1. Tinnitus – An ENT Perspective Mr. Marcus Choo

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. Tinnitus sufferers  Ludwig van Beethoven  Joan of Arc  Oscar Wilde  Vincent van Gogh  Charles Darwin  Neil Young  Eric Clapton  Bono  Sting  Barbara Streisand  William Shatner  Ronald Regan

5. 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

10. Mechanism of Hearing

14. 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

15. 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

16. Pathophysiology

17. 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

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

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

20. 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

21. Normal Ear

22. Diseased ear

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

24. Audiogram

25. MRI

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

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

28. 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

29. Support  Irish Tinnitus Association  DeafHear.ie  Hearing Aid Specialist  www.tinnitus.org

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

31. 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

32. Hearing Aids

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

35. Tinnitus Masking Device  Essentially counteracts tinnitus  Generate noise bands  Tinnitus Instruments  Combination of hearing aid and masker

36. 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

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

38. 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

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

40. Tinnitus Retraining Therapy

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

42. 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

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

44. Medications  No magical cure  Serc  Lignocaine  Temporary, intravenous  Alprazolam  Xanax  Side effects

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

46. 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

47. Alternative Therapies  Hypnotherapy  Acupuncture  Ear canal magnets  Hopi ear candles

48. Alternative Therapies

49. 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?

50. 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