TinnitusTinnitusA Clinical UpdateA Clinical Update

Jennifer L Smullen, MDJennifer L Smullen, MDFred F Telischi, MD MEE FACSFred F Telischi, MD MEE FACS

February 17, 2005February 17, 2005

DefinitionDefinition

Perception of noise in the absence of Perception of noise in the absence of acoustic stimuliacoustic stimuli

Aberrant auditory phenomenon unrelated to Aberrant auditory phenomenon unrelated to an external source of soundan external source of sound

Sensation of sound arising within the headSensation of sound arising within the head

TinnitologyTinnitology

Discipline first described in 1987 devoted to Discipline first described in 1987 devoted to understanding how the perception of an understanding how the perception of an aberrant auditory phenomenon can be aberrant auditory phenomenon can be translated into sensation and effecttranslated into sensation and effect

DefinitionsDefinitions

ObjectiveObjective

SubjectiveSubjective

PulsatilePulsatile

Pulsatile TinnitusPulsatile Tinnitus

EtiologyEtiology

EvaluationEvaluation

ManagementManagement

Etiology of Pulsatile TinnitusEtiology of Pulsatile Tinnitus

ArterialArterial– AtherosclerosisAtherosclerosis– AV malformation or fistulaAV malformation or fistula– High flow statesHigh flow states– Vascular loopVascular loop– Glomus tumorsGlomus tumors– Aberrant carotid arteryAberrant carotid artery– Persistent stapedial arteryPersistent stapedial artery

VenousVenous NonvascularNonvascular

Etiology of Pulsatile TinnitusEtiology of Pulsatile Tinnitus

ArterialArterial VenousVenous

– Dehiscent jugular bulbDehiscent jugular bulb– Sigmoid sinus thrombosisSigmoid sinus thrombosis– Pseudotumor cerebriPseudotumor cerebri

NonvascularNonvascular

Etiology of Pulsatile TinnitusEtiology of Pulsatile Tinnitus

ArterialArterial VenousVenous NonvascularNonvascular

– Palatal myoclonusPalatal myoclonus– Middle ear myoclonusMiddle ear myoclonus– Patulous ETPatulous ET

Evaluation of Pulsatile TinnitusEvaluation of Pulsatile Tinnitus

HistoryHistory OtoscopyOtoscopy AuscultationAuscultation Palpation and IJ compressionPalpation and IJ compression Complete ENT examComplete ENT exam Ophthalmology and Neurology as indicatedOphthalmology and Neurology as indicated

Evaluation of Pulsatile TinnitusEvaluation of Pulsatile Tinnitus

AudiogramAudiogram Impedance audiometryImpedance audiometry ABR if Pseudotumor cerebri suspectedABR if Pseudotumor cerebri suspected CBC, TSHCBC, TSH

Duplex carotid USDuplex carotid US MRI/MRAMRI/MRA CTCT

Management of Pulsatile TinnitusManagement of Pulsatile Tinnitus

ArterialArterial– AtherosclerosisAtherosclerosis– AV malformation or fistulaAV malformation or fistula– High flow statesHigh flow states– Vascular loopVascular loop– Glomus tumorsGlomus tumors– Aberrant carotid arteryAberrant carotid artery– Persistent stapedial arteryPersistent stapedial artery

Management of Pulsatile TinnitusManagement of Pulsatile Tinnitus

VenousVenous– Dehiscent jugular bulbDehiscent jugular bulb– Sigmoid sinus thrombosisSigmoid sinus thrombosis– Pseudotumor cerebriPseudotumor cerebri

DiamoxDiamox Weight lossWeight loss VP shuntVP shunt

Management of Pulsatile TinnitusManagement of Pulsatile Tinnitus

NonvascularNonvascular– Palatal myoclonusPalatal myoclonus– Middle ear myoclonusMiddle ear myoclonus– Patulous ETPatulous ET

Subjective TinnitusSubjective Tinnitus

Paresthesia of the somatosensory systemParesthesia of the somatosensory system Central neuropathic painCentral neuropathic pain Unilateral or bilateralUnilateral or bilateral Constant or fluctuatingConstant or fluctuating Variety of sounds Variety of sounds Associated with hyperacusis, phonophobia Associated with hyperacusis, phonophobia

and SNHLand SNHL

EpidemiologyEpidemiology

36 million Americans affected36 million Americans affected Approximately 2 million severelyApproximately 2 million severely Age 50-71 highest prevalenceAge 50-71 highest prevalence 12% men over 6512% men over 65 7% women over 657% women over 65 64% adults with normal hearing perceive tinnitus 64% adults with normal hearing perceive tinnitus

in silencein silence

Tucker et al, Otol Head & Neck Jan 2005Tucker et al, Otol Head & Neck Jan 2005

Where is Tinnitus?Where is Tinnitus?

EarEar

BrainBrain

BothBoth

What Causes Tinnitus?What Causes Tinnitus?

Uncoupled OHC’sUncoupled OHC’s

Aberrant afferent activityAberrant afferent activity

Loss of GABAergic inhibitory neuronsLoss of GABAergic inhibitory neurons

Measuring TinnitusMeasuring Tinnitus

Audiometric evaluationAudiometric evaluation

Outcome measuresOutcome measures– Tinnitus Outcome ProfileTinnitus Outcome Profile– Tinnitus Intensity IndexTinnitus Intensity Index– Tinnitus Annoyance IndexTinnitus Annoyance Index– Tinnitus Stress IndexTinnitus Stress Index– Tinnitus Handicap InventoryTinnitus Handicap Inventory– Measurement of Depression ScaleMeasurement of Depression Scale

Animal Models of TinnitusAnimal Models of Tinnitus

Jastreboff and the thirsty ratJastreboff and the thirsty rat Bauer et alBauer et al

– ChinchillaChinchilla– Food leverFood lever– Sound-induced tinnitusSound-induced tinnitus– Behavioral evidenceBehavioral evidence– Physiologic evidencePhysiologic evidence

Increased firing in DCNIncreased firing in DCN

Bauer et al Bauer et al Otolaryngologic Clinics of North AmericaOtolaryngologic Clinics of North America2003(2) 2003(2)

Treatment of Subjective TinnitusTreatment of Subjective Tinnitus

MeniettMeniett Hyperbaric oxygenHyperbaric oxygen AcupunctureAcupuncture BenzodiazepinesBenzodiazepines LidocaineLidocaine SteroidsSteroids StapedectomyStapedectomy Electrical stimulationElectrical stimulation Eighth nerve sectionEighth nerve section

HabituationHabituation MaskingMasking Cochlear implantCochlear implant MisoprostolMisoprostol EnoxaparinEnoxaparin SSRI’sSSRI’s GabapentinGabapentin GentamicinGentamicin Ginkgo BilobaGinkgo Biloba

Meniett DeviceMeniett Device

Randomized ,double-blind, placebo-Randomized ,double-blind, placebo-controlled study of tinnitus in Meniere’s controlled study of tinnitus in Meniere’s diseasedisease

NO EFFECTNO EFFECT

Thompsen et al Otol Neurotol Jan 2005Thompsen et al Otol Neurotol Jan 2005

Hyperbaric OxygenHyperbaric Oxygen

Meta analysis Meta analysis

256 patients with SSNHL256 patients with SSNHL

NO EFFECTNO EFFECT

Bennett et al, Cochrane Database Syst Rev. 2005 Jan Bennett et al, Cochrane Database Syst Rev. 2005 Jan

AcupunctureAcupuncture

2 unblinded studies showed improvement2 unblinded studies showed improvement

4 blinded studies showed no effect4 blinded studies showed no effect

NO EFFECTNO EFFECT

Park J et al Arch Otolaryngol Head Neck Surg 2000 AprPark J et al Arch Otolaryngol Head Neck Surg 2000 Apr

Birch S J Altern Complement Med. 2004 Jun Birch S J Altern Complement Med. 2004 Jun

BenzodiazepinesBenzodiazepines

Tinnitus caused by reduction in inhibitionTinnitus caused by reduction in inhibition GABA neurotransmitter of inhibition in auditory pathwaysGABA neurotransmitter of inhibition in auditory pathways Benzodiazepines enhance GABA effectsBenzodiazepines enhance GABA effects

Review of 3357 patientsReview of 3357 patients 32% control with clonazepam32% control with clonazepam 67% control with alprazolam67% control with alprazolam

EFFECTIVEEFFECTIVE

Vernon JA, Vernon JA, Otolaryngol Clin North AmOtolaryngol Clin North Am 2003;36(2) 2003;36(2) Shulman A et al, Int Tinnitus J 2002;8(1) Shulman A et al, Int Tinnitus J 2002;8(1)

LidocaineLidocaine Amide local anesthetic Amide local anesthetic Axoplasmic sodium channel blockade Axoplasmic sodium channel blockade Kroath 1960 IT LidocaineKroath 1960 IT Lidocaine Sakata 220 earsSakata 220 ears

– 34% resolved, 50% decreased, 10% unchanged34% resolved, 50% decreased, 10% unchanged– Returned to baseline in 4 weeksReturned to baseline in 4 weeks

Side effects: vertigo, nausea vomitingSide effects: vertigo, nausea vomiting

EFFECTIVEEFFECTIVE

Sakata E et al, Auris Nasus Larynx 1984;11(1)Sakata E et al, Auris Nasus Larynx 1984;11(1)

IT SteroidsIT Steroids

50 patients50 patients Treated 3 times daily for 3 monthsTreated 3 times daily for 3 months 37 resolved or improved permanently37 resolved or improved permanently Consistent with other studies showing an average Consistent with other studies showing an average

of 70% improvedof 70% improved

EFFECTIVEEFFECTIVE

Cesarani A et al Int Tinnitus J. 2002;8(2)Cesarani A et al Int Tinnitus J. 2002;8(2)

OtosclerosisOtosclerosis

Stapedectomy 40 patientsStapedectomy 40 patients– 85% improved 85% improved – 12% had no change12% had no change– 2.5% worse 2.5% worse – 52.5% complete resolution 52.5% complete resolution

Prospective Study 48 patients 91% improvedProspective Study 48 patients 91% improved

EFFECTIVEEFFECTIVE

Sparano A et al, Int Tinnitus J. 2004;10(1)Sparano A et al, Int Tinnitus J. 2004;10(1)

Sobrinho PG et al, Int Tinnitus J. 2004;10(2)Sobrinho PG et al, Int Tinnitus J. 2004;10(2)

Electrical StimulationElectrical Stimulation

First used in 1800’sFirst used in 1800’s Extradural implanted electrodesExtradural implanted electrodes TENSTENS Cochlear implantsCochlear implants

EFFECTIVEEFFECTIVE

De Ridder D J Neurosurg. 2004 Mar;100(3) De Ridder D J Neurosurg. 2004 Mar;100(3)

Tinnitus Retraining TherapyTinnitus Retraining Therapy

Habituation exercises designed by Habituation exercises designed by JastreboffJastreboff

12-18 months12-18 months Decouples tinnitus and the emotional Decouples tinnitus and the emotional

response to tinnitusresponse to tinnitus No more effective than directed counselingNo more effective than directed counseling

Possibly EFFECTIVEPossibly EFFECTIVE

MaskingMasking

Wearable MaskersWearable Maskers– Hearing aidsHearing aids– Tinnitus maskersTinnitus maskers– Tinnitus instrumentsTinnitus instruments– High frequency bone conduction High frequency bone conduction

HiSonic Tinnitus Relief DeviceHiSonic Tinnitus Relief Device Environmental MaskersEnvironmental Maskers

– Recorded sound- Petroff Audio TechnologiesRecorded sound- Petroff Audio Technologies– White noiseWhite noise

– EFFECTIVEEFFECTIVE

Ultra High Frequency Muscle Ultra High Frequency Muscle VibrationVibration

15 patients15 patients Tactaid transducerTactaid transducer 60% had relief after one 60% had relief after one

treatment treatment Effects lasted up to 4 monthsEffects lasted up to 4 months

Possibly EFFECTIVEPossibly EFFECTIVE

Lenhardt ML et al, Int Tinnitus J. 2003;9(1)Lenhardt ML et al, Int Tinnitus J. 2003;9(1)

AntidepressantsAntidepressants

Amitriptyline Amitriptyline Selective serotonin reuptake inhibitors, Selective serotonin reuptake inhibitors,

SSRI’sSSRI’s Tricyclic antidepressantsTricyclic antidepressants

EFFECTIVEEFFECTIVE

Ginkgo BilobaGinkgo Biloba

Randomized placebo-controlled double-Randomized placebo-controlled double-blind trial and meta-analysis of randomized blind trial and meta-analysis of randomized trials trials

NO EFFECTNO EFFECT

Rejali D et al, Clin Otolaryngol. 2004 Jun;29(3)Rejali D et al, Clin Otolaryngol. 2004 Jun;29(3)

Electromagnetic therapy Electromagnetic therapy

Randomized, prospective, double-blind, Randomized, prospective, double-blind, placebo-controlled pilot study placebo-controlled pilot study

37 patients received 30-minute treatments 37 patients received 30-minute treatments with the Diapulse device three times a week with the Diapulse device three times a week for 1 month for 1 month

NO EFFECTNO EFFECT

Ghossaini SN Laryngoscope. 2004 Mar;114(3) Ghossaini SN Laryngoscope. 2004 Mar;114(3)

EnoxaparinEnoxaparin

Anticoagulant, low molecular weight heparinAnticoagulant, low molecular weight heparin Randomized, placebo-controlled study of 40 Randomized, placebo-controlled study of 40

patientspatients Hospitalized for 10 daysHospitalized for 10 days 2000 IU BID2000 IU BID All patients had complete reliefAll patients had complete relief

EFFECTIVEEFFECTIVE

Mora R et al, Int Tinnitus J. 2003;9(2)Mora R et al, Int Tinnitus J. 2003;9(2)

SummarySummaryProbably EffectiveProbably Effective

LidocaineLidocaine BenzodiazepinesBenzodiazepines AntidepressantsAntidepressants Electrical StimulationElectrical Stimulation EnoxaparinEnoxaparin DexamethasoneDexamethasone

Mixed EffectsMixed Effects TRTTRT GentamicinGentamicin Muscle vibrationMuscle vibration

Likely Not EffectiveLikely Not Effective AcupunctureAcupuncture CarbamazepineCarbamazepine Ginkgo BilobaGinkgo Biloba GabapentinGabapentin Pulsed EM Pulsed EM HB O2HB O2 MeniettMeniett