Download Hissing and Buzzing and Ringing, Oh My! The Diagnosis and

Hissing and Buzzing
and Ringing, Oh My!
The Diagnosis and Treatment
of Tinnitus
Carol Rousseau, M.A., CCC-A
Rochester Hearing and Speech Center
Rochester, NY
12 May 2006
DEFINITION
• The perception of sound in one or both
ears or in the head when no external
sound is present (American Tinnitus
Association, 2006)
Po-TAY-to, Po-TAH-to….
• Both TINN-ni-tus and Tin-EYE-tis are
acceptable pronunciations
• Originated from the Latin verb “Tinnire”
meaning to ring or tinkle
• Geography
– West Coast: Second syllable
– Middle America: First syllable
– East Coast: Evenly Divided
Some History…
• First recorded appearance is about 2000
years ago by the Phoenicians
• Noted in Egyptian hieroglyphics
• Aristotle (384-322 B.C.) wrote of it
• Physician Galen (129-199 B.C.) described it as
“echoes”
• Jean Marie Gaspard Itard in 1821 mentioned
“True” and “False” Tinnitus, which we now
refer as “Objective” and “Subjective”
More History…
• 1975 Dr. Jack Vernon introduced the
first wearable masker device
• In 1990, Jastreboff introduced popular
therapeutic approach called “Tinnitus
Retraining Therapy (TRT)
Some Statistics…
• Over 50 Million Americans experience
Tinnitus to some degree
• 12 Million severe enough to seek
medical attention
• 2 Million so seriously debilitated that
they can not function on a normal basis
(ATA, 2006)
More Statistics…
• 6-20% of U.S. population describe noise
as bothersome
• 1% say it interferes with day-to-day
activities (Gelfand, 1997)
Famous People with Tinnitus
• Musicians
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Neil Young
Pete Townsend
Barbara Streisand
Sting
Eric Clapton
Jeff Beck
James Hatfield
(Metallica)
– Lars Ulrich (Metallica)
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George Martin
George Harrison
Ted Nugent
Bono (u2)
The Edge (u2)
Paul Schaffer
Trent Rezner
Dave Pirner (Soul
Asylum)
– Huey Lewis
– Beethoven
Famous People with Tinnitus
• Actors
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William Shatner
Leonard Nimoy
Steve Martin
Burt Reynolds
Sylvester Stallone
Tony Randall
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Jerry Stiller
Florence Henderson
Keanu Reeves
Larry King
David Letterman
Cher
Famous People with Tinnitus
• Historical/Political
– Jean-Jacques Rousseau
– Thomas Edison
– Dwight D. Eisenhower
– Martin Luther
– Alan Shepard
– Vincent Van Gogh
– Charles Darwin
Description
• Head Noise
• Ear Noise
• Ringing
• Buzzing
• Chirping
• Hissing
• Humming
• Pulsing
• Roaring
Characteristics of Tinnitus
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Quality
Pitch
Loudness
Location
Characteristics of Tinnitus: Quality
• 79% of patients described their tinnitus
as a pure tone
– Single, double, and tri-toned
• 6% described it as noise
• 15% mixture of pure tone and noise
(Vernon, 1998)
Characteristics of Tinnitus: Pitch
• Most frequently described pitch of the
tone as 8000Hz (Vernon, 1998; Sandlin
& Olsson, 2000)
Characteristics of Tinnitus: Loudness
• 88% described loudness of 11 dB SL or
less
• Overall average loudness level as 5.7 dB
SL
Characteristics of Tinnitus: Location
• Both ears
– 55%
• One ear only
– 20%
• Head
– 24%
• Varied
– 1%
Causes of Tinnitus
• Mostly unknown
– 47%
• Noise Exposure
– 25%
• Head Injury/Brain Trauma
– 8%
• Ear Pathology
– 7%
• Ototoxic Medications and other
– 13% (Vernon, 1998)
Causes of Tinnitus:
Diet
• May be related to food allergies or
sensitivities
• Salicylates naturally occurs in some foods
may produce tinnitus
– Almonds, cloves, gingerbread, mustard, mint
flavors
– Apples, Apricots, Blackberries, Grapes, Raisins,
Oranges, Strawberries, Raspberries, avocados
– Bell and green peppers, olives, cucumbers, white
potatos
– Processed foods
– Alcohol, especially beer and gin
Causes of Tinnitus:
Noise
• 90% of ATA members also report
hearing loss (ATA, 2006)
• Many of those have high frequency
hearing loss associated with noise
• Effects of loud noise can worsen
existing tinnitus
Mechanisms of Tinnitus:
Just What is Going on in the Ear?
• Vibrations
• Phase-locked spontaneous discharge of cell
bodies
• Aberrant behavior of the efferent system
• Involvement of Neurotransmitter substances
• Central Origin (the brain)
• Vascular Compression of the 7th nerve
Mechanisms of Tinnitus:
Just What is Going on in the Ear?
• CNS phenomenon dictated by peripheral
activity
– Something akin to Phantom Limb phenomenon
• Lockwood (1998) theorized that tinnitus is
based in the auditory cortex, and not the
cochlea
• Other theories state that it may be caused by
alterations in the function of the inferior
colliculus
Mechanisms of Tinnitus:
Just What is Going on in the Ear?
• Jastreboff (1995) theorized that tinnitus may
involve a discordant dysfunction of OHC and
IHC systems
– One system becomes dysfunctional because of
loss of cell population
– Difference is created in the activity of the two
different type of fibers
• Many theorize that tinnitus is a symptom of
many causes based on a number of different
mechanisms
Medical Aspects of Tinnitus:
Types of Tinnitus
• Medical diseases and emotional factors
may cause and/or affect severity of
tinnitus
• Two types
– Objective
– Subjective
Objective Tinnitus
• Also called Audible Tinnitus
• Can be heard by physician
– Via external ear canal or mastoid bone
• Corresponds to respiration or heartbeat
Objective Tinnitus:
Corresponding to Respiration
• May be caused by abnormally patent
Eustachian Tube
• Usually experienced short time
• May be caused by extreme weight loss
or after an extended illness
• Symptoms relieved by lying down or
putting head in lowered position
Objective Tinnitus:
Sharp or Irregular Clicks
• Heard for several seconds or minutes at
a time
• Contractions of soft palate or muscles
of the middle ear
• Cause unknown
Objective Tinnitus:
Pulsatile Tinnitus
• Synchronous with heartbeat/pulse
• May indicate cardiac or vascular
abnormalities
– Abnormal vascular flow from arteries to
veins somewhere in the head/neck
– Also may be secondary to turbulence of
major vessels from arteriosclerosis or
narrowing of blood from artery to vein
Objective Tinnitus:
Rushing or Flowing
• Vascular tumors of the Middle Ear
– Glomus Tumor
• Rare
Subjective Tinnitus
• More frequent than Objective Tinnitus
• Most people experience this at some point
• Various medical conditions cause or affect
subjective tinnitus
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Otologic disorders
Cardiovascular abnormalities
Metabolic diseases
Neurologic disorders
Drugs/Pharmaceuticals
Dental factors
Psychological/emotional factors
Subjective Tinnitus:
Otologic Causes
• Hearing Loss considered the most common
cause of tinnitus
– 90% have some form of ear disease
• SNHL most frequent
– Majority have a 30 dB or higher HL from 3 to 8
kHz
– Mostly the result of aging or noise exposure
– Often characterized as high-pitched
– Usually described as mild
Subjective Tinnitus:
Cardiovascular Disorders
• 37% of tinnitus patients also have
cardiovascular complaints (Schleuning, 1998)
• Often characterized as low pitched pulsating
sound
• Alteration of blood flow in the head can be
cause a low frequency hum
• High blood pressure
• Anemia
• Arteriosclerosis
Subjective Tinnitus:
Metabolic Disease
• Rare, and may be associated with other
disorders that may be causing tinnitus
– Diabetes
– Thyroid disease
– High cholesterol levels
– Vitamin deficiencies
Subjective Tinnitus:
Neurologic Disease
• Head trauma
– 10% of tinnitus patients had skull fracture or
severe closed head injury (Schleuning, 1998)
– Result of damage to the internal structure of the
inner ear with nerve or hair cell damage
– Usually diminishes over time
– Whiplash injury may involve nerve input from the
neck and shoulders along with concussion damage
to the inner ear
• Meningitis
• Multiple Sclerosis
Subjective Tinnitus:
Pharmacological Factors
• All types of drugs can be considered as a
possible cause
• Most frequent:
– anti-inflammatory drugs
• Aspirin and aspirin-containing medications
– Percodan
– Bufferin
– Ecotrin
• Nonsteroidal Anti-inflammatory drugs (not as severe as
aspirin)
– Naprosin
– Ibuprophen
Subjective Tinnitus:
Pharmacological Factors
– Antibiotics
• Aminoglycosides (tinnitus more pronounced when paired
with diuretics)
– Streptomycin
– Kanamycin
– Gentamicin
– Sedatives or antidepressants
– Quinine-containing medications for muscle cramps
or arrhythmia
– Heavy Metals
• Mercury
• Arsenic
• Lead in high doses
Subjective Tinnitus:
Pharmacological Factors
• Stimulants
– Tobacco
– Caffeine
• Constricts blood vessels
• Make cells of the inner ear more
irritable and more likely to randomly
discharge
Subjective Tinnitus:
Dental Factors
• Temporomandibular-joint (TMJ)
problems
• Lower pitch
• Related to jaw activity
• Grinding and painful teeth and ear pain
are other symptoms
Subjective Tinnitus:
Psychological Factors
• Stress and fatigue play a role in severity
of complaint
• Increases perception of problem more
than causes tinnitus
• Similar symptoms as depression
– 15-20 of Tinnitus patients
Pulsatile Tinnitus
• Can be objective or subjective
• Characterized as a “thumping” sound that is
often synchronous with heartbeat
• Usually originates from vascular structures
inside the head or neck
– Arterial or venous
– Other structures classified as non-vascular
• Refer to ENT
Pulsatile Tinnitus
• Glomus Tumor
– Benign vascular tumors located usually in
the ear
– Red mass behind an intact TM
– Hearing Loss
• Hypertension
– May start after starting medications to
control blood pressure
– Usually subsides after 4-6 weeks
Etiologies of Pulsatile Tinnitus:
Arterial
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Atherosclerotic Carotid Artery Disease
Tortuous (twisted) Arteries
Fibromuscular Dysplasia
Intracranial Arterio-venous Fistulae and
Aneurysms
Vascular Compression fo the 8th Cranial Nerve
Aortic Murmurs
Paget’s Disease
Increased Cardiac Output (Amemia,
Thyrotoxicosis, Pregnancy)
Etiologies of Pulsatile Tinnitus:
Venous
• Benign Intracranial Hypertension
• Jugular Bulb Abnormalities
• Abnormal Condylar and Mastoid
Emissary Veins
Etiologies of Pulsatile Tinnitus:
Nonvascular
• Neoplasms of the skull and temporal
bone
• Palatal, Tensor Tympani, and Stapedial
Muscle Myoclonus
• Patulous Eustachian Tube
• Cholesterol Granuloma of the Middle
Ear
Otologic Causes for Tinnitus
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Described as moderate or severe
Meniere’s disease
Chronic Suppurative Otitis Media
Viral Infections of the ear
Otoscleroris
Acoustic Neuroma
– Unilateral
• Sudden Hearing loss
Assessment of Tinnitus
Assessment of Tinnitus:
Two Perspectives
• Identify the source of the tinnitus
• Assess of how the tinnitus affects the
person
Assessment of Tinnitus
• Psychoacoustic Measurements
• Electophysical Measurements
• Psychological Evaluation
Psychoacoustic Measurements
• Audiolgical measurements of pitch and
loudness
– Audiometric evaluations
– Pitch Matching
– Loudness Matching
– Minimum Masking Level
– Residual Inhibition
Audimetric Evaluation
• Basic test battery
• Pure tone AC threshold frequencies
from 250 to 12,000 Hz including half
octaves
Pitch Matching
• Can be done on a standard audimeter
• Tinnitus synthesizer more accurate
• Audiologist instructs patient to judge whether
pitch of 1st or 2nd tones is close to the tinnitus
sound
• Bracket until find closest pitch
• Patient then identifies type of sound (pure
tone, narrow band noise, speech noise, or
white noise)
• If unilateral, then choose opposite ear
Loudness Matching
• Similar to process to Pitch Matching
• Delivered in 1 dB steps
• Seldom exceeds 11 dB SL
Minimum Masking Level
• Determine the minimum level of white
noise needed to effectively mask the
ongoing tinnitus
• Tested in 1 dB steps
• Monaurally or binaurally, depending on
location of tinnitus
Residual Inhibition
• White noise is presented for 60 seconds
• Patient then assesses whether the tinnitus is
gone, diminished, unchanged or louder
• Time it takes for the tinnitus to return is
recorded
– Complete Residual Inhibition (CRI) -- tinnitus is
completely absent after exposure
– Partial Residual Inhibition (PRI) – tinnitus is
reduced for a period of time
Subjective Assessment
• Subjective description of quality and
duration
• Determine the effect on the patient
• Psychometric tinnitus inventories
– Tinnitus Severity Scale
– Tinnitus Handicap Inventory
Electroacoustic Measurements
• Auditory Brainstem Response
• Otoacoustic Emissions
• Also MRI and CT scans
Psychological Evaluation
• Determining the impact of the tinnitus
on the patient
– Annoyance
– Sleep Disturbance
– Emotional Stress
Treatment of Tinnitus
Treatment of Tinnitus
• Medical
– Traditional
– Alternative
• Psychological
• Tinnitus Maskers
Medical Management – Traditional
• Medicine and surgery largely unsuccessful
– Lidocaine – a local anaesthetic
• Injected into vein of patient
• Short term effect of suppressing tinnitus
• May be toxic to liver
– Xanax
• Anti-Anxiety
• Reduced tension
• Highly Addictive
– Carbamazepine
• Anti-epilepsy
Medical Management – Traditional
– Anti-Depression Drugs
• Prozac
• Elavil
• Norpramin
• Zoloft
Alternative Therapies
• Magnets in the Ear Canal
– Japanese Study by Takeda
• Mounted in cotton wool close to the TM
• 56 patients tried, 37 reported some
improvement
– Coles tried to repeat study
• 51 patients total: 26 active, 25 placebo
• Active: 7 improved, 7 got worse
• Placebo: 4 improved, 3 got worse
Alternative Therapies
• Glinkgo Biloba
– Most popular herbal treatment
– 21 tinnitus patients took part in
uncontrolled trial (Cole, 1998)
• One 14 mg tablet 3 times per day for 12 weeks
• 11 reported no change
• 4 slightly less
• 5 slightly worse
Alternative Therapies
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Acupuncture
Vitamin Therapy
Massage Therapy
Chiropractic Therapy
Counseling
• Have been more successful in treatment
of tinnitus
– Biofeedback
– Behavior Modification
– Relaxation Training
– Cognitive Therapy
• Focus on changing the patient’s attitude toward
the tinnitus
Tinnitus Maskers
• Masks the actual sound of the tinnitus
– Generates white noise
– Patient can adjust intensity and frequency
shape
• Hearing Aids
• Combination devices
– Masker and hearing aid
Sound Therapy
• Works by reducing the difference
between tinnitus sounds and
background sounds
• Provided by CDs/tapes, sound
generators
• Type of sound depends on sound of
tinnitus and hearing loss
Tinnitus Maskers
Sound Therapy:
Tinnitus and Music
• Besides masking, provides relaxation
• Hallam (1989) combined with Tinnitus
Habitation Therapy
• Henry % Wilson (2001) combined with
Cognitive Behavioral Therapy
• Active Music Listening
– Patient actively interacts with music
• Passive Music Listening
– Listens and relaxes
Tinnitus Retraining Therapy (TRT)
• Created by Dr. Pawel Jastreboff at the
University of Maryland in late 1980s
• He referred to this as a
neurophysiological model of tinnitus
• Based on theory of habituation
– Retrain the cortical areas
• Goal is to make tinnitus a non-issue in
one’s life
Tinnitus Retraining Therapy (TRT)
• Jastreboff’s model
– Source of tinnitus (locus is the brain)
– Detection of sound (subcortical)
– Perception and evaluation (auditory and
other cortical areas)
– Emotional associations (limbic system)
– Annoyance (autonomic nervous system)
Tinnitus Retraining Therapy (TRT)
• Use of sound therapy and counseling
– Sound generators and environmental
sounds, as well as hearing aids
– Counseling is a big part of the therapy;
educating the patient what is happening in
the ears and brain
• Process takes 6 to 18 months
Thanks and Good Night!