Transcript Tinnitus
Tinnitus Diagnosis and Treatment Hossein Talebi; PhD of Audiology Assistant Professor of Audiology Isfahan University of Medical Sciences Introduction • Tinnitus is defined as sensations of hearing in the absence of external sounds The burden of tinnitus 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 Sound features of tinnitus NOISE CRITERIA POSSIBLE FEATURES Onset Sudden, gradual Pattern Pulsatile, intermittent, constant, fluctuating Site Right or left ear, both ears, within head Loudness Wide range, varying over time Quality Pure tone, noise, polyphonic Pitch Very high, high, medium, low Tinnitus sufferers • • • • • • Ludwig van Beethoven Vincent van Gogh Charles Darwin Neil Young Eric Clapton Ronald Regan 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 Effects of Tinnitus • • • • Concentration Hearing Insomnia Psychological Ear Anatomy Ear Anatomy Mechanism of Hearing 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 Peripheral events lead to central neurological changes Brain response to auditory deprivation • Patients with tinnitus exhibit enhanced auditory sensitivity DECREASED SOUND INPUT INCREASED SOUND SENSITIVITY • This is caused by hyperactivity of the auditory central nervous system • In patients with tinnitus and hearing loss, the tinnitus pitch and the hearing loss frequency spectrum are usually matched Tinnitus is a balance of sensory input and spontaneous activity • The decreased input from the cochlea, due to outer hair cell damage, results in readjustments in the central auditory system resulting in abnormal neural activity including hyperactivity, bursting discharges and increases in neural synchrony. AUDITORY DEPRIVATION AND CENTRAL GAIN ALTERED SPONTANEOUS NEURONAL ACTIVITY TINNITUS 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 Psychological associations with tinnitus A Team 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 vs. Diseased Ear Evaluation of Tinnitus • Audiological (hearing) Tests Audiogram, tympanogram Specialized hearing tests: SOAE, ECochG, ABR • MRI Associated symptoms Asymmetric hearing loss Evaluation - Subjective Tinnitus • Audiometry - assymetrical hearing loss, unilateral tinnitus - MRI r/o post fossa • Complete questionnaire for perceived severity:THI Measurement of Tinnitus • Pitch, loudness, minimum masking level, residual inhibition/post masking • Minimum masking level most clinical use • Pitch - match most prominent pure tone, poor reliability, octave difference • Loudness - Adjust pure tone to tinnitus • Most < 7 dB SL, may be 2 dB Measurement of Tinnitus • Minimal masking level - number of decibels to cover tinnitus • Residual inhibition - response of patients tinnitus post masking ENT Referral ENT Referral Acoustic Neuroma 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 Hearing Aids Hearing aids are central to tinnitus management • Reports of the use of hearing aids in the management of tinnitus go back over 60 years • Because hearing loss is often associated with tinnitus, at least partial restoration of hearing should help to reduce the central gain in auditory perception that is a feature of tinnitus • A recent scoping review of studies of hearing aids in tinnitus revealed that 17/18 publications showed improvements in tinnitus symptoms by fitting hearing aids 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 Combination of hearing aid and masker 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 Instrument 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 Normal Condition Tinnitus Condition Counseling alone Sound Therapy alone 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 • Medication Psychological and behavioural support INTERVENTION DESCRIPTION Counselling and education • • Delivered in person, to groups and via the internet Variable results may depend on personal characteristics • Designed to modify maladaptive behavioural and emotional responses One-to-one and group settings, delivered by psychologists or psychiatrists, or via internet Statistically significant reductions in severity of tinnitus symptoms (P<0.05) Cognitive behavioural therapy Relaxation therapy • • • May help reduce tinnitus symptoms and depressive symptoms Treatment • • • • • • • • Basic advice Hearing Aid Tinnitus Masking Device Tinnitus Instrument Tinnitus Retraining Therapy Psychological Treatment Medication Alternative Treatments Medications DRUG CLASS EXAMPLES OF DRUGS USED IN TINNITUS Antidepressants tricyclics, selective serotonin reuptake inhibitors Antipsychotics sulpiride Mood stabilisers gabapentin, valproate Sedatives/hypnoti benzodiazepines cs • No approved drugs (European Medicines Agency [EMA] or US Food and Drug Administration [FDA]) • Some psychopharmacological agents may help reduce the severity of psychological issues associated with tinnitus, and some may also lessen tinnitus symptoms Treatment • • • • • • • • Basic advice Hearing Aid Tinnitus Masking Device Tinnitus Instrument Tinnitus Retraining Therapy Psychological Treatment Medication Alternative Treatments Alternative Therapies • Vitamins B1, B3, B6, B12, zinc, calcium, Mg • Laser Therapy Germany Thought to increase ATP in cochlea Alternative Therapies • Hypnotherapy • Acupuncture • Ear canal magnets 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 Thank you for Your Attention