Hissing and Buzzing and Ringing, Oh My!

The Diagnosis and Treatment of Tinnitus

Carol Rousseau, M.A., CCC-ARochester Hearing and Speech

CenterRochester, NY12 May 2006

DEFINITION

• The perception of sound in one or both ears or in the head when no external sound is present (American Tinnitus Association, 2006)

Po-TAY-to, Po-TAH-to….

• Both TINN-ni-tus and Tin-EYE-tis are acceptable pronunciations

• Originated from the Latin verb “Tinnire” meaning to ring or tinkle

• Geography– West Coast: Second syllable– Middle America: First syllable– East Coast: Evenly Divided

Some History…• First recorded appearance is about 2000

years ago by the Phoenicians• Noted in Egyptian hieroglyphics• Aristotle (384-322 B.C.) wrote of it• Physician Galen (129-199 B.C.)

described it as “echoes”• Jean Marie Gaspard Itard in 1821

mentioned “True” and “False” Tinnitus, which we now refer as “Objective” and “Subjective”

More History…

• 1975 Dr. Jack Vernon introduced the first wearable masker device

• In 1990, Jastreboff introduced popular therapeutic approach called “Tinnitus Retraining Therapy (TRT)

Some Statistics…

• Over 50 Million Americans experience Tinnitus to some degree

• 12 Million severe enough to seek medical attention

• 2 Million so seriously debilitated that they can not function on a normal basis (ATA, 2006)

More Statistics…

• 6-20% of U.S. population describe noise as bothersome

• 1% say it interferes with day-to-day activities (Gelfand, 1997)

Famous People with Tinnitus• Musicians

– Neil Young– Pete Townsend– Barbara Streisand– Sting– Eric Clapton– Jeff Beck– James Hatfield

(Metallica)– Lars Ulrich (Metallica)

– George Martin– George Harrison– Ted Nugent– Bono (u2)– The Edge (u2)– Paul Schaffer– Trent Rezner– Dave Pirner (Soul

Asylum)– Huey Lewis– Beethoven

Famous People with Tinnitus

• Actors– William Shatner– Leonard Nimoy– Steve Martin– Burt Reynolds– Sylvester Stallone– Tony Randall

– Jerry Stiller– Florence

Henderson– Keanu Reeves– Larry King– David Letterman– Cher

Famous People with Tinnitus

• Historical/Political– Jean-Jacques Rousseau– Thomas Edison– Dwight D. Eisenhower– Martin Luther– Alan Shepard– Vincent Van Gogh– Charles Darwin

Description• Head Noise• Ear Noise• Ringing• Buzzing• Chirping

• Hissing• Humming• Pulsing• Roaring

Characteristics of Tinnitus

• Quality• Pitch• Loudness• Location

Characteristics of Tinnitus: Quality

• 79% of patients described their tinnitus as a pure tone– Single, double, and tri-toned

• 6% described it as noise• 15% mixture of pure tone and

noise (Vernon, 1998)

Characteristics of Tinnitus: Pitch

• Most frequently described pitch of the tone as 8000Hz (Vernon, 1998; Sandlin & Olsson, 2000)

Characteristics of Tinnitus: Loudness

• 88% described loudness of 11 dB SL or less

• Overall average loudness level as 5.7 dB SL

Characteristics of Tinnitus: Location

• Both ears– 55%

• One ear only– 20%

• Head– 24%

• Varied– 1%

Causes of Tinnitus• Mostly unknown

– 47%

• Noise Exposure– 25%

• Head Injury/Brain Trauma– 8%

• Ear Pathology– 7%

• Ototoxic Medications and other– 13% (Vernon, 1998)

Causes of Tinnitus:Diet• May be related to food allergies or

sensitivities• Salicylates naturally occurs in some foods

may produce tinnitus– Almonds, cloves, gingerbread, mustard, mint

flavors– Apples, Apricots, Blackberries, Grapes, Raisins,

Oranges, Strawberries, Raspberries, avocados– Bell and green peppers, olives, cucumbers, white

potatos– Processed foods– Alcohol, especially beer and gin

Causes of Tinnitus:Noise

• 90% of ATA members also report hearing loss (ATA, 2006)

• Many of those have high frequency hearing loss associated with noise

• Effects of loud noise can worsen existing tinnitus

Mechanisms of Tinnitus: Just What is Going on in the Ear?

• Vibrations• Phase-locked spontaneous discharge of

cell bodies• Aberrant behavior of the efferent system• Involvement of Neurotransmitter

substances• Central Origin (the brain)• Vascular Compression of the 7th nerve

Mechanisms of Tinnitus: Just What is Going on in the Ear?

• CNS phenomenon dictated by peripheral activity– Something akin to Phantom Limb

phenomenon

• Lockwood (1998) theorized that tinnitus is based in the auditory cortex, and not the cochlea

• Other theories state that it may be caused by alterations in the function of the inferior colliculus

Mechanisms of Tinnitus: Just What is Going on in the Ear?

• Jastreboff (1995) theorized that tinnitus may involve a discordant dysfunction of OHC and IHC systems– One system becomes dysfunctional because

of loss of cell population– Difference is created in the activity of the

two different type of fibers

• Many theorize that tinnitus is a symptom of many causes based on a number of different mechanisms

Medical Aspects of Tinnitus:Types of Tinnitus

• Medical diseases and emotional factors may cause and/or affect severity of tinnitus

• Two types– Objective– Subjective

Objective Tinnitus

• Also called Audible Tinnitus• Can be heard by physician

– Via external ear canal or mastoid bone

• Corresponds to respiration or heartbeat

Objective Tinnitus: Corresponding to Respiration

• May be caused by abnormally patent Eustachian Tube

• Usually experienced short time• May be caused by extreme weight

loss or after an extended illness• Symptoms relieved by lying down

or putting head in lowered position

Objective Tinnitus: Sharp or Irregular Clicks

• Heard for several seconds or minutes at a time

• Contractions of soft palate or muscles of the middle ear

• Cause unknown

Objective Tinnitus:Pulsatile Tinnitus

• Synchronous with heartbeat/pulse• May indicate cardiac or vascular

abnormalities– Abnormal vascular flow from arteries

to veins somewhere in the head/neck– Also may be secondary to turbulence

of major vessels from arteriosclerosis or narrowing of blood from artery to vein

Objective Tinnitus:Rushing or Flowing

• Vascular tumors of the Middle Ear– Glomus Tumor

• Rare

Subjective Tinnitus• More frequent than Objective Tinnitus• Most people experience this at some point• Various medical conditions cause or affect

subjective tinnitus– Otologic disorders– Cardiovascular abnormalities– Metabolic diseases– Neurologic disorders– Drugs/Pharmaceuticals– Dental factors– Psychological/emotional factors

Subjective Tinnitus:Otologic Causes

• Hearing Loss considered the most common cause of tinnitus– 90% have some form of ear disease

• SNHL most frequent– Majority have a 30 dB or higher HL from 3 to

8 kHz– Mostly the result of aging or noise exposure– Often characterized as high-pitched– Usually described as mild

Subjective Tinnitus:Cardiovascular Disorders• 37% of tinnitus patients also have

cardiovascular complaints (Schleuning, 1998)

• Often characterized as low pitched pulsating sound

• Alteration of blood flow in the head can be cause a low frequency hum

• High blood pressure• Anemia• Arteriosclerosis

Subjective Tinnitus:Metabolic Disease

• Rare, and may be associated with other disorders that may be causing tinnitus– Diabetes– Thyroid disease– High cholesterol levels– Vitamin deficiencies

Subjective Tinnitus:Neurologic Disease• Head trauma

– 10% of tinnitus patients had skull fracture or severe closed head injury (Schleuning, 1998)

– Result of damage to the internal structure of the inner ear with nerve or hair cell damage

– Usually diminishes over time– Whiplash injury may involve nerve input from

the neck and shoulders along with concussion damage to the inner ear

• Meningitis• Multiple Sclerosis

Subjective Tinnitus:Pharmacological Factors• All types of drugs can be considered as

a possible cause• Most frequent:

– anti-inflammatory drugs• Aspirin and aspirin-containing medications

– Percodan– Bufferin– Ecotrin

• Nonsteroidal Anti-inflammatory drugs (not as severe as aspirin)

– Naprosin– Ibuprophen

Subjective Tinnitus:Pharmacological Factors

– Antibiotics• Aminoglycosides (tinnitus more pronounced when

paired with diuretics)– Streptomycin– Kanamycin– Gentamicin

– Sedatives or antidepressants– Quinine-containing medications for muscle

cramps or arrhythmia– Heavy Metals

• Mercury• Arsenic• Lead in high doses

Subjective Tinnitus:Pharmacological Factors

• Stimulants – Tobacco– Caffeine

• Constricts blood vessels• Make cells of the inner ear more

irritable and more likely to randomly discharge

Subjective Tinnitus:Dental Factors

• Temporomandibular-joint (TMJ) problems

• Lower pitch• Related to jaw activity• Grinding and painful teeth and ear

pain are other symptoms

Subjective Tinnitus:Psychological Factors

• Stress and fatigue play a role in severity of complaint

• Increases perception of problem more than causes tinnitus

• Similar symptoms as depression– 15-20 of Tinnitus patients

Pulsatile Tinnitus

• Can be objective or subjective• Characterized as a “thumping” sound

that is often synchronous with heartbeat

• Usually originates from vascular structures inside the head or neck– Arterial or venous– Other structures classified as non-vascular

• Refer to ENT

Pulsatile Tinnitus

• Glomus Tumor– Benign vascular tumors located

usually in the ear– Red mass behind an intact TM– Hearing Loss

• Hypertension– May start after starting medications

to control blood pressure– Usually subsides after 4-6 weeks

Etiologies of Pulsatile Tinnitus:Arterial• Atherosclerotic Carotid Artery Disease• Tortuous (twisted) Arteries• Fibromuscular Dysplasia• Intracranial Arterio-venous Fistulae and

Aneurysms• Vascular Compression fo the 8th Cranial

Nerve• Aortic Murmurs• Paget’s Disease• Increased Cardiac Output (Amemia,

Thyrotoxicosis, Pregnancy)

Etiologies of Pulsatile Tinnitus:Venous

• Benign Intracranial Hypertension• Jugular Bulb Abnormalities• Abnormal Condylar and Mastoid

Emissary Veins

Etiologies of Pulsatile Tinnitus:Nonvascular

• Neoplasms of the skull and temporal bone

• Palatal, Tensor Tympani, and Stapedial Muscle Myoclonus

• Patulous Eustachian Tube• Cholesterol Granuloma of the

Middle Ear

Otologic Causes for Tinnitus

• Described as moderate or severe• Meniere’s disease• Chronic Suppurative Otitis Media• Viral Infections of the ear• Otoscleroris• Acoustic Neuroma

– Unilateral

• Sudden Hearing loss

Assessment of Tinnitus

Assessment of Tinnitus:Two Perspectives

• Identify the source of the tinnitus• Assess of how the tinnitus affects

the person

Assessment of Tinnitus

• Psychoacoustic Measurements• Electophysical Measurements• Psychological Evaluation

Psychoacoustic Measurements

• Audiolgical measurements of pitch and loudness– Audiometric evaluations– Pitch Matching– Loudness Matching– Minimum Masking Level– Residual Inhibition

Audimetric Evaluation

• Basic test battery• Pure tone AC threshold frequencies

from 250 to 12,000 Hz including half octaves

Pitch Matching• Can be done on a standard audimeter• Tinnitus synthesizer more accurate• Audiologist instructs patient to judge

whether pitch of 1st or 2nd tones is close to the tinnitus sound

• Bracket until find closest pitch• Patient then identifies type of sound

(pure tone, narrow band noise, speech noise, or white noise)

• If unilateral, then choose opposite ear

Loudness Matching

• Similar to process to Pitch Matching

• Delivered in 1 dB steps• Seldom exceeds 11 dB SL

Minimum Masking Level

• Determine the minimum level of white noise needed to effectively mask the ongoing tinnitus

• Tested in 1 dB steps• Monaurally or binaurally,

depending on location of tinnitus

Residual Inhibition• White noise is presented for 60 seconds• Patient then assesses whether the

tinnitus is gone, diminished, unchanged or louder

• Time it takes for the tinnitus to return is recorded– Complete Residual Inhibition (CRI) -- tinnitus

is completely absent after exposure– Partial Residual Inhibition (PRI) – tinnitus is

reduced for a period of time

Subjective Assessment

• Subjective description of quality and duration

• Determine the effect on the patient

• Psychometric tinnitus inventories– Tinnitus Severity Scale– Tinnitus Handicap Inventory

Electroacoustic Measurements

• Auditory Brainstem Response• Otoacoustic Emissions• Also MRI and CT scans

Psychological Evaluation

• Determining the impact of the tinnitus on the patient– Annoyance– Sleep Disturbance– Emotional Stress

Treatment of Tinnitus

Treatment of Tinnitus

• Medical– Traditional– Alternative

• Psychological• Tinnitus Maskers

Medical Management – Traditional • Medicine and surgery largely

unsuccessful– Lidocaine – a local anaesthetic

• Injected into vein of patient• Short term effect of suppressing tinnitus• May be toxic to liver

– Xanax• Anti-Anxiety• Reduced tension• Highly Addictive

– Carbamazepine• Anti-epilepsy

Medical Management – Traditional

– Anti-Depression Drugs• Prozac• Elavil• Norpramin• Zoloft

Alternative Therapies

• Magnets in the Ear Canal– Japanese Study by Takeda

• Mounted in cotton wool close to the TM• 56 patients tried, 37 reported some

improvement

– Coles tried to repeat study• 51 patients total: 26 active, 25 placebo• Active: 7 improved, 7 got worse• Placebo: 4 improved, 3 got worse

Alternative Therapies

• Glinkgo Biloba– Most popular herbal treatment– 21 tinnitus patients took part in

uncontrolled trial (Cole, 1998)• One 14 mg tablet 3 times per day for 12

weeks• 11 reported no change• 4 slightly less• 5 slightly worse

Alternative Therapies

• Acupuncture• Vitamin Therapy• Massage Therapy• Chiropractic Therapy

Counseling

• Have been more successful in treatment of tinnitus– Biofeedback– Behavior Modification– Relaxation Training– Cognitive Therapy

• Focus on changing the patient’s attitude toward the tinnitus

Tinnitus Maskers

• Masks the actual sound of the tinnitus– Generates white noise– Patient can adjust intensity and

frequency shape

• Hearing Aids• Combination devices

– Masker and hearing aid

Sound Therapy

• Works by reducing the difference between tinnitus sounds and background sounds

• Provided by CDs/tapes, sound generators

• Type of sound depends on sound of tinnitus and hearing loss

Tinnitus Maskers

                                    

                                                                                          

Sound Therapy:Tinnitus and Music• Besides masking, provides relaxation• Hallam (1989) combined with Tinnitus

Habitation Therapy• Henry % Wilson (2001) combined with

Cognitive Behavioral Therapy• Active Music Listening

– Patient actively interacts with music

• Passive Music Listening– Listens and relaxes

Tinnitus Retraining Therapy (TRT)• Created by Dr. Pawel Jastreboff at the

University of Maryland in late 1980s• He referred to this as a

neurophysiological model of tinnitus• Based on theory of habituation

– Retrain the cortical areas• Goal is to make tinnitus a non-issue

in one’s life

Tinnitus Retraining Therapy (TRT)

• Jastreboff’s model– Source of tinnitus (locus is the brain)– Detection of sound (subcortical)– Perception and evaluation (auditory

and other cortical areas)– Emotional associations (limbic system)– Annoyance (autonomic nervous

system)

Tinnitus Retraining Therapy (TRT)

• Use of sound therapy and counseling– Sound generators and environmental

sounds, as well as hearing aids– Counseling is a big part of the

therapy; educating the patient what is happening in the ears and brain

• Process takes 6 to 18 months

Thanks and Good Night!