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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