TinnitusTinnitus

Prof. Hamad Al-MuhaimeedProf. Hamad Al-MuhaimeedProfessor/ConsultantProfessor/Consultant

Department of OtorhinolaryngologyKing Abdulaziz University Hospital

TinnitusTinnitus

• DefinitionDefinition• ClassificationClassification• Objective tinnitus – pulsatile Objective tinnitus – pulsatile • Subjective tinnitusSubjective tinnitus• TheoriesTheories• EvaluationEvaluation• TreatmentTreatment

IntroductionIntroduction

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

• Tinnere Tinnere – means “ringing” in Latin– means “ringing” in Latin• Includes Buzzing, roaring, clicking, Includes Buzzing, roaring, clicking,

pulsatile soundspulsatile sounds

TinnitusTinnitus

• May be perceived as unilateral or May be perceived as unilateral or bilateralbilateral

• Originating in the ears or around the Originating in the ears or around the headhead

• 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 40 million affected in the United StatesStates

• 10 million severely affected10 million severely affected• Most common in 40-70 year-oldsMost common in 40-70 year-olds• More common in men than womenMore common in men than women

ClassificationClassification

• Objective tinnitusObjective tinnitus – sound produced – sound produced by paraauditory structures which by paraauditory structures which may be heard by an examinermay be heard by an examiner

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

Objective -Pulsatile Objective -Pulsatile tinnitustinnitus

• Arteriovenous Arteriovenous malformationsmalformations

• Vascular tumorsVascular tumors• Venous humVenous hum• AtherosclerosisAtherosclerosis• Ectopic carotid arteryEctopic carotid artery• Persistent stapedial Persistent stapedial

arteryartery• Dehiscent jugular Dehiscent jugular

bulbbulb• Vascular loopsVascular loops

• Cardiac murmursCardiac murmurs• PregnancyPregnancy• AnemiaAnemia• ThyrotoxicosisThyrotoxicosis• Paget’s diseasePaget’s disease• Benign intracranial Benign intracranial

hypertensionhypertension

Subjective TinnitusSubjective Tinnitus• Much more common than Much more common than

objectiveobjective• Usually nonpulsatileUsually nonpulsatile

• PresbycusisPresbycusis• Noise exposureNoise exposure• Meniere’s diseaseMeniere’s disease• OtosclerosisOtosclerosis• Head traumaHead trauma• Acoustic neuromaAcoustic neuroma• DrugsDrugs• Middle ear effusionMiddle ear effusion• TMJ problemsTMJ problems• DepressionDepression• HyperlipidemiaHyperlipidemia• MeningitisMeningitis• SyphilisSyphilis

Conductive hearing lossConductive hearing loss

• Conductive hearing loss decreases Conductive hearing loss decreases level of background noiselevel of background noise

• Normal paraauditory sounds seem Normal paraauditory sounds seem amplifiedamplified

• Cerumen impaction, otosclerosis, Cerumen impaction, otosclerosis, middle ear effusion are examplesmiddle ear effusion are examples

• Treating the cause of conductive Treating the cause of conductive hearing loss may alleviate the tinnitushearing loss may alleviate the tinnitus

Mechanism Mechanism

• Poorly understood mechanisms of Poorly understood mechanisms of tinnitus productiontinnitus production

• 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

Drugs that cause tinnitusDrugs that cause tinnitus

• AntinflammatoriesAntinflammatories• Antibiotics Antibiotics

(aminoglycosides)(aminoglycosides)• Antidepressants Antidepressants

(heterocyclines)(heterocyclines)

• AspirinAspirin• QuinineQuinine• Loop diureticsLoop diuretics• Chemotherapeutic Chemotherapeutic

agents (cisplatin, agents (cisplatin, vincristine)vincristine)

Evaluation - HistoryEvaluation - History

• Careful historyCareful history• QualityQuality• PitchPitch• LoudnessLoudness• 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 Evaluation – Physical ExamExam

• 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 Search for audible bruit in pulsatile

tinnitustinnitus– 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 Evaluation – Physical ExamExam

• Light exercise to increase pulsatile Light exercise to increase pulsatile tinnitustinnitus

• Light pressure on the neck Light pressure on the neck (decreases venous hum)(decreases venous hum)

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

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

Evaluation - AudiometryEvaluation - Audiometry

• PTA, speech descrimination scores, PTA, speech descrimination scores, tympanometry, acoustic reflexestympanometry, acoustic reflexes

• Pitch matchingPitch matching• Loudness matchingLoudness matching• Masking levelMasking level

Laboratory studiesLaboratory studies

• As indicated by history and physical As indicated by history and physical examexam

• Possibilities include:Possibilities include:– HematocritHematocrit– FTA absorption testFTA absorption test– Blood chemistriesBlood chemistries– Thyroid studiesThyroid studies– Lipid batteryLipid battery

TreatmentsTreatments

• Multiple Multiple treatmentstreatments

• Avoidance of Avoidance of dietary stimulants: dietary stimulants: coffee, tea, cola, coffee, tea, cola, etc.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 Many medications have been researched for the treatment of researched for the treatment of tinnitus:tinnitus:– Intravenous lidocaine suppresses tinnitus Intravenous lidocaine suppresses tinnitus

but is impractical to use clinicallybut is impractical to use clinically– Tocainide is oral analog which is Tocainide is oral analog which is

ineffectiveineffective– Carbamazepine ineffective and may Carbamazepine ineffective and may

cause bone marrow suppressioncause bone marrow suppression

Treatments - MedicinesTreatments - Medicines

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

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

– Dependence problem, long-term use is Dependence problem, long-term use is not recommendednot recommended

Treatments - MedicinesTreatments - Medicines

• 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

• 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 Shown to be effective in some trials and

not in othersnot in others– Needs further studyNeeds further study

TreatmentsTreatments

• Hearing aids – amplification of Hearing aids – amplification of background noise can decrease background noise can decrease tinnitustinnitus

• Maskers – produce sound to mask Maskers – produce sound to mask tinnitustinnitus

• Tinnitus instrument – combination of Tinnitus instrument – combination of hearing aid and maskerhearing aid and masker

TreatmentsTreatments

• Cochlear implantsCochlear implants– Have shown some promise in relief of Have shown some promise in relief of

tinnitustinnitus– Ito and Sakakihara (1994) reported that Ito and Sakakihara (1994) reported that

in 26 patients implanted who had in 26 patients implanted who had tinnitus 77% reported either tinnitus tinnitus 77% reported either tinnitus was abolished or suppressed, 8% was abolished or suppressed, 8% reported worseningreported worsening

TreatmentsTreatments

• SurgerySurgery– Used for treatment of arteriovenous Used for treatment of arteriovenous

malformations, glomus tumors, malformations, glomus tumors, otosclerosis, acoustic neuromaotosclerosis, acoustic neuroma

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

ConclusionsConclusions

• Tinnitus is a common problem with an Tinnitus is a common problem with an extensive differentialextensive differential

• Need to identify medical process if Need to identify medical process if involvedinvolved

• Pulsatile/Nonpulsatile is important Pulsatile/Nonpulsatile is important distinctiondistinction

• Will only become more common with aging Will only become more common with aging of our populationof our population

• Research into mechanism and treatments Research into mechanism and treatments is needed to better help our patientsis needed to better help our patients