1. Diagnosis and Treatment/Management of Tinnitus Yongbing Shi, M.D., Ph.D. Tinnitus Clinic OHSU Department of Otolaryngology Head & Neck Surgery

2. What Tinnitus Is Definition: A perception of sound without external sound source A common symptom – 15% of population Subjective and objective tinnitus

3. What Cause Tinnitus Changes in the auditory system: conductive hearing loss (outer and middle ear disorders), sensorineural hearing loss (inner ear/central auditory pathways) Systemic diseases: head/neck injury, anemia, renal diseases, hormonal disturbances Medications: ototoxic antibiotics, anti- inflammatories, quinine products, cytotoxic medications, and others

6. How Tinnitus Is Generated Altered neuronal activities along the auditory pathway: de-afferentation; loss of inhibition; enhanced spontaneous activities; rhythmic activities; Abnormal activation of auditory cortex Self-sustaining and perpetuating activities Neuroplasticity in chronic tinnitus

8. How Tinnitus Affects Patients In addition to annoying auditory perception Involvement of non-auditory neural structures in the CNS Interactions between auditory and non- auditory activities Non-auditory symptoms are a major part of the tinnitus problem

9. Evaluation of a Tinnitus Patient Establish the diagnoses Look for treatable causes Determine severity of tinnitus Determine relations between tinnitus and non-auditory complaints Identify non-auditory factors that may contribute to tinnitus complaints

10. Establish Tinnitus Diagnoses Is it tinnitus Subjective or objective tinnitus Other qualities of tinnitus: acute/chronic, high/low pitches, unilateral/bilateral, constant/intermittent, pulsatile/non-pulsatile Possible causal/underlysing conditions Associated non-auditory diagnoses

12. Determine Severity of Tinnitus Self-rated tinnitus loudness Matched tinnitus loudness Tinnitus severity evaluation questionnaires (THI, TSI, TQ, TFI, etc) Mild: education/reassurance/counseling, hearing aids or masking devices Moderate: plus habituation therapies, possibly medications and follow up Severe: plus referrals

13. Determine Relations between Tinnitus and Non-Auditory Complaints Sleep: how insomnia and tinnitus affect each other Mood disturbances: how anxiety, stress and other mood changes affect tinnitus and vice versa Cognitive dysfunction: does tinnitus affect the patient’s concentration, memory, learning and other abilities Vicious circle

14. Identify Non-Auditory Factors Contributing to Complaints Personality Relational difficulties Emotional difficulties Economical difficulties Behavioral problems

15. Tinnitus Treatment Treat causal conditions Manage tinnitus and related problems when there is no treatable causes

16. Management of Tinnitus with No Treatable Causes Reduce tinnitus perception Promote tinnitus habituation Improve sleep Address mood disturbances Counsel on life style changes and other related issues Judicious use of alternative medicine approaches Management goal: minimal tinnitus impact on patient, improved functioning and quality of life

17. Reduce Tinnitus Perception Sound therapy (masking): sound generators, personal listening devices, sound pillow, bed side sound machines, etc. Sound choices: band noises, tonal sounds, music, patterned sounds, etc Hearing aids: double benefits Combination units Cochlear implants Ultrasound devices Medications: benzodiazepines, etc.

18. Promote Tinnitus Habituation Acoustic stimulation (sound therapy): broadband noise (TRT), adjusted tonal sounds (Neuromoics) Patient education and counseling Long term follow ups Time Management of other contributing factors: sleep, anxiety, depression, stress, etc.

19. Improve Sleep Medications: alprazolam, zolpidem, melatonin receptor agonists, antidepressants, etc. Masking in bedroom: bed side machines, sound pillow, headband headphones Sleep hygiene: sleep habit, factors affecting sleep Psychological conditions affecting sleep Other medical conditions affecting sleep: OSA, systemic medical diseases, etc. Referral to specialty sleep clinic

20. Address Mood Disturbances First hand counseling Medications: anti-depressants, anxiolytics, other sedatives and anti-seizure medications Referral to specialists: psychiatrist, psychologist

21. Counsel on Other Related Issues Socioeconomic issues: job, finance, work- related stress, etc Relations: family issues, social activities, etc Other activities: music, hunting, racing, etc Life style changes: smoking, alcohol, diet, etc Other medical issues potentially affecting tinnitus: hypertension, diabetes, anemia, hypothyroidism, depression, etc

22. Judicious Use of Alternative Medicine Approaches Herbal medicine and supplements Acupuncture Chiropractic treatments, etc

23. Team Approach General practitioner Otolaryngologist Audiologist Neurophysiologist Psychiatrist/psychologist Dentist Other specialists Social workers Family members

24. Take Home Points Thorough evaluation including non-auditory issues Treat causes whenever possible Management of chronic tinnitus (there is NO cure) includes reducing tinnitus perception, habituation to tinnitus and management of related non-auditory issues Goal: reduced tinnitus impact and improved functioning and quality of life