Transcript Overview of tinnitus – including the role of hearing aids in tinnitus

Tinnitus
Diagnosis and Treatment
Dr Mandana Amiri
Otolaryngologist
KUMS
Objectives
• To describe the key features of tinnitus
• To show how tinnitus is a substantial health burden
• To reveal the role of hearing loss in tinnitus
• To present the options for management, including the central role of hearing aids
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Slide 2
What is tinnitus?
• Perception of sound but no external
source
• Usually experienced as buzzing, hissing or
ringing
–
Not fully-formed sounds
e.g. speech or music
–
Not sound hallucinations experienced
during bouts of mental illness
–
Occurs in one or both ears, or arising
within the head
• It can have a profound effect on the
sufferer
“… perceived severity of tinnitus
correlates closer to psychological and
general health factors, such as pain or
insomnia, than to audiometrical
parameters …”
Langguth B, et al. (2013) Lancet Neurol.12:920-930; Zöger S et al. (2006) Psychosomatics. 47:282-288.
(Zoger et al, 2006)
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Slide 3
The burden of tinnitus
SCALE OF
PROBLEM
IMPACT
TINNITUS RISK
FACTORS
A GROWING
PROBLEM
• Tinnitus affects
• Tinnitus limits
• Hearing
• Increasing size
10%–15% of the
general
population
worldwide
• This is an
estimated 280
million people
daily living in
1%–2% of
people with
tinnitus
impairment
• Increasing age
of the elderly
population
• Gender (male)
• Frequency of
• Exposure to
noise
Geocze L, et al. (2013) Braz J Otorhinolaryngol.79:106-111; Langguth B, et al. (2013) Lancet Neurol.12:920930; Roberts LE, et al. (2010) J Neurosci. 30:14972-14979.
noise exposure
in work and
leisure
environments
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Slide 4
Evaluating tinnitus severity
• Tinnitus is highly variable. Some patients
are able to cope with the noise and their
lives continue as normal.
Langguth B, et al. (2013) Lancet Neurol.12:920-930.
• At the other extreme, some patients suffer
so much that daily living is difficult and
they are unable to work. Others suffer a
level of impairment between these two
levels.
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Slide 5
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
Effects of Tinnitus
• Concentration
• Hearing
• Insomnia
• Psychological
Tinnitus sufferers
• Ludwig van Beethoven
• Vincent van Gogh
• Charles Darwin
• Neil Young
• Eric Clapton
• Ronald Regan
Sound features of tinnitus
Sounds experienced in tinnitus can vary according to several criteria:
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
Langguth B, et al. (2013) Lancet Neurol.12:920-930.
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Slide 9
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
• Pulsatile
• Synchronous with Pulse
• Arterial etiologies
• Arteriovenous fistula or malformation
• Paraganglioma (glomus tympanicum or jugulare)
• Persistent stapedial artery
• Intratympanic carotid artery
• Increased cardiac output (pregnancy, thyrotoxicosis)
• Venous etiologies
• Venous hum
• Sigmoid sinus and jugular bulb anomalies
• Asynchronous with Pulse
• Palatal myoclonus
• Tensor tympani or stapedius muscle myoclonus
• Nonpulsatile
• Spontaneous otoacoustic emission
• Patulous eustachian tube
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Slide 11
• Pattern of hearing loss
•
•
•
•
•
•
•
•
•
Noise-induced hearing loss
Presbycusis
Somatic tinnitus
Temporomandibular joint dysfunction
Cervical dysfunction
Gaze evoked
Cutaneous evoked
General somatosensory modulated
Typewriter tinnitus
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Slide 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
Peripheral events lead to central neurological changes
• A range of peripheral events can lead to central neuronal changes that manifest as tinnitus
• Other factors can be involved in either the development or the persistence of tinnitus
HEARING LOSS
CENTRAL
NOISE TRAUMA
AUDITORY
PATHWAY
OTOTOXIC
DRUGS
TINNITUS ONSET
TINNITUS
PERSISTENCE
NEURONAL
ABNORMALITIES
AUDITORY
NERVE
ABNORMALITIES
Langguth B, et al. (2013) Lancet Neurol.12:920-930.
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Slide 14
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
–
Homeostatic pathways cause increased central ‘gain’ (i.e. sensitivity) in response to
auditory deprivation to:
1. Maintain
2. Ensure
central nervous system activity during low sensory input
nerve activity is modulated to respond to changes in sensory input
• In patients with tinnitus and hearing loss, the tinnitus pitch and the hearing loss frequency
spectrum are usually matched
Hebert S, et al. (2013) J Neurosci 33:2356-2364; Langguth B, et al. (2013) Lancet Neurol.12:920-930; Norena
AJ, Farley BJ. (2013) Hearing Res 295:161-171.
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Slide 15
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
Norena AJ, Farley BJ. (2013) Hearing Res 295:161-171.
Kaltenbach JA. (2011) „Tinnitus: models and mechanisms“. Hear Res. June; 276 (1-2) : 52 – 60.
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Slide 16
Tinnitus and hearing loss
Most patients with tinnitus have some degree of hearing loss
75%–90%
ABOUT 80%
OF PATIENTS
WITH
OTOSCLEROSIS
HAVE TINNITUS
OF PATIENTS
WITH IDIOPATHIC
SENSORINEURAL
HEARING LOSS
HAVE TINNITUS
“Hearing loss is a hidden disability and
to have tinnitus is sort of like a double
whammy”
Family physician with moderate tinnitus, Canada
Axelsson A, Ringdahl A (1989) Br J Audiol 23:53-62; Ayache D, et al (2003) Otol Neurotol 24:48-51; NosratiZarenoe R et al (2007) Acta Otolaryngol 127:1168-1175; Sobrinho PG et al. (2004) Int Tinnitus J 10:197-201;
Schaette R et al. (2012) PLoS One 10.1371/journal. pone.0035238.
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Slide 17
Tinnitus and distress: a vicious cycle
• Experiencing sound in the absence of an external stimulus can be emotionally upsetting
• This reaction can make the sounds appear worse
• This results in a vicious cycle of worsening tinnitus and increasing distress
TINNITUS
EMOTIONAL
DISTRESS
Schaette R. (2012) Phonak Focus 42.
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Pathophysiology
Other psychological associations with tinnitus
• Tinnitus is associated with increased levels of psychological problems
–
24/90 (26.7%) versus 5/90 (5.6%) for age-matched controls without tinnitus
HYPOCHONDRIA
HYPERACUSIS
ANXIETY
TINNITUS
COGNITIVE
IMPAIRMENT
Andersson G, McKenna L. (2006) Acta Otolaryngol Suppl. 556:39-43; Belli H, et al. (2012) Gen Hosp
Psychiatry. 34:282-9; Jackson J, et al. (2013) Int J Audiol. E-pub ahead of print; Langguth B, et al. (2013)
Lancet Neurol.12:920-930.
DEPRESSION
SLEEP
PROBLEMS
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Slide 20
Anxiety and depression correlate with severity of tinnitus
TINNITUS (ALL SEVERITIES),
N=80
HIGH-RISK OF CHRONIC,
DISABLING TINNITUS, N=144
r
P
r
P
Current minor depression (SCID)
0.42
<0.0001
0.43
<0.0001
Major depression (SCID)
0.41
0.0002
0.39
<0.0001
Current anxiety disorder (SCID)
0.12
NS
0.28
0.0010
0.01
NS
0.26
0.0023
0.42
<0.0001
0.48
<0.0001
Depression (HADS)
0.30
0.0079
0.38
<0.0001
Anxiety (HADS)
0.35
0.0018
0.45
<0.0001
Total (HADS)
0.36
0.0014
0.46
<0.0001
Current multiple anxiety disorders
(SCID)
Current depression and/or anxiety
disorders (SCID)
r = correlation coefficient between severity of tinnitus and prevalence of depression and anxiety (higher r = stronger correlation)
HADS: Hospital Anxiety and Depression Scale; NS: non statistically significant; SCID: Structured Clinical Interview for DSM-III-R
Zöger S et al. (2006) Psychosomatics. 47:282-288.
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Slide 21
Other tinnitus-associated problems
SLEEP PROBLEMS
COGNITIVE
IMPAIRMENT
HYPERACUSIS
• Sleep disturbance is
• Patients with tinnitus can
• Hyperacusis is an
common in patients with
tinnitus
• In particular, the time taken to
achieve sleep may be
lengthened in tinnitus
patients
• Insomnia and tinnitus-
associated distress can work
together in a worsening spiral
to adversely affect
psychological wellbeing
exhibit depressive
functioning and/or anxious
vigilance
• Cognitive performance can
be worse among tinnitus
sufferers versus controls in
the absence of depression
and anxiety
oversensitivity to certain
sound frequencies or
volumes
• It is common among tinnitus
sufferers and may be a
consequence of tinnitus
• In an age-matched control
study, 60% of tinnitus
sufferers reported
hyperacusis, compared to
20% of controls
• Hyperacusis is measureable
in tinnitus ears with and
without hearing loss
Andersson G, McKenna L. (2006) Acta Otolaryngol Suppl. 556:39-43; Bastos de Magalhaes SL, et al. (2003) Int Tinnitus J. 9:79-83; Belli H, et al. (2012) Gen Hosp
Psychiatry. 34:282-9; Hebert S, et al. (2013) J Neurosci. 33:2356-2364; Jackson J, et al. (2013) Int J Audiol. E-pub ahead of print; Langguth B, et al. (2013) Lancet
Neurol.12:920-930; Wallhäusser-Franke E, et al. Sleep Med Rev. 17:65-74.
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Slide 22
Etiologies
• Idiopathic (most common)
• Outer ear disease
– Wax,
foreign body, infection
• Middle ear disease
– Infection,
perforated eardrum, ossicular problems, tumor
Etiologies
• Inner ear disease
– Presbyacusis
(older age hearing loss)
– Meniere’s disease
– Acoustic neuroma
– Noise exposure
– Drugs
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
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 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
“The majority of studies reviewed
support the use of hearing aids for
tinnitus management. Clinicians
should feel reassured that some
evidence shows support for the
use of hearing aids for treating
tinnitus …”
Shekhawat et al, 2013
Shekhawat GS, et al. (2013) J Am Acad Audiol. 24:747-762
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Slide 29
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
Hoare DJ, et al. (2011) Laryngoscope 121:1555-1564; Langguth B, et al. (2013). Lancet Neurol.12:920-930
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Slide 31
Drug options for tinnitus management
DRUG CLASS
EXAMPLES OF DRUGS USED IN TINNITUS
Antidepressants
tricyclics, selective serotonin reuptake inhibitors
Antipsychotics
sulpiride
Mood stabilisers
gabapentin, valproate
Sedatives/hypnotic
benzodiazepines
s
• 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
Belli H, et al. (2012) Gen Hosp Psychiatry. 34:282-9; Langguth B, et al. (2013) Lancet Neurol.12:920-930
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Slide 32
Tinnitus management options
Currently, there is no cure for tinnitus, but management is possible
EVIDENCE BASED
TINNITUS
MANAGEMENT
APPROACHES
e.g. TINNITUS
RETRAINING THERAPY
HEARING AIDS
DRUGS
TINNITUS
COUNSELLING
SOUND THERAPY
Belli H, et al. (2012) Gen Hosp Psychiatry. 34:282-9; Langguth B, et al. (2013) Lancet Neurol.12:920-930;
Shekhawat GS, et al. (2013) J Am Acad Audiol. 24:747-762
COGNITIVE
BEHAVIOURAL
THERAPY
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Slide 33
The need for multidisciplinary care
• Tinnitus management should include hearing aids with appropriate frequency ranges
together with psychological support and education
• This requires a multidisciplinary care team
–
GP, ENT specialist, psychologist/psychiatrist and hearing-care professional
• As a leading supplier of hearing aids, Phonak can be another member of your team,
helping your patient to have the optimal hearing aid for their situation
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Slide 34
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.
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Slide 36