Tinnitus
Diagnosis and Treatment
Hossein Talebi; PhD of Audiology
Assistant Professor of Audiology
Isfahan University of Medical Sciences
Introduction
• Tinnitus is defined as sensations of hearing in the
absence of external sounds
The burden of tinnitus
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
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
Tinnitus sufferers
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Ludwig van Beethoven
Vincent van Gogh
Charles Darwin
Neil Young
Eric Clapton
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
Effects of Tinnitus
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Concentration
Hearing
Insomnia
Psychological
Ear Anatomy
Ear Anatomy
Mechanism of Hearing
Mechanism of Hearing
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
Peripheral events lead to central
neurological changes
Brain response to auditory deprivation
• Patients with tinnitus exhibit enhanced auditory
sensitivity
DECREASED
SOUND INPUT
INCREASED
SOUND
SENSITIVITY
• This is caused by hyperactivity of the auditory central
nervous system
• In patients with tinnitus and hearing loss, the tinnitus
pitch and the hearing loss frequency spectrum are
usually matched
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.
AUDITORY
DEPRIVATION
AND CENTRAL
GAIN
ALTERED
SPONTANEOUS
NEURONAL
ACTIVITY
TINNITUS
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
Psychological associations with
tinnitus
A Team 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
• 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
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Duration, nature, effects
Non vs. pulsatile
Noise exposure
Other ear symptoms
• Ear examination
 Rule out outer/middle ear disease
 Tuning fork tests
Normal Ear vs. Diseased Ear
Evaluation of Tinnitus
• Audiological (hearing) Tests
 Audiogram, tympanogram
 Specialized hearing tests: SOAE, ECochG, ABR
• MRI
 Associated symptoms
 Asymmetric hearing loss
Evaluation - Subjective Tinnitus
• Audiometry - assymetrical hearing loss,
unilateral tinnitus - MRI r/o post fossa
• Complete questionnaire for perceived
severity:THI
Measurement of Tinnitus
• Pitch, loudness, minimum masking level,
residual inhibition/post masking
• Minimum masking level most clinical use
• Pitch - match most prominent pure tone, poor
reliability, octave difference
• Loudness - Adjust pure tone to tinnitus
• Most < 7 dB SL, may be 2 dB
Measurement of Tinnitus
• Minimal masking level - number of decibels to
cover tinnitus
• Residual inhibition - response of patients
tinnitus post masking
ENT Referral
ENT Referral
Acoustic Neuroma
Treatment
• Aim to improve habituation rather than “cure”
tinnitus
• Most people don’t seek treatment
• Multitude of potential treatments
• Problems with scientific evidence
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
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 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
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
• Essentially counteracts tinnitus
• Generate noise bands
• Tinnitus Instruments
 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
• 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
Normal Condition
Tinnitus Condition
Counseling alone
Sound Therapy alone
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
Treatment
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Basic advice
Hearing Aid
Tinnitus Masking Device
Tinnitus Instrument
Tinnitus Retraining Therapy
Psychological Treatment
Medication
Alternative Treatments
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
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Delivered in person, to groups and via the internet
Variable results may depend on personal characteristics
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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)
Cognitive
behavioural
therapy
Relaxation
therapy
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May help reduce tinnitus symptoms and depressive symptoms
Treatment
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Basic advice
Hearing Aid
Tinnitus Masking Device
Tinnitus Instrument
Tinnitus Retraining Therapy
Psychological Treatment
Medication
Alternative Treatments
Medications
DRUG CLASS
EXAMPLES OF DRUGS USED IN TINNITUS
Antidepressants
tricyclics, selective serotonin reuptake inhibitors
Antipsychotics
sulpiride
Mood stabilisers
gabapentin, valproate
Sedatives/hypnoti
benzodiazepines
cs
• 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
Treatment
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Basic advice
Hearing Aid
Tinnitus Masking Device
Tinnitus Instrument
Tinnitus Retraining Therapy
Psychological Treatment
Medication
Alternative Treatments
Alternative Therapies
• Vitamins
 B1, B3, B6, B12, zinc, calcium, Mg
• Laser Therapy
 Germany
 Thought to increase ATP in cochlea
Alternative Therapies
• Hypnotherapy
• Acupuncture
• Ear canal magnets
Transcranial Magnetic Stimulation
• 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
▫ 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
Thank you for Your Attention