period of five minutes or longer, is related to many conditions that involve the auditory pathway, for example perforations of the eardrum, otosclerosis, cholesteatoma, Meniere's disease and acoustic neuromas. Symptoms are usually one sided and need investigation and maybe treatment. But treatment does not always help unless the hearing is improved as in the surgical treatment of otosclerosis. Thus, anything that affects the auditory pathway can give an abnormal perception of sound just as a poke in the eye or the prodrome to a migraine can make the patient 'see' flashing lights. This abnormal auditory experience acts as a warning signal to the brain, much as the sound of rustling leaves in the jungle would put an animal on alert. In the jungle, the sound would be investigated by finding out whether it is the wind or a snake; if the latter then flight or fight comes into action. In humans, internal sounds that are unexplained and unexpected cause the same reaction. If the sounds persist in the absence of a real threat the brain filters them out before they reach the level of perception. A good example is hearing a clock stop when before it was not noticed ticking in the background.

2 What can you offer patients with tinnitus in the way of symptom relief or cure?

Therapy aims to enhance natural filtering. This involves a thorough history, examination and investigations to exclude underlying conditions. Then the patient is advised not to be in quiet places as the tinnitus may re-emerge, and to optimise the hearing if this is poor.

Management of sleep patterns is important, as a tired patient will have the perception of tinnitus enhanced, just as any other symptom is enhanced by tiredness. Stress management and cognitive behaviour therapy all have a part to play. Unfortunately there is no pill to 'cure' tinnitus, since it is not a disease but a symptom involving one or several neurotransmitters. A better understanding of the auditory pathways will help understand the mechanisms and several major groups are researching this area.

3 How common is benign positional vertigo (BPPV) and what causes it? Can it be diagnosed from the history and examination alone or should we always refer?

BPPV is a clinical diagnosis based on symptoms and physical signs. The histopathology that has been suggested (crystal deposits in the posterior semicircular canal) is dubious and has not been confirmed. BPPV is the onset of rotary vertigo as an individual adopts a particular position, commonly on lying down and turning to one side.

The vertigo is severe, lasts several minutes then subsides to leave the patient feeling unsteady for a long while. There are many variants and the feeling among ENT surgeons is that the condition in its nonclassical form is more prevalent than we thought.The history is of vertigo (a sensation of unreal movement) that lasts for a while, not just for moments, and which may be associated with nausea. Its onset is associated with turning movement, but this may be obscured in the history. The general ENT examination is usually normal, but the Hallpike test is often positive.

4 Can you explain the Hallpike manoeuvre? Should we offer the Epley manoeuvre?

If the Hallpike test (see right) is positive – which is usually clear – the Epley manoeuvre is indicated.

5 Parents who have had grommets in childhood now expect their children to have them too! What are the current recommendations for watching and waiting in glue ear?

Glue ear is the presence of fluid in the middle ear in the absence of infection and present for three months or more. Most cases resolve naturally and virtually every study has shown that every four months 50% get better spontaneously. However, a core of patients do not. Thus, a wait and watch approach is valid and is what seems to happen in the UK as opposed to the US and the rest of the EU. In the UK, the patient sees the GP, has treatment and if this fails is referred.

The ENT junior doctor prescribes a different treatment. By now the child has a good chance of spontaneous recovery. The children who see the senior specialist registrar or consultant usually have well-established glue ear, and the waiting list will sort out those who will get better on their own.

6 How long should we watch and wait in glue ear? What are the red flags and are there any treatments worth using in the meantime?

A recent US study showed that grommets are not indicated unless:

• there are speech and language problems• there are behavioural problems related to the hearing loss• there are degenerative changes in the eardrum• the hearing level is 40dB or worse.

These are the children we see in NHS clinics.A long-term observational study from Dunedin, New Zealand, assessed children's global ability including speech and language development, social skills and IQ. A period of untreated hearing loss over a year or so resulted in a delay in development as everyone expected. What was unexpected was that once the hearing loss was treated, the children did not catch up and at age 15 to 17 there was still a small but significant difference. Thus a wait and watch policy has its drawbacks and the watcher has to be able to spot whether the eardrum is becoming atrophic and retracted.Given these constraints, a watch and wait approach for, say, six months is reasonable if none of the four exclusion criteria exist. This means you need to be able to see the eardrum and test the hearing.Whatever the cause of the middle ear fluid – infection, allergy, parental smoking, adenoidal hypertrophy – the problem is mechanical and there are no treatments that clear the fluid and restore the hearing other than ventilating the middle ear.

7 Adults often come back with prolonged bilateral Eustachian tube block. Any tips for helping it to clear, and when should we refer?

The generalised, non-pain response from the outer, middle and inner ears is a feeling of pressure, fullness and blockage. The responses from the inner ear frequently cannot be distinguished from those in the middle ear during pressure changes or a cold.

The inner ear pressure cannot, however, be relieved, except momentarily by a Valsalva manoeuvre to inflate the middle ear. If the ear drum is normal and there is no middle ear fluid, the problem is unlikely to be the Eustachian tube. Also check the neck for pain and tightness because of the chance of referred symptoms and check the temporo mandibular joints for pain and crepitus as they can also give sensations of blockage. Grommets should not be inserted in normal eardrums with normal tympanometry and no other symptoms.

Professor Tony Wright is a consultant otologist at the Royal National Nose, Throat and Ear Hospital and professor of otolaryngology at the University College London Ear Institute

Competing interests None declared

Take-home points

• Subjective tinnitus occurs in at least 10% of the population

• There are many variants of BPPV and the condition in its nonclassical form may be more prevalent than we thought

• Every three or four months, 50% of patients who still have glue ear get better spontaneously

• A wait and watch policy has drawbacks and the watcher must be able to detect if the eardrum is becoming atrophic and retracted

• The generalised, non-pain response from the outer, middle and inner ears is a feeling of pressure, fullness and blockage; responses from the inner ear often cannot be distinguished from those from the middle ear during pressure changes or a cold

Hallpike test

• The patient sits on a couch with the doctor standing on one side. • The patient's head is held by the doctor and turned so that their eyes meet. • The patient is then rapidly laid back, with their head turned to one side and while maintaining continuous eye contact with the doctor, to a lying position below couch level. • In BPPV, there is a short delay of up to 20 seconds followed by the onset of marked vertigo with a rotary nystagmus (a rhythmic, oscillating, conjugal movement of the eyes).• This sensation stops after a while – it fatigues.If the process is repeated the severity is less – it adapts.• Any other response is not BPPV and suggests central problems – an MRI scan is advised.

WHAT WILL I DO NOW

Dr Wynne-Jones responds to the answers to her questions

• I will borrow Professor Wright's explanation of tinnitus to help patients understand how to help themselves

• I will try the Hallpike manoeuvre when appropriate, and follow this with the Epley manoeuvre if the former testis positive

• When patients present with blocked ears, I will examine and question them more rigorously

Dr Melanie Wynne-Jones is a GP and GP trainerin Marple, Cheshire

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