Tinnitus – An ENT Perspective

1. Tinnitus – An ENT Perspective Mr. Marcus Choo

2. 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!

3. 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

4. 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

5. 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

6. Causes • Noise exposure • Medication • Infection • Older age hearing loss • Meniere’s Disease • Outer/Middle ear disease • Acoustic neuroma • Unknown (by far the most common)

7. Effects of Tinnitus • Concentration • Hearing • Insomnia • Psychological

8. Ear Anatomy

9. Ear Anatomy

10. Mechanism of Hearing

11. Mechanism of Hearing

12. Mechanism of Hearing

13. Mechanism of Hearing

14. 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

15. 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

16. Pathophysiology

17. 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

18. Differential Diagnosis • Idiopathic (most common) • Outer ear disease • Wax, foreign body, infection • Middle ear disease • Infection, perforated eardrum, ossicular problems, tumour

19. Differential Diagnosis • Inner ear disease • Presbyacusis (older age hearing loss) • Meniere’s disease • Acoustic neuroma • Noise exposure • Drugs

20. 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

21. Normal Ear

22. Diseased ear

23. Evaluation of Tinnitus • Audiological (hearing) Tests • Audiogram, tympanogram • Specialised hearing tests • MRI • Associated symptoms • Asymmetric hearing loss

24. Audiogram

25. MRI

26. Treatment • Aim to improve habituation rather than “cure” tinnitus • Most people don’t seek treatment • Multitude of potential treatments • Problems with scientific evidence

27. Treatment • Basic advice • Hearing Aid • Tinnitus Masking Device • Tinnitus Instrument • Tinnitus Retraining Therapy • Psychological Treatment • Medication • Alternative Treatments

28. 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

29. Support • Irish Tinnitus Association • DeafHear.ie • Hearing Aid Specialist • www.tinnitus.org

30. Treatment • Basic advice • Hearing Aid • Tinnitus Masking Device • Tinnitus Instrument • Tinnitus Retraining Therapy • Psychological Treatment • Medication • Alternative Treatments

31. 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

32. Hearing Aids

33. Hearing Aids

34. Treatment • Basic advice • Hearing Aid • Tinnitus Masking Device • Tinnitus Instrument • Tinnitus Retraining Therapy • Psychological Treatment • Medication • Alternative Treatments

35. Tinnitus Masking Device • Essentially counteracts tinnitus • Generate noise bands • Tinnitus Instruments • Combination of hearing aid and masker

36. 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

37. Treatment • Basic advice • Hearing Aid • Tinnitus Masking Device • Tinnitus Instrument • Tinnitus Retraining Therapy • Psychological Treatment • Medication • Alternative Treatments

38. 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

39. Tinnitus Retraining Therapy • May take several months to take effect • Minimum 12 months treatment • Involves wearing ear noise generator, table top generator

40. Tinnitus Retraining Therapy

41. Treatment • Basic advice • Hearing Aid • Tinnitus Masking Device • Tinnitus Instrument • Tinnitus Retraining Therapy • Psychological Treatment • Medication • Alternative Treatments

42. 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

43. Treatment • Basic advice • Hearing Aid • Tinnitus Masking Device • Tinnitus Instrument • Tinnitus Retraining Therapy • Psychological Treatment • Medication • Alternative Treatments

44. Medications • No magical cure • Serc • Lignocaine • Temporary, intravenous • Alprazolam • Xanax • Side effects

45. Treatment • Basic advice • Hearing Aid • Tinnitus Masking Device • Tinnitus Instrument • Tinnitus Retraining Therapy • Psychological Treatment • Medication • Alternative Treatments

46. 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

47. Alternative Therapies • Hypnotherapy • Acupuncture • Ear canal magnets • Hopi ear candles

48. Alternative Therapies

49. 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?

50. 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