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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 – – – – – – – Neil Young Pete Townsend Barbara Streisand Sting Eric Clapton Jeff Beck James Hatfield (Metallica) – Lars Ulrich (Metallica) – – – – – – – – 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 – – – – – – William Shatner Leonard Nimoy Steve Martin Burt Reynolds Sylvester Stallone Tony Randall – – – – – – 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 • • • • 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 – – – – – – – 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 • • • • • • • • 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 • • • • • • 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 • • • • 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!