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

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 Noise Exposure 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 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

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 Psychological Tinnitus Maskers 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 Hearing Aids 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!