Tinnitus Diagnosis and Treatment Hossein Talebi; PhD of Audiology Assistant Professor of Audiology...

Tinnitus Diagnosis and Treatment

Hossein Talebi; PhD of AudiologyAssistant Professor of AudiologyIsfahan University of Medical Sciences

Introduction• Tinnitus is defined as sensations of hearing in

the absence of external sounds

The burden of tinnitus

Introduction• Prevalence increases with age• 80% of people don’t seek help• 6-8% of those affected are severe• 40% of patients experience depression• Can vary between barely perceptible noise to a

deafening roar• Very little is understood about its cause or cure

Sound features of tinnitusNOISE CRITERIA

POSSIBLE FEATURES

Onset Sudden, gradual

Pattern Pulsatile, intermittent, constant, fluctuating

Site Right or left ear, both ears, within head

Loudness Wide range, varying over time

Quality Pure tone, noise, polyphonic

Pitch Very high, high, medium, low

Tinnitus sufferers

• Ludwig van Beethoven• Vincent van Gogh• Charles Darwin• Neil Young• Eric Clapton• Ronald Regan

Types of Tinnitus

•Objective: caused by sounds generated somewhere in the body

•Subjective: perception of meaningless sounds without any physical sound being present

•Auditory hallucinations: perceptions of meaningful sounds such as music or speech

Causes

Effects of Tinnitus

•Concentration•Hearing•Insomnia•Psychological

Ear Anatomy

Ear Anatomy

Mechanism of Hearing

Mechanism of Hearing

Mechanism of Hearing

Pathophysiology• Poorly understood

• Range of theories from loss of outer hair cell function to increased spontaneous activity of central nerves

• Can be generated from any part of the auditory system from the ear to the Central Nervous System (CNS)

• This then may become modified by the CNS

Peripheral events lead to central neurological changes

Brain response to auditory deprivation•Patients with tinnitus exhibit enhanced auditory sensitivity

•This is caused by hyperactivity of the auditory central nervous system• In patients with tinnitus and hearing loss, the tinnitus pitch and the hearing loss frequency spectrum are usually matched

DECREASED SOUND INPUT INCREASED

SOUND SENSITIVITY

Tinnitus is a balance of sensory input and spontaneous activity

• The decreased input from the cochlea, due to outer hair cell damage, results in readjustments in the central auditory system resulting in abnormal neural activity including hyperactivity, bursting discharges and increases in neural synchrony.

TINNITUS

AUDITORY DEPRIVATION AND CENTRAL

GAIN

ALTERED SPONTANEOUS NEURONAL

ACTIVITY

Pathophysiology• When the perception of tinnitus is associated

with negative reinforcement, the autonomic nervous system is activated.

• Physiological and psychological reactions then lead to enhancement of the tinnitus signal

• Often compared with chronic pain

Pathophysiology

Psychological associations with tinnitus

A Team Approach• Thorough evaluation to rule out significant

pathology• Treatment of other ear disorders eg. infection• Explanation of test results• Explanation of tinnitus mechanisms • Treatment options• Treatment of severe psychological disorders• Follow-up

Differential Diagnosis•Idiopathic (most common)

•Outer ear disease– Wax, foreign body, infection

•Middle ear disease– Infection, perforated eardrum, ossicular

problems, tumour

Differential Diagnosis

•Inner ear disease– Presbyacusis (older age hearing loss)– Meniere’s disease– Acoustic neuroma– Noise exposure– Drugs

Evaluation of Tinnitus

•Thorough history Duration, nature, effects Non vs. pulsatile Noise exposure Other ear symptoms

•Ear examination Rule out outer/middle ear disease Tuning fork tests

Normal Ear vs. Diseased Ear

Evaluation of Tinnitus

•Audiological (hearing) Tests Audiogram, tympanogram Specialized hearing tests: SOAE, ECochG,

ABR

•MRI Associated symptoms Asymmetric hearing loss

Evaluation - Subjective Tinnitus

•Audiometry - assymetrical hearing loss, unilateral tinnitus - MRI r/o post fossa

•Complete questionnaire for perceived severity:THI

Measurement of Tinnitus

•Pitch, loudness, minimum masking level, residual inhibition/post masking

•Minimum masking level most clinical use•Pitch - match most prominent pure tone,

poor reliability, octave difference•Loudness - Adjust pure tone to tinnitus•Most < 7 dB SL, may be 2 dB

Measurement of Tinnitus

•Minimal masking level - number of decibels to cover tinnitus

•Residual inhibition - response of patients tinnitus post masking

ENT Referral

ENT Referral

Acoustic Neuroma

Treatment

•Aim to improve habituation rather than “cure” tinnitus

•Most people don’t seek treatment•Multitude of potential treatments•Problems with scientific evidence

Treatment• Basic advice• Hearing Aid• Tinnitus Masking Device• Tinnitus Instrument• Tinnitus Retraining Therapy• Psychological Treatment• Medication• Alternative Treatments

Basic Advice• Reassurance• The first step is to understand the problem• Avoid aggravating factors eg. noise, NSAIDs• Decreased intake of stimulants eg. caffeine and

nicotine• Relaxation• Avoiding silence• White noise eg. Detuned radio

Treatment• Basic advice• Hearing Aid• Tinnitus Masking Device• Tinnitus Instrument• Tinnitus Retraining Therapy• Psychological Treatment• Medication• Alternative Treatments

Hearing Aids• Essentially for poor hearing• Increases ambient noise• Decreases stress of poor hearing• Various shapes and sizes• Cost• Limitations• Up to 90% may benefit

Hearing Aids

Hearing aids are central to tinnitus management

• Reports of the use of hearing aids in the management of tinnitus go back over 60 years

• Because hearing loss is often associated with tinnitus, at least partial restoration of hearing should help to reduce the central gain in auditory perception that is a feature of tinnitus

• A recent scoping review of studies of hearing aids in tinnitus revealed that 17/18 publications showed improvements in tinnitus symptoms by fitting hearing aids

Treatment• Basic advice• Hearing Aid• Tinnitus Masking Device• Tinnitus Instrument• Tinnitus Retraining Therapy• Psychological Treatment• Medication• Alternative Treatments

Tinnitus Masking Device• Essentially counteracts tinnitus• Generate noise bands• Tinnitus Instruments

Combination of hearing aid and masker

Wide Band Noise Generators• Emit ‘white noise’• Elimination of silence• White noise boring: tendency to ignore• Gives the tinnitus sufferer something tangible to

work with• Reduce the starkness of the tinnitus signal

Treatment• Basic advice• Hearing Aid• Tinnitus Masking Device• Tinnitus Instrument• Tinnitus Retraining Therapy• Psychological Treatment• Medication• Alternative Treatments

Tinnitus Retraining Therapy• Based on evidence that a person can habituate to

acoustic noise in the environment

• Goal is to weaken or remove the functional connections between the auditory pathways

• Key elements: counseling and sound therapy

Normal Condition

Tinnitus Condition

Counseling alone

Sound Therapy alone

Counseling and Sound Therapy

Tinnitus Retraining Therapy• May take several months to take effect

• Minimum 12 months treatment

• Involves wearing ear noise generator, table top generator

Tinnitus Retraining Therapy

Treatment• Basic advice• Hearing Aid• Tinnitus Masking Device• Tinnitus Instrument• Tinnitus Retraining Therapy• Psychological Treatment• Medication• Alternative Treatments

Psychological Treatment• Relaxation therapy• Hypnosis• Cognitive Behavioural Therapy

Information, managing aggravating factors Applied relaxation Cognitive restructuring of thoughts and beliefs Sleep management advice Improvement in quality of life, not tinnitus itself

• Medication

Psychological and behavioural support

INTERVENTION DESCRIPTION

Counselling and education

• Delivered in person, to groups and via the internet• Variable results may depend on personal characteristics

Cognitive behavioural therapy

• Designed to modify maladaptive behavioural and emotional responses

• One-to-one and group settings, delivered by psychologists or psychiatrists, or via internet

• Statistically significant reductions in severity of tinnitus symptoms (P<0.05)

Relaxation therapy

• May help reduce tinnitus symptoms and depressive symptoms

Treatment• Basic advice• Hearing Aid• Tinnitus Masking Device• Tinnitus Instrument• Tinnitus Retraining Therapy• Psychological Treatment• Medication• Alternative Treatments

Medications

• No approved drugs (European Medicines Agency [EMA] or US Food and Drug Administration [FDA])

• Some psychopharmacological agents may help reduce the severity of psychological issues associated with tinnitus, and some may also lessen tinnitus symptoms

DRUG CLASS EXAMPLES OF DRUGS USED IN TINNITUS

Antidepressants tricyclics, selective serotonin reuptake inhibitors

Antipsychotics sulpiride

Mood stabilisers gabapentin, valproate

Sedatives/hypnotics

benzodiazepines

Treatment• Basic advice• Hearing Aid• Tinnitus Masking Device• Tinnitus Instrument• Tinnitus Retraining Therapy• Psychological Treatment• Medication• Alternative Treatments

Alternative Therapies•Vitamins

B1, B3, B6, B12, zinc, calcium, Mg

•Laser Therapy Germany Thought to increase ATP in cochlea

Alternative Therapies

•Hypnotherapy•Acupuncture•Ear canal magnets

Transcranial Magnetic Stimulation• Brain stimulation

▫ Identify active areas with PET▫ Apply magnetic stimulation (rTMS)▫ Evidence in small trials that there is some effect on

tinnitus▫ More detailed research awaited

• Questions▫ Can this be clinically useful or is it just an experimental technique?▫ Long term safety?

Conclusion Tinnitus is a common condition

Main role of ENT Surgeon is to exclude major illness and co-ordinate further treatment

Basic advice and counseling as well as empathic support is paramount

More severe cases may require psychological support, masking devices or Tinnitus Retraining Therapy

Thank you for Your Attention