marcus choo presentation apr 2010

Tinnitus – An ENT Perspective

Mr. Marcus Choo

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!

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

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

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

Causes

Noise exposureMedication InfectionOlder age hearing lossMeniere’s DiseaseOuter/Middle ear diseaseAcoustic neuromaUnknown (by far the most common)

Effects of Tinnitus Concentration Hearing Insomnia Psychological

Ear Anatomy

Mechanism of Hearing

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

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

Pathophysiology

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

Differential Diagnosis

Idiopathic (most common)

Outer ear disease– Wax, foreign body, infection

Middle ear disease– Infection, perforated eardrum, ossicular problems,

tumour

Differential Diagnosis Inner ear disease

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

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

Normal Ear

Diseased ear

Evaluation of Tinnitus Audiological (hearing) Tests

Audiogram, tympanogram Specialised hearing tests

MRI Associated symptoms Asymmetric hearing loss

Audiogram

Treatment Aim to improve habituation rather than

“cure” tinnitus

Most people don’t seek treatment Multitude of potential treatments Problems with scientific evidence

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

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

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

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

Hearing Aids

Tinnitus Masking Device Essentially counteracts tinnitus Generate noise bands Tinnitus Instruments

Combination of hearing aid and masker

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

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

Tinnitus Retraining Therapy May take several months to take effect

Minimum 12 months treatment

Involves wearing ear noise generator, table top generator

Tinnitus Retraining Therapy

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

Medications No magical cure Serc Lignocaine

Temporary, intravenous

Alprazolam Xanax Side effects

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

Alternative Therapies Hypnotherapy Acupuncture Ear canal magnets Hopi ear candles

Alternative Therapies

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?

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

marcus choo presentation apr 2010

Documents

ear disorders

perception of tinnitus

sensations of hearing

tinnitus signaloften

commonouter ear diseasewax

autonomic nervous system

central nervous system

auditory system