Tinnitus – An ENT Perspective
Mr. Marcus Choo
Introduction
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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
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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
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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
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Objective: caused by sounds generated somewhere in
the body
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Subjective: perception of meaningless sounds without
any physical sound being present
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Auditory hallucinations: perceptions of meaningful
sounds such as music or speech
Causes
Noise exposure
 Medication
 Infection
 Older age hearing loss
 Meniere’s Disease
 Outer/Middle ear disease
 Acoustic neuroma
 Unknown (by far the most common)
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Effects of Tinnitus
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Concentration
Hearing
Insomnia
Psychological
Ear Anatomy
Ear Anatomy
Mechanism of Hearing
Mechanism of Hearing
Mechanism of Hearing
Mechanism of Hearing
Pathophysiology
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Poorly understood
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Range of theories from loss of outer hair cell function to
increased spontaneous activity of central nerves
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Can be generated from any part of the auditory system from the
ear to the Central Nervous System (CNS)
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This then may become modified by the CNS
Pathophysiology
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When the perception of tinnitus is associated with negative
reinforcement the autonomic nervous system is activated
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Physiological and psychological reactions then lead to
enhancement of the tinnitus signal
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Often compared with chronic pain
Pathophysiology
An ENT Surgeons Approach
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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
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Idiopathic (most common)
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Outer ear disease
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Wax, foreign body, infection
Middle ear disease
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Infection, perforated eardrum, ossicular problems, tumour
Differential Diagnosis
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Inner ear disease
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Presbyacusis (older age hearing loss)
Meniere’s disease
Acoustic neuroma
Noise exposure
Drugs
Evaluation of Tinnitus
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Thorough history
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Duration, nature, effects
Non vs pulsatile
Noise exposure
Other ear symptoms
Ear examination
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Rule out outer/middle ear disease
Tuning fork tests
Normal Ear
Diseased ear
Evaluation of Tinnitus
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Audiological (hearing) Tests
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Audiogram, tympanogram
Specialised hearing tests
MRI
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Associated symptoms
Asymmetric hearing loss
Audiogram
MRI
Treatment
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Aim to improve habituation rather than “cure”
tinnitus
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Most people don’t seek treatment
Multitude of potential treatments
Problems with scientific evidence
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Treatment
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Basic advice
Hearing Aid
Tinnitus Masking Device
Tinnitus Instrument
Tinnitus Retraining Therapy
Psychological Treatment
Medication
Alternative Treatments
Basic Advice
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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
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Irish Tinnitus Association
DeafHear.ie
Hearing Aid Specialist
www.tinnitus.org
Treatment
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Basic advice
Hearing Aid
Tinnitus Masking Device
Tinnitus Instrument
Tinnitus Retraining Therapy
Psychological Treatment
Medication
Alternative Treatments
Hearing Aids
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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
Hearing Aids
Treatment
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Basic advice
Hearing Aid
Tinnitus Masking Device
Tinnitus Instrument
Tinnitus Retraining Therapy
Psychological Treatment
Medication
Alternative Treatments
Tinnitus Masking Device
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Essentially counteracts tinnitus
Generate noise bands
Tinnitus Instruments
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Combination of hearing aid and masker
Wide Band Noise Generators
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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
Treatment
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Basic advice
Hearing Aid
Tinnitus Masking Device
Tinnitus Instrument
Tinnitus Retraining Therapy
Psychological Treatment
Medication
Alternative Treatments
Tinnitus Retraining Therapy
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Based on evidence that a person can habituate to acoustic
noise in the environment
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Goal is to weaken or remove the functional connections
between the auditory pathways
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Key elements: counseling and sound therapy
Tinnitus Retraining Therapy
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May take several months to take effect
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Minimum 12 months treatment
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Involves wearing ear noise generator, table top generator
Tinnitus Retraining Therapy
Treatment
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Basic advice
Hearing Aid
Tinnitus Masking Device
Tinnitus Instrument
Tinnitus Retraining Therapy
Psychological Treatment
Medication
Alternative Treatments
Psychological Treatment
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Relaxation therapy
Hypnosis
Cognitive Behavioural Therapy
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Information, managing aggravating factors
Applied relaxation
Cognitive restructuring of thoughts and beliefs
Sleep management advice
Improvement in quality of life, not tinnitus itself
Medication
Treatment
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Basic advice
Hearing Aid
Tinnitus Masking Device
Tinnitus Instrument
Tinnitus Retraining Therapy
Psychological Treatment
Medication
Alternative Treatments
Medications
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No magical cure
Serc
Lignocaine
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Temporary, intravenous
Alprazolam
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Xanax
Side effects
Treatment
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Basic advice
Hearing Aid
Tinnitus Masking Device
Tinnitus Instrument
Tinnitus Retraining Therapy
Psychological Treatment
Medication
Alternative Treatments
Alternative Therapies
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Herbs
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Vitamins
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Ginkgo biloba (over 100 studies), black cohosh, Mullein
B1, B3, B6, B12, folate, zinc, calcium, Mg, Mn
Laser Therapy
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Germany
Thought to increase ATP in cochlea
Alternative Therapies
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Hypnotherapy
Acupuncture
Ear canal magnets
Hopi ear candles
Alternative Therapies
Transcranial Magnetic Stimulation
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Brain stimulation
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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
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Can this be clinically useful or is it just an experimental technique?
Long term safety?
Conclusion
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Tinnitus is a common condition
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Main role of ENT Surgeon is to exclude major illness and coordinate further treatment
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Basic advice and counseling as well as empathic support is
paramount
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More severe cases may require psychological support, masking
devices or Tinnitus Retraining Therapy