1. Hissing and Buzzing and Ringing, Oh My
Hissing and Buzzing and Ringing, Oh My! The Diagnosis and Treatment of Tinnitus
Carol Rousseau, M.A., CCC-A
Rochester Hearing and Speech Center
Rochester, NY
12 May 2006

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

3. 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

4. Some History…
First recorded appearance is about 2000 years ago by the Phoenicians
Noted in Egyptian hieroglyphics
Aristotle ( B.C.) wrote of it
Physician Galen ( 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”

5. More History…
1975 Dr. Jack Vernon introduced the first wearable masker device
In 1990, Jastreboff introduced popular therapeutic approach called “Tinnitus Retraining Therapy (TRT)

6. 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)

7. More Statistics… 6-20% of U.S. population describe noise as bothersome
1% say it interferes with day-to-day activities (Gelfand, 1997)

8. 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

9. 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

10. Famous People with Tinnitus
Historical/Political
Jean-Jacques Rousseau
Thomas Edison
Dwight D. Eisenhower
Martin Luther
Alan Shepard
Vincent Van Gogh
Charles Darwin

11. Description Head Noise Ear Noise Ringing Buzzing Chirping Hissing
Humming
Pulsing
Roaring

12. Characteristics of Tinnitus
Quality
Pitch
Loudness
Location

13. 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)

14. Characteristics of Tinnitus: Pitch
Most frequently described pitch of the tone as 8000Hz (Vernon, 1998; Sandlin & Olsson, 2000)

15. Characteristics of Tinnitus: Loudness
88% described loudness of 11 dB SL or less
Overall average loudness level as 5.7 dB SL

16. Characteristics of Tinnitus: Location
Both ears
55%
One ear only
20%
Head
24%
Varied 1%

17. Causes of Tinnitus Mostly unknown Noise Exposure
47%
Noise Exposure
25%
Head Injury/Brain Trauma 8%
Ear Pathology 7%
Ototoxic Medications and other
13% (Vernon, 1998)

18. 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

19. 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

20. 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

21. 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

22. 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

23. Medical Aspects of Tinnitus: Types of Tinnitus
Medical diseases and emotional factors may cause and/or affect severity of tinnitus
Two types
Objective
Subjective

24. Objective Tinnitus Also called Audible Tinnitus
Can be heard by physician
Via external ear canal or mastoid bone
Corresponds to respiration or heartbeat

25. 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

26. 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

27. 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

28. Objective Tinnitus: Rushing or Flowing
Vascular tumors of the Middle Ear
Glomus Tumor
Rare

29. 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

30. 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

31. 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

32. 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

33. 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

34. 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

35. 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

36. Subjective Tinnitus: Pharmacological Factors
Stimulants
Tobacco
Caffeine
Constricts blood vessels
Make cells of the inner ear more irritable and more likely to randomly discharge

37. Subjective Tinnitus: Dental Factors
Temporomandibular-joint (TMJ) problems
Lower pitch
Related to jaw activity
Grinding and painful teeth and ear pain are other symptoms

38. 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

39. 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

40. Pulsatile Tinnitus Glomus Tumor Hypertension
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

41. 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)

42. Etiologies of Pulsatile Tinnitus: Venous
Benign Intracranial Hypertension
Jugular Bulb Abnormalities
Abnormal Condylar and Mastoid Emissary Veins

43. 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

44. 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

45. Assessment of Tinnitus

46. Assessment of Tinnitus: Two Perspectives
Identify the source of the tinnitus
Assess of how the tinnitus affects the person

47. Assessment of Tinnitus
Psychoacoustic Measurements
Electophysical Measurements
Psychological Evaluation

48. Psychoacoustic Measurements
Audiolgical measurements of pitch and loudness
Audiometric evaluations
Pitch Matching
Loudness Matching
Minimum Masking Level
Residual Inhibition

49. Audimetric Evaluation
Basic test battery
Pure tone AC threshold frequencies from 250 to 12,000 Hz including half octaves

50. 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

51. Loudness Matching Similar to process to Pitch Matching
Delivered in 1 dB steps
Seldom exceeds 11 dB SL

52. 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

53. 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

54. Subjective Assessment
Subjective description of quality and duration
Determine the effect on the patient
Psychometric tinnitus inventories
Tinnitus Severity Scale
Tinnitus Handicap Inventory

55. Electroacoustic Measurements
Auditory Brainstem Response
Otoacoustic Emissions
Also MRI and CT scans

56. Psychological Evaluation
Determining the impact of the tinnitus on the patient
Annoyance
Sleep Disturbance
Emotional Stress

57. Treatment of Tinnitus

58. Treatment of Tinnitus Medical Psychological Tinnitus Maskers
Traditional
Alternative
Psychological
Tinnitus Maskers

59. 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

60. Medical Management – Traditional
Anti-Depression Drugs
Prozac
Elavil
Norpramin
Zoloft

61. 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

62. 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

63. Alternative Therapies
Acupuncture
Vitamin Therapy
Massage Therapy
Chiropractic Therapy

64. 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

65. Tinnitus Maskers Masks the actual sound of the tinnitus Hearing Aids
Generates white noise
Patient can adjust intensity and frequency shape
Hearing Aids
Combination devices
Masker and hearing aid

66. 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

67. Tinnitus Maskers
                                                                                          
                                    

68. 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

69. 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

70. 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)

71. 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

72. Thanks and Good Night!