1. Tinnitus Prof. Hamad Al-Muhaimeed Professor/Consultant Department of Otorhinolaryngology King Abdulaziz University Hospital

2. Tinnitus DefinitionDefinition ClassificationClassification Objective tinnitus – pulsatileObjective tinnitus – pulsatile Subjective tinnitusSubjective tinnitus TheoriesTheories EvaluationEvaluation TreatmentTreatment

3. Introduction Tinnitus -“The perception of sound in the absence of external stimuli.”Tinnitus -“The perception of sound in the absence of external stimuli.” Tinnere – means “ringing” in LatinTinnere – means “ringing” in Latin Includes Buzzing, roaring, clicking, pulsatile soundsIncludes Buzzing, roaring, clicking, pulsatile sounds

4. Tinnitus May be perceived as unilateral or bilateralMay be perceived as unilateral or bilateral Originating in the ears or around the headOriginating in the ears or around the head First or only symptom of a disease process or auditory/psychological annoyanceFirst or only symptom of a disease process or auditory/psychological annoyance

5. Tinnitus 40 million affected in the United States40 million affected in the United States 10 million severely affected10 million severely affected Most common in 40-70 year-oldsMost common in 40-70 year-olds More common in men than womenMore common in men than women

6. Classification Objective tinnitus – sound produced by paraauditory structures which may be heard by an examinerObjective tinnitus – sound produced by paraauditory structures which may be heard by an examiner Subjective tinnitus – sound is only perceived by the patient (most common)Subjective tinnitus – sound is only perceived by the patient (most common)

7. Objective -Pulsatile tinnitus Arteriovenous malformationsArteriovenous malformations Vascular tumorsVascular tumors Venous humVenous hum AtherosclerosisAtherosclerosis Ectopic carotid arteryEctopic carotid artery Persistent stapedial arteryPersistent stapedial artery Dehiscent jugular bulbDehiscent jugular bulb Vascular loopsVascular loops Cardiac murmurs Pregnancy Anemia Thyrotoxicosis Paget’s disease Benign intracranial hypertension

8. Subjective Tinnitus Much more common than objectiveMuch more common than objective Usually nonpulsatileUsually nonpulsatile Presbycusis Noise exposure Meniere’s disease Otosclerosis Head trauma Acoustic neuroma Drugs Middle ear effusion TMJ problems Depression Hyperlipidemia Meningitis Syphilis

9. Conductive hearing loss Conductive hearing loss decreases level of background noiseConductive hearing loss decreases level of background noise Normal paraauditory sounds seem amplifiedNormal paraauditory sounds seem amplified Cerumen impaction, otosclerosis, middle ear effusion are examplesCerumen impaction, otosclerosis, middle ear effusion are examples Treating the cause of conductive hearing loss may alleviate the tinnitusTreating the cause of conductive hearing loss may alleviate the tinnitus

10. Mechanism Poorly understood mechanisms of tinnitus productionPoorly understood mechanisms of tinnitus production Abnormal conditions in the cochlea, cochlear nerve, ascending auditory pathways, auditory cortexAbnormal conditions in the cochlea, cochlear nerve, ascending auditory pathways, auditory cortex Hyperactive hair cellsHyperactive hair cells Chemical imbalance Chemical imbalance

11. Drugs that cause tinnitus AntinflammatoriesAntinflammatories Antibiotics (aminoglycosides)Antibiotics (aminoglycosides) Antidepressants (heterocyclines)Antidepressants (heterocyclines) Aspirin Quinine Loop diuretics Chemotherapeutic agents (cisplatin, vincristine)

12. Evaluation - History Careful historyCareful history QualityQuality PitchPitch LoudnessLoudness Constant/intermittentConstant/intermittent OnsetOnset Alleviating/aggravating factorsAlleviating/aggravating factors

13. Evaluation - History InfectionInfection TraumaTrauma Noise exposureNoise exposure Medication usageMedication usage Medical historyMedical history Hearing lossHearing loss VertigoVertigo PainPain Family historyFamily history Impact on patientImpact on patient

14. Evaluation – Physical Exam Complete head & neck examComplete head & neck exam General physical examGeneral physical exam Otoscopy (glomus tympanicum, dehiscent jugular bulb)Otoscopy (glomus tympanicum, dehiscent jugular bulb) Search for audible bruit in pulsatile tinnitusSearch for audible bruit in pulsatile tinnitus –Auscultate over orbit, mastoid process, skull, neck, heart using bell and diaphragm of stethoscope –Toynbee tube to auscultate EAC

15. Evaluation – Physical Exam Light exercise to increase pulsatile tinnitusLight exercise to increase pulsatile tinnitus Light pressure on the neck (decreases venous hum)Light pressure on the neck (decreases venous hum) Valsalva maneuver (decrease venous hum)Valsalva maneuver (decrease venous hum) Turning the head (decrease venous hum)Turning the head (decrease venous hum)

16. Evaluation - Audiometry PTA, speech descrimination scores, tympanometry, acoustic reflexesPTA, speech descrimination scores, tympanometry, acoustic reflexes Pitch matchingPitch matching Loudness matchingLoudness matching Masking levelMasking level

17. Laboratory studies As indicated by history and physical examAs indicated by history and physical exam Possibilities include:Possibilities include: –Hematocrit –FTA absorption test –Blood chemistries –Thyroid studies –Lipid battery

18. Treatments Multiple treatmentsMultiple treatments Avoidance of dietary stimulants: coffee, tea, cola, etc.Avoidance of dietary stimulants: coffee, tea, cola, etc. Smoking cessationSmoking cessation Avoid medications known to cause tinnitusAvoid medications known to cause tinnitus Reassurance White noise from radio or home masking machine

19. Treatments - Medicines Many medications have been researched for the treatment of tinnitus:Many medications have been researched for the treatment of tinnitus: –Intravenous lidocaine suppresses tinnitus but is impractical to use clinically –Tocainide is oral analog which is ineffective –Carbamazepine ineffective and may cause bone marrow suppression

20. Treatments - Medicines Alprazolam (Xanax)Alprazolam (Xanax) –Johnson et al (1993) found 76% of 17 patients had reduction in the loudness of their tinnitus using both a tinnitus synthesizer and VAS (dose 0.5mg-1.5 mg/day) –Dependence problem, long-term use is not recommended

21. Treatments - Medicines Nortriptyline and amitriptylineNortriptyline and amitriptyline –May have some benefit –Dobie et al reported on 92 patients –67% nortriptlyine benefit, 40%placebo Ginko bilobaGinko biloba –Extract at doses of 120-160mg per day –Shown to be effective in some trials and not in others –Needs further study

22. Treatments Hearing aids – amplification of background noise can decrease tinnitusHearing aids – amplification of background noise can decrease tinnitus Maskers – produce sound to mask tinnitusMaskers – produce sound to mask tinnitus Tinnitus instrument – combination of hearing aid and maskerTinnitus instrument – combination of hearing aid and masker

23. Treatments Cochlear implantsCochlear implants –Have shown some promise in relief of tinnitus –Ito and Sakakihara (1994) reported that in 26 patients implanted who had tinnitus 77% reported either tinnitus was abolished or suppressed, 8% reported worsening

24. Treatments SurgerySurgery –Used for treatment of arteriovenous malformations, glomus tumors, otosclerosis, acoustic neuroma –Some authors have reported success with cochlear nerve section in patients who have intractable tinnitus and have failed all other treatments, this is not widely accepted

25. Conclusions Tinnitus is a common problem with an extensive differentialTinnitus is a common problem with an extensive differential Need to identify medical process if involvedNeed to identify medical process if involved Pulsatile/Nonpulsatile is important distinctionPulsatile/Nonpulsatile is important distinction Will only become more common with aging of our populationWill only become more common with aging of our population Research into mechanism and treatments is needed to better help our patientsResearch into mechanism and treatments is needed to better help our patients