Tinnitus. Tinnitus Definition Classification Objective tinnitus Subjective tinnitus Theories ...

TinnitusTinnitus

TinnitusTinnitus

DefinitionDefinition ClassificationClassification Objective tinnitus Objective tinnitus Subjective tinnitusSubjective tinnitus TheoriesTheories EvaluationEvaluation TreatmentTreatment

IntroductionIntroduction

Tinnitus -“The perception of sound in the Tinnitus -“The perception of sound in the absence of external stimuli.”absence of external stimuli.”

Tinnire Tinnire – means “ringing” in Latin– means “ringing” in Latin Includes buzzing, hissing, roaring, clicking, Includes buzzing, hissing, roaring, clicking,

pulsatile soundspulsatile sounds For some, an unbearable sound that For some, an unbearable sound that

drives them to contemplate suicide.drives them to contemplate suicide.

TinnitusTinnitus

May be perceived as unilateral or bilateralMay be perceived as unilateral or bilateral Originating in the ears or around the headOriginating in the ears or around the head First or only symptom of a disease First or only symptom of a disease

process or auditory/psychological process or auditory/psychological annoyanceannoyance

TinnitusTinnitus

40 million affected in the United States40 million affected in the United States 10 million severely affected10 million severely affected Most common in 40-70 year-oldsMost common in 40-70 year-olds Roughly equal prevalence in men and Roughly equal prevalence in men and

womenwomen

ClassificationClassification

Objective tinnitusObjective tinnitus – sound produced by – sound produced by paraauditory structures which may be paraauditory structures which may be heard by an examiner, often pulsatileheard by an examiner, often pulsatile

Subjective tinnitusSubjective tinnitus – sound is only – sound is only perceived by the patient (most common)perceived by the patient (most common)

TinnitusTinnitus

Pulsatile tinnitus – matches pulse or a Pulsatile tinnitus – matches pulse or a rushing sound rushing sound Possible vascular etiologyPossible vascular etiology Objective or subjectiveObjective or subjective Increased or turbulent blood flow through Increased or turbulent blood flow through

paraauditory structuresparaauditory structures

Objective tinnitusObjective tinnitus

Vascular (pulsatile)Vascular (pulsatile) A/V malformationsA/V malformations Vascular tumorsVascular tumors Venous hum (cardiac Venous hum (cardiac

murmurs, anemia, BIH, murmurs, anemia, BIH, thyrotoxicosis, pregnancy, thyrotoxicosis, pregnancy, dehiscent jugular bulb)dehiscent jugular bulb)

AtherosclerosisAtherosclerosis Ectopic carotid arteryEctopic carotid artery Persistent stapedial arteryPersistent stapedial artery Vascular loopsVascular loops

NeuromuscularNeuromuscular PalatomyclonusPalatomyclonus Stapedial muscle spasmStapedial muscle spasm

Patulous eustachian Patulous eustachian tubetube

Arteriovenous MalformationsArteriovenous Malformations

Congenital lesionsCongenital lesions Occipital artery and transverse sinus, Occipital artery and transverse sinus,

internal carotid and vertebral arteries, internal carotid and vertebral arteries, middle meningeal and greater superficial middle meningeal and greater superficial petrosal arteriespetrosal arteries

MandibleMandible Brain parenchymaBrain parenchyma DuraDura

Arteriovenous MalformationsArteriovenous Malformations

Pulsatile tinnitusPulsatile tinnitus HeadacheHeadache PapilledemaPapilledema Discoloration of skin or mucosaDiscoloration of skin or mucosa

Vascular tumorsVascular tumors

Glomus tympanicumGlomus tympanicum Paraganglioma of middle ear Paraganglioma of middle ear Loud pulsatile tinnitus which may decrease Loud pulsatile tinnitus which may decrease

with ipsilateral carotid artery compressionwith ipsilateral carotid artery compression Reddish mass behind tympanic membrane Reddish mass behind tympanic membrane

which blanches with positive pressurewhich blanches with positive pressure Conductive hearing lossConductive hearing loss

Vascular tumorsVascular tumors

Glomus jugulareGlomus jugulare Paraganglioma of jugular fossaParaganglioma of jugular fossa Loud pulsatile tinnitusLoud pulsatile tinnitus Conductive hearing loss if into middle earConductive hearing loss if into middle ear Cranial neuropathiesCranial neuropathies

Venous humVenous hum

Benign intracranial hypertensionBenign intracranial hypertension Dehiscent jugular bulbDehiscent jugular bulb Transverse sinus partial obstructionTransverse sinus partial obstruction Increased cardiac output from Increased cardiac output from

PregnancyPregnancy ThyrotoxicosisThyrotoxicosis AnemiaAnemia

Benign Intracranial HypertensionBenign Intracranial Hypertension

Also called pseudotumor cerebriAlso called pseudotumor cerebri Young, obese, female patientsYoung, obese, female patients Hearing lossHearing loss Aural fullnessAural fullness DizzinessDizziness HeadachesHeadaches Visual disturbanceVisual disturbance Papilledema, pressure >200mm H20 on LPPapilledema, pressure >200mm H20 on LP


Sismanis and Smoker 1994Sismanis and Smoker 1994 100 patients with pulsatile tinnitus100 patients with pulsatile tinnitus 42 found to have BIH syndrome42 found to have BIH syndrome 16 glomus tumors16 glomus tumors 15 atherosclerotic carotid artery disease15 atherosclerotic carotid artery disease


TreatmentTreatment Weight lossWeight loss DiureticsDiuretics Subarachnoid-peritoneal shuntSubarachnoid-peritoneal shunt Gastric bypass for weight reductionGastric bypass for weight reduction

Neuromuscular CausesNeuromuscular Causes

Palatal myoclonusPalatal myoclonus Clicking soundClicking sound Rapid (60-200 beats/min), intermittentRapid (60-200 beats/min), intermittent Contracture of tensor palantini, levator Contracture of tensor palantini, levator

palatini, levator veli palatini, tensor tympani, palatini, levator veli palatini, tensor tympani, salpingopharyngeal, superior constrictorssalpingopharyngeal, superior constrictors

Muscle spasm seen orally or transnasallyMuscle spasm seen orally or transnasally Rhythmic compliance change on Rhythmic compliance change on

tympanogram tympanogram

MyoclonusMyoclonus

Palatal myoclonus associations:Palatal myoclonus associations: Multiple Sclerosis and other degenerative Multiple Sclerosis and other degenerative

neurological disordersneurological disorders Small vessel diseaseSmall vessel disease Brain stem tumorsBrain stem tumors

Treatments: muscle relaxants, botulinum toxin Treatments: muscle relaxants, botulinum toxin injectioninjection

Stapedius Muscle SpasmStapedius Muscle Spasm

Idiopathic stapedial muscle spasmIdiopathic stapedial muscle spasm Rough, rumbling, crackling soundRough, rumbling, crackling sound Exacerbated by outside soundsExacerbated by outside sounds Brief and intermittentBrief and intermittent May be able to see tympanic membrane May be able to see tympanic membrane

movementmovement

Treatments: avoidance of stimulants, muscle Treatments: avoidance of stimulants, muscle relaxants, sometimes surgical division of tensor relaxants, sometimes surgical division of tensor tympani and stapedius musclestympani and stapedius muscles

Patulous Eustachian TubePatulous Eustachian Tube

Eustachian tube remains open abnormallyEustachian tube remains open abnormally Ocean roar soundOcean roar sound Changes with respirationChanges with respiration Lying down or head in dependent position Lying down or head in dependent position

provides reliefprovides relief Tympanogram will show changes in compliance Tympanogram will show changes in compliance

with respirationwith respiration Associated with significant weight loss, radiation Associated with significant weight loss, radiation

to the nasopharynxto the nasopharynx

Subjective TinnitusSubjective Tinnitus

OtologicOtologic Hearing loss (presbycusis, Hearing loss (presbycusis,

noise exposure, otosclerosis, noise exposure, otosclerosis, middle ear effusion)middle ear effusion)

Meniere’s diseaseMeniere’s disease Acoustic neuromaAcoustic neuroma

Ototoxic drugs or Ototoxic drugs or substancessubstances

NeurologicNeurologic MSMS Head traumaHead trauma

MetabolicMetabolic Thyroid disordersThyroid disorders HyperlipidemiaHyperlipidemia B12 def B12 def

PsychPsych Depression/anxietyDepression/anxiety

InfectiousInfectious SyphilisSyphilis MeningitisMeningitis

Conductive hearing lossConductive hearing loss

Conductive hearing loss decreases level of Conductive hearing loss decreases level of background noisebackground noise

Normal paraauditory sounds seem amplifiedNormal paraauditory sounds seem amplified Cerumen impaction, otosclerosis, middle ear Cerumen impaction, otosclerosis, middle ear

effusion, otosclerosis, perforated TM, EAC effusion, otosclerosis, perforated TM, EAC swelling are examplesswelling are examples

Treating the cause of conductive hearing loss Treating the cause of conductive hearing loss may alleviate the tinnitusmay alleviate the tinnitus

Sensorineural hearing lossSensorineural hearing loss

Indicates abnormality of the inner ear or Indicates abnormality of the inner ear or cochlear portion of the 8cochlear portion of the 8thth CN CN

NIHL and presbycusis most commonNIHL and presbycusis most common

Other subjective tinnitusOther subjective tinnitus

Poorly understood mechanisms of tinnitus Poorly understood mechanisms of tinnitus productionproduction

Abnormal conditions in the cochlea, Abnormal conditions in the cochlea, cochlear nerve, ascending auditory cochlear nerve, ascending auditory pathways, auditory cortexpathways, auditory cortex

Hyperactive hair cellsHyperactive hair cells Chemical imbalanceChemical imbalance

CNS MechanismsCNS Mechanisms

Reorganization of central pathways with Reorganization of central pathways with hearing loss (similar to phantom limb pain)hearing loss (similar to phantom limb pain)

Disinhibition of dorsal cochlear nucleus Disinhibition of dorsal cochlear nucleus with increase in spontaneous activity of with increase in spontaneous activity of central auditory systemcentral auditory system

Neurophysiologic ModelNeurophysiologic Model

Proposed by JastreboffProposed by Jastreboff Result of interaction of subsystems in the Result of interaction of subsystems in the

nervous systemnervous system Auditory pathways playing a role in development Auditory pathways playing a role in development

and appearance of tinnitusand appearance of tinnitus Limbic system responsible for tinnitus Limbic system responsible for tinnitus

annoyanceannoyance Negative reinforcement enhances perception of Negative reinforcement enhances perception of

tinnitus and increases time it is perceivedtinnitus and increases time it is perceived

Role of DepressionRole of Depression

Depression is more prevalent in patients Depression is more prevalent in patients with chronic tinnitus than in those without with chronic tinnitus than in those without tinnitustinnitus

Folmer et al (1999) reported patients with Folmer et al (1999) reported patients with depression rated the severity of their depression rated the severity of their tinnitus higher although loudness scores tinnitus higher although loudness scores were the samewere the same

Which comes first, depression or tinnitus?Which comes first, depression or tinnitus?

Ototoxic DrugsOtotoxic Drugs

AnalgesicAnalgesic ASA, NSAIDsASA, NSAIDs

Antibiotics Antibiotics AminoglycosidesAminoglycosides ErthyromycinErthyromycin VancomycinVancomycin ChloramphenicolChloramphenicol TetracyclineTetracycline

Loop diureticsLoop diuretics

Chemotherapeutic agentsChemotherapeutic agents CisplatinCisplatin VincristineVincristine MethotrexateMethotrexate BleomycinBleomycin

OthersOthers ChloroquineChloroquine Heavy metalsHeavy metals QuinineQuinine Heterocyclic Heterocyclic

antidepressantsantidepressants

Evaluation - HistoryEvaluation - History

Careful historyCareful history QualityQuality PitchPitch LoudnessLoudness Unilateral vs BilateralUnilateral vs Bilateral Constant/intermittentConstant/intermittent OnsetOnset Alleviating/aggravating factorsAlleviating/aggravating factors

Evaluation - HistoryEvaluation - History InfectionInfection TraumaTrauma Noise exposureNoise exposure Medication usageMedication usage Medical historyMedical history Hearing lossHearing loss VertigoVertigo PainPain Family historyFamily history Impact on patientImpact on patient

Evaluation – Physical ExamEvaluation – Physical Exam

Complete head & neck examComplete head & neck exam General physical examGeneral physical exam Otoscopy (glomus tympanicum, dehiscent Otoscopy (glomus tympanicum, dehiscent

jugular bulb)jugular bulb) Search for audible bruit in pulsatile tinnitusSearch for audible bruit in pulsatile tinnitus

Auscultate over orbit, mastoid process, skull, Auscultate over orbit, mastoid process, skull, neck, heart using bell and diaphragm of neck, heart using bell and diaphragm of stethoscopestethoscope

Toynbee tube to auscultate EACToynbee tube to auscultate EAC

Evaluation – Physical ExamEvaluation – Physical Exam

Light exercise to increase pulsatile tinnitusLight exercise to increase pulsatile tinnitus Light pressure on the neck (decreases Light pressure on the neck (decreases

venous hum)venous hum) Valsalva maneuver (decrease venous Valsalva maneuver (decrease venous

hum)hum) Turning the head (decrease venous hum)Turning the head (decrease venous hum)

Evaluation - AudiometryEvaluation - Audiometry

Pure tone air, bone and speech Pure tone air, bone and speech descrimination scores, tympanometry, descrimination scores, tympanometry, acoustic reflexesacoustic reflexes

Weber and Rinne testsWeber and Rinne tests Pitch matchingPitch matching Loudness matchingLoudness matching Masking levelMasking level

Evaluation - AudiometryEvaluation - Audiometry

Vascular or palatomyoclonus induced Vascular or palatomyoclonus induced tinnitus – graph of compliance vs. timetinnitus – graph of compliance vs. time

Patulous Eustachian tube – changes in Patulous Eustachian tube – changes in compliance with respirationcompliance with respiration

Asymmetric sensorineural hearing loss or Asymmetric sensorineural hearing loss or speech discrimination, unilateral tinnitus speech discrimination, unilateral tinnitus suggests possible acoustic neuroma - MRIsuggests possible acoustic neuroma - MRI

Laboratory studiesLaboratory studies

As indicated by history and physical examAs indicated by history and physical exam Possibilities include:Possibilities include:

HematocritHematocrit FTA-ABSFTA-ABS Blood chemistriesBlood chemistries Thyroid studiesThyroid studies Lipid panelLipid panel B12, zinc ?B12, zinc ?

ImagingImaging

Pulsatile tinnitusPulsatile tinnitus Reviewed by Weissman and Hirsch (2000)Reviewed by Weissman and Hirsch (2000) Contrast enhanced CT of temporal bones, Contrast enhanced CT of temporal bones,

skull base, brain, calvaria as first-line skull base, brain, calvaria as first-line studystudy

Sismanis and Smoker (1994) Sismanis and Smoker (1994) recommended CT for retrotympanic mass, recommended CT for retrotympanic mass, MRI/MRA if normal otoscopyMRI/MRA if normal otoscopy

Glomus tympanicum – bone algorithm CT Glomus tympanicum – bone algorithm CT scan best shows extent of massscan best shows extent of mass

May not be able to see enhancement of May not be able to see enhancement of small tumorsmall tumor

Tumor enhances on T1-weighted images Tumor enhances on T1-weighted images with gadolinium or on T2-weighted imageswith gadolinium or on T2-weighted images

Glomus TympanicumGlomus Tympanicum

From: Weissman JL, Hirsch BE. Imaging of tinnitus: a review. Radiology 2000;216:343.

ImagingImaging

Glomus jugulareGlomus jugulare Erosion of osseous jugular fossaErosion of osseous jugular fossa Enhance with contrast, may not be able to Enhance with contrast, may not be able to

differentiate jugular vein and tumordifferentiate jugular vein and tumor Enhance with T1-weighted MRI with Enhance with T1-weighted MRI with

gadolinium and on T2-weighted imagesgadolinium and on T2-weighted images Characteristic “salt and pepper” appearance Characteristic “salt and pepper” appearance

on MRIon MRI

Glomus jugulareGlomus jugulare

From: Weissman JL, Hirsch BE. Imaging of

tinnitus: a review. Radiology 2000;216:344.

Glomus jugulareGlomus jugulare

“salt and pepper appearance”


ImagingImaging

Arteriovenous malformations – readily Arteriovenous malformations – readily apparent on contrasted CT and MRIapparent on contrasted CT and MRI

Normal otoscopic exam and pulsatile Normal otoscopic exam and pulsatile tinnitus may be dural arteriovenous fistulatinnitus may be dural arteriovenous fistula Often invisible on contrasted CT and Often invisible on contrasted CT and

MRI/MRAMRI/MRA Angiography may be only diagnostic testAngiography may be only diagnostic test

ImagingImaging

Shin et al (2000)Shin et al (2000) MRI/MRA initially if subjective pulsatile tinnitusMRI/MRA initially if subjective pulsatile tinnitus Angiography if objective with audible bruit in Angiography if objective with audible bruit in

order to identify dural arteriovenous fistulaorder to identify dural arteriovenous fistula

ImagingImaging

Acoustic NeuromaAcoustic Neuroma Unilateral tinnitus, asymmetric sensorineural Unilateral tinnitus, asymmetric sensorineural

hearing loss or speech descrimination scoreshearing loss or speech descrimination scores T1-weighted MRI with gadolinium T1-weighted MRI with gadolinium

enhancement of CP angle is study of choiceenhancement of CP angle is study of choice Thin section T2-weighted MRI of temporal Thin section T2-weighted MRI of temporal

bones and IACs may be acceptable screening bones and IACs may be acceptable screening testtest

Acoustic NeuromaAcoustic Neuroma


Collins RD. Algorithmic diagnosis of symptoms and signs: a cost-effective approach. 2d ed. Philadelphia: Lippincott Williams & Wilkins, 2003:568-9.

ENT Referral

ENT Referral

TreatmentsTreatments

Multiple treatmentsMultiple treatments Avoidance of dietary Avoidance of dietary

stimulants: coffee, stimulants: coffee, tea, cola, etc.tea, cola, etc.

Smoking cessationSmoking cessation Avoid medications Avoid medications

known to cause known to cause tinnitustinnitus

ReassuranceReassurance White noise from White noise from

radio or home radio or home masking machinemasking machine

Treatments - MedicinesTreatments - Medicines

Many medications have been researched Many medications have been researched for the treatment of tinnitus:for the treatment of tinnitus: Intravenous lidocaine suppresses tinnitus but Intravenous lidocaine suppresses tinnitus but

is impractical to use clinicallyis impractical to use clinically Tocainide is oral analog which is ineffectiveTocainide is oral analog which is ineffective Carbamazepine ineffective and may cause Carbamazepine ineffective and may cause

bone marrow suppressionbone marrow suppression


Alprazolam (Xanax)Alprazolam (Xanax) Johnson et al (1993) found 76% of 17 patients Johnson et al (1993) found 76% of 17 patients

had reduction in the loudness of their tinnitus had reduction in the loudness of their tinnitus using both a tinnitus synthesizer and VAS using both a tinnitus synthesizer and VAS (dose 0.5mg-1.5 mg/day)(dose 0.5mg-1.5 mg/day)

Dependence problem, long-term use is not Dependence problem, long-term use is not recommendedrecommended


Nortriptyline and amitriptylineNortriptyline and amitriptyline May have some benefitMay have some benefit Dobie et al reported on 92 patients Dobie et al reported on 92 patients 67% nortriptlyine benefit, 40%placebo67% nortriptlyine benefit, 40%placebo

SSRI’sSSRI’s Ginko bilobaGinko biloba

Extract at doses of 120-160mg per day Extract at doses of 120-160mg per day Shown to be effective in some trials and not in othersShown to be effective in some trials and not in others Needs further studyNeeds further study

NiacinNiacin


Hearing aids – amplification of background Hearing aids – amplification of background noise can decrease tinnitusnoise can decrease tinnitus

Maskers – produce sound to mask tinnitusMaskers – produce sound to mask tinnitus Tinnitus instrument – combination of Tinnitus instrument – combination of

hearing aid and maskerhearing aid and masker


Tinnitus Retraining TherapyTinnitus Retraining Therapy Based on neurophysiologic modelBased on neurophysiologic model Combination of masking with low level Combination of masking with low level

broadband noise for several hours per day broadband noise for several hours per day and counseling to achieve habituation of the and counseling to achieve habituation of the reaction to tinnitus and perception of the reaction to tinnitus and perception of the tinnitus itselftinnitus itself


Electrical stimulation of the cochleaElectrical stimulation of the cochlea Transcutaneous, round window, promontory Transcutaneous, round window, promontory

stimulation have all been triedstimulation have all been tried Direct current can cause permanent damageDirect current can cause permanent damage Steenersen and Cronin have used Steenersen and Cronin have used

transcutaneous stimulation of the auricle and transcutaneous stimulation of the auricle and tragus decreasing tinnitus in 53% of 500 tragus decreasing tinnitus in 53% of 500 patientspatients


Cochlear implantsCochlear implants Have shown some promise in relief of tinnitusHave shown some promise in relief of tinnitus Ito and Sakakihara (1994) reported that in 26 Ito and Sakakihara (1994) reported that in 26

patients implanted who had tinnitus 77% patients implanted who had tinnitus 77% reported either tinnitus was abolished or reported either tinnitus was abolished or suppressed, 8% reported worseningsuppressed, 8% reported worsening


SurgerySurgery Used for treatment of arteriovenous Used for treatment of arteriovenous

malformations, glomus tumors, otosclerosis, malformations, glomus tumors, otosclerosis, acoustic neuromaacoustic neuroma

Some authors have reported success with Some authors have reported success with cochlear nerve section in patients who have cochlear nerve section in patients who have intractable tinnitus and have failed all other intractable tinnitus and have failed all other treatments, this is not widely acceptedtreatments, this is not widely accepted


BiofeedbackBiofeedback HypnosisHypnosis Magnetic stimulationMagnetic stimulation AcupunctureAcupuncture Conflicting reports of benefitConflicting reports of benefit

ConclusionsConclusions Tinnitus is a common problem with an extensive Tinnitus is a common problem with an extensive

differentialdifferential Need to identify medical process if involvedNeed to identify medical process if involved Pulsatile/Nonpulsatile is important distinctionPulsatile/Nonpulsatile is important distinction Unilateral vs BilateralUnilateral vs Bilateral Associated hearing loss, vertigoAssociated hearing loss, vertigo Thorough head and neck physical exam and audiometry Thorough head and neck physical exam and audiometry

testing is necessary for all patientstesting is necessary for all patients In general, tinnitus that is pulsatile, unilateral, and assoc In general, tinnitus that is pulsatile, unilateral, and assoc

w/ other unilateral otologic symptoms is more worrisome w/ other unilateral otologic symptoms is more worrisome and should warrant ENT referral.and should warrant ENT referral.

ReferencesReferences Crummer R, Ghinwa H. Crummer R, Ghinwa H. Diagnostic Approach to TinnitusDiagnostic Approach to Tinnitus. American . American

Family Physician. 2004; 69: 120-126.Family Physician. 2004; 69: 120-126.

Tinnitus. Tinnitus Definition Classification Objective tinnitus Subjective tinnitus Theories ...

Documents

Transcript of Tinnitus. Tinnitus Definition Classification Objective tinnitus Subjective tinnitus Theories ...