- Hearing loss
- Fullness of the ear
- Sensitivity to noise
- Eye symptoms
- Drop attacks (Tumarkin’s otholic crisis)
Some vestibular disorders have symptoms of hearing loss. There are a range of rehabilitation options available to aid listening ability. For some people counselling and straightforward communication tactics is enough; however, for others a hearing aid is needed. In a small proportion of sufferers who develop profound hearing loss in both ears and find that conventional hearing aids are not helpful, a cochlear implant may be suitable to provide a sense of hearing.
Vestibular disorders that may have symptoms of hearing loss include:
- Ménière’s disease
- Migraine-associated vertigo
- Perilymph fistula
- Superior Canal Dehiscence Syndrome (SCD)
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Tinnitus is a hidden symptom which is highly distressing and can affect a person’s quality of life. Tinnitus comes from the Latin word meaning ‘to ring’; people hear a wide variety of noises such as buzzing, humming and whistling. Tinnitus is often worse at quiet times for example when trying to get to sleep as there isn’t the background noise to distract you from the sound. Although there is no cure it is possible to teach people how to manage their tinnitus, reduce their awareness of the sound and reduce their distress.
Management of tinnitus
Many ENT departments offer a variety of treatments for managing tinnitus; this could include adjustment to medication, counselling, relaxation therapy, stress management and advice with hearing aids, white noise generations (WNG) and environmental sound enrichment.
Vestibular disorders that can include tinnitus:
- Ménière’s disease
- Migraine-associated vertigo
- Perilymph fistula
- Superior canal dehiscence syndrome (SCD)
For more information on tinnitus, visit the British Tinnitus Association (external website).
Fullness of the ear
Some people with a vestibular condition experience the sensation of ‘fullness’ or aural pressure which can be incredibly uncomfortable. The fullness can also fluctuate and for some cause considerable distress. Some patients can gauge that their condition is starting again if they notice a change in the sensation of the ‘fullness’. For some this sensation may disappear completely however for others it can become chronic with the constant feeling of pressure. In patients with Ménière’s disease this condition can fluctuate with the acuteness of the condition.
Sensitivity to noise
Some people have especially sensitive hearing and are unable to tolerate ordinary levels of noise, this can occur with people with normal hearing as well as people with hearing loss. There are different component which can contribute to sensitive hearing such as hyperacusis, phonophobia and misophonia.
Hyperacusis is the medical term used to describe the abnormal discomfort of everyday sounds that some people experience. Hyperacusis is due to an alteration in the central processing of sound in the auditory pathways where there is an abnormally strong reaction from exposure to moderate sound levels.
Misophonia is the intense dislike of being exposed to a certain sound. The auditory pathways may be functioning normally, but there is an abnormally strong reaction of the limbic (emotional system) and autonomic nervous system (body control system) to which the auditory system is intimately connected. Sometimes because of the belief that it will damage the ear, or makes symptoms (sensitivity, or tinnitus) worse. If this dislike is very strong we may call it ‘phonophobia’ literally - fear of sound. Often normal environmental sounds like traffic, kitchen sounds, doors closing, or even loud speech, cannot be tolerated, even though under any circumstances they cannot be damaging to anyone. Misophonia can lead to hyperacusis (changes in central auditory processing), and a consequent persistence of abnormal loudness perception. In practice, most people with decreased sound tolerance have both hyperacusis and phonophobia/misophonia together in varying proportions.
How can the symptoms be managed?
In treating these conditions, it is important to diagnose which condition is present and which is dominant.
Avoidance of silence
Many people seek silence as a way to escape from the pressures of everyday life. However complete silence is not found in nature, and should be considered ‘unnatural’. The absence of sound stimulation leads to an increase in auditory gain (amplification) in the subconscious auditory pathways. The brain is always looking for the best way it can for auditory signals. This process is enhanced by silence which is considered to be one of the signs of possible predator activity. The auditory filters ‘open’ in an attempt to monitor the external sound environment. External sounds may then increase dramatically in their perceived intensity and intrusiveness.
Some people take to wearing ear plugs, perhaps at night, to avoid sounds becoming intrusive, and this simply worsens the sensitivity. When hyperacusis develops there is a great temptation to plug the ear to exclude unwelcome sounds. This is actually making things worse, as it encourages further increase in the amplification of sounds on their way to the auditory (hearing) cortex. When these sounds are heard in the absence of plugs, their perceived loudness is greatly increased.
Noise generators and wearable sound generators (WSGs)
Hyperacusis can be managed most effectively by using noise generators alongside a programme that aimed at reducing the fear and anxiety associated with sound exposure.
Research in the 1980s (Hazell & Sheldrake 1991) showed that the use of wide band noise applied to the ear by wearable sound generators can help in the treatment of abnormal hypersensitivity of hearing. This is particularly true in hyperacusis, where on some occasions, particularly in young children, it is all the treatment required.
The sound from the instruments needs to be applied very gently and gradually to the ear beginning at a low level, always to both ears, and under the supervision of an audiologist with experience in this process of desensitization and with training in TRT. The effect, which in some cases may be quite dramatic, results in a ‘turning down’ of central auditory gain and a reduced perception of loudness for previously distressing sounds.
Never undertake any sound therapy without proper advice. Sound tapes - e.g. pink noise, can make certain hyperacusis and phonophobic patients considerably worse. In each case carefully explanation of the mechanism of central processing must be given, so that individuals can understand and believe what has happened to them, and that the whole process is reversible with time, and the appropriate therapy.
Where misophonia (dislike) or phonophobia (fear of sound) exists, no permanent change in discomfort can be achieved without a successful behavioural programme aimed at reversing inappropriate beliefs responsible for the conditioned aversive response. This is true for any phobia (e.g. claustrophobia, arachnophobia, fear of heights etc). The whole process of desensitization can take quite a long time, commonly six months to a year, but is achievable in most cases.
Another possible symptom is headache or pains over the scalp. As the balance is also involved with maintaining the correct position of the head, the muscles of the neck and scalp are constantly being brought into play to achieve this. Some abnormalities of balance will cause this reflex to be triggered at the wrong time, resulting in spasm often in small areas of the head and neck musculature. This can present a quite severe pain which may move about in its location and cause distress and concern to sufferers.
Some people experience eye symptoms that include the inability to focus, rapid eye movement and blurred vision. This can occur because the balance mechanism is linked with the control of the eye movement and stability. Therefore the balance mechanism enables us to keep our eyes fixed on some object while we are walking about moving our head. Any loss of this eye control by the balance mechanism can result in a completely uncontrolled eye movement. In the worst case, the eyes move rapidly from side to side (referred to by doctors as nystagmus) and this produces a sensation of rotation of the environment rather like being spun round rapidly on a swing or roundabout. Blurring of vision, although it may be due to other eye problems, can often be the result of a balance disturbance.
Drop attacks (Tumarkin’s otholic crisis)
Drop attacks, known as Tumarkin’s otolithic crisis, are when a person falls to the ground with no warning. The person remains awake and does not lose consciousness.
Who is affected by Tumarkin’s otholithic crisis?
Drop attacks are sometimes experienced in the later stages of Ménière’s disease. They do not affect everyone.
How does Tumarkin’s otholithic affect you?
A drop attack feels as if you are being pushed violently and suddenly, causing you to fall. Symptoms are usually gone as quickly as they appear, and you can get up straight away and carry on with whatever you were doing (unless you get a drop attack at the same time as an acute attack of vertigo). During these attacks, the hair cells on your otoliths are suddenly activated, causing your balance to be severely disrupted. Experts do not know how or why this happens.