Tinnitus

Introduction Tinnitus is defined as sensations of hearing in the absence of external sounds 155 million Americans have sought treatment 1/3 of the population have had tinnitus at some stage in their lives Up to 20% of the population currently experience tinnitus “Google” search for tinnitus identified 4.2 million sites!

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

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 Noise exposure Medication Infection Older age hearing loss Meniere’s Disease Outer/Middle ear disease Acoustic neuroma Unknown (by far the most common)

Effects of Tinnitus Concentration Hearing Insomnia Psychological

Ear Anatomy

Ear Anatomy

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

Pathophysiology deafferentation (hearing loss) leads to pathologic reorganization of the auditory pathway. Hearing loss decreases the afferent stream of neural activity from the cochlea to the auditory cortex. Chronic deafferentation alters activity in the auditory brainstem and midbrain, which alters the tonotopic organization of the auditory cortex. Brainstem spontaneous activity may increase, and midbrain patterns may change (e.g., with aberrant synchronization or bursting) because of compensatory downregulation of inhibition. Altered activity in the auditory pathway may be responsible for the tinnitus percept.

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

An ENT Surgeons 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

Diseased ear

Evaluation of Tinnitus Audiological (hearing) Tests Audiogram, tympanogram Specialised hearing tests MRI Associated symptoms Asymmetric hearing loss

Audiogram

MRI

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

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

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 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

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 Neurofeedback

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

Medications No magical cure Mg TCA Gabapentin SSRI,SNRI BZD Melatonin

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

Alternative Therapies Herbs Ginkgo biloba (over 100 studies), black cohosh, Mullein Vitamins B1, B3, B6, B12, folate, zinc, calcium, Mg, Mn Laser Therapy Germany Thought to increase ATP in cochlea

Alternative Therapies Hypnotherapy Acupuncture Ear canal magnets Hopi ear candles

Alternative Therapies

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