Tinnitus

Diagnosis and Treatment

Hossein Talebi; PhD of Audiology

Assistant Professor of Audiology
Isfahan University of Medical Sciences
Introduction
• Tinnitus is defined as sensations of hearing in the
absence of external sounds
The burden of tinnitus
Introduction
• Prevalence increases with age
• 80% of people don’t seek help
• 6-8% of those affected are severe
• 40% of patients experience depression
• Can vary between barely perceptible noise to a deafening
roar
• Very little is understood about its cause or cure
 Sound features of tinnitus
NOISE CRITERIA POSSIBLE FEATURES

Onset Sudden, gradual

Pattern Pulsatile, intermittent, constant, fluctuating

Site Right or left ear, both ears, within head

Loudness Wide range, varying over time

Quality Pure tone, noise, polyphonic

Pitch Very high, high, medium, low

Tinnitus sufferers
• Ludwig van Beethoven
• Vincent van Gogh
• Charles Darwin
• Neil Young
• Eric Clapton
• Ronald Regan
Types of Tinnitus
• Objective: caused by sounds generated
somewhere in the body

• Subjective: perception of meaningless sounds

without any physical sound being present

• Auditory hallucinations: perceptions of

meaningful sounds such as music or speech
Causes
Effects of Tinnitus
• Concentration
• Hearing
• Insomnia
• Psychological
Ear Anatomy
Ear Anatomy
Mechanism of Hearing
Mechanism of Hearing
Mechanism of Hearing
Pathophysiology
• Poorly understood

• Range of theories from loss of outer hair cell function to

increased spontaneous activity of central nerves

• Can be generated from any part of the auditory system

from the ear to the Central Nervous System (CNS)

• This then may become modified by the CNS

Peripheral events lead to central
neurological changes
Brain response to auditory deprivation
• Patients with tinnitus exhibit enhanced auditory
sensitivity
DECREASED
SOUND INPUT
INCREASED
SOUND
SENSITIVITY

• This is caused by hyperactivity of the auditory central

nervous system
• In patients with tinnitus and hearing loss, the tinnitus
pitch and the hearing loss frequency spectrum are
usually matched
Tinnitus is a balance of sensory input
and spontaneous activity
• The decreased input from the cochlea, due to outer hair cell damage,
results in readjustments in the central auditory system resulting in
abnormal neural activity including hyperactivity, bursting
discharges and increases in neural synchrony.

AUDITORY ALTERED
DEPRIVATION SPONTANEOUS
AND CENTRAL NEURONAL
GAIN ACTIVITY

TINNITUS
Pathophysiology
• When the perception of tinnitus is associated with
negative reinforcement, the autonomic nervous system is
activated.

• Physiological and psychological reactions then lead to

enhancement of the tinnitus signal

• Often compared with chronic pain

Pathophysiology
Psychological associations with
tinnitus
A Team Approach
• Thorough evaluation to rule out significant pathology
• Treatment of other ear disorders eg. infection
• Explanation of test results
• Explanation of tinnitus mechanisms
• Treatment options
• Treatment of severe psychological disorders
• Follow-up
Differential Diagnosis
• Idiopathic (most common)

• Outer ear disease

– Wax, foreign body, infection

• Middle ear disease

– Infection, perforated eardrum, ossicular problems,
tumour
Differential Diagnosis
• Inner ear disease
– Presbyacusis (older age hearing loss)
– Meniere’s disease
– Acoustic neuroma
– Noise exposure
– Drugs
Evaluation of Tinnitus
• Thorough history
 Duration, nature, effects
 Non vs. pulsatile
 Noise exposure
 Other ear symptoms

• Ear examination
 Rule out outer/middle ear disease
 Tuning fork tests
Normal Ear vs. Diseased Ear
Evaluation of Tinnitus
• Audiological (hearing) Tests
 Audiogram, tympanogram
 Specialized hearing tests: SOAE, ECochG, ABR

• MRI
 Associated symptoms
 Asymmetric hearing loss
Evaluation - Subjective Tinnitus
• Audiometry - assymetrical hearing loss,
unilateral tinnitus - MRI r/o post fossa
• Complete questionnaire for perceived
severity:THI
Measurement of Tinnitus
• Pitch, loudness, minimum masking level,
residual inhibition/post masking
• Minimum masking level most clinical use
• Pitch - match most prominent pure tone, poor
reliability, octave difference
• Loudness - Adjust pure tone to tinnitus
• Most < 7 dB SL, may be 2 dB
Measurement of Tinnitus
• Minimal masking level - number of decibels to
cover tinnitus
• Residual inhibition - response of patients
tinnitus post masking
 ENT Referral

ENT Referral
Acoustic Neuroma
Treatment
• Aim to improve habituation rather than “cure”
tinnitus

• Most people don’t seek treatment

• Multitude of potential treatments
• Problems with scientific evidence
Treatment
• Basic advice
• Hearing Aid
• Tinnitus Masking Device
• Tinnitus Instrument
• Tinnitus Retraining Therapy
• Psychological Treatment
• Medication
• Alternative Treatments
Basic Advice
• Reassurance
• The first step is to understand the problem
• Avoid aggravating factors eg. noise, NSAIDs
• Decreased intake of stimulants eg. caffeine and nicotine
• Relaxation
• Avoiding silence
• White noise eg. Detuned radio
Treatment
• Basic advice
• Hearing Aid
• Tinnitus Masking Device
• Tinnitus Instrument
• Tinnitus Retraining Therapy
• Psychological Treatment
• Medication
• Alternative Treatments
Hearing Aids
• Essentially for poor hearing
• Increases ambient noise
• Decreases stress of poor hearing
• Various shapes and sizes
• Cost
• Limitations
• Up to 90% may benefit
Hearing Aids
Hearing aids are central to tinnitus
management
• Reports of the use of hearing aids
in the management of tinnitus go
back over 60 years
• Because hearing loss is often
associated with tinnitus, at least
partial restoration of hearing
should help to reduce the central
gain in auditory perception that is
a feature of tinnitus
• A recent scoping review of studies
of hearing aids in tinnitus
revealed that 17/18 publications
showed improvements in tinnitus
symptoms by fitting hearing aids
Treatment
• Basic advice
• Hearing Aid
• Tinnitus Masking Device
• Tinnitus Instrument
• Tinnitus Retraining Therapy
• Psychological Treatment
• Medication
• Alternative Treatments
Tinnitus Masking Device
• Essentially counteracts tinnitus
• Generate noise bands
• Tinnitus Instruments
 Combination of hearing aid and masker
Wide Band Noise Generators
• Emit ‘white noise’
• Elimination of silence
• White noise boring: tendency to ignore
• Gives the tinnitus sufferer something tangible to work
with
• Reduce the starkness of the tinnitus signal
Treatment
• Basic advice
• Hearing Aid
• Tinnitus Masking Device
• Tinnitus Instrument
• Tinnitus Retraining Therapy
• Psychological Treatment
• Medication
• Alternative Treatments
Tinnitus Retraining Therapy
• Based on evidence that a person can habituate to
acoustic noise in the environment

• Goal is to weaken or remove the functional connections

between the auditory pathways

• Key elements: counseling and sound therapy

Normal Condition
Tinnitus Condition
Counseling alone
Sound Therapy alone
Counseling and Sound Therapy
Tinnitus Retraining Therapy
• May take several months to take effect

• Minimum 12 months treatment

• Involves wearing ear noise generator, table top generator

Tinnitus Retraining Therapy
Treatment
• Basic advice
• Hearing Aid
• Tinnitus Masking Device
• Tinnitus Instrument
• Tinnitus Retraining Therapy
• Psychological Treatment
• Medication
• Alternative Treatments
Psychological Treatment
• Relaxation therapy
• Hypnosis
• Cognitive Behavioural Therapy
 Information, managing aggravating factors
 Applied relaxation
 Cognitive restructuring of thoughts and beliefs
 Sleep management advice
 Improvement in quality of life, not tinnitus itself

• Medication
Psychological and behavioural
support
INTERVENTION DESCRIPTION

Counselling and • Delivered in person, to groups and via the internet

education • Variable results may depend on personal characteristics
• Designed to modify maladaptive behavioural and emotional
responses
Cognitive
• One-to-one and group settings, delivered by psychologists or
behavioural
psychiatrists, or via internet
therapy
• Statistically significant reductions in severity of tinnitus symptoms
(P<0.05)
Relaxation
• May help reduce tinnitus symptoms and depressive symptoms
therapy
Treatment
• Basic advice
• Hearing Aid
• Tinnitus Masking Device
• Tinnitus Instrument
• Tinnitus Retraining Therapy
• Psychological Treatment
• Medication
• Alternative Treatments
Medications
DRUG CLASS EXAMPLES OF DRUGS USED IN TINNITUS

Antidepressants tricyclics, selective serotonin reuptake inhibitors

Antipsychotics sulpiride

Mood stabilisers gabapentin, valproate

Sedatives/hypnoti
benzodiazepines
cs

• No approved drugs (European Medicines Agency [EMA] or US Food and

Drug Administration [FDA])
• Some psychopharmacological agents may help reduce the severity of
psychological issues associated with tinnitus, and some may also lessen
tinnitus symptoms
Treatment
• Basic advice
• Hearing Aid
• Tinnitus Masking Device
• Tinnitus Instrument
• Tinnitus Retraining Therapy
• Psychological Treatment
• Medication
• Alternative Treatments
Alternative Therapies
• Vitamins
 B1, B3, B6, B12, zinc, calcium, Mg

• Laser Therapy
 Germany
 Thought to increase ATP in cochlea
Alternative Therapies
• Hypnotherapy
• Acupuncture
• Ear canal magnets
Transcranial Magnetic Stimulation
• Brain stimulation
▫ Identify active areas with PET
▫ Apply magnetic stimulation (rTMS)
▫ Evidence in small trials that there is some effect on tinnitus
▫ More detailed research awaited
• Questions
▫ Can this be clinically useful or is it just an
experimental technique?
▫ Long term safety?
Conclusion
 Tinnitus is a common condition

 Main role of ENT Surgeon is to exclude major illness and

co-ordinate further treatment

 Basic advice and counseling as well as empathic support

is paramount

 More severe cases may require psychological support,

masking devices or Tinnitus Retraining Therapy
Thank you for Your Attention