tinnitus – an ent perspective
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Tinnitus – An ENT Perspective. Mr. Marcus Choo. 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 - PowerPoint PPT PresentationTRANSCRIPT
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Tinnitus – An ENT Perspective
Mr. Marcus Choo
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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!
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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
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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
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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
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Causes
Noise exposureMedication InfectionOlder age hearing lossMeniere’s DiseaseOuter/Middle ear diseaseAcoustic neuromaUnknown (by far the most common)
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Effects of Tinnitus Concentration Hearing Insomnia Psychological
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Ear Anatomy
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Ear Anatomy
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Mechanism of Hearing
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Mechanism of Hearing
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Mechanism of Hearing
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Mechanism of Hearing
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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
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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
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Pathophysiology
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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
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Differential Diagnosis
Idiopathic (most common)
Outer ear disease– Wax, foreign body, infection
Middle ear disease– Infection, perforated eardrum, ossicular problems,
tumour
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Differential Diagnosis Inner ear disease
– Presbyacusis (older age hearing loss)– Meniere’s disease– Acoustic neuroma– Noise exposure– Drugs
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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
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Normal Ear
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Diseased ear
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Evaluation of Tinnitus Audiological (hearing) Tests
Audiogram, tympanogram Specialised hearing tests
MRI Associated symptoms Asymmetric hearing loss
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Audiogram
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MRI
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Treatment Aim to improve habituation rather than
“cure” tinnitus
Most people don’t seek treatment Multitude of potential treatments Problems with scientific evidence
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Treatment Basic advice Hearing Aid Tinnitus Masking Device Tinnitus Instrument Tinnitus Retraining Therapy Psychological Treatment Medication Alternative Treatments
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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
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Support Irish Tinnitus Association DeafHear.ie Hearing Aid Specialist www.tinnitus.org
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Treatment Basic advice Hearing Aid Tinnitus Masking Device Tinnitus Instrument Tinnitus Retraining Therapy Psychological Treatment Medication Alternative Treatments
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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
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Hearing Aids
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Hearing Aids
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Treatment Basic advice Hearing Aid Tinnitus Masking Device Tinnitus Instrument Tinnitus Retraining Therapy Psychological Treatment Medication Alternative Treatments
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Tinnitus Masking Device Essentially counteracts tinnitus Generate noise bands Tinnitus Instruments
Combination of hearing aid and masker
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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
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Treatment Basic advice Hearing Aid Tinnitus Masking Device Tinnitus Instrument Tinnitus Retraining Therapy Psychological Treatment Medication Alternative Treatments
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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
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Tinnitus Retraining Therapy May take several months to take effect
Minimum 12 months treatment
Involves wearing ear noise generator, table top generator
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Tinnitus Retraining Therapy
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Treatment Basic advice Hearing Aid Tinnitus Masking Device Tinnitus Instrument Tinnitus Retraining Therapy Psychological Treatment Medication Alternative Treatments
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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
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Treatment Basic advice Hearing Aid Tinnitus Masking Device Tinnitus Instrument Tinnitus Retraining Therapy Psychological Treatment Medication Alternative Treatments
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Medications No magical cure Serc Lignocaine
Temporary, intravenous
Alprazolam Xanax Side effects
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Treatment Basic advice Hearing Aid Tinnitus Masking Device Tinnitus Instrument Tinnitus Retraining Therapy Psychological Treatment Medication Alternative Treatments
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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
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Alternative Therapies Hypnotherapy Acupuncture Ear canal magnets Hopi ear candles
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Alternative Therapies
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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?
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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