Tinnitus FAQ
	www.bixby.org/faq/tinnitus.html a resource for understanding tinnitus, not a substitute for a health care provider

How is Tinnitus Diagnosed?

BAER Test

Bedside Test

Fibromyalgia Syndrome (FMS)

The following flowchart from the Cecil Textbook of Medicine, 1992 (19th ed.), W.B. Saunders, shows the logic for diagnosing the common causes of tinnitus (note that this chart omits some causes, such as TMJ disorders).

ear exam-->(audible sounds)-+-->sync w/respiration-->patent eustachian
   |                        |                        tube
   |                        |
   |                        | 
   |                        |
   |                        +-->sync w/pulse-->aneurysm, vascular tumor,
   v                        |                  vascular malformation,
(no audible sounds)         |                  venous hum
   |                        |
   |                        |
   |                        |
   |                        +-->continuous-->venous hum, acoustic
   |                                         emissions
   |
   |
   v
neurological exam-->(normal)-->audiogram
   |                             |
   |                             |
   |                             +-->normal-->idiopathic tinnitus
   |                             |
   |                             |
   |                             +-->conductive hearing loss
   v                             |             |
(brain stem signs)               |             v
   |                             |     impacted cerumen, chronic
   |                             |     otitis, otosclerosis
   |                             |
   v                             |
multiple sclerosis,              +-->sensorineural hearing loss
tumor, ischemic                               |
infarction                                    v
                                          BAER Test
                                              |
                                              v
                                    +---------+--------------+
                                    |                        |
                                    |                        |
                                    v                        v
                                 abnormal (neural)      normal cochlear
                                    |                        |
                                    |                        |
                                    |                        |
                                    v                        v
                                 acoustic neuroma       noise damage
                                 other tumors           ototoxic drugs
                                 vascular compression   labyrinthitis
                                                        Meniere's Disease
                                                        perilymph fistula
                                                        presbycusis

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This test records evoked responses from scalp electrodes at 0 to 10 msec (early potential), 10 to 50 msec (middle potential), and 50 to 500 msec (late potential) using a click stimulus. The early potentials indicate the electrical activity at the cochlea, eighth cranial nerve, and the brain stem. The later (middle and late) potentials indicate cortical activity. A computer is used to average the recorded responses from the 1000 to 2000 clicks used during the test, to separate the evoked response potential from any background noise. The early evoked responses may be used to estimate the magnitude of hearing loss and to differentiate whether cochlea, eighth nerve, or brain-stem lesions are the source.

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Bedside tests are used for a basic analysis of hearing loss and consist of four tests.

The first test, A quick test for speech range hearing loss, is where the examiner observes the patient's response to spoken commands at different intensities (whisper, conversation, shouting).

In the second test, a tuning fork test is used to permits a rough assessment of the hearing level of the patient for pure tones of known frequency. The clinician uses their own hearing level as a refernce standard.

In the Rinne test, nerve conduction is compared to bone conduction by holding a tuning fork (preferably 512 Hz) against the mastoid process until the sound can no longer be heard. The tuning fork is then placed one inch from the ear. In normal subjects, the tuning fork should be heard about twice as long by air as by bone. If bone conduction is better than air conduction, the hearing loss is determined to be conductive.

The Weber test uses a tuning fork which is placed on the patient's forehead or upper teeth. Nomally the sound produced by the tuning fork seems to be heard at the center of the head. If sound appears to come from the side of the unilateral hearing loss, the hearing loss is conductive. However, if the sound appears to occur on the side away from the side of unilateral hearing loss, the hearing loss is sensorineural. The Weber test is often unreliable in conductive hearing loss, because the patient cannot accept the fact that hearing appears to be better in the diseased ear.

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Fibro- means fiber; my- means muscle; algia- means pain and, when put together, means pain in the nonskeletal parts of the musculoskeletal system - the muscles, tendons, and ligaments. FMS is not new. First described in 1816, the medical profession went on to call it by many different names, including chronic rheumatism, myalgia, pressure point syndrome, and fibrositis. In 1987, the AMA recognized FMS as a true illness (syndrome, not a disease) and a major cause of disability.

One symptom of FMS is ringing in the ear, which may be caused by deep masseter (related to the large muscle that raises the lower jaw) TrPs (trigger points) which result in a ringing or low roaring sound in the ears. The sound may vary, from a crackling noise to that of a continuous tone made when a telephone is off the hook. It is estimated that approximately one-third of the people with FMS have tinnitus.

FMS is an extremely involved group of symptoms (muscle pain, fatigue and sleep disturbance, depression and anxiety, headaches, TMJ, etc.) and t-faq cannot begin to convey a thorough definition of FMS. For more information, check the following resources:

Associations:

National Fibromyalgia Research Association
P.O. Box 500
Salem, OR 97308
503-588-1411

Association de la Fibromyositre du Quebec
643 rue Notre Dame
Repentigny, PQ J6A 2W1

Fibromyalgia Alliance of America, Inc.
P.O. Box 16600
Washington, DC 20041-6600
202-310-1818; FAX 703-620-1525

Fibromyalgia Alliance of America
P.O. Box 21990
Columbus, OH 43221-0990
614-457-4222

Books:

Williamson, Miryam Ehrlich, fibromyalgia: a compreshensive approach, Thomas Allen & Sons Canada Ltd., ISBN 0-8027-7484-9, 1996.

Starlanyl, Devin, MD and Copeland, Mary Ellen, M.S., M.A., Fibromyalgia & Chronic Myofascial Pain Syndrome, a survival manual, New Harbinger Publications, Inc., ISBN 1-57224-046-6, 1996.

Online:

FIBROM-L:

the internet fibromyalgia discussion group providing information and support for FMS sufferes and their families. To subscribe, send email to listserv@mitvma.mit.edu, writing subscribe FIBROM-L your name.

alt.med.fibromyalgia:

an internet newsgroup for FMS. Messages sent to FIBROM-L will also appear in this newsgroup.

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Remember, the t-faq is a resource. For medical care, visit your health care professional.