1. Tinnitus

2. 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!

3. 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

4. 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

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

7. Effects of Tinnitus
Concentration
Hearing
Insomnia
Psychological

8. Ear Anatomy

9. Ear Anatomy

10. Mechanism of Hearing

11. Mechanism of Hearing

12. 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

13. 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.

14. 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

15. Pathophysiology

16. 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

17. Differential Diagnosis
Idiopathic (most common)
Outer ear disease
Wax, foreign body, infection
Middle ear disease
Infection, perforated eardrum, ossicular problems, tumour

18. Differential Diagnosis
Inner ear disease
Presbyacusis (older age hearing loss)
Meniere’s disease
Acoustic neuroma
Noise exposure
Drugs

19. 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

20. Normal Ear

21. Diseased ear

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

23. Audiogram

24. MRI

25. Treatment Aim to improve habituation rather than “cure” tinnitus
Most people don’t seek treatment
Multitude of potential treatments
Problems with scientific evidence

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

27. 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

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

29. 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

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

31. Tinnitus Masking Device
Essentially counteracts tinnitus
Generate noise bands
Tinnitus Instruments

32. 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

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

34. 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

35. Tinnitus Retraining Therapy
May take several months to take effect
Minimum 12 months treatment
Involves wearing ear noise generator, table top generator

36. Tinnitus Retraining Therapy

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

38. 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

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

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

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

42. 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

43. Alternative Therapies
Hypnotherapy
Acupuncture
Ear canal magnets
Hopi ear candles

44. Alternative Therapies

45. 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?

46. 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