Tinnitus Diagnosis and Treatment

Dr Mandana Amiri Otolaryngologist

KUMS

Objectives

• To describe the key features of tinnitus

• To show how tinnitus is a substantial health burden

• To reveal the role of hearing loss in tinnitus

• To present the options for management, including the central role of hearing aids

04/21/23 Slide 2

What is tinnitus?

• Perception of sound but no external source

• Usually experienced as buzzing, hissing or ringing

– Not fully-formed sounds e.g. speech or music

– Not sound hallucinations experienced during bouts of mental illness

– Occurs in one or both ears, or arising within the head

• It can have a profound effect on the sufferer

“… perceived severity of tinnitus correlates closer to psychological and general health factors, such as pain or insomnia, than to audiometrical parameters …”

(Zoger et al, 2006)

Langguth B, et al. (2013) Lancet Neurol.12:920-930; Zöger S et al. (2006) Psychosomatics. 47:282-288. 04/21/23 Slide 3

The burden of tinnitus

SCALE OF PROBLEM

IMPACTTINNITUS RISK FACTORS

A GROWING PROBLEM

• Tinnitus affects 10%–15% of the general population worldwide

• This is an estimated 280 million people

• Tinnitus limits daily living in 1%–2% of people with tinnitus

• Hearing impairment

• Increasing age

• Gender (male)

• Exposure to noise

• Increasing size of the elderly population

• Frequency of noise exposure in work and leisure environments

Geocze L, et al. (2013) Braz J Otorhinolaryngol.79:106-111; Langguth B, et al. (2013) Lancet Neurol.12:920-930; Roberts LE, et al. (2010) J Neurosci. 30:14972-14979.

04/21/23 Slide 4

Evaluating tinnitus severity

• At the other extreme, some patients suffer so much that daily living is difficult and they are unable to work. Others suffer a level of impairment between these two levels.

• Tinnitus is highly variable. Some patients are able to cope with the noise and their lives continue as normal.

Langguth B, et al. (2013) Lancet Neurol.12:920-930. 04/21/23 Slide 5

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

Effects of Tinnitus

• Concentration• Hearing• Insomnia• Psychological

Tinnitus sufferers

• Ludwig van Beethoven• Vincent van Gogh• Charles Darwin• Neil Young• Eric Clapton• Ronald Regan

Sound features of tinnitus

NOISE CRITERIA POSSIBLE FEATURES

Onset Sudden, gradual

Pattern Pulsatile, intermittent, constant, fluctuating

Site Right or left ear, both ears, within head

Loudness Wide range, varying over time

Quality Pure tone, noise, polyphonic

Pitch Very high, high, medium, low

Sounds experienced in tinnitus can vary according to several criteria:

Langguth B, et al. (2013) Lancet Neurol.12:920-930. 04/21/23 Slide 9

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

04/21/23 Slide 11

• Pulsatile

• Synchronous with Pulse

• Arterial etiologies

• Arteriovenous fistula or malformation

• Paraganglioma (glomus tympanicum or jugulare)

• Persistent stapedial artery

• Intratympanic carotid artery

• Increased cardiac output (pregnancy, thyrotoxicosis)

• Venous etiologies

• Venous hum

• Sigmoid sinus and jugular bulb anomalies

• Asynchronous with Pulse

• Palatal myoclonus

• Tensor tympani or stapedius muscle myoclonus

• Nonpulsatile

• Spontaneous otoacoustic emission

• Patulous eustachian tube

• Pattern of hearing loss

• Noise-induced hearing loss

• Presbycusis

• Somatic tinnitus

• Temporomandibular joint dysfunction

• Cervical dysfunction

• Gaze evoked

• Cutaneous evoked

• General somatosensory modulated

• Typewriter tinnitus

04/21/23 Slide 12

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

Peripheral events lead to central neurological changes

• A range of peripheral events can lead to central neuronal changes that manifest as tinnitus

• Other factors can be involved in either the development or the persistence of tinnitus

HEARING LOSS

NOISE TRAUMA

OTOTOXIC DRUGS

AUDITORY NERVE ABNORMALITIES

CENTRAL

AUDITORY

PATHWAY

NEURONAL

ABNORMALITIES

TINNITUS ONSETTINNITUS PERSISTENCE

Langguth B, et al. (2013) Lancet Neurol.12:920-930. 04/21/23 Slide 14

Brain response to auditory deprivation

• Patients with tinnitus exhibit enhanced auditory sensitivity

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

– Homeostatic pathways cause increased central ‘gain’ (i.e. sensitivity) in response to auditory deprivation to:

1. Maintain central nervous system activity during low sensory input

2. Ensure nerve activity is modulated to respond to changes in sensory input

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

DECREASED SOUND INPUT INCREASED

SOUND SENSITIVITY

Hebert S, et al. (2013) J Neurosci 33:2356-2364; Langguth B, et al. (2013) Lancet Neurol.12:920-930; Norena AJ, Farley BJ. (2013) Hearing Res 295:161-171.

04/21/23 Slide 15

Tinnitus is a balance of sensory input and spontaneous activity

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.

TINNITUS

AUDITORY DEPRIVATION AND CENTRAL

GAIN

ALTERED SPONTANEOUS

NEURONAL ACTIVITY

Norena AJ, Farley BJ. (2013) Hearing Res 295:161-171.Kaltenbach JA. (2011) „Tinnitus: models and mechanisms“. Hear Res. June; 276 (1-2) : 52 – 60.

04/21/23 Slide 16

Tinnitus and hearing loss

Most patients with tinnitus have some degree of hearing loss

75%–90% OF PATIENTS

WITH OTOSCLEROSIS HAVE TINNITUS

ABOUT 80%

OF PATIENTS WITH IDIOPATHIC SENSORINEURAL HEARING LOSS HAVE TINNITUS

“Hearing loss is a hidden disability and to have tinnitus is sort of like a double whammy”

Family physician with moderate tinnitus, Canada

Axelsson A, Ringdahl A (1989) Br J Audiol 23:53-62; Ayache D, et al (2003) Otol Neurotol 24:48-51; Nosrati-Zarenoe R et al (2007) Acta Otolaryngol 127:1168-1175; Sobrinho PG et al. (2004) Int Tinnitus J 10:197-201; Schaette R et al. (2012) PLoS One 10.1371/journal. pone.0035238.

04/21/23 Slide 17

Tinnitus and distress: a vicious cycle

• Experiencing sound in the absence of an external stimulus can be emotionally upsetting

• This reaction can make the sounds appear worse

• This results in a vicious cycle of worsening tinnitus and increasing distress

TINNITUS

EMOTIONAL DISTRESS

Schaette R. (2012) Phonak Focus 42. 04/21/23 Slide 18

Pathophysiology

Other psychological associations with tinnitus

• Tinnitus is associated with increased levels of psychological problems

– 24/90 (26.7%) versus 5/90 (5.6%) for age-matched controls without tinnitus

HYPOCHONDRIA

HYPERACUSIS

COGNITIVE IMPAIRMENT

TINNITUS

ANXIETY

DEPRESSION

SLEEP PROBLEMS

Andersson G, McKenna L. (2006) Acta Otolaryngol Suppl. 556:39-43; Belli H, et al. (2012) Gen Hosp Psychiatry. 34:282-9; Jackson J, et al. (2013) Int J Audiol. E-pub ahead of print; Langguth B, et al. (2013) Lancet Neurol.12:920-930.

04/21/23 Slide 20

r = correlation coefficient between severity of tinnitus and prevalence of depression and anxiety (higher r = stronger correlation)

HADS: Hospital Anxiety and Depression Scale; NS: non statistically significant; SCID: Structured Clinical Interview for DSM-III-R

Anxiety and depression correlate with severity of tinnitus

TINNITUS (ALL SEVERITIES), N=80

HIGH-RISK OF CHRONIC, DISABLING TINNITUS, N=144

r P r P

Current minor depression (SCID) 0.42 <0.0001 0.43 <0.0001

Major depression (SCID) 0.41 0.0002 0.39 <0.0001

Current anxiety disorder (SCID) 0.12 NS 0.28 0.0010

Current multiple anxiety disorders (SCID)

0.01 NS 0.26 0.0023

Current depression and/or anxiety disorders (SCID)

0.42 <0.0001 0.48 <0.0001

Depression (HADS) 0.30 0.0079 0.38 <0.0001

Anxiety (HADS) 0.35 0.0018 0.45 <0.0001

Total (HADS) 0.36 0.0014 0.46 <0.0001

Zöger S et al. (2006) Psychosomatics. 47:282-288. 04/21/23 Slide 21

Other tinnitus-associated problems

SLEEP PROBLEMSCOGNITIVE IMPAIRMENT

HYPERACUSIS

• Sleep disturbance is common in patients with tinnitus

• In particular, the time taken to achieve sleep may be lengthened in tinnitus patients

• Insomnia and tinnitus-associated distress can work together in a worsening spiral to adversely affect psychological wellbeing

• Patients with tinnitus can exhibit depressive functioning and/or anxious vigilance

• Cognitive performance can be worse among tinnitus sufferers versus controls in the absence of depression and anxiety

• Hyperacusis is an oversensitivity to certain sound frequencies or volumes

• It is common among tinnitus sufferers and may be a consequence of tinnitus

• In an age-matched control study, 60% of tinnitus sufferers reported hyperacusis, compared to 20% of controls

• Hyperacusis is measureable in tinnitus ears with and without hearing loss

Andersson G, McKenna L. (2006) Acta Otolaryngol Suppl. 556:39-43; Bastos de Magalhaes SL, et al. (2003) Int Tinnitus J. 9:79-83; Belli H, et al. (2012) Gen Hosp Psychiatry. 34:282-9; Hebert S, et al. (2013) J Neurosci. 33:2356-2364; Jackson J, et al. (2013) Int J Audiol. E-pub ahead of print; Langguth B, et al. (2013) Lancet Neurol.12:920-930; Wallhäusser-Franke E, et al. Sleep Med Rev. 17:65-74.

04/21/23 Slide 22

Etiologies

•Idiopathic (most common)

• Outer ear disease– Wax, foreign body, infection

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

Etiologies

•Inner ear disease

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

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

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 are central to tinnitus management

• 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

“The majority of studies reviewed support the use of hearing aids for tinnitus management. Clinicians should feel reassured that some evidence shows support for the use of hearing aids for treating

tinnitus …”

Shekhawat et al, 2013

Shekhawat GS, et al. (2013) J Am Acad Audiol. 24:747-762 04/21/23 Slide 29

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

Psychological and behavioural support

INTERVENTION DESCRIPTION

Counselling and education

• Delivered in person, to groups and via the internet• Variable results may depend on personal characteristics

Cognitive behavioural therapy

• Designed to modify maladaptive behavioural and emotional responses

• One-to-one and group settings, delivered by psychologists or psychiatrists, or via internet

• Statistically significant reductions in severity of tinnitus symptoms (P<0.05)

Relaxation therapy • May help reduce tinnitus symptoms and depressive symptoms

Hoare DJ, et al. (2011) Laryngoscope 121:1555-1564; Langguth B, et al. (2013). Lancet Neurol.12:920-930 04/21/23 Slide 31

Drug options for tinnitus management

• 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

DRUG CLASS EXAMPLES OF DRUGS USED IN TINNITUS

Antidepressants tricyclics, selective serotonin reuptake inhibitors

Antipsychotics sulpiride

Mood stabilisers gabapentin, valproate

Sedatives/hypnotics

benzodiazepines

Belli H, et al. (2012) Gen Hosp Psychiatry. 34:282-9; Langguth B, et al. (2013) Lancet Neurol.12:920-930 04/21/23 Slide 32

Tinnitus management options

Currently, there is no cure for tinnitus, but management is possible

HEARING AIDS

DRUGS

SOUND THERAPY

TINNITUS

EVIDENCE BASED TINNITUS

MANAGEMENT APPROACHES

e.g. TINNITUS RETRAINING THERAPY

COUNSELLING

COGNITIVE BEHAVIOURAL

THERAPY

Belli H, et al. (2012) Gen Hosp Psychiatry. 34:282-9; Langguth B, et al. (2013) Lancet Neurol.12:920-930; Shekhawat GS, et al. (2013) J Am Acad Audiol. 24:747-762

04/21/23 Slide 33

The need for multidisciplinary care

• Tinnitus management should include hearing aids with appropriate frequency ranges together with psychological support and education

• This requires a multidisciplinary care team

– GP, ENT specialist, psychologist/psychiatrist and hearing-care professional

• As a leading supplier of hearing aids, Phonak can be another member of your team, helping your patient to have the optimal hearing aid for their situation

04/21/23 Slide 34

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

Thank you.

04/21/23 Slide 36