TinnitusAlexandra D. Costlow, B.S.

According to Merriam-Webster

From Latin, tinnire, to ringOf imitative originFirst Known

Use: 1843

http://www.merriam-webster.com/dictionary/tinnitus

The Many Sounds of Tinnitus

Ringing Hissing Roaring Whistling Swishing Buzzing Chirping, crickets Clicking “It goes along with my heartbeat.”*

Hear, Neuromonics Will Show You

http://www.neuromonics.com/patient/treatment/index.aspx?id=50

Common Audiological Causes Hearing loss Cerumen accumulation/occlusion Eustachian tube blockage Otitis media Exposure to loud noise Ototoxic chemicals* Otosclerosis - frequently Meniere’s Disease (episodic tinnitus along with

hearing loss, dizziness, and aural fullness) Acoustic neuroma – Even when the tumor is removed,

50% of pts continue to experience tinnitus (Benson et al., 2009)

http://www.emedicinehealth.com/tinnitus/page2_em.htm

…So Who’s Hearing Things Now?

SUBJECTIVE TINNITUS Only the patient

perceives head noise This is the more

common form

OBJECTIVE TINNITUS

Head noise is audible to the patient and to the professional

Relatively rare Originates in the ear,

head, or neck Muscular or vascular

etiology Myoclonus is found in

pts with degenerative diseases*Benson, A.G., McGuire, J.F., Djalilian, H.R., Hanks,

K.M., Robbins, W.K. (2009)

Myoclonus

The neuromuscular control over ear muscles deteriorates in an individual with good very good sensory perception.

The stapedius and/ or tensor tympani muscles repeatedly contract and relax.

This results in audible click noises arising from the ear.

Can be unilateral or bilateral. Treatment is lysis of the muscle/s

through tympanotomy incision.Benson, A.G., McGuire, J.F., Djalilian, H.R.,

Hanks, K.M., Robbins, W.K. (2009)

Other Causes of “Click” Tinnitus Jaw joint misalignment

i.e. the tempero-mandibular joint (TMJ)

http://www.emedicinehealth.com/tinnitus/page2_em.htm

Cardiological Etiology

CAROTID ARTERY

Injury due to aging or surgery

Ectasia: Dilation, expansion, distentsion, bulging

Blood flow through the artery is tumultuous

Follows the pt’s heartbeat

Can be ausculated by the examiner

JUGULAR VEIN AND BULB More common than

the 2 other objective etiologies

Produces a “Venous hum”

Pt describes a vibratory or low-pitched sound

Benson, A.G., McGuire, J.F., Djalilian, H.R., Hanks, K.M., Robbins, W.K. (2009)

Anatomical Reference – Jugular Vein (External)

http://www.frca.co.uk/article.aspx?articleid=100030

Anatomical Reference – Carotid Artery

http://www.nlm.nih.gov/medlineplus/ency/presentations/100124_1.htm

Causes of Pulsatile Tinnitus

Suggests involvement of blood flow through vessels near the ear May be normal or pathological

Space-occupying lesions Anemia* (Contributing cause) Overactive thyroid Hypertension Benign intracranial pressure

http://www.emedicinehealth.com/tinnitus/page2_em.htm

Red Flags

Sudden onset tinnitus (with or without hearing loss)

Sudden onset hearing loss and tinnitus

Unilateral tinnitus Pulsatile tinnitus Report of tinnitus + symptoms of a

stroke Sudden difficulty communicating,

movement disorders, personality changes

http://www.emedicinehealth.com/tinnitus/page4_em.htm

Getting to the Crux

Tinnitus is a symptom, NOT a disease.

The pathology causing tinnitus may be outside of the scope of audiologists.

The actual “cause” of tinnitus depends on pathophysiology.

Understanding the pathophysiology will help us (AuDs, PhDs, MDs, DOs, neurologists, neurosurgeons, etc…) to better treat people who experience tinnitus.

A Familiar Scenario

Patient: I’ve had this ringing in my ears for years. My doctor told me that there’s no cure for it. Is that true?

Audiologist:

Pathophysiology

Nuerophysiologically, “ … Tinnitus is the consequence of the brain’s response to input deprivation from the auditory periphery” (Benson et al., 2009).

Leaver et al. (2011) suggest that tinnitus occurs due to abnormal function of the limbic system, which controls emotion. Suggests link to depression, anxiety?

Pathophysiology

In a healthy cochlea, there is a tonotopic organization (peripheral).

Signal travels from the cochlea to the midbrain to the auditory cortex.

Pathophysiology

In a damaged cochlea, cortical and subcortical pathways adapt to lack of stimulation (plasticity) and the tonotopic organization (not just of the cochlea, but rather of the projections from the cochlea mesencephalon cortex) is altered (Benson et al., 2009).

Neuroplasticity may take the form of: Creation or elimination of synapses, including their

axons and dendrites, causing changes in how effectively the electrical signal is transmitted (Moller).

Anatomical Reference - Synapse

http://hshgp.genome.washington.edu/teacher_resources/modules-view.htm

Pathophysiology

In the auditory cortex, the area that no longer receives stimulation due to cochlear injury is called the lesion projection zone (LPZ).

Following cochlear injury, neurons in the LPZ change in two ways: Increase in spontaneous firing rate Neurons that are adjacent to the

LPZ represent a larger frequency range (Benson et al., 2009)

Pathophysiology

This mechanism is believed to be the neurophysiological correlate of tinnitus (Benson et al., 2009).

A key understanding in tinnitus research over the years was that although tinnitus presents in the ear, it is a neurological phenomenon. As evidenced by the fact that if the auditory

nerve was severed, tinnitus was yet able to persist (Moller).

How is Tinnitus Quantified?

May use pitch and loudness mapping 90% of pts report tinnitus at an intensity

level of <20 dB 84% of pts report tinnitus at an intensity

level of <9 dB These measures are useful for masking

devices Do these measures match subjective

reports of tinnitus severity?(Benson et al., 2009)

How is Tinnitus Quantified?

The Tinnitus Handicap Inventory Self-report measure Validated in 1996 Measures how tinnitus affects daily life▪ Functional, Emotional, and Catastrophic

subscales

(Newman, Jacobson, & Spitzer, 1996)

Tinnitus’ Kissing Cousins

If the patient has tinnitus: Sound may be distorted. Patient may also have hyperacusis

and/or phonphobia (Moller). The patient may have anxiety, isolation,

and/or depression.

Treatment

May depend on etiology Glomus tumor: Surgical removal Meniere’s Disease: Endolymphatic shunt,

labyrinthectomy, antibiotic injection

Courtesy of Hood Labs www.earassociates.com

Treatment

Let’s hear from Roger Miller, PhD, Director for Hearing and Balance at NIDCD http://ocplmedia.od.nih.gov/nihradio/

20110113NIDCDtinnitus.mp3?utm_source=twitterfeed&utm_medium=twitter▪ Behavioral: Tinnitus Feedback Retraining,

Support Groups, Counseling (informational and affective)▪ Masking ▪ Vagal Nerve Stimulation: Like pressing

“Reset” button in the brain

Treatment

Pharmacologic: Treat symptoms related to tinnitus, such as depression and anxiety. Nortriptyline (50 mg): Most effective drug, although it

causes dry mouth and takes 3-4 weeks to build up summative effect for benefit.

SSRIs Paroxetine (10 mg) AKA Paxil Sertraline (50 mg/d) AKA Zoloft: Reduced tinnitus

severity, as well as symptoms of depression and anxiety

Benzodiazepines: Treats tinnitus as an anxiety disorder BUT should not use these if depression is present (and often it is).

(Benson et al., 2009)

Non-Traditional Treatment

Electrical Stimulation Overall, mixed success▪ Stimulation may only be effective during

stimulus presentation First attempted by Volta in the 1800s

Types: Cutaneous, brain stimulation,

promontory stimulation New: Repetitive transcranial magnetic

stimulation (rTMS)(Benson et al., 2009)

Repetitive Transcranial Magnetic Stimulation (rTMS)

The Society for Neurosciencewww.sfn.org

Non-Traditional Treatment Biofeedback

Commonly used for the management of pain Pt monitors involuntary bodily processes such

as heart rate, blood pressure, and muscle tension through electromyography (EMG) and electroencephalography (EEG) (UMMC, 2011).

Goal is to reduce anxiety and/or stress that may aggravate tinnitus

Conducted by a psychologist <80% of pts report reduction in tinnitus

symptoms (Benson et al., 2009).

Non-Traditional Treatment

Homeopathic Therapy Ginko Biloba: Antioxidant that inhibits

platelet aggregation promotes circulation to small blood vessels such as those that supply the cochlea.

Niacin: May provide smooth muscle relaxation and promote circulation to small blood vessels.▪ Pts may report that Niacin reduces severity of

tinnitus (Benson et al., 2009).

Pediatrics

Prevalence varies Shetye and Kennedy (2010) noted it occurs

in 12 - 36% of children with normal hearing and in <66% of children with hearing loss.

Shetye and Kennedy (2010) noted that 3 – 10% of children are significantly affected by it.

May be more difficult to identify in children Might pediatric tinnitus become more

prevalent due to environment?

(Shetye & Kennedy, 2010).

Areas of Further Research – Moving from Anecdotal to Evidence-Based Practice

Caffeine: Anecdotal evidence tells us that caffeine consumption exacerbates tinnitus. St. Claire et al. (2010) found that caffeine

consumption had no effect on tinnitus severity but that caffeine withdrawal symptoms were observed.

Heritability: Anecdotally, tinnitus may “Run in families.” Kvestad et al. (2010) found low heritability of

tinnitus.

Works Cited

American Tinnitus Association (ATA). What you should know about tinnitus. Retrieved from http://www.ata.org/sites/ata.org/files/pdf/ATA%20Facts% 20About%20Tinnitus.pdf

AnaesthesiaUK. (2010). Cannulation of the internal jugular vein. [Graphic].

Benson, A.G., McGuire, J.F., Djalilian, H.R., Hanks, K.M., Robbins, W.K. (2009). Inner Ear, tinnitus. MedScape online encyclopedia. Retrieved from http://emedicine. medscape.com/article/856916-overview

Gurr, P., Owen, G. Reid, A. & Canter, R. (1993). Tinnitus in pregnancy. Clinical Otolaryngology, 18(4), 294-297.

Kvestad, E., Czajkowski, N., Engdahl, B., Hoffman, H., & Tambs, K. (2010). Low heritability of tinnitus: Results from the second Nord-Trandelag study. Archives of Otolaryngology, Head and Neck Suergery, 136(2), 178-182.

Leaver, A.M., Renier, L., Chevillet, M.A., Morgan, S., Kim, H.J., Rauschecker, J.P.(2011). Dysregulation of limbic and auditory networks in tinnitus. Neuron, 69(1), 33-43.

  Moller, A. R. Pathophysiology of tinnitus. [Powerpoint slides] presented at the University of

Texas at Dallas, School of Behavioral and Brain Sciences. Retrieved from http://www.slideworld.org/slideshow.aspx/Pathophysiology-of-tinnitus-ppt-4329

Works Cited

Neuromonics Inc. (2011). What tinnitus sounds like. Retrieved from http://www.neuromonics.com/patient/treatment/index.aspx?id=50

Newman, C.W., Jacobson, G.P., & Spitzer, J.B. (1996). Development of the tinnitus handicap inventory. Archives of Otolaryngology, Head and Neck Surgery, 122(2), 143-8.

Shetye, A., & Kennedy, V. (2010). Tinnitus in children: An uncommon symptom? Archives in disease in childhood, 95(8), 645-648.

St. Claire, L., Stothart, G., McKenna, L., & Rogers, P.J. (2010) Caffeine abstinence: An ineffective and potentially distressing tinnitus therapy. International Journal of Audiology, 49(1), 24–29.

The Society for Neuroscience. (2011). Obsessive-compulsive disorder. Retrieved from http://www.sfn.org/index.aspx?pagename=brainbriefings_ obsessivecompulsivedisorder

University of Maryland Medical Center. (2011). Biofeedback. Retrieved from http://www.umm.edu/altmed/articles/biofeedback-000349.htm

U.S. Department of Health and Human Services National Institutes of Health. (2011). Carotid artery surgery – series. In MedLine Plus. Retrieved from http:// www.nlm.nih.gov/medlineplus/ency/presentations/100124_1.htm