Introduction



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Introduction

  • Introduction

  • Epidemiology.

  • Types/classification.

  • Etiology .

  • Pathophysiology.

  • Features/measurements.

  • Diagnosis & investigations

  • Management

  • Conclusion



Tinnire – to ring. Tinnitus - ringing in the ear.

  • Tinnire – to ring. Tinnitus - ringing in the ear.

  • perception of sound in absence of stimulation /no external acoustic source.

  • A Conscious experience of a sound that originates in the head of the owner.

  • hissing, sizzling and buzzing, pulsatile

  • can be persistent, intermittent, or throbbing.

  • Tinnitus is an element of the symptom profile of several significant otological pathologies.



In US,37-40M i.e 12-14% americans1.

  • In US,37-40M i.e 12-14% americans1.

  • 30% of adults,6% incapacitated

  • Peak age-40-70Yrs

  • M>F higher risk(12% M over 65,only 7% F)

  • Whites>blacks

  • prevalence increases with age & with HL

  • > risk in low economic status.



Subjective-has a neurophysiological origin

  • Subjective-has a neurophysiological origin

  • Objective

    • Vascular somatosounds
        • Morphological
        • Dynamic
    • Myogenic sounds
    • Patulous ET
    • TMJ abnormality
    • SOAEs


AVMs

  • AVMs

  • Vascular tumors

  • Venous hum

  • Atherosclerosis

  • Ectopic carotid artery

  • Persistent stapedial artery

  • Dehiscent jugular bulb

  • Vascular loops



Subjective tinnitus:-

  • Subjective tinnitus:-

  • Otological:-noise ,infections,presbycusis,menieres, otosclerosis, neuromas,cerumen,labyrinthitis.

  • Trauma-neck injuries,explosions,closed head injuries.

  • CNS disorders-meningitis.

  • Metabolic disorders, auto-immune disorders

  • Depression, anxiety

  • Medications, drug abuse



heterogeneity in the tinnitus population-many different mechanisms.

  • heterogeneity in the tinnitus population-many different mechanisms.

  • Little known about physiologic mechanism

  • Modified neural activity in central auditory system due to peripheral auditory structures damage2

  • Cochlear ;Non-cochlear mechanisms of tinnitus generation



Hyperactive hair cells or nerve fibers

  • Hyperactive hair cells or nerve fibers

  • Chemical imbalance

  • Reduced suppressive influence of CNS



Discordant damage of IHC and OHC:-IHCs more resistant to damage.3

  • Discordant damage of IHC and OHC:-IHCs more resistant to damage.3

  • modification of auditory afferent activity leading to tinnitus perception

  • SOAEs-rarely correspond to the judged frequency of the tinnitus4

  • Biochemical models-Endogenous dynorphins(stress) potentiate glutamate within the cochlea5



Jastreboff neurophysiological model6-auditory perceptual, emotional and reactive systems

  • Jastreboff neurophysiological model6-auditory perceptual, emotional and reactive systems

  • Increased neural activity- dorsal cochlear nucleus (DCN), IC,cortical activity.

  • Analogies with pain7

    • chronic pain
    • phantom pain:-Cortical re-organisation


Modified neural activity in central auditory system due to peripheral auditory structures damage

  • Modified neural activity in central auditory system due to peripheral auditory structures damage

  • Tonotopic frequency matching from periphery to cortex is altered.

  • increased spontaneous firing & increased fqcy presentation of bordering neurons( plasticity)

  • detrimental cortical adaptation to input deprivation from the sensory periphery



These changes lead to abnormal interaction btn auditory & other central pathways.

  • These changes lead to abnormal interaction btn auditory & other central pathways.

  • Mechanism by which other symptoms e.g depression,fear & anxiety are produced.

  • Coupling of auditory system with other central systems like limbic & autonomic NS6 –basis of neuro-physiological approach to tinnitus.





Principally,auditory pathway & several non auditory systems play essential role in tinnitus.

  • Principally,auditory pathway & several non auditory systems play essential role in tinnitus.

  • Stresses non auditory system dominates in determining annoyance level.

  • Proposis treatment by inducing & facilitating habituation to tinnitus signal.

  • Goal-to reach level though patient percieves tinnitus as unchanged,they arent aware of it &/or no annoyance occurs.



Clinically not as relevant.mainly in research.

  • Clinically not as relevant.mainly in research.

  • Pitch-equate a pure tone pitch to that of tinnitus.

  • Loudness-most <7 dBel

  • Minimum masking level-no of dBels of sound required to cover tinnitus.

  • Residual inhibition(postmasking effects)-periods of decreased or no tinnitus after masking.



evaluate presence & severity of the tinnitus.

  • evaluate presence & severity of the tinnitus.

  • VAS assess loudness, pitch, & disturbance of the tinnitus

  • Tinnitus Handicap Inventory

  • Tinnitus Reaction Questionnaire

  • Tinnitus Functional Index-severity,negative impact,Rx-related changes



Underestimated-no vocabulary to explain,may consider it normal,fear to disclose(withdrawal)

  • Underestimated-no vocabulary to explain,may consider it normal,fear to disclose(withdrawal)

  • Look for changes in attention,depression,poor school performance,insomnia.

  • 6-13% 10 of children with normal hearing on &off

  • 24-29% -with hearing difficulties.

  • Causes-inborn,ME infections,wax, deafness, noise,meningitis,asprin ,ET dysfunction.



Thorough History & PE.-etiology may be picked.

  • Thorough History & PE.-etiology may be picked.

  • History:-

  • noise exposure/trauma

  • HL & vertigo+/- dizziness,otalgia,

  • Quality- buzzing,rushing, roaring ,flactuating.

  • Trauma- head/neck

  • Medical history

  • Medications/drug use

  • Depression/somatoform disorders

  • Tinnitus handicup inventory.



General exam vital.

  • General exam vital.

  • Thorough H/N exam.

  • Otoscopy-wax,glomus,dehiscent jugular bulb etc

  • Auscultation –bruit,venous hums

  • Light exercise,neck compression,valsalva manoeuvers.

  • Audiometric tests-PTA ,speech, impedence testing, OAE,



No diagnostic modality to objectively measure or confirm tinnitus.

  • No diagnostic modality to objectively measure or confirm tinnitus.

  • FBC,ESR,U&Es..VDRL,HIV.

  • CT scans, angiograhy, MRI, PET,Magnetic studies especially for pulsatile tinnitus.



Various treatments –unsuccessful/unproven

  • Various treatments –unsuccessful/unproven

  • Cochlea,NTs &receptors,ion channels.

  • Treatment methods not able to reduce or eliminate the sensation on any consistent basis

  • no drug that has been approved specifically for its treatment

  • Comorbidities- hearing loss, mental health problems, or sleep disorders.



Medical/Physiological Treatments

  • Medical/Physiological Treatments

    • Pharmacological Treatment
    • Transcranial Magnetic Stimulation
    • Complementary and Alternative Medicine Therapies
  • surgical treatments

  • Sound treatments/technologies

    • Hearing Aids
    • Cochlear Implants
    • Sound Generators
    • Tinnitus Retraining Therapy
    • Neuromonics Tinnitus Treatment 13-combines acoustic stimulation with a structured program of counseling support by a clinician


Psychological/behavioral treatments

  • Psychological/behavioral treatments

    • Cognitive Behavioral Therapy
    • Biofeedback, Education, and Relaxation Therapies
    • Progressive Tinnitus Management


Glutamate rerceptor antagonist –caroverine, memantine, Acamprosate

  • Glutamate rerceptor antagonist –caroverine, memantine, Acamprosate

  • activate GABA receptors

  • Antidepressants-amitriptyline,nortriptyline, trimipramine

  • Anxiolytics-Alprazolam-

  • Anticonvulsants- Carbamazepine, Gabapentin

  • Vasodilators/vasoactive substances- Prostaglandin E1

  • Selective serotonin-reuptake inhibitors: fluoxetine and paroxetine

  • Lidocaine IV/transtympanic.



Transcranial Magnetic Stimulation 17-

    • Transcranial Magnetic Stimulation 17-
    • Complementary and Alternative Medicine Therapies
      • Ginkgo Biloba Extract 18- glutamate antagonist, strong anti-oxidant
      • Acupuncture 19, and hyperbaric oxygen
      • diet modifications eg avoid high-sodium foods, caffeine, chocolate, and other stimulants


aim- to modify harmful behaviours & thoughts using “deconditioning” technique

  • aim- to modify harmful behaviours & thoughts using “deconditioning” technique

  • reduces arousal levels via relaxation therapy &changing –ve thoughts through cognitive therapy.

  • Goebel et al 20 confirm the long-term benefits of CBT for tinnitus.



Based on neurophysiological model.

  • Based on neurophysiological model.

  • Conditioned reflexes involving connections of auditory with limbic & ANS are retrained such that the subconscious part of auditory pathway blocks the tinnitus signal.

  • Acoustic input with unimportant information is ignored(habituation)

  • Inducing & sustaining habituation of conditioned reflexes removes –ve impact of tinnitus



Goal-train CNS to interpret tinnitus as unimportant & ignore it.

  • Goal-train CNS to interpret tinnitus as unimportant & ignore it.

  • Has 2 components:-

  • -intensive direct counselling.

  • -sound therapy using sound generators which emit low level broad band noise.

  • Not masking-cant habituate a signal that cannot be detected.

  • Jastreboff 21 reported success in over 80% of his cases.



control or habituate to the perceived ringing and the subsequent distress.

  • control or habituate to the perceived ringing and the subsequent distress.

  •  Biofeedback therapy-listens to audio signal from EMG of frontalis muscle

  • reduces perceived ringing &muscle tension

  • strategies to self-manage their tinnitus.

  • Relaxation therapies -focus pt’s attention away from the sound;psychologically improving symptoms.



PET /fMRI help in research into the mechanisms and hence treatment of tinnitus.

  • PET /fMRI help in research into the mechanisms and hence treatment of tinnitus.

  • Transcranial DC Stimulation(tDCS)

  • Transcranial magnetic stimulation.



difficult to study and treat -no objective tools to quantify and measure.

  • difficult to study and treat -no objective tools to quantify and measure.

  • no therapeutically successful treatment in terms of medium or long term remission

  • no universally accepted therapies for managing tinnitus

  • interactions among the auditory, cognitive, affective, and mental health issues.



1.Heller AJ. Classification and epidemiology of tinnitus. Otolaryngol Clin N Am 2003;36:239-248

  • 1.Heller AJ. Classification and epidemiology of tinnitus. Otolaryngol Clin N Am 2003;36:239-248

  • 2.Eggermont JJ, Roberts LE. The neuroscience of tinnitus. Trends Neurosci. 2004;27:676–682

  • 3.Hazell JWP, Jastreboff PJ. Tinnitus. I. Auditory mechanisms: a model for tinnitus and hearing impairment. J Otolaryngol 1990; 19: 1–5

  • 4.Penner MJ. An estimate of the prevalence of tinnitus caused by spontaneous otoacoustic emissions. Arch Otolaryngol Head Neck Surg 1990; 115: 871–5

  • 5.Sahey TL, Nodar RH. A biochemical model of peripheral tinnitus. Hear Res 2001; 152: 43–54

  • 6.Jastreboff PJ, Gray WC, Gold SL. Neurophysiological approach to tinnitus patients. Am J Otol 1996;17:236-240.

  • 7.Moller AR. Similarities between severe tinnitus and chronic pain. J Am Acad Audiol 2000; 11: 115–24

  • 8.Kitahara M. Tinnitus Pathophysiology and Management. Igaku-Shoin: Tokyo, New York; 1998.

  • 9.Moller AR. Pathophysiology of tinnitus. Otolaryngol Clin N Am 2003;36:249-266

  • 10.Baguley DM, McFerran DJ. Current perspectives on tinnitus. Arch Dis Child 2002; 86: 141–3

  • 11.Denk DM, Ehrenberger K. Tinnitus: causes, diagnosis, therapy Wien Med Wochenschr, 142(11-12):259-62

  • 12..Schwaber MK. Medical evaluation of tinnitus. Otolaryngol Clin N Am 2003;36:287-292

  • .



13.anley PJ, Davis PB. Treatment of tinnitus with a customized, dynamic acoustic neural stimulus: underlying principles and clinical efficacy. Trends Amplif. 2008;12:210–22

  • 13.anley PJ, Davis PB. Treatment of tinnitus with a customized, dynamic acoustic neural stimulus: underlying principles and clinical efficacy. Trends Amplif. 2008;12:210–22

  • 14.Ehrenberger K. Topical administration of Caroverine in somatic tinnitus treatment: proof-of-concept study. Int Tinnitus J. 2005;11:34–7.

  • 15.Bauer CA, Brozoski TJ. Effect of gabapentin on the sensation and impact of tinnitus. Laryngoscope. 2006;116:675–81

  • 16.Baldo P, Doree C, Lazzarini R, Molin P, McFerran D. Antidepressants for patients with tinnitus. Cochrane Database of Systematic Reviews. 2006;(Issue 4) 17Kleinjung T, Vielsmeier V, Landgrebe M, Hajak G, Langguth B. Transcranial magnetic stimulation: a new diagnostic and therapeutic tool for tinnitus patients. Int Tinnitus J. 2008;14:112–8.

  • 18.Hilton M, Stuart E. Ginkgo biloba for tinnitus. Cochrane Database Syst Rev 2004;(2):CD003852. PMID: 15106224.

  • 19.Park J, White AR, Ernst E. Efficacy of acupuncture as a treatment for tinnitus: a systematic review. Arch Otolaryngol Head Neck Surg 2000 Apr;126(4):489-92. PMID: 10772302.:CD003853

  • 20.Goebel G, Kahl M, Arnold W, Fichter M. 15 years prospective follow-up study of behavioural therapy in a large samplke of inpatients with chronic tinnitus. Acta Otolaryngol. 2006;126:70–9.

  • 21.Jastreboff PJ, Jastreboff MM. Tinnitus retraining therapy for patients with tinnitus and decreased sound tolerance. Otolaryngol Clin N Am 2003;36:321-336

  • 22.Phillips JS, McFerran D. Tinnitus Retraining Therapy (TRT) for tinnitus. Cochrane Database Syst Rev 2010 Mar 17;(3):CD007330. PMID: 20238353

  • 23.Seidman MD, Babu S. Alternative medications and other treatments for tinnitus: Facts from fiction. Otolaryngol Clin N Am 2003;36:359-381.

  • 24..Mirz F, Pedersen CB, Ishizu K, Johannsen P, Ovesen T, Stodkilde-Jorgensen H, Gjedde A. Positron emission tomography of cortical centes of tinnitus. Hear Res 1999;134:133-144..



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