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TINNITUS
DEFINITION:
Tinnitus may be defined variously, as 'a sound perceived for more than five minutes at a time, in the
absence of any external acoustical or electrical stimulation of the ear and not occurring immediately
after exposure to loud noise, phantom auditory perception, or 'head noise'.
CLASSIFICATION
I. GENERAL CLASSIFICATION
Subjective
Objective
Pulsatile
Non Pulsatile
Continuous
Non Continuous
Unilateral
Bilateral
With Hearing loss
Without hearing loss
Acute
Chronic
Vascular
Non Vascular
Aureum (ear)
Capitum (head)
Mild
Moderate
Severe
II. CLASSIFICATION BY SITE
1) EAC
a. FB/Cerumen/lnfection
b. Tumour
c. Atresia
2) Tympanic membrane
a. Perforation
b. Atelectasis
3) Middle ear
a. Effusion
b. Ossicular—fixation/discontinuity
c. Tumour
d. Vascular
e. Neuromuscular
4) Cochlear
5) Retrocochlear
a. CP angle tumour
b. CNS tumour/inflammation
6) Miscellaneous
a.
b.
c.
d.
e.
f.
Patulous eustachian tube
TMJ dysfunction
Head injury
Extracranial aneurysm
AV malformations
Venous hum
III. MAJOR CATEGORIES
1) VIBRATORY
a) Vascular
i.
ii.
iii.
iv.
v.
vi.
AV malformation
Aneurysms
Venous hum
Eagle's syndrome
Glomus tumour
Hypertension
b) Neuromuscular
i.
ii.
iii.
iv.
Palatal myoclonus
Stapedial muscle spasm
Tensor tympani muscle spasm
TMJ joint dysfunction
c) Miscellaneous
i.
ii.
Patulous Eustachian tube
Local inflammation
2) NON VIBRATORY
a) Peripheral
i.
ii.
iii.
External auditory canal
Middle ear
Cochlea.
b) Central
i.
ii.
iii.
Auditory nerve
Brain stem
CNS
Conditions known to cause or be assocation: with non vibratory tinnitus • Presbyacusis • Trauma •
Conductive hearing loss • Tumours • Meniere's disease • Vitamin deficiency • Trace mineral deficiency •
Hypothyroidism • Diabetes mellitus • Labyrinthitis • Bell's palsy • Circulatory disorders • Otosclerosis
IV. 1. PHYSIOLOGICAL
1) Muscular hums
2) Muscular snaps
2. PATHOPHYSIOLOGICAL
1)
2)
3)
4)
Spontaneous
Noise induced
Drug induced
Trauma
3. PATHOLOGICAL
1)
2)
3)
4)
5)
Extra auditory: Muscular, respiratory, vascular
Conductive
Sensori Neural
Reflexes—TMJ/Cervical
Psychological—Hallucination, imaginary
4. PSEUDOTINNITUS
1) Environmental
2) Feigned
SUBJECTIVE' VERSUS 'OBJECTIVE' TINNITUS
Tinnitus is sometimes described as either subjective, audible only to the patient, or objective, audible
to the examiner as well, and in the latter case usually caused by arteriovenous malformations, glomus
tumours, palatal or tympanic myoclonus.
AUDITORY HALLUCINATIONS
Tinnitus usually differs markedly from auditory hallucinations by the absence of the organization of
its content.
In the form of repetitive voices or musical themes, auditory hallucinations are usually reported by the
elderly, psychiatric patients or by subjects suffering from chronic alcoholism.
LOUDNESS RECRUITMENT
HYPERACUSIS
Oversensitivity to loud sounds
Excessively loud perception of normal sound
EPIDEMIOLOGY OF TINNITUS
15% in UK have spontaneous tinnitus
7.5% seek medical attention
Tinnitus prevalence is a positive function of age: 38 percent of patients < 40 years and 62 percent of
patients > 40 years.
RELATION TO HEARING IMPAIRMENT
In >74% of people having hearing loss also complaint of tinnitus
LATERALITY OF TINNITUS
Left ear affected more than right
SOCIOECONOMIC STATUS
High socioeconomic group
DIAGNOSIS
A detailed History
Physical examination, including:
Palpation and light compression of the jugular vein may diminish tinnitus of venous origin
Auscultation of the neck and cranium for the presence of carotid bruit or blood turbulence due to
Arteriovenous Malformation
Otoscopy/otomicroscopy may reveal glomus tumours
Oropharyngeal Examination could reveal contraction of the soft palate in palatal myoclonus.
Tympanometry may demonstrate myoclonic activity and patulous Eustachian tube.
PTA
Imaging with gadolinium-enhanced computed tomography (CT) and magnetic resonance imaging
(MRI) is necessary in most cases. Angiography can be done for vascular lesions.
MANAGEMENT OF TINNITUS
PSYCHOACOUSTICAL MEASUREMENTS OF TINNITUS
Psycho acoustical measurement of tinnitus is the only method for 'authentication' of the presence of
tinnitus currently used in routine clinical practice, based on comparison of tinnitus with external
sounds
Psycho acoustical measurements of tinnitus include assessment of the Pitch, Bandwidth, Loudness,
Maskability of tinnitus and residual inhibition. (MBPL)
TINNITUS RETRAINING THERAPY (TRT)
1)
2)
3)
1)
2)
3)
COUNSELLING
Medical Counselling
Lay Counselling (by the one who was a previous sufferer of tinnitus himself)
Psychological counselling
PSYCHOLOGICAL TREATMENT
Cognitive therapy – alter dysfunctional mood states and reducing stress
Relaxation training therapy
Hypnosis
TREATMENT OF UNDERLYING DISORDERS
1) Medical or surgical treatment of underlying disorder
NONSPECIFIC MEDICAL TREATMENT
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
Antidepressants
Ca2+ channel antagonists
Antiepileptics
GABA analogues
Prostaglandin analogues
Lidocaine – Lidocaine is one of the most intriguing drugs used in controlling tinnitus and,
probably, the most effective one. >83% patients show good response
Intratympanic steroid injection i.e. dexamethasone 8mg/mL OR Hydrocortisone
100mg/mL). 0.5 to 0.8 mL of steroid is instilled into middle ear by using No 19 spinal
needle. Weekly injections for 3 weeks. Steroid acts as a neuroprotector of the inner ear
and improves the neuronal function after injuries caused by ischaemia, trauma or
neurodegenerative lesions.
Tranquilizers
Antitinnitus medications (Clonazepam, Flecainide, Carbamazapine, Sodium Valproate
Sedatives
Ginko Biloba extracts
Diatery suppliments – NaF (eg in Menieres disease), Zn, Vitamins
INSTRUMENTATION
HEARING AIDS
Hearing aids are the first line in management for patients with tinnitus and hearing loss.
Cochlear implants, which electronically stimulate the auditory system, have revolutionized the
management of patients with profound hearing loss and have been found useful in
abolishing/reducing tinnitus in a significant number of cases.
Sound therapy is currently an essential part of treatment of tinnitus and hyperacusis.
Tinnitus maskers are wearable behind-the ear or in the ear devices, used for presentation of sounds
in a controlled manner in order to reduce or eliminate the perception of tinnitus.
SURGICAL TREATMENT OF TINNITUS
Auditory nerve section, or cochlear destruction, have provided little evidence of effectiveness and
may even make tinnitus worse