1. VERTIGO AND TINNITUS Yard.Doc.Dr.Müzeyyen Doğan

2. Learning goal and objectives of the lesson Learning goal of the lesson: Learning goal of the lesson: The learner should know the main clinical features and investigation of the tinnitus Learning objectives of the lesson the learner will be able to: describe the tınnıtus, type of tinnitus describe the tınnıtus, type of tinnitus explain the evaluation methods for tinnitus explain the evaluation methods for tinnitus explain the rehabilitation methods for tinnitus explain the rehabilitation methods for tinnitus

3. Learning goal and objectives of the lesson Learning goal of the lesson: The learner should know the main clinical features and investigation of the vertigo Learning objectives of the lesson the learner will be able to: take a directed history from patient with vertigo take a directed history from patient with vertigo list the evaluation methods for peripheral vestibular system list the evaluation methods for peripheral vestibular system describe the peripheral causes of vertigo describe the peripheral causes of vertigo Skill objectives the learner will be able to evaluate the patient’s nystagmus during acute attack of peripheral vertigo. evaluate the patient’s nystagmus during acute attack of peripheral vertigo. learn how to approach the patient with cochleovestibular pathology learn how to approach the patient with cochleovestibular pathology

4. Vertigo

5. Steps 1.History Taking 2.Clear definition (Vertiginous or Nonvertiginous dizziness) 3.Peripheral or Central Vertigo 4.Psychogenic Vertigo

6. Differential diagnosis 1.Dizziness2.Presyncope 3.Disequilibrium:Unsteady gait 4.Light-headedness

7. Symptoms Unconscious Unconscious Pallor Pallor Sweating Sweating Nausea/Vomiting Nausea/Vomiting Auditory Symptoms :Hearing loss, Tinnitus, aural (ear) fullness Auditory Symptoms :Hearing loss, Tinnitus, aural (ear) fullness Diplacusis Diplacusis Paracusis Paracusis Neurologic Symptoms: numbness, weakness, difficulty with swallowing or speech Neurologic Symptoms: numbness, weakness, difficulty with swallowing or speech

8. Definition a subjective sensation of movement May feel either that him involving in space or that objects in the environment are moving around him.

9. History Taking Description of the sensation (including associated symptoms) Description of the sensation (including associated symptoms) Onset (acute, gradual) Onset (acute, gradual) Duration (date sensation was first noted, length of time it lasts) Duration (date sensation was first noted, length of time it lasts) Intensity (how troubling is it?) Intensity (how troubling is it?) Exacerbations (activities, positions, circumstances that worsen situation) Exacerbations (activities, positions, circumstances that worsen situation)

10. Remissions (activities, positions circumstances that make sensation better) Remissions (activities, positions circumstances that make sensation better) Medications (prescription, herbal, over the counter) Medications (prescription, herbal, over the counter) Other medical problems (diabetes, hypertension, heart disease, etc) Other medical problems (diabetes, hypertension, heart disease, etc) Psychosocial (any stressors?) Psychosocial (any stressors?)

11. Physical Examinations Mental conditions Mental conditions Vital Signs: Bp,HR Vital Signs: Bp,HR Otoscopy Otoscopy Ascultation of the neck for bruits Ascultation of the neck for bruits Rinne Test Rinne Test Weber’s Test Weber’s Test

12. Rinne Test

13. Weber’s Test

14. Neurologic exams Neurologic examsNystagmusRomberg’sGait Dix-Hallpike Maneuver

16. Peripheral Vertigo vs Central Vertigo FeaturesPeripheral Vertigo Central Vertigo Conscious Unconscious NystagmusHorizontal/rotaryVertical Related to position changing YesNo SymptomsAuditory symptoms (aural fullness,tinnitus,hearing loss) Neurologic symptoms (disequilibrium,gait)

17. Comparison of Common Diseases FeaturesBPPVMeniere (Labyrinthitis) PsychogenicCentral Vertigo Type of Vertigo Positional SpontaneousVariable Duration of Vertigo 1-2min30min-2hrsSeveral yearsSeveral days-months Symptoms Auditory symptoms (aural fullness,tinnitus,hearing loss) Palpitations,hyperventilationNeurologic symptoms (Disequilibrium, unconscious) Nystagmus Horizontal/rotary Horizontal Vertical Dix-hallpike maneuver + -/+-- Neurologic exam (Romberg’s sign) --- + Treatment Repositioning Maneuver1.Salt-restricted diets 2.Diuretics 3.Vestibular suppressants (Meclizine) 4.Surgical;Gentamycin infusion into the middle ear Anti-anxiety or Anti – depression drugs Further examinations(MRI,CT)

18. Peripheral Vertigo Benign paroxysmal positional vertigo: most common in adults Benign paroxysmal positional vertigo: most common in adults Acute Labyrinthitis Acute Labyrinthitis Chronic Labyrinthitis (Meniere’s Syndrome) Chronic Labyrinthitis (Meniere’s Syndrome) Toxic Labyrinthitis Toxic Labyrinthitis Vestibular Neuronitis Vestibular Neuronitis Acoustic Nerve Lesions Acoustic Nerve Lesions Labyrinthine Ischemia Labyrinthine Ischemia

20. Central vertigo Brainstem Lesions Brainstem Lesions Intravascular: Vertebrobasilar insufficiency Intravascular: Vertebrobasilar insufficiency Tumors Tumors Intracranial infection Intracranial infection Demyelinating diseases: Multiple Sclerosis, Syringobulbia Demyelinating diseases: Multiple Sclerosis, Syringobulbia

21. Conclusions 1.History Taking 2.Physical Examinations 3.Psychogenic Vertigo must be consider 4.Labs for necessary

22. Tinnitus

23. Tinnitus Definition Definition Classification Classification Objective tinnitus Objective tinnitus Subjective tinnitus Subjective tinnitus Theories Theories Evaluation Evaluation Treatment Treatment

24. Introduction Tinnitus -“The perception of sound in the absence of external stimuli.” Tinnitus -“The perception of sound in the absence of external stimuli.” Tinnire – means “ringing” in Latin Tinnire – means “ringing” in Latin Includes buzzing, hissing, roaring, clicking, pulsatile sounds Includes buzzing, hissing, roaring, clicking, pulsatile sounds For some, an unbearable sound that drives them to contemplate suicide. For some, an unbearable sound that drives them to contemplate suicide.

25. Tinnitus May be perceived as unilateral or bilateral May be perceived as unilateral or bilateral Originating in the ears or around the head Originating in the ears or around the head First or only symptom of a disease process or auditory/psychological annoyance First or only symptom of a disease process or auditory/psychological annoyance

26. Tinnitus 40 million affected in the United States 40 million affected in the United States 10 million severely affected 10 million severely affected Most common in 40-70 year-olds Most common in 40-70 year-olds Roughly equal prevalence in men and women Roughly equal prevalence in men and women

27. Classification Objective tinnitus – sound produced by paraauditory structures which may be heard by an examiner, often pulsatile Objective tinnitus – sound produced by paraauditory structures which may be heard by an examiner, often pulsatile Subjective tinnitus – sound is only perceived by the patient (most common) Subjective tinnitus – sound is only perceived by the patient (most common)

28. Tinnitus Pulsatile tinnitus – matches pulse or a rushing sound Pulsatile tinnitus – matches pulse or a rushing sound Possible vascular etiology Possible vascular etiology Objective or subjective Objective or subjective Increased or turbulent blood flow through paraauditory structures Increased or turbulent blood flow through paraauditory structures

29. Objective tinnitus Vascular (pulsatile) Vascular (pulsatile) A/V malformations A/V malformations Vascular tumors Vascular tumors Venous hum (cardiac murmurs, anemia, BIH, thyrotoxicosis, pregnancy, dehiscent jugular bulb) Venous hum (cardiac murmurs, anemia, BIH, thyrotoxicosis, pregnancy, dehiscent jugular bulb) Atherosclerosis Atherosclerosis Ectopic carotid artery Ectopic carotid artery Persistent stapedial artery Persistent stapedial artery Vascular loops Vascular loops Neuromuscular Neuromuscular Palatomyclonus Stapedial muscle spasm Patulous eustachian tube Patulous eustachian tube

30. Arteriovenous Malformations Congenital lesions Congenital lesions Occipital artery and transverse sinus, internal carotid and vertebral arteries, middle meningeal and greater superficial petrosal arteries Occipital artery and transverse sinus, internal carotid and vertebral arteries, middle meningeal and greater superficial petrosal arteries Mandible Mandible Brain parenchyma Brain parenchyma Dura Dura

31. Arteriovenous Malformations Pulsatile tinnitus Pulsatile tinnitus Headache Headache Papilledema Papilledema Discoloration of skin or mucosa Discoloration of skin or mucosa

32. Vascular tumors Glomus tympanicum Glomus tympanicum Paraganglioma of middle ear Paraganglioma of middle ear Loud pulsatile tinnitus which may decrease with ipsilateral carotid artery compression Loud pulsatile tinnitus which may decrease with ipsilateral carotid artery compression Reddish mass behind tympanic membrane which blanches with positive pressure Reddish mass behind tympanic membrane which blanches with positive pressure Conductive hearing loss Conductive hearing loss

33. Vascular tumors Glomus jugulare Glomus jugulare Paraganglioma of jugular fossa Paraganglioma of jugular fossa Loud pulsatile tinnitus Loud pulsatile tinnitus Conductive hearing loss if into middle ear Conductive hearing loss if into middle ear Cranial neuropathies Cranial neuropathies

34. Venous hum Benign intracranial hypertension Benign intracranial hypertension Dehiscent jugular bulb Dehiscent jugular bulb Transverse sinus partial obstruction Transverse sinus partial obstruction Increased cardiac output from Increased cardiac output from Pregnancy Pregnancy Thyrotoxicosis Thyrotoxicosis Anemia Anemia

35. Benign Intracranial Hypertension Also called pseudotumor cerebri Also called pseudotumor cerebri Young, obese, female patients Young, obese, female patients Hearing loss Hearing loss Aural fullness Aural fullness Dizziness Dizziness Headaches Headaches Visual disturbance Visual disturbance Papilledema, pressure >200mm H20 on LP Papilledema, pressure >200mm H20 on LP

36. Benign Intracranial Hypertension Sismanis and Smoker 1994 Sismanis and Smoker 1994 100 patients with pulsatile tinnitus 100 patients with pulsatile tinnitus 42 found to have BIH syndrome 42 found to have BIH syndrome 16 glomus tumors 16 glomus tumors 15 atherosclerotic carotid artery disease 15 atherosclerotic carotid artery disease

37. Benign Intracranial Hypertension Treatment Treatment Weight loss Weight loss Diuretics Diuretics Subarachnoid-peritoneal shunt Subarachnoid-peritoneal shunt Gastric bypass for weight reduction Gastric bypass for weight reduction

38. Neuromuscular Causes Palatal myoclonus Palatal myoclonus Clicking sound Clicking sound Rapid (60-200 beats/min), intermittent Rapid (60-200 beats/min), intermittent Contracture of tensor palantini, levator palatini, levator veli palatini, tensor tympani, salpingopharyngeal, superior constrictors Contracture of tensor palantini, levator palatini, levator veli palatini, tensor tympani, salpingopharyngeal, superior constrictors Muscle spasm seen orally or transnasally Muscle spasm seen orally or transnasally Rhythmic compliance change on tympanogram Rhythmic compliance change on tympanogram

39. Myoclonus Palatal myoclonus associations: Palatal myoclonus associations: Multiple Sclerosis and other degenerative neurological disorders Multiple Sclerosis and other degenerative neurological disorders Small vessel disease Small vessel disease Brain stem tumors Brain stem tumors Treatments: muscle relaxants, botulinum toxin injection Treatments: muscle relaxants, botulinum toxin injection

40. Stapedius Muscle Spasm Idiopathic stapedial muscle spasm Idiopathic stapedial muscle spasm Rough, rumbling, crackling sound Rough, rumbling, crackling sound Exacerbated by outside sounds Exacerbated by outside sounds Brief and intermittent Brief and intermittent May be able to see tympanic membrane movement May be able to see tympanic membrane movement Treatments: avoidance of stimulants, muscle relaxants, sometimes surgical division of tensor tympani and stapedius muscles Treatments: avoidance of stimulants, muscle relaxants, sometimes surgical division of tensor tympani and stapedius muscles

41. Patulous Eustachian Tube Eustachian tube remains open abnormally Eustachian tube remains open abnormally Ocean roar sound Ocean roar sound Changes with respiration Changes with respiration Lying down or head in dependent position provides relief Lying down or head in dependent position provides relief Tympanogram will show changes in compliance with respiration Tympanogram will show changes in compliance with respiration Associated with significant weight loss, radiation to the nasopharynx Associated with significant weight loss, radiation to the nasopharynx

42. Subjective Tinnitus Otologic Otologic Hearing loss (presbycusis, noise exposure, otosclerosis, middle ear effusion) Hearing loss (presbycusis, noise exposure, otosclerosis, middle ear effusion) Meniere’s disease Meniere’s disease Acoustic neuroma Acoustic neuroma Ototoxic drugs or substances Ototoxic drugs or substances Neurologic Neurologic MS MS Head trauma Head trauma Metabolic Metabolic Thyroid disorders Hyperlipidemia B12 def Psych Psych Depression/anxiety Infectious Infectious Syphilis Meningitis

43. Conductive hearing loss Conductive hearing loss decreases level of background noise Conductive hearing loss decreases level of background noise Normal paraauditory sounds seem amplified Normal paraauditory sounds seem amplified Cerumen impaction, otosclerosis, middle ear effusion, otosclerosis, perforated TM, EAC swelling are examples Cerumen impaction, otosclerosis, middle ear effusion, otosclerosis, perforated TM, EAC swelling are examples Treating the cause of conductive hearing loss may alleviate the tinnitus Treating the cause of conductive hearing loss may alleviate the tinnitus

44. Sensorineural hearing loss Indicates abnormality of the inner ear or cochlear portion of the 8 th CN Indicates abnormality of the inner ear or cochlear portion of the 8 th CN NIHL and presbycusis most common NIHL and presbycusis most common

45. Other subjective tinnitus Poorly understood mechanisms of tinnitus production Poorly understood mechanisms of tinnitus production Abnormal conditions in the cochlea, cochlear nerve, ascending auditory pathways, auditory cortex Abnormal conditions in the cochlea, cochlear nerve, ascending auditory pathways, auditory cortex Hyperactive hair cells Hyperactive hair cells Chemical imbalance Chemical imbalance

46. CNS Mechanisms Reorganization of central pathways with hearing loss (similar to phantom limb pain) Reorganization of central pathways with hearing loss (similar to phantom limb pain) Disinhibition of dorsal cochlear nucleus with increase in spontaneous activity of central auditory system Disinhibition of dorsal cochlear nucleus with increase in spontaneous activity of central auditory system

47. Neurophysiologic Model Proposed by Jastreboff Proposed by Jastreboff Result of interaction of subsystems in the nervous system Result of interaction of subsystems in the nervous system Auditory pathways playing a role in development and appearance of tinnitus Auditory pathways playing a role in development and appearance of tinnitus Limbic system responsible for tinnitus annoyance Limbic system responsible for tinnitus annoyance Negative reinforcement enhances perception of tinnitus and increases time it is perceived Negative reinforcement enhances perception of tinnitus and increases time it is perceived

48. Role of Depression Depression is more prevalent in patients with chronic tinnitus than in those without tinnitus Depression is more prevalent in patients with chronic tinnitus than in those without tinnitus Folmer et al (1999) reported patients with depression rated the severity of their tinnitus higher although loudness scores were the same Folmer et al (1999) reported patients with depression rated the severity of their tinnitus higher although loudness scores were the same Which comes first, depression or tinnitus? Which comes first, depression or tinnitus?

49. Ototoxic Drugs Analgesic Analgesic ASA, NSAIDs ASA, NSAIDs Antibiotics Antibiotics Aminoglycosides Aminoglycosides Erthyromycin Erthyromycin Vancomycin Vancomycin Chloramphenicol Chloramphenicol Tetracycline Tetracycline Loop diuretics Loop diuretics Chemotherapeutic agents Chemotherapeutic agents Cisplatin Vincristine Methotrexate Bleomycin Others Others Chloroquine Heavy metals Quinine Heterocyclic antidepressants

50. Evaluation - History Careful history Careful history Quality Quality Pitch Pitch Loudness Loudness Unilateral vs Bilateral Unilateral vs Bilateral Constant/intermittent Constant/intermittent Onset Onset Alleviating/aggravating factors Alleviating/aggravating factors

51. Evaluation - History Infection Infection Trauma Trauma Noise exposure Noise exposure Medication usage Medication usage Medical history Medical history Hearing loss Hearing loss Vertigo Vertigo Pain Pain Family history Family history Impact on patient Impact on patient

52. Evaluation – Physical Exam Complete head & neck exam Complete head & neck exam General physical exam General physical exam Otoscopy (glomus tympanicum, dehiscent jugular bulb) Otoscopy (glomus tympanicum, dehiscent jugular bulb) Search for audible bruit in pulsatile tinnitus Search for audible bruit in pulsatile tinnitus Auscultate over orbit, mastoid process, skull, neck, heart using bell and diaphragm of stethoscope Auscultate over orbit, mastoid process, skull, neck, heart using bell and diaphragm of stethoscope Toynbee tube to auscultate EAC Toynbee tube to auscultate EAC

53. Evaluation – Physical Exam Light exercise to increase pulsatile tinnitus Light exercise to increase pulsatile tinnitus Light pressure on the neck (decreases venous hum) Light pressure on the neck (decreases venous hum) Valsalva maneuver (decrease venous hum) Valsalva maneuver (decrease venous hum) Turning the head (decrease venous hum) Turning the head (decrease venous hum)

54. Evaluation - Audiometry Pure tone air, bone and speech descrimination scores, tympanometry, acoustic reflexes Pure tone air, bone and speech descrimination scores, tympanometry, acoustic reflexes Weber and Rinne tests Weber and Rinne tests Pitch matching Pitch matching Loudness matching Loudness matching Masking level Masking level

55. Evaluation - Audiometry Vascular or palatomyoclonus induced tinnitus – graph of compliance vs. time Vascular or palatomyoclonus induced tinnitus – graph of compliance vs. time Patulous Eustachian tube – changes in compliance with respiration Patulous Eustachian tube – changes in compliance with respiration Asymmetric sensorineural hearing loss or speech discrimination, unilateral tinnitus suggests possible acoustic neuroma - MRI Asymmetric sensorineural hearing loss or speech discrimination, unilateral tinnitus suggests possible acoustic neuroma - MRI

56. Laboratory studies As indicated by history and physical exam As indicated by history and physical exam Possibilities include: Possibilities include: Hematocrit Hematocrit FTA-ABS FTA-ABS Blood chemistries Blood chemistries Thyroid studies Thyroid studies Lipid panel Lipid panel B12, zinc ? B12, zinc ?

57. Imaging Pulsatile tinnitus Pulsatile tinnitus Reviewed by Weissman and Hirsch (2000) Reviewed by Weissman and Hirsch (2000) Contrast enhanced CT of temporal bones, skull base, brain, calvaria as first-line study Contrast enhanced CT of temporal bones, skull base, brain, calvaria as first-line study Sismanis and Smoker (1994) recommended CT for retrotympanic mass, MRI/MRA if normal otoscopy Sismanis and Smoker (1994) recommended CT for retrotympanic mass, MRI/MRA if normal otoscopy

58. Glomus tympanicum – bone algorithm CT scan best shows extent of mass Glomus tympanicum – bone algorithm CT scan best shows extent of mass May not be able to see enhancement of small tumor May not be able to see enhancement of small tumor Tumor enhances on T1-weighted images with gadolinium or on T2-weighted images Tumor enhances on T1-weighted images with gadolinium or on T2-weighted images

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

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

61. Imaging Glomus jugulare Glomus jugulare Erosion of osseous jugular fossa Erosion of osseous jugular fossa Enhance with contrast, may not be able to differentiate jugular vein and tumor Enhance with contrast, may not be able to differentiate jugular vein and tumor Enhance with T1-weighted MRI with gadolinium and on T2-weighted images Enhance with T1-weighted MRI with gadolinium and on T2-weighted images Characteristic “salt and pepper” appearance on MRI Characteristic “salt and pepper” appearance on MRI

62. Glomus jugulare From: Weissman JL, Hirsch BE. Imaging of tinnitus: a review. Radiology 2000;216:344.

63. Glomus jugulare “salt and pepper appearance” From: Weissman JL, Hirsch BE. Imaging of tinnitus: a review. Radiology 2000;216:344.

64. Imaging Arteriovenous malformations – readily apparent on contrasted CT and MRI Arteriovenous malformations – readily apparent on contrasted CT and MRI Normal otoscopic exam and pulsatile tinnitus may be dural arteriovenous fistula Normal otoscopic exam and pulsatile tinnitus may be dural arteriovenous fistula Often invisible on contrasted CT and MRI/MRA Often invisible on contrasted CT and MRI/MRA Angiography may be only diagnostic test Angiography may be only diagnostic test

65. Imaging Shin et al (2000) Shin et al (2000) MRI/MRA initially if subjective pulsatile tinnitus MRI/MRA initially if subjective pulsatile tinnitus Angiography if objective with audible bruit in order to identify dural arteriovenous fistula Angiography if objective with audible bruit in order to identify dural arteriovenous fistula

66. Imaging Acoustic Neuroma Acoustic Neuroma Unilateral tinnitus, asymmetric sensorineural hearing loss or speech descrimination scores Unilateral tinnitus, asymmetric sensorineural hearing loss or speech descrimination scores T1-weighted MRI with gadolinium enhancement of CP angle is study of choice T1-weighted MRI with gadolinium enhancement of CP angle is study of choice Thin section T2-weighted MRI of temporal bones and IACs may be acceptable screening test Thin section T2-weighted MRI of temporal bones and IACs may be acceptable screening test

67. Acoustic Neuroma From: Weissman JL, Hirsch BE. Imaging of tinnitus: a review. Radiology 2000;216:348.

68. Acoustic Neuroma From: Weissman JL, Hirsch BE. Imaging of tinnitus: a review. Radiology 2000;216:348.

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

70. Treatments Multiple treatments Multiple treatments Avoidance of dietary stimulants: coffee, tea, cola, etc. Avoidance of dietary stimulants: coffee, tea, cola, etc. Smoking cessation Smoking cessation Avoid medications known to cause tinnitus Avoid medications known to cause tinnitus Reassurance Reassurance White noise from radio or home masking machine White noise from radio or home masking machine

71. Treatments - Medicines Many medications have been researched for the treatment of tinnitus: Many medications have been researched for the treatment of tinnitus: Intravenous lidocaine suppresses tinnitus but is impractical to use clinically Intravenous lidocaine suppresses tinnitus but is impractical to use clinically Tocainide is oral analog which is ineffective Tocainide is oral analog which is ineffective Carbamazepine ineffective and may cause bone marrow suppression Carbamazepine ineffective and may cause bone marrow suppression

72. Treatments - Medicines Alprazolam (Xanax) Alprazolam (Xanax) Johnson et al (1993) found 76% of 17 patients had reduction in the loudness of their tinnitus using both a tinnitus synthesizer and VAS (dose 0.5mg-1.5 mg/day) Johnson et al (1993) found 76% of 17 patients had reduction in the loudness of their tinnitus using both a tinnitus synthesizer and VAS (dose 0.5mg-1.5 mg/day) Dependence problem, long-term use is not recommended Dependence problem, long-term use is not recommended

73. Treatments - Medicines Nortriptyline and amitriptyline Nortriptyline and amitriptyline May have some benefit May have some benefit Dobie et al reported on 92 patients Dobie et al reported on 92 patients 67% nortriptlyine benefit, 40%placebo 67% nortriptlyine benefit, 40%placebo SSRI’s SSRI’s Ginko biloba Ginko 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 others Shown to be effective in some trials and not in others Needs further study Needs further study Niacin Niacin

74. Treatments Hearing aids – amplification of background noise can decrease tinnitus Hearing aids – amplification of background noise can decrease tinnitus Maskers – produce sound to mask tinnitus Maskers – produce sound to mask tinnitus Tinnitus instrument – combination of hearing aid and masker Tinnitus instrument – combination of hearing aid and masker

75. Treatments Tinnitus Retraining Therapy Tinnitus Retraining Therapy Based on neurophysiologic model Based on neurophysiologic model Combination of masking with low level broadband noise for several hours per day and counseling to achieve habituation of the reaction to tinnitus and perception of the tinnitus itself Combination of masking with low level broadband noise for several hours per day and counseling to achieve habituation of the reaction to tinnitus and perception of the tinnitus itself

76. Treatments Electrical stimulation of the cochlea Electrical stimulation of the cochlea Transcutaneous, round window, promontory stimulation have all been tried Transcutaneous, round window, promontory stimulation have all been tried Direct current can cause permanent damage Direct current can cause permanent damage Steenersen and Cronin have used transcutaneous stimulation of the auricle and tragus decreasing tinnitus in 53% of 500 patients Steenersen and Cronin have used transcutaneous stimulation of the auricle and tragus decreasing tinnitus in 53% of 500 patients

77. Treatments Cochlear implants Cochlear implants Have shown some promise in relief of tinnitus Have shown some promise in relief of tinnitus Ito and Sakakihara (1994) reported that in 26 patients implanted who had tinnitus 77% reported either tinnitus was abolished or suppressed, 8% reported worsening Ito and Sakakihara (1994) reported that in 26 patients implanted who had tinnitus 77% reported either tinnitus was abolished or suppressed, 8% reported worsening

78. Treatments Surgery Surgery Used for treatment of arteriovenous malformations, glomus tumors, otosclerosis, acoustic neuroma Used for treatment of arteriovenous malformations, glomus tumors, otosclerosis, acoustic neuroma Some authors have reported success with cochlear nerve section in patients who have intractable tinnitus and have failed all other treatments, this is not widely accepted Some authors have reported success with cochlear nerve section in patients who have intractable tinnitus and have failed all other treatments, this is not widely accepted

79. Treatments Biofeedback Biofeedback Hypnosis Hypnosis Magnetic stimulation Magnetic stimulation Acupuncture Acupuncture Conflicting reports of benefit Conflicting reports of benefit

80. Conclusions Tinnitus is a common problem with an extensive differential Tinnitus is a common problem with an extensive differential Need to identify medical process if involved Need to identify medical process if involved Pulsatile/Nonpulsatile is important distinction Pulsatile/Nonpulsatile is important distinction Unilateral vs Bilateral Unilateral vs Bilateral Associated hearing loss, vertigo Associated hearing loss, vertigo Thorough head and neck physical exam and audiometry testing is necessary for all patients Thorough head and neck physical exam and audiometry testing is necessary for all patients In general, tinnitus that is pulsatile, unilateral, and assoc w/ other unilateral otologic symptoms is more worrisome and should warrant ENT referral. In general, tinnitus that is pulsatile, unilateral, and assoc w/ other unilateral otologic symptoms is more worrisome and should warrant ENT referral.