hissing and buzzing and ringing, oh my! the diagnosis and treatment of tinnitus carol rousseau,...
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Hissing and Buzzing and Ringing, Oh My!
The Diagnosis and Treatment of Tinnitus
Carol Rousseau, M.A., CCC-ARochester Hearing and Speech
CenterRochester, NY12 May 2006
DEFINITION
• The perception of sound in one or both ears or in the head when no external sound is present (American Tinnitus Association, 2006)
Po-TAY-to, Po-TAH-to….
• Both TINN-ni-tus and Tin-EYE-tis are acceptable pronunciations
• Originated from the Latin verb “Tinnire” meaning to ring or tinkle
• Geography– West Coast: Second syllable– Middle America: First syllable– East Coast: Evenly Divided
Some History…• First recorded appearance is about 2000
years ago by the Phoenicians• Noted in Egyptian hieroglyphics• Aristotle (384-322 B.C.) wrote of it• Physician Galen (129-199 B.C.)
described it as “echoes”• Jean Marie Gaspard Itard in 1821
mentioned “True” and “False” Tinnitus, which we now refer as “Objective” and “Subjective”
More History…
• 1975 Dr. Jack Vernon introduced the first wearable masker device
• In 1990, Jastreboff introduced popular therapeutic approach called “Tinnitus Retraining Therapy (TRT)
Some Statistics…
• Over 50 Million Americans experience Tinnitus to some degree
• 12 Million severe enough to seek medical attention
• 2 Million so seriously debilitated that they can not function on a normal basis (ATA, 2006)
More Statistics…
• 6-20% of U.S. population describe noise as bothersome
• 1% say it interferes with day-to-day activities (Gelfand, 1997)
Famous People with Tinnitus• Musicians
– Neil Young– Pete Townsend– Barbara Streisand– Sting– Eric Clapton– Jeff Beck– James Hatfield
(Metallica)– Lars Ulrich (Metallica)
– George Martin– George Harrison– Ted Nugent– Bono (u2)– The Edge (u2)– Paul Schaffer– Trent Rezner– Dave Pirner (Soul
Asylum)– Huey Lewis– Beethoven
Famous People with Tinnitus
• Actors– William Shatner– Leonard Nimoy– Steve Martin– Burt Reynolds– Sylvester Stallone– Tony Randall
– Jerry Stiller– Florence
Henderson– Keanu Reeves– Larry King– David Letterman– Cher
Famous People with Tinnitus
• Historical/Political– Jean-Jacques Rousseau– Thomas Edison– Dwight D. Eisenhower– Martin Luther– Alan Shepard– Vincent Van Gogh– Charles Darwin
Characteristics of Tinnitus: Quality
• 79% of patients described their tinnitus as a pure tone– Single, double, and tri-toned
• 6% described it as noise• 15% mixture of pure tone and
noise (Vernon, 1998)
Characteristics of Tinnitus: Pitch
• Most frequently described pitch of the tone as 8000Hz (Vernon, 1998; Sandlin & Olsson, 2000)
Characteristics of Tinnitus: Loudness
• 88% described loudness of 11 dB SL or less
• Overall average loudness level as 5.7 dB SL
Causes of Tinnitus• Mostly unknown
– 47%
• Noise Exposure– 25%
• Head Injury/Brain Trauma– 8%
• Ear Pathology– 7%
• Ototoxic Medications and other– 13% (Vernon, 1998)
Causes of Tinnitus:Diet• May be related to food allergies or
sensitivities• Salicylates naturally occurs in some foods
may produce tinnitus– Almonds, cloves, gingerbread, mustard, mint
flavors– Apples, Apricots, Blackberries, Grapes, Raisins,
Oranges, Strawberries, Raspberries, avocados– Bell and green peppers, olives, cucumbers, white
potatos– Processed foods– Alcohol, especially beer and gin
Causes of Tinnitus:Noise
• 90% of ATA members also report hearing loss (ATA, 2006)
• Many of those have high frequency hearing loss associated with noise
• Effects of loud noise can worsen existing tinnitus
Mechanisms of Tinnitus: Just What is Going on in the Ear?
• Vibrations• Phase-locked spontaneous discharge of
cell bodies• Aberrant behavior of the efferent system• Involvement of Neurotransmitter
substances• Central Origin (the brain)• Vascular Compression of the 7th nerve
Mechanisms of Tinnitus: Just What is Going on in the Ear?
• CNS phenomenon dictated by peripheral activity– Something akin to Phantom Limb
phenomenon
• Lockwood (1998) theorized that tinnitus is based in the auditory cortex, and not the cochlea
• Other theories state that it may be caused by alterations in the function of the inferior colliculus
Mechanisms of Tinnitus: Just What is Going on in the Ear?
• Jastreboff (1995) theorized that tinnitus may involve a discordant dysfunction of OHC and IHC systems– One system becomes dysfunctional because
of loss of cell population– Difference is created in the activity of the
two different type of fibers
• Many theorize that tinnitus is a symptom of many causes based on a number of different mechanisms
Medical Aspects of Tinnitus:Types of Tinnitus
• Medical diseases and emotional factors may cause and/or affect severity of tinnitus
• Two types– Objective– Subjective
Objective Tinnitus
• Also called Audible Tinnitus• Can be heard by physician
– Via external ear canal or mastoid bone
• Corresponds to respiration or heartbeat
Objective Tinnitus: Corresponding to Respiration
• May be caused by abnormally patent Eustachian Tube
• Usually experienced short time• May be caused by extreme weight
loss or after an extended illness• Symptoms relieved by lying down
or putting head in lowered position
Objective Tinnitus: Sharp or Irregular Clicks
• Heard for several seconds or minutes at a time
• Contractions of soft palate or muscles of the middle ear
• Cause unknown
Objective Tinnitus:Pulsatile Tinnitus
• Synchronous with heartbeat/pulse• May indicate cardiac or vascular
abnormalities– Abnormal vascular flow from arteries
to veins somewhere in the head/neck– Also may be secondary to turbulence
of major vessels from arteriosclerosis or narrowing of blood from artery to vein
Subjective Tinnitus• More frequent than Objective Tinnitus• Most people experience this at some point• Various medical conditions cause or affect
subjective tinnitus– Otologic disorders– Cardiovascular abnormalities– Metabolic diseases– Neurologic disorders– Drugs/Pharmaceuticals– Dental factors– Psychological/emotional factors
Subjective Tinnitus:Otologic Causes
• Hearing Loss considered the most common cause of tinnitus– 90% have some form of ear disease
• SNHL most frequent– Majority have a 30 dB or higher HL from 3 to
8 kHz– Mostly the result of aging or noise exposure– Often characterized as high-pitched– Usually described as mild
Subjective Tinnitus:Cardiovascular Disorders• 37% of tinnitus patients also have
cardiovascular complaints (Schleuning, 1998)
• Often characterized as low pitched pulsating sound
• Alteration of blood flow in the head can be cause a low frequency hum
• High blood pressure• Anemia• Arteriosclerosis
Subjective Tinnitus:Metabolic Disease
• Rare, and may be associated with other disorders that may be causing tinnitus– Diabetes– Thyroid disease– High cholesterol levels– Vitamin deficiencies
Subjective Tinnitus:Neurologic Disease• Head trauma
– 10% of tinnitus patients had skull fracture or severe closed head injury (Schleuning, 1998)
– Result of damage to the internal structure of the inner ear with nerve or hair cell damage
– Usually diminishes over time– Whiplash injury may involve nerve input from
the neck and shoulders along with concussion damage to the inner ear
• Meningitis• Multiple Sclerosis
Subjective Tinnitus:Pharmacological Factors• All types of drugs can be considered as
a possible cause• Most frequent:
– anti-inflammatory drugs• Aspirin and aspirin-containing medications
– Percodan– Bufferin– Ecotrin
• Nonsteroidal Anti-inflammatory drugs (not as severe as aspirin)
– Naprosin– Ibuprophen
Subjective Tinnitus:Pharmacological Factors
– Antibiotics• Aminoglycosides (tinnitus more pronounced when
paired with diuretics)– Streptomycin– Kanamycin– Gentamicin
– Sedatives or antidepressants– Quinine-containing medications for muscle
cramps or arrhythmia– Heavy Metals
• Mercury• Arsenic• Lead in high doses
Subjective Tinnitus:Pharmacological Factors
• Stimulants – Tobacco– Caffeine
• Constricts blood vessels• Make cells of the inner ear more
irritable and more likely to randomly discharge
Subjective Tinnitus:Dental Factors
• Temporomandibular-joint (TMJ) problems
• Lower pitch• Related to jaw activity• Grinding and painful teeth and ear
pain are other symptoms
Subjective Tinnitus:Psychological Factors
• Stress and fatigue play a role in severity of complaint
• Increases perception of problem more than causes tinnitus
• Similar symptoms as depression– 15-20 of Tinnitus patients
Pulsatile Tinnitus
• Can be objective or subjective• Characterized as a “thumping” sound
that is often synchronous with heartbeat
• Usually originates from vascular structures inside the head or neck– Arterial or venous– Other structures classified as non-vascular
• Refer to ENT
Pulsatile Tinnitus
• Glomus Tumor– Benign vascular tumors located
usually in the ear– Red mass behind an intact TM– Hearing Loss
• Hypertension– May start after starting medications
to control blood pressure– Usually subsides after 4-6 weeks
Etiologies of Pulsatile Tinnitus:Arterial• Atherosclerotic Carotid Artery Disease• Tortuous (twisted) Arteries• Fibromuscular Dysplasia• Intracranial Arterio-venous Fistulae and
Aneurysms• Vascular Compression fo the 8th Cranial
Nerve• Aortic Murmurs• Paget’s Disease• Increased Cardiac Output (Amemia,
Thyrotoxicosis, Pregnancy)
Etiologies of Pulsatile Tinnitus:Venous
• Benign Intracranial Hypertension• Jugular Bulb Abnormalities• Abnormal Condylar and Mastoid
Emissary Veins
Etiologies of Pulsatile Tinnitus:Nonvascular
• Neoplasms of the skull and temporal bone
• Palatal, Tensor Tympani, and Stapedial Muscle Myoclonus
• Patulous Eustachian Tube• Cholesterol Granuloma of the
Middle Ear
Otologic Causes for Tinnitus
• Described as moderate or severe• Meniere’s disease• Chronic Suppurative Otitis Media• Viral Infections of the ear• Otoscleroris• Acoustic Neuroma
– Unilateral
• Sudden Hearing loss
Assessment of Tinnitus:Two Perspectives
• Identify the source of the tinnitus• Assess of how the tinnitus affects
the person
Assessment of Tinnitus
• Psychoacoustic Measurements• Electophysical Measurements• Psychological Evaluation
Psychoacoustic Measurements
• Audiolgical measurements of pitch and loudness– Audiometric evaluations– Pitch Matching– Loudness Matching– Minimum Masking Level– Residual Inhibition
Audimetric Evaluation
• Basic test battery• Pure tone AC threshold frequencies
from 250 to 12,000 Hz including half octaves
Pitch Matching• Can be done on a standard audimeter• Tinnitus synthesizer more accurate• Audiologist instructs patient to judge
whether pitch of 1st or 2nd tones is close to the tinnitus sound
• Bracket until find closest pitch• Patient then identifies type of sound
(pure tone, narrow band noise, speech noise, or white noise)
• If unilateral, then choose opposite ear
Loudness Matching
• Similar to process to Pitch Matching
• Delivered in 1 dB steps• Seldom exceeds 11 dB SL
Minimum Masking Level
• Determine the minimum level of white noise needed to effectively mask the ongoing tinnitus
• Tested in 1 dB steps• Monaurally or binaurally,
depending on location of tinnitus
Residual Inhibition• White noise is presented for 60 seconds• Patient then assesses whether the
tinnitus is gone, diminished, unchanged or louder
• Time it takes for the tinnitus to return is recorded– Complete Residual Inhibition (CRI) -- tinnitus
is completely absent after exposure– Partial Residual Inhibition (PRI) – tinnitus is
reduced for a period of time
Subjective Assessment
• Subjective description of quality and duration
• Determine the effect on the patient
• Psychometric tinnitus inventories– Tinnitus Severity Scale– Tinnitus Handicap Inventory
Electroacoustic Measurements
• Auditory Brainstem Response• Otoacoustic Emissions• Also MRI and CT scans
Psychological Evaluation
• Determining the impact of the tinnitus on the patient– Annoyance– Sleep Disturbance– Emotional Stress
Medical Management – Traditional • Medicine and surgery largely
unsuccessful– Lidocaine – a local anaesthetic
• Injected into vein of patient• Short term effect of suppressing tinnitus• May be toxic to liver
– Xanax• Anti-Anxiety• Reduced tension• Highly Addictive
– Carbamazepine• Anti-epilepsy
Alternative Therapies
• Magnets in the Ear Canal– Japanese Study by Takeda
• Mounted in cotton wool close to the TM• 56 patients tried, 37 reported some
improvement
– Coles tried to repeat study• 51 patients total: 26 active, 25 placebo• Active: 7 improved, 7 got worse• Placebo: 4 improved, 3 got worse
Alternative Therapies
• Glinkgo Biloba– Most popular herbal treatment– 21 tinnitus patients took part in
uncontrolled trial (Cole, 1998)• One 14 mg tablet 3 times per day for 12
weeks• 11 reported no change• 4 slightly less• 5 slightly worse
Counseling
• Have been more successful in treatment of tinnitus– Biofeedback– Behavior Modification– Relaxation Training– Cognitive Therapy
• Focus on changing the patient’s attitude toward the tinnitus
Tinnitus Maskers
• Masks the actual sound of the tinnitus– Generates white noise– Patient can adjust intensity and
frequency shape
• Hearing Aids• Combination devices
– Masker and hearing aid
Sound Therapy
• Works by reducing the difference between tinnitus sounds and background sounds
• Provided by CDs/tapes, sound generators
• Type of sound depends on sound of tinnitus and hearing loss
Sound Therapy:Tinnitus and Music• Besides masking, provides relaxation• Hallam (1989) combined with Tinnitus
Habitation Therapy• Henry % Wilson (2001) combined with
Cognitive Behavioral Therapy• Active Music Listening
– Patient actively interacts with music
• Passive Music Listening– Listens and relaxes
Tinnitus Retraining Therapy (TRT)• Created by Dr. Pawel Jastreboff at the
University of Maryland in late 1980s• He referred to this as a
neurophysiological model of tinnitus• Based on theory of habituation
– Retrain the cortical areas• Goal is to make tinnitus a non-issue
in one’s life
Tinnitus Retraining Therapy (TRT)
• Jastreboff’s model– Source of tinnitus (locus is the brain)– Detection of sound (subcortical)– Perception and evaluation (auditory
and other cortical areas)– Emotional associations (limbic system)– Annoyance (autonomic nervous
system)
Tinnitus Retraining Therapy (TRT)
• Use of sound therapy and counseling– Sound generators and environmental
sounds, as well as hearing aids– Counseling is a big part of the
therapy; educating the patient what is happening in the ears and brain
• Process takes 6 to 18 months