Transcript Presentation TINNITUS

TINNITUS
BY:DR NDUATI J. MWANGI
SUPERVISOR:DR MASINDE P.
02/08/14 (b)
outline
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Introduction
Epidemiology.
Types/classification.
Etiology .
Pathophysiology.
Features/measurements.
Diagnosis & investigations
Management
Conclusion
Introduction
• Tinnire – to ring. Tinnitus - ringing in the ear.
• perception of sound in absence of stimulation /no
external acoustic source.
• A Conscious experience of a sound that originates in
the head of the owner.
• hissing, sizzling and buzzing, pulsatile
• can be persistent, intermittent, or throbbing.
• Tinnitus is an element of the symptom profile of
several significant otological pathologies.
Epidemiology
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In US,37-40M i.e 12-14% americans1.
30% of adults,6% incapacitated
Peak age-40-70Yrs
M>F higher risk(12% M over 65,only 7% F)
Whites>blacks
prevalence increases with age & with HL
> risk in low economic status.
1.Heller AJ. Classification and epidemiology of tinnitus. Otolaryngol Clin N Am 2003;36:239-248.
Types/classification
• Subjective-has a neurophysiological origin
• Objective
 Vascular somatosounds
Morphological
Dynamic
 Myogenic sounds
 Patulous ET
 TMJ abnormality
 SOAEs
1.Heller AJ. Classification and epidemiology of tinnitus. Otolaryngol Clin N Am 2003;36:239-248.
Objective -Pulsatile tinnitus
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AVMs
Vascular tumors
Venous hum
Atherosclerosis
Ectopic carotid artery
Persistent stapedial
artery
• Dehiscent jugular bulb
• Vascular loops
•Cardiac murmurs
•Pregnancy
•Anemia
•Thyrotoxicosis
•Paget’s disease
•Benign intracranial
hypertension
Etiology
Subjective tinnitus:• Otological:-noise ,infections,presbycusis,menieres,
otosclerosis, neuromas,cerumen,labyrinthitis.
• Trauma-neck injuries,explosions,closed head injuries.
• CNS disorders-meningitis.
• Metabolic disorders, auto-immune disorders
• Depression, anxiety
• Medications, drug abuse
Mechanisms of tinnitus
• heterogeneity in the tinnitus population-many
different mechanisms.
• Little known about physiologic mechanism
• Modified neural activity in central auditory
system due to peripheral auditory structures
damage2
• Cochlear ;Non-cochlear mechanisms of
tinnitus generation
2.Eggermont JJ, Roberts LE. The neuroscience of tinnitus. Trends Neurosci. 2004;27:676–682.
Mechanisms of tinnitus
• Hyperactive hair cells or nerve fibers
• Chemical imbalance
• Reduced suppressive influence of CNS
Cochlear mechanisms
• Discordant damage of IHC and OHC:-IHCs more
resistant to damage.3
• modification of auditory afferent activity leading to
tinnitus perception
• SOAEs-rarely correspond to the judged frequency of
the tinnitus4
• Biochemical models-Endogenous dynorphins(stress)
potentiate glutamate within the cochlea5
3.Hazell JWP, Jastreboff PJ. Tinnitus. I. Auditory mechanisms: a model for tinnitus and hearing impairment. J Otolaryngol 1990; 19: 1–5
4.Penner MJ. An estimate of the prevalence of tinnitus caused by spontaneous otoacoustic emissions. Arch Otolaryngol Head Neck Surg 1990; 115: 871–5
5.Sahey TL, Nodar RH. A biochemical model of peripheral tinnitus. Hear Res 2001; 152: 43–54
Non-cochlear mechanisms
• Jastreboff neurophysiological model6-auditory
perceptual, emotional and reactive systems
• Increased neural activity- dorsal cochlear
nucleus (DCN), IC,cortical activity.
• Analogies with pain7
– chronic pain
– phantom pain:-Cortical re-organisation
6.Jastreboff PJ, Gray WC, Gold SL. Neurophysiological approach to tinnitus patients. Am J Otol 1996;17:236-240.
7.Moller AR. Similarities between severe tinnitus and chronic pain. J Am Acad Audiol 2000; 11: 115–24
Pathophysiology
• Modified neural activity in central auditory
system due to peripheral auditory structures
damage
• Tonotopic frequency matching from periphery
to cortex is altered.
• increased spontaneous firing & increased fqcy
presentation of bordering neurons( plasticity)
• detrimental cortical adaptation to input
deprivation from the sensory periphery
8.Kitahara M. Tinnitus Pathophysiology and Management. Igaku-Shoin: Tokyo, New York; 1998.
9.Moller AR. Pathophysiology of tinnitus. Otolaryngol Clin N Am 2003;36:249-266
Pathophysiology cont’d
• These changes lead to abnormal interaction
btn auditory & other central pathways.
• Mechanism by which other symptoms e.g
depression,fear & anxiety are produced.
• Coupling of auditory system with other central
systems like limbic & autonomic NS6 –basis of
neuro-physiological approach to tinnitus.
6.Jastreboff PJ, Gray WC, Gold SL. Neurophysiological approach to tinnitus patients. Am J Otol 1996;17:236-240.
Jastreboff neurophysiolgical model(4)
6.Jastreboff PJ, Gray WC, Gold SL. Neurophysiological approach to tinnitus patients. Am J Otol 1996;17:236-240.
Neurophysiological model cont’d(4)
• Principally,auditory pathway & several non
auditory systems play essential role in tinnitus.
• Stresses non auditory system dominates in
determining annoyance level.
• Proposis treatment by inducing & facilitating
habituation to tinnitus signal.
• Goal-to reach level though patient percieves
tinnitus as unchanged,they arent aware of it
&/or no annoyance occurs.
6.Jastreboff PJ, Gray WC, Gold SL. Neurophysiological approach to tinnitus patients. Am J Otol 1996;17:236-240.
Acoustic features(measurement)
• Clinically not as relevant.mainly in research.
• Pitch-equate a pure tone pitch to that of
tinnitus.
• Loudness-most <7 dBel
• Minimum masking level-no of dBels of sound
required to cover tinnitus.
• Residual inhibition(postmasking effects)periods of decreased or no tinnitus after
masking.
Clinical measures
• evaluate presence & severity of the tinnitus.
• VAS assess loudness, pitch, & disturbance of the
tinnitus
• Tinnitus Handicap Inventory
• Tinnitus Reaction Questionnaire
• Tinnitus Functional Index-severity,negative
impact,Rx-related changes
Tinnitus in children
• Underestimated-no vocabulary to explain,may
consider it normal,fear to disclose(withdrawal)
• Look for changes in attention,depression,poor
school performance,insomnia.
• 6-13% 10 of children with normal hearing on
&off
• 24-29% -with hearing difficulties.
• Causes-inborn,ME infections,wax, deafness,
noise,meningitis,asprin ,ET dysfunction.
10.Baguley DM, McFerran DJ. Current perspectives on tinnitus. Arch Dis Child 2002; 86: 141–3
Diagnosis/evaluation
• Thorough History & PE.-etiology may be picked.
History:• noise exposure/trauma
• HL & vertigo+/- dizziness,otalgia,
• Quality- buzzing,rushing, roaring ,flactuating.
• Trauma- head/neck
• Medical history
• Medications/drug use
• Depression/somatoform disorders
• Tinnitus handicup inventory.
11.Denk DM, Ehrenberger K. Tinnitus: causes, diagnosis, therapy Wien Med Wochenschr, 142(11-12):259-62
12..Schwaber MK. Medical evaluation of tinnitus. Otolaryngol Clin N Am 2003;36:287-292.
Physical examination
• General exam vital.
• Thorough H/N exam.
• Otoscopy-wax,glomus,dehiscent jugular bulb
etc
• Auscultation –bruit,venous hums
• Light exercise,neck compression,valsalva
manoeuvers.
• Audiometric tests-PTA ,speech, impedence
testing, OAE,
Investigations
• No diagnostic modality to objectively measure
or confirm tinnitus.
• FBC,ESR,U&Es..VDRL,HIV.
• CT scans, angiograhy, MRI, PET,Magnetic
studies especially for pulsatile tinnitus.
Management
• Various treatments –unsuccessful/unproven
• Cochlea,NTs &receptors,ion channels.
• Treatment methods not able to reduce or
eliminate the sensation on any consistent
basis
• no drug that has been approved specifically
for its treatment
• Comorbidities- hearing loss, mental health
problems, or sleep disorders.
• Medical/Physiological Treatments
– Pharmacological Treatment
– Transcranial Magnetic Stimulation
– Complementary and Alternative Medicine Therapies
• surgical treatments
• Sound treatments/technologies
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Hearing Aids
Cochlear Implants
Sound Generators
Tinnitus Retraining Therapy
Neuromonics Tinnitus Treatment 13-combines acoustic stimulation with
a structured program of counseling support by a clinician
13.anley PJ, Davis PB. Treatment of tinnitus with a customized, dynamic acoustic neural stimulus: underlying principles and clinical efficacy. Trends
Amplif. 2008;12:210–22.
• Psychological/behavioral treatments
– Cognitive Behavioral Therapy
– Biofeedback, Education, and Relaxation Therapies
– Progressive Tinnitus Management
Medical
• Glutamate rerceptor antagonist –caroverine,
memantine, Acamprosate
• activate GABA receptors
• Antidepressants-amitriptyline,nortriptyline,
trimipramine
• Anxiolytics-Alprazolam• Anticonvulsants- Carbamazepine, Gabapentin
• Vasodilators/vasoactive substances- Prostaglandin E1
• Selective serotonin-reuptake inhibitors: fluoxetine
and paroxetine
• Lidocaine IV/transtympanic.
14.Ehrenberger K. Topical administration of Caroverine in somatic tinnitus treatment: proof-of-concept study. Int Tinnitus J. 2005;11:34–7.
15.Bauer CA, Brozoski TJ. Effect of gabapentin on the sensation and impact of tinnitus. Laryngoscope. 2006;116:675–81
16.Baldo P, Doree C, Lazzarini R, Molin P, McFerran D. Antidepressants for patients with tinnitus. Cochrane Database of Systematic Reviews.
2006;(Issue 4):CD003853
Others
• Transcranial Magnetic Stimulation 17• proven effect in auditory hallucinations .
• Reduction of tinnitus loudness
• Complementary and Alternative Medicine Therapies
• Ginkgo Biloba Extract 18- glutamate antagonist, strong
anti-oxidant
• Acupuncture 19, and hyperbaric oxygen
• diet modifications eg avoid high-sodium foods,
caffeine, chocolate, and other stimulants
17Kleinjung T, Vielsmeier V, Landgrebe M, Hajak G, Langguth B. Transcranial magnetic stimulation: a new diagnostic and therapeutic tool for tinnitus patients. Int
Tinnitus J. 2008;14:112–8.
18.Hilton M, Stuart E. Ginkgo biloba for tinnitus. Cochrane Database Syst Rev 2004;(2):CD003852. PMID: 15106224.
19.Park J, White AR, Ernst E. Efficacy of acupuncture as a treatment for tinnitus: a systematic review. Arch Otolaryngol Head Neck Surg 2000 Apr;126(4):489-92.
PMID: 10772302.
Cognitive-Behavioral Therapy (CBT)
• aim- to modify harmful behaviours & thoughts
using “deconditioning” technique
• reduces arousal levels via relaxation therapy
&changing –ve thoughts through cognitive
therapy.
• Goebel et al 20 confirm the long-term benefits
of CBT for tinnitus.
20.Goebel G, Kahl M, Arnold W, Fichter M. 15 years prospective follow-up study of behavioural therapy in a large samplke of
inpatients with chronic tinnitus. Acta Otolaryngol. 2006;126:70–9.
Tinnitus Retraining Therapy
• Based on neurophysiological model.
• Conditioned reflexes involving connections of
auditory with limbic & ANS are retrained such
that the subconscious part of auditory pathway
blocks the tinnitus signal.
• Acoustic input with unimportant information is
ignored(habituation)
• Inducing & sustaining habituation of conditioned
reflexes removes –ve impact of tinnitus
21.Jastreboff PJ, Jastreboff MM. Tinnitus retraining therapy for patients with tinnitus and decreased sound tolerance. Otolaryngol Clin N Am 2003;36:321-336
22.Phillips JS, McFerran D. Tinnitus Retraining Therapy (TRT) for tinnitus. Cochrane Database Syst Rev 2010 Mar 17;(3):CD007330. PMID: 20238353
TRT
• Goal-train CNS to interpret tinnitus as
unimportant & ignore it.
• Has 2 components:-intensive direct counselling.
-sound therapy using sound generators which
emit low level broad band noise.
• Not masking-cant habituate a signal that cannot
be detected.
• Jastreboff 21 reported success in over 80% of his
cases.
21.Jastreboff PJ, Jastreboff MM. Tinnitus retraining therapy for patients with tinnitus and decreased sound tolerance. Otolaryngol Clin N Am 2003;36:321-336.
Biofeedback, Education, and Relaxation
Therapies
• control or habituate to the perceived ringing
and the subsequent distress.
• Biofeedback therapy-listens to audio signal
from EMG of frontalis muscle
• reduces perceived ringing &muscle tension
• strategies to self-manage their tinnitus.
• Relaxation therapies -focus pt’s attention away
from the sound;psychologically improving
symptoms.
23.Seidman MD, Babu S. Alternative medications and other treatments for tinnitus: Facts from fiction. Otolaryngol Clin N Am 2003;36:359-381.
Future
• PET /fMRI help in research into the
mechanisms and hence treatment of tinnitus.
• Transcranial DC Stimulation(tDCS)
• Transcranial magnetic stimulation.
24..Mirz F, Pedersen CB, Ishizu K, Johannsen P, Ovesen T, Stodkilde-Jorgensen H, Gjedde A. Positron emission tomography of cortical centes of tinnitus.
Hear Res 1999;134:133-144..
Conclusion
• difficult to study and treat -no objective tools
to quantify and measure.
• no therapeutically successful treatment in
terms of medium or long term remission
• no universally accepted therapies for
managing tinnitus
• interactions among the auditory, cognitive,
affective, and mental health issues.
References
1.Heller AJ. Classification and epidemiology of tinnitus. Otolaryngol Clin N Am
2003;36:239-248
2.Eggermont JJ, Roberts LE. The neuroscience of tinnitus. Trends Neurosci.
2004;27:676–682
3.Hazell JWP, Jastreboff PJ. Tinnitus. I. Auditory mechanisms: a model for tinnitus and
hearing impairment. J Otolaryngol 1990; 19: 1–5
4.Penner MJ. An estimate of the prevalence of tinnitus caused by spontaneous
otoacoustic emissions. Arch Otolaryngol Head Neck Surg 1990; 115: 871–5
5.Sahey TL, Nodar RH. A biochemical model of peripheral tinnitus. Hear Res 2001; 152:
43–54
6.Jastreboff PJ, Gray WC, Gold SL. Neurophysiological approach to tinnitus patients.
Am J Otol 1996;17:236-240.
7.Moller AR. Similarities between severe tinnitus and chronic pain. J Am Acad Audiol
2000; 11: 115–24
8.Kitahara M. Tinnitus Pathophysiology and Management. Igaku-Shoin: Tokyo, New
York; 1998.
9.Moller AR. Pathophysiology of tinnitus. Otolaryngol Clin N Am 2003;36:249-266
10.Baguley DM, McFerran DJ. Current perspectives on tinnitus. Arch Dis Child 2002; 86:
141–3
11.Denk DM, Ehrenberger K. Tinnitus: causes, diagnosis, therapy Wien Med
Wochenschr, 142(11-12):259-62
12..Schwaber MK. Medical evaluation of tinnitus. Otolaryngol Clin N Am 2003;36:287292
References
13.anley PJ, Davis PB. Treatment of tinnitus with a customized, dynamic acoustic neural stimulus:
underlying principles and clinical efficacy. Trends Amplif. 2008;12:210–22
14.Ehrenberger K. Topical administration of Caroverine in somatic tinnitus treatment: proof-of-concept
study. Int Tinnitus J. 2005;11:34–7.
15.Bauer CA, Brozoski TJ. Effect of gabapentin on the sensation and impact of tinnitus.
Laryngoscope. 2006;116:675–81
16.Baldo P, Doree C, Lazzarini R, Molin P, McFerran D. Antidepressants for patients with tinnitus.
Cochrane Database of Systematic Reviews. 2006;(Issue 4) 17Kleinjung T, Vielsmeier V, Landgrebe
M, Hajak G, Langguth B. Transcranial magnetic stimulation: a new diagnostic and therapeutic tool for
tinnitus patients. Int Tinnitus J. 2008;14:112–8.
18.Hilton M, Stuart E. Ginkgo biloba for tinnitus. Cochrane Database Syst Rev 2004;(2):CD003852.
PMID: 15106224.
19.Park J, White AR, Ernst E. Efficacy of acupuncture as a treatment for tinnitus: a systematic review.
Arch Otolaryngol Head Neck Surg 2000 Apr;126(4):489-92. PMID: 10772302.:CD003853
20.Goebel G, Kahl M, Arnold W, Fichter M. 15 years prospective follow-up study of behavioural therapy in a
large samplke of inpatients with chronic tinnitus. Acta Otolaryngol. 2006;126:70–9.
21.Jastreboff PJ, Jastreboff MM. Tinnitus retraining therapy for patients with tinnitus and decreased sound
tolerance. Otolaryngol Clin N Am 2003;36:321-336
22.Phillips JS, McFerran D. Tinnitus Retraining Therapy (TRT) for tinnitus. Cochrane Database Syst Rev 2010
Mar 17;(3):CD007330. PMID: 20238353
23.Seidman MD, Babu S. Alternative medications and other treatments for tinnitus: Facts from fiction.
Otolaryngol Clin N Am 2003;36:359-381.
24..Mirz F, Pedersen CB, Ishizu K, Johannsen P, Ovesen T, Stodkilde-Jorgensen H, Gjedde A. Positron emission
tomography of cortical centes of tinnitus. Hear Res 1999;134:133-144..
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