Introduction

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-
• proven effect in auditory hallucinations .
• Reduction of tinnitus loudness
• 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

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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..

THANK YOU

• THANK YOU