Tinnitus in the Older Adult

Drugs Aging 2004; 21 (5): 297-305THERAPY IN PRACTICE 1170-229X/04/0005-0297/$31.00/0

© 2004 Adis Data Information BV. All rights reserved.

Tinnitus in the Older AdultEpidemiology, Pathophysiology and Treatment Options

Nadir Ahmad and Michael Seidman

Department of Otolaryngology – Head and Neck Surgery, Henry Ford Health System, Detroit,Michigan, USA

ContentsAbstract . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2971. Epidemiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2982. Pathophysiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2993. Evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3004. Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3015. Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 304

Tinnitus is the perception of sound in the absence of an apparent acousticAbstractstimulus. More than 35 million Americans experience tinnitus, with 2–3 millionseverely debilitated by this distressing symptom. The prevalence increases withage and there is a high incidence associated with both noise-induced and age-relat-ed hearing loss. Although there are several theories regarding the pathophysiologyof tinnitus, the precise mechanism remains to be elucidated. The most compellingof these is the hypothesis that tinnitus occurs as a result of spontaneous andaberrant neural activity at any level along the auditory axis, even after cochlearnerve transection or labyrinthine ablation.

There are numerous aetiologies associated with tinnitus. Tinnitus, in clinicalpractice, is characterised as either objective or subjective. The distinction isrelevant in terms of both aetiology and treatment. Despite a large number oftherapeutic interventions and studies claiming success in treating tinnitus, a cureremains elusive. However, there are several potential treatment options that offerpatients varying degrees of symptomatic improvement and enhanced quality oflife.

It is imperative to formulate a rational and systematic approach in evaluatingan older adult with tinnitus. An individualised treatment regimen and the creationof a strong therapeutic relationship are the hallmarks of successful management ofthe patient with tinnitus.

Tinnitus is derived from the Latin word tinnire, the various descriptions attributed to this conditionmeaning ‘to ring’ and describes the perception of include a ringing, roaring, buzzing, chirping, hum-sound or noise emanating from the ears or head in ming or clicking sound. The sound may be continu-the absence of an evident external stimulus. Among ous in nature, vibratory (or nonvibratory), low-

298 Ahmad & Seidman

-pitched, high-pitched, multi-pitched or pulsatileand is frequently accompanied by hearing loss. Tin-nitus is clinically heterogeneous, reflecting multipleaetiologies, and its complexity is related to its bio-logical and psychological components. It is impera-tive to realise that tinnitus is a symptom, not adisease.

Most people experience tinnitus at some timeduring their life, often after noise exposure, but thisis generally transient and does not significantly af-fect their quality of life (Ahmad A, personal obser-vation). The vast majority of patients with tinnitusare not particularly bothered by their tinnitus andlearn to ignore it. However, those who experienceeither protracted or intractable tinnitus are oftendiscouraged by the apparent lack of proven andsuccessful therapies to combat this distressingsymptom. This problem is further exacerbated by a

Table I. Causes of objective tinnitus

Vascular (pulsatile tinnitus resulting from turbulent bloodflow)

Arteriosclerosis

Aneurysms

Arterio-venous malformations

Benign intracranial hypertension

Carotid stenosis

Dehiscent jugular bulb

Glomus tumours (jugulare and tympanicum)

Hydrocephalus

Hyperdynamic states (anaemia, pregnancy, hyperthyroidism)

Vascular loops

Venous anomalies

Muscular (contractions resulting in clicking, vibrationalsound)

Palatal myoclonus

Middle ear muscle myoclonus (tensor tympani, stapedius)

Miscellaneous

Patulous eustachian tube

limited understanding of its pathophysiology.In clinical practice, it is customary to characterise ly debilitated by this symptom.[2] It is estimated that

tinnitus as either objective or subjective. This dis- 12 million patients seek a professional opinion re-tinction is relevant in terms of both aetiology and garding this symptom. Men are more commonlytreatment. Objective tinnitus is rare and refers to a affected and the prevalence increases with age. Ap-sound that is also appreciated by an independent proximately 10–12% of men aged 65–74 years ex-examiner, often by auscultation. It can be generated, perience tinnitus.[2] In the hearing-impaired popula-for example, by rhythmic muscular spasms (e.g. tion, the prevalence of tinnitus is 75–80%.[2] A Brit-palatal myoclonus)[1] and turbulent blood flow. Sub- ish study reported that 10% of adults experiencedjective tinnitus, the predominant form, is experi-

prolonged spontaneous tinnitus lasting for moreenced solely by the patient. This type of tinnitus has

than 5 minutes, 1% had tinnitus resulting in severea complex origin and extensive differential diag-

annoyance and 0.5% had tinnitus that was so severenosis, and is often complicated by psychological

that they were unable to lead a normal life.[3] Fur-factors. Table I and table II outline the variousthermore, a Swedish study showed that 14.2% ofcauses of objective and subjective tinnitus.adults experienced tinnitus often or always andThe purpose of this article is to provide a rational2.4% were severely affected.[4] A 1996 survey ofand systematic approach to the successful manage-13 000 people with tinnitus, conducted by the Amer-ment of tinnitus in the older adults by highlightingican Tinnitus Association, showed that 71% report-the currently available treatment strategies. Formu-ed being depressed as a result of their tinnitus, 69%lating an individualised evaluation and treatmentthought that it interfered with social interaction,regimen, and creating a strong therapeutic relation-57% thought that it affected their work and 86%ship are the most effective methods of managingthought that it hindered the general enjoyment ofdebilitating tinnitus.life.[5] Additionally, three-quarters of respondentsexperienced a hearing loss that they felt could bene-1. Epidemiologyfit from a hearing aid; however, only one-quarter ofthem had a hearing aid. A majority of chronic tinni-Tinnitus affects approximately 35–50 million

Americans, with approximately 2–3 million severe- tus patients report dissatisfaction with their treat-

© 2004 Adis Data Information BV. All rights reserved. Drugs Aging 2004; 21 (5)

Tinnitus in the Older Adult 299

ment regimen. Thus, it is apparent that this distres- A theory that has gained increasing acceptancesing symptom pervades all aspects of one’s life, and states that lesions along the auditory tract cause anoften the lack of appropriate guidance and treatment alteration of normal sensory input to the auditorycan create undue frustration and anxiety on the part cortex, resulting in reorganisation of the auditoryof the patient. This frustration is often shared by the tract. The cortical neurons that were initially respon-treating physician, as there is currently no known sive to a particular frequency respond by acquiringcure. Thus, patients are all too often told to ‘learn to an increased sensitivity to the tone frequencies oflive with it’. Learning to live with it is an inappropri- adjacent pools of neurons, known as lesion-edgeate response and it must be realised that many peo-ple with severe tinnitus can achieve some reliefthrough a careful and thoughtful treatment plan.

2. Pathophysiology

Several theories have been proposed to explainthe tinnitus phenomenon, but the lack of consensusreflects the complex and elusive nature of this symp-tom. Initially, tinnitus was thought to originate as aresult of cochlear damage. The high incidence ofcochlear damage in those experiencing tinnitus ledmany to suggest that end-organ hair cell damageresulted in aberrant and independent stimulation ofthe cochlear nerve. This, in turn, would be processedby the auditory cortex and perceived as a specifictype of sound with a characteristic frequency. How-ever, there have been no histopathological or physi-ological studies implicating end-organ damage asthe inciting event.[6] The observation that tinnitusoccurs in those with complete resection of the eighthcranial nerve supports the assertion that the centralnervous system is involved in the generation andperception of abnormal sound or noise (Ahmad A,personal observation). This central-origin hypo-thesis has been attributed to increased spontaneousneural activity, resulting in aberrant sound percep-tion. Kaltenbach and Afman[7] hypothesised thatnoise-induced tinnitus may result from increasedhyperactivity in the dorsal cochlear nucleus, whichis induced by intense tone exposure. The alteredneurons continued to behave as though they werestimulated, even in the absence of a tone. Zachareket al.[8] demonstrated that hyperactivity in the dorsalcochlear nucleus was maintained despite partial andcomplete cochlear ablation. This observation sug-gests that spontaneous activity originates centrallyand is not dependent on input from the cochlea.

Table II. Causes of subjective tinnitus

Otological

Infectious

middle ear effusion

otitis externa

Neoplastic

cholesteatoma

meningioma

osteoma/exostosis

vestibular schwannoma

Labyrinthine

Meniere’s disease

noise-induced hearing loss

perilymphatic fistula

presbyacusis

Other

impacted cerumen

otosclerosis

Neurological

Multiple sclerosis

Migraine

Seizure disorders

Stress

Traumatic

Head trauma

Ossicular discontinuity

Tympanic membrane perforation

Neck injuries

Drugs (adverse effects)

Salicylates, NSAIDs, loop diuretics, aminglycosides and manyothers

Miscellaneous

Temporomandibular joint disorders

Nutritional deficiencies (zinc, iron, magnesium, cyanocobalamin[vitamin B12])

Metabolic disturbances (hyperlipidaemia, hypercholesterolaemia,hypercoagulable state)

Dietary (salt, caffeine, alcohol [ethanol], simple sugars,monosodium glutamate and other food additives)

Depression


300 Ahmad & Seidman

frequencies.[9] This phenomenon may account for patients have associated hearing loss or vertigo. Thethe phantom pain associated with limb amputation. clinician must be aware of drug-drug interactions, asHence, tinnitus has been referred to as an auditory many older adults receive several medications forphantom phenomenon.[10] The distorted perception their various ailments. Patient’s past medical historyof pain or distress in both limb amputation and may also reveal an inciting cause. Hypertension,tinnitus most likely reflects a maladaptive response diabetes mellitus, atherosclerosis, anaemia andof higher-order cortical centres.[11,12] A model pro- temporomandibular joint (TMJ) complaints are ex-posed by Hazell and Jastreboff[13] suggested that the amples of conditions associated with tinnitus.[6]

limbic system plays a large role in the response to The Tinnitus Handicap Inventory (THI), a scien-tinnitus and accounts for the emotional component tifically validated 25-item, self-perceived measureof this symptom. Thus, the aetiology of tinnitus is of the impact of tinnitus on daily living, is easy todiverse and may result from abnormal neural excita- administer and determines the severity and affect ontion of various levels of the tonotopically organised the patient’s quality of life.[15] During the evalua-auditory axis. It is further complicated by patient’s tion, attention should be addressed to the psychoso-emotional and psychological state. cial issues of the patient, in particular, whether he/

she experiences depression. Chronic malnourish-3. Evaluation ment and dehydration are more common in the older

adults, thus it is important to rule out potentiallyThe management of an older adult with tinnitus treatable contributing causes, such as metabolic and

entails a detailed evaluation before a specific treat- electrolyte abnormalities. A simple battery of labor-ment regimen can be instituted. A multidisciplinary atory tests, including complete blood count, electro-team approach, comprising the expertise of an oto- lyte panel, and measurements of lipids, blood glu-laryngologist, audiologist and, occasionally, a psy- cose and thyroid function, should be ordered duringchiatrist, is advocated to meet the symptomatic and the initial evaluation.emotional needs of the patient. Although patient

A focused otolaryngological and neurologicaleducation and counselling is undoubtedly an impor-physical examination are subsequently undertakentant adjunct to treating tinnitus, a survey of over 100to rule out pathological conditions originating frompatients revealed that counselling alone resulted inthe vestibular system (such as Meniere’s disease andsymptom improvement in <20% of patients.[14]

acoustic neuroma) or the central nervous systemTinnitus is not a specific disease entity, but rather

(such as multiple sclerosis and migraine). Duringa symptom, with many potential causes. Therefore,

the examination, emphasis should be placed ona thorough patient history and physical examination

structures that can potentially generate the particularare essential components of the initial evaluation.

sound, such as the TMJ, theCharacteristics of the perceived sound, such as type,

palate and vascular structures in the head andlocation (unilateral and bilateral), pitch, loudness,neck. There are several noteworthy associations thatduration and extent to which it is affecting thethe clinician must keep in mind while examining thepatient’s lifestyle, are fundamental features of thetinnitus patient. For example, unilateral sen-initial work-up. The onset, exacerbating or alleviat-sorineural hearing loss and tinnitus are suggestive ofing factors, and associated neurological signs oran acoustic neuroma and the presence, on otoscopicsymptoms must be ascertained as they help to nar-examination, of a pulsatile, purple mass behind therow the differential diagnosis. Additionally, the pa-tympanic membrane should prompt an investigationtient should be questioned about their use of poten-for a glomus tumour.tially ototoxic drugs (aspirin [acetylsalicylic acid],

aminoglycoside antibacterials or quinine), exposure A comprehensive audiological evaluation is ad-to industrial or occupational noise, previous history ministered after the initial workup. This evaluationof head trauma, family history and whether the includes an audiogram to measure pure-tone thresh-



olds (from air and bone conduction) and speech surance and counselling as the initial form of treat-discrimination, measurement of auditory reflexes, ment. This is supplemented with a trial of dietarytympanometry to measure the impedance of the modification and restriction. As an example, reduc-middle ear to acoustic energy and in selected cases, tion of caffeine, sodium, alcohol (ethanol), simplespontaneous oto-acoustic emission testing[16] may sugars (i.e. sweets) and nicotine intake are initiatedbe performed. In a patient with unilateral tinnitus for a period of 1 month. At the subsequent encoun-and hearing loss, further investigation is warranted. ter, the patient is asked whether there has beenThe combination of a high-frequency hearing loss, noticeable improvement in the tinnitus. Additional-poor speech discrimination, and unilateral tinnitus ly, counselling on diet and hydration should beshould alert the clinician of a possible acoustic neu- offered as older adults commonly experience miner-roma. Auditory brain-stem evoked responses and al and electrolyte deficiencies.imaging with computed tomography or magnetic Those with moderate-to-moderately severe tinni-resonance imaging provide information on the loca-

tus, which may interfere with sleep and performingtion of the lesion along the auditory tract. A patient

routine daily activities, should be managed morewith pulsatile tinnitus, or suspected of having a

intensively. The use of hearing aids, masking de-glomus tumour, may need evaluation with a magnet-

vices (sound-generating instruments that produceic resonance angiogram, or an angiogram. Addition-

ambient sounds), and habituation therapy are avail-al tests, such as electroencephalography, may beable options in the initial treatment regimen. Habitu-required to rule out seizure abnormalities or mi-ation or tinnitus retraining therapy (TRT) is derivedgraine equivalents that could have tinnitus as afrom a neurophysiological model of tinnitus devel-symptom.oped by Jastreboff et al.[14] and Henry et al.[17] Thismodel implicates the limbic system (responsible for4. Treatmentsetting one’s emotional state) and the autonomicsystem (generates the ‘flight’ or ‘fight’ response) asThe management of an older adult with tinnituscontributing factors in the perception of tinnitus,entails an individualised approach and dependsmainly its annoyance. TRT entails both directivelargely on its severity and affect on the patient’scounselling, which aims to allay the fears of thequality of life. Although there are numerous reportspatients by educating them on the results of theirclaiming success in treating tinnitus with variousmedical and audiological evaluation, as well asdrugs and herbal therapies, these are mostly anecdo-sound therapy.[17] Directive counselling involves antal and not convincingly supported by adequatelyin-depth discussion to educate the patient on whydesigned clinical trials. Many of these pharmacolog-tinnitus occurs. The goal of sound therapy is toical agents are potentially effective; however, theachieve habituation of the tinnitus, where patientsorigin and perception of tinnitus are diverse and,become unaware of the presence of the tinnitushence, it has been difficult to define measures of

efficacy or cure. Nevertheless, there are many treat- (although it remains when they focus on it). Further-ment options available to patients with tinnitus. more, even if tinnitus persists, it should not evoke

annoyance. Habituation to tinnitus is induced byA proposed method of managing patients withexposing the patient to low-level broadband noisetinnitus is to initially categorise them into three(just below the patient’s perceived tinnitus sound),primary groups: mild, moderate and severe, accord-

ing to the degree of distress they are experiencing. produced by wearable noise generators. This noiseThis determination is made, in part, by a patient’s is hypothesised to decrease the aberrant signals toown subjective assessment, and standardised using which the brain responds and, hence, neuronal over-the THI. activity will diminish.[14] For habituation to occur,

masking of the tinnitus must be avoided. JastreboffPatients with mild tinnitus that does not interfereet al.[14] state that one cannot learn to ‘tune out’with their activities of daily living are offered reas-


302 Ahmad & Seidman

something one cannot hear. TRT takes as long as 2 verse effects with the patient prior to selecting ayears to complete and has been reported to provide particular medication.significant improvement in 80% of patients with Medications that are commonly prescribed fortinnitus.[18] However, critics argue that TRT is not as tinnitus include tricyclic antidepressants (amitripty-effective as cognitive-behavioural intervention[19]

line) and benzodiazepines (alprazolam, diazepam).and that the confusion in selecting adequate treat-

Other medications that have achieved varying de-ment and control subjects, the lack of appropriately

grees of success include nicotinic acid, betahistine,designed clinical trials comparing TRT with otherGinkgo biloba extract, gabapentin, carbamazepine,treatments, and the poor choice of outcome mea-baclofen and clonazepam (table III). The effective-sures, limit the value of this therapeutic modality.[20]

ness of these medications is largely anecdotal andThe tinnitus masking technique is another alter-native to the management of the patient with mild-to-moderate tinnitus. Masking devices produce‘white noise’, sounds such as waterfalls and oceanwaves, which mask the tinnitus and may help toreduce its perceived annoyance. Hearing aids mayalso be beneficial in making the tinnitus less dis-tracting. There have been reports of tinnitus sup-pression with cochlear implantation, although themechanism remains unclear.[21,22] A recent study of38 patients with severe to profound hearing loss andtinnitus noted that 35 patients (92%) experienced areduction in tinnitus intensity after cochlear implan-tation.[21] Further study into the mechanisms bywhich currently available multichannel cochlear im-plants decrease tinnitus severity is warranted. Gen-erally, it is believed that the electrical impulses arereducing the tinnitus. This has been the basis ofelectrical promontory stimulation which, accordingto Steenerson and Cronin,[23] can improve tinnitus inapproximately 50% of patients.

In patients experiencing moderately severe-to-severe tinnitus, pharmacological therapy may be ofconsiderable benefit in conjunction with the modali-ties mentioned earlier. Currently, there is no knowndrug or curative therapy that is US FDA approvedfor the treatment of tinnitus. Clinical trials that at-tempt to demonstrate the benefit of a specific thera-peutic intervention have been limited by poorly de-signed methodology and outcome measures and donot reflect the magnitude of placebo effects, whichare considerable in these patients.[24] However, nu-merous studies have suggested that, in selected pa-tients, certain medications may reduce tinnitus se-verity. It is imperative to discuss the potential ad-

Table III. Medications that might be useful for tinnitus

Drug class Medication

Anaesthetics Lidocaine (lignocaine)

Procaine

Antidepressants Nortriptyline

Paroxetine

Fluoxetine

Sertraline

Bupropion

Amitriptyline

Antiepileptic drugs Carbamazepine

Phenytoin

Anti-anxiety agents Alprazolam

Clonazepam

Diazepam

Antihistamines Chlorphenamine (chlorpheniramine)

Meclozine

Diuretics Furosemide (frusemide)

Vasoactive medications Ergoloid mesylates

Vinpocetine

Pentoxifylline

Herbs Ginkgo biloba

Cimicifuga (black cohosh)

Ligustrum

Pulsatilla

St John’s Wort (Hypericum perforatum)

Vitamins and minerals Magnesium (400 mg/day)

Calcium (1000 mg/day)

Potassium (3500 mg/day)

Zinc

Cyanocobalamin (vitamin B12)

β-Carotene

Selenium

Ascorbic acid (vitamin C)

Tocopherol (vitamin E)

Nicotinic acid



randomised clinical trials have generally failed to intratympanic protocol, as described by Shea, withan approximately 50% overall success rate.[31]show a significant benefit to patients with tinnitus.

An increased interest in the use of complementa-Tricyclic antidepressants are useful in patientsry and alternative medicine (CAM) to treat tinnituswith concomitant depression. A 12-week, double-is the result of dissatisfaction with conventionalblind, randomised controlled trial, conducted bytreatments, which have not been shown to conclu-Sullivan et al.,[25] demonstrated that nortriptylinesively address this distressing symptom. Vitaminwas superior to placebo in decreasing depression,supplementation (B complex), mineral supplemen-functional disability and tinnitus loudness asso-tation (zinc,[32] magnesium, calcium), herbal ex-ciated with severe chronic tinnitus. According to thetracts (Ginkgo biloba), other alternative remedies1996 American Tinnitus Association survey, the(ergoloid mesylates, vinpocetine), and acupunctureincidence of depression among patients with tinnitusare examples of treatments that fall under the rubricis approximately 70%.[5] A trial of antidepressantof CAM. Although these treatments have not beentherapy should be considered in these patients, withextensively studied in randomised, clinical trials,careful monitoring of the adverse effects of drugsthere are numerous anecdotal reports touting theirand interactions with other drugs. Benzodiazepinesbenefit in tinnitus management. Ginkgo biloba is thehave a significant potential for adverse effects andmost extensively studied of the CAM therapies.are not routinely used as a first-line treatment. Stud-However, a recently conducted double-blind, place-ies have generally not supported their benefit inbo-controlled trial found that this extract was nocontrolling tinnitus and their risks must be weighedmore effective than placebo in treating tinnitus.[33]

with any marginal benefit they may provide to theUnfortunately, this study chose a dose that was toopatient.[26,27] The leading exception to this is al-low as, according to the German Commission E,[34]

prazolam which, in one randomised, placebo-con-the appropriate dose to consider is 240mg of atrolled study, has been shown to reduce tinnitus instandardised Ginkgo preparation, twice daily. Theup to 76% of the treated patients.[28] Alprazolam wasdose used in the above referenced study wasnoted to be less addictive and less sedating than160 mg/day.other benzodiazepines.

There may be some correlation between the de-Initial reports that lidocaine (lignocaine) sup-cline in vitamin B12 levels and the increasing preva-pressed tinnitus were misleading, as the effects werelence of tinnitus in older adults. A study by Shemeshtemporary and the potential for adverse effects andet al.[35] showed a high prevalence (47%) of vitamintinnitus exacerbation limited its use as a therapeuticB12 deficiency in patients with chronic tinnitus. Thisoption.[26,27] Silverstein et al.[29] employed in-deficiency was more widespread and severe in thetratympanic corticosteroid delivery for the treatmenttinnitus group that was associated with noise expo-of tinnitus and reported that 15 out of 32 (47%)sure. This suggests a relationship between vitaminpatients noted improvement in their tinnitus, mostB12 deficiency and dysfunction of the auditory path-often in patients with Meniere’s disease and tinnitusway. Supplemental cyanocobalamin (vitamin B12)(9 out of 15; 60%). Further studies to elucidate thewas found to provide some relief in several patientsmechanism of intratympanic corticosteroid activitywith severe tinnitus.[35] Because cyanocobalamin isin tinnitus and confirm these promising results arepoorly absorbed when consumed, a suggested dailywarranted. Shea and Ge[30] have been treating pa-dose is 1000μg. Cyanocobalamin is better absorbedtients with Meniere’s disease, who have tinnitus,if it is dissolved under the tongue, and best absorbedutilising a combination of counselling, systemicallyif it is given by injection.administered lidocaine and intratympanic lidocaine,

dexamethasone, and hyaluronan. They have report- The use of CAM treatments has attracted bothed excellent success, but their work has not been interest due to their anecdotal success and derisionreplicated. The senior author (Seidman) has used the for the lack of scientific evidence of their purported


304 Ahmad & Seidman

success. It remains to be seen whether these thera- their tinnitus, as the possibility of worsening symp-toms always exists.peutic modalities will gain increasing acceptance in

the conventional medical community. These alter-5. Conclusionnative therapies are used by 40–50% of Americans

to treat a wide array of chronic and debilitating Tinnitus is clinically heterogeneous and its com-symptoms.[36] As a growing number of patients so- plexity reflects the multitude of potential aetiologieslicit the internet for advice on treatment options for and areas along the auditory axis that can generatetinnitus, it is incumbent upon the clinician being this distressing and debilitating symptom. This com-aware of these various remedies (table III) and their plexity partly explains the lack of a proven, singlepotential for benefit as well as harm. cure and the difficulty in designing an appropriate

scientific methodology to assess various potentialThe management of patients who are severelytreatment options. However, a systematic evaluationdisabled by their tinnitus is complex and requires theand an individualised treatment approach are theincorporation of several therapeutic modalities. Ex-hallmarks of tinnitus management and offer patientstensive counselling, patient education and psycho-the best currently available potential for either a curelogical evaluation are offered initially, with the useor improvement in their symptoms. Advocating spe-of concomitant habituation therapy. Masking ther-cific treatments should be guided by an understand-apy is an alternative, but has not yielded the successing of the risk/benefit ratio of these options and theof tinnitus retraining.[37] Psychotropics are pre-degree to which a patient is suffering from tinnitus.scribed for those with intractable or persistent tinni-Further studies to elucidate the nature and locationtus, especially in those with associated depression.of the tinnitus ‘generator’ will stimulate research toOther treatments that have anecdotal reports of suc-develop more effective treatment modalities.cess in addressing severe tinnitus include electrical

stimulation, stellate ganglion blocks, hyperbaric ox-Acknowledgementsygen, and biofeedback techniques.[38]

The authors have provided no information on sources ofSurgery is indicated in an extremely limited sub-funding or on conflicts of interest directly relevant to theset of patients with severe, intractable tinnitus andcontent of this review.

reports of success with various procedures havebeen controversial. Patients who perceive their tin- Referencesnitus as originating in the nonfunctioning ear (de- 1. Seidman MD, Arenberg JG, Shirwany NA. Palatal myoclonus

as a cause of objective tinnitus: a report of six cases and aspite objective evidence of no auditory function)review of the literature. Ear Nose Throat J 1999 April; 78 (4):may be the candidates for surgery. The surgical292-4, 296-7

options include transcochlear cochleovestibular 2. Adams PF, Hendershot GE, Marano MA. Current estimatesfrom the National Health Interview Survey, 1996. Hyattsvilleneurectomy (CVN), translabyrinthine CVN and(MD): National Center for Health Statistics, 1999

microvascular decompression. The success rate in 3. Vesterager V. Fortnightly review: tinnitus: investigation andmanagement. BMJ 1997; 314: 728-31reducing tinnitus perception for transcochlear CVN

4. Axelsson A, Ringdahl A. Tinnitus: a study of its prevalence andis approximately 67%,[38,39] for translabyrinthinecharacteristics. Br J Audiol 1989; 23: 53-62

CVN the success rate is 40%[38,40] and microvascular 5. Tinnitus statistics [online]. Available from URL: http://www.stop-the-ring.com/tinnitus_statistics.htm [Accesseddecompression for those with a vascular loop pul-2003 Apr 15]sating on the cochlear nerve has been reported to 6. Ator GA, Lambert PR, Canalis RF. Tinnitus. In: Canalis RF,

improve tinnitus in 29% of males and 55% of fe- Lambert PR, editors. The ear: comprehensive otology. Phila-delphia (PA): Lippincott Williams & Wilkins, 2000: 559-70males.[41] Another study revealed a 60% improve-

7. Kaltenbach JA, Afman CE. Hyperactivity in the dorsal cochlearment with microvascular decompression in patients nucleus after intense sound exposure and its resemblance to

tone-evoked activity: a physiologic model for tinnitus. Hearwith tinnitus assessed by survey responses.[42] Pa-Res 2000 Feb; 140 (1-2): 165-72tients must be carefully counselled prior to any 8. Zacharek MA, Kaltenbach JA, Mathog TA, et al. Effects of

surgical procedure designed to reduce the severity of cochlear ablation on noise induced hyperactivity in the hamster



dorsal cochlear nucleus: implications for the origin of noise 28. Johnson RM, Brummett R, Schleuning A. Use of alprazolam forinduced tinnitus. Hear Res 2002 Oct; 172 (1-2): 137-43 relief of tinnitus: a double blind study. Arch Otolaryngol Head

Neck Surg 1993 Aug; 119 (8): 842-59. Eggermont JJ. Central tinnitus. Auris Nasus Larynx 2003 Feb;30 Suppl.: 7-12 29. Silverstein H, Choo D, Rosenberg SI, et al. Intratympanic

steroid treatment of inner ear disease and tinnitus (preliminary10. Jastreboff P. Phantom auditory perception (tinnitus): mechan-report). Ear Nose Throat J 1996 Aug; 75 (8): 468-71isms of generation and perception. Neurosci Res 1990 Aug; 8

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Tinnitus in the Older Adult