Tinnitus is defined as sensations of hearing in the absence of external sounds



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Tinnitus is defined as sensations of hearing in the absence of external sounds

  • Tinnitus is defined as sensations of hearing in the absence of external sounds





Prevalence increases with age

  • 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





Ludwig van Beethoven

  • Ludwig van Beethoven

  • Vincent van Gogh

  • Charles Darwin

  • Neil Young

  • Eric Clapton

  • Ronald Regan



Objective: caused by sounds generated somewhere in the body

  • 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





Concentration

  • Concentration

  • Hearing

  • Insomnia

  • Psychological













Poorly understood

  • 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





Patients with tinnitus exhibit enhanced auditory sensitivity

  • Patients with tinnitus exhibit enhanced auditory sensitivity

  • This is caused by hyperactivity of the auditory central nervous system

  • In patients with tinnitus and hearing loss, the tinnitus pitch and the hearing loss frequency spectrum are usually matched



The decreased input from the cochlea, due to outer hair cell damage, results in readjustments in the central auditory system resulting in abnormal neural activity including hyperactivity, bursting discharges and increases in neural synchrony.

  • The decreased input from the cochlea, due to outer hair cell damage, results in readjustments in the central auditory system resulting in abnormal neural activity including hyperactivity, bursting discharges and increases in neural synchrony.



When the perception of tinnitus is associated with negative reinforcement, the autonomic nervous system is activated.

  • 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







Thorough evaluation to rule out significant pathology

  • 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



Idiopathic (most common)

  • Idiopathic (most common)

  • Outer ear disease

    • Wax, foreign body, infection
  • Middle ear disease

    • Infection, perforated eardrum, ossicular problems, tumour


Inner ear disease

  • Inner ear disease

    • Presbyacusis (older age hearing loss)
    • Meniere’s disease
    • Acoustic neuroma
    • Noise exposure
    • Drugs




Thorough history

  • Thorough history

      • Duration, nature, effects
      • Non vs. pulsatile
      • Noise exposure
      • Other ear symptoms
  • Ear examination

      • Rule out outer/middle ear disease
      • Tuning fork tests




Audiological (hearing) Tests

  • Audiological (hearing) Tests

      • Audiogram, tympanogram
      • Specialized hearing tests: SOAE, ECochG, ABR
  • MRI

      • Associated symptoms
      • Asymmetric hearing loss


Audiometry - assymetrical hearing loss, unilateral tinnitus - MRI r/o post fossa

  • Audiometry - assymetrical hearing loss, unilateral tinnitus - MRI r/o post fossa

  • Complete questionnaire for perceived severity:THI



Pitch, loudness, minimum masking level, residual inhibition/post masking

  • Pitch, loudness, minimum masking level, residual inhibition/post masking

  • Minimum masking level most clinical use

  • Pitch - match most prominent pure tone, poor reliability, octave difference

  • Loudness - Adjust pure tone to tinnitus

  • Most < 7 dB SL, may be 2 dB



Minimal masking level - number of decibels to cover tinnitus

  • Minimal masking level - number of decibels to cover tinnitus

  • Residual inhibition - response of patients tinnitus post masking







Aim to improve habituation rather than “cure” tinnitus

  • Aim to improve habituation rather than “cure” tinnitus

  • Most people don’t seek treatment

  • Multitude of potential treatments

  • Problems with scientific evidence



Basic advice

  • Basic advice

  • Hearing Aid

  • Tinnitus Masking Device

  • Tinnitus Instrument

  • Tinnitus Retraining Therapy

  • Psychological Treatment

  • Medication

  • Alternative Treatments



Reassurance

  • 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



Basic advice

  • Basic advice

  • Hearing Aid

  • Tinnitus Masking Device

  • Tinnitus Instrument

  • Tinnitus Retraining Therapy

  • Psychological Treatment

  • Medication

  • Alternative Treatments



Essentially for poor hearing

  • Essentially for poor hearing

  • Increases ambient noise

  • Decreases stress of poor hearing

  • Various shapes and sizes

  • Cost

  • Limitations

  • Up to 90% may benefit





Reports of the use of hearing aids in the management of tinnitus go back over 60 years

  • Reports of the use of hearing aids in the management of tinnitus go back over 60 years

  • Because hearing loss is often associated with tinnitus, at least partial restoration of hearing should help to reduce the central gain in auditory perception that is a feature of tinnitus

  • A recent scoping review of studies of hearing aids in tinnitus revealed that 17/18 publications showed improvements in tinnitus symptoms by fitting hearing aids



Basic advice

  • Basic advice

  • Hearing Aid

  • Tinnitus Masking Device

  • Tinnitus Instrument

  • Tinnitus Retraining Therapy

  • Psychological Treatment

  • Medication

  • Alternative Treatments



Essentially counteracts tinnitus

  • Essentially counteracts tinnitus

  • Generate noise bands

  • Tinnitus Instruments

      • Combination of hearing aid and masker


Emit ‘white noise’

  • 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



Basic advice

  • Basic advice

  • Hearing Aid

  • Tinnitus Masking Device

  • Tinnitus Instrument

  • Tinnitus Retraining Therapy

  • Psychological Treatment

  • Medication

  • Alternative Treatments



Based on evidence that a person can habituate to acoustic noise in the environment

  • 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













May take several months to take effect

  • May take several months to take effect

  • Minimum 12 months treatment

  • Involves wearing ear noise generator, table top generator





Basic advice

  • Basic advice

  • Hearing Aid

  • Tinnitus Masking Device

  • Tinnitus Instrument

  • Tinnitus Retraining Therapy

  • Psychological Treatment

  • Medication

  • Alternative Treatments



Relaxation therapy

  • 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





Basic advice

  • Basic advice

  • Hearing Aid

  • Tinnitus Masking Device

  • Tinnitus Instrument

  • Tinnitus Retraining Therapy

  • Psychological Treatment

  • Medication

  • Alternative Treatments



  • No approved drugs (European Medicines Agency [EMA] or US Food and Drug Administration [FDA])

  • Some psychopharmacological agents may help reduce the severity of psychological issues associated with tinnitus, and some may also lessen tinnitus symptoms



Basic advice

  • Basic advice

  • Hearing Aid

  • Tinnitus Masking Device

  • Tinnitus Instrument

  • Tinnitus Retraining Therapy

  • Psychological Treatment

  • Medication

  • Alternative Treatments



Vitamins

  • Vitamins

      • B1, B3, B6, B12, zinc, calcium, Mg
  • Laser Therapy

      • Germany
      • Thought to increase ATP in cochlea


Hypnotherapy

  • Hypnotherapy

  • Acupuncture

  • Ear canal magnets



Brain 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?


Tinnitus is a common condition

  • 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







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