Tinnitus A Clinical Update

1
TinnitusA Clinical Update

• Jennifer L Smullen, MD
• Fred F Telischi, MD MEE FACS
• February 17, 2005

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Definition

• Perception of noise in the absence of acoustic
  stimuli
• Aberrant auditory phenomenon unrelated to an
  external source of sound
• Sensation of sound arising within the head

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Tinnitology

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

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Definitions

• Objective
• Subjective
• Pulsatile

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Pulsatile Tinnitus

• Etiology
• Evaluation
• Management

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Etiology of Pulsatile Tinnitus

• Arterial
• Atherosclerosis
• AV malformation or fistula
• High flow states
• Vascular loop
• Glomus tumors
• Aberrant carotid artery
• Persistent stapedial artery
• Venous
• Nonvascular

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Etiology of Pulsatile Tinnitus

• Arterial
• Venous
• Dehiscent jugular bulb
• Sigmoid sinus thrombosis
• Pseudotumor cerebri
• Nonvascular

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Etiology of Pulsatile Tinnitus

• Arterial
• Venous
• Nonvascular
• Palatal myoclonus
• Middle ear myoclonus
• Patulous ET

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Evaluation of Pulsatile Tinnitus

• History
• Otoscopy
• Auscultation
• Palpation and IJ compression
• Complete ENT exam
• Ophthalmology and Neurology as indicated

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Evaluation of Pulsatile Tinnitus

• Audiogram
• Impedance audiometry
• ABR if Pseudotumor cerebri suspected
• CBC, TSH
• Duplex carotid US
• MRI/MRA
• CT

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Management of Pulsatile Tinnitus

• Arterial
• Atherosclerosis
• AV malformation or fistula
• High flow states
• Vascular loop
• Glomus tumors
• Aberrant carotid artery
• Persistent stapedial artery

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Management of Pulsatile Tinnitus

• Venous
• Dehiscent jugular bulb
• Sigmoid sinus thrombosis
• Pseudotumor cerebri
• Diamox
• Weight loss
• VP shunt

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Management of Pulsatile Tinnitus

• Nonvascular
• Palatal myoclonus
• Middle ear myoclonus
• Patulous ET

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Subjective Tinnitus

• Paresthesia of the somatosensory system
• Central neuropathic pain
• Unilateral or bilateral
• Constant or fluctuating
• Variety of sounds
• Associated with hyperacusis, phonophobia and SNHL

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Epidemiology

• 36 million Americans affected
• Approximately 2 million severely
• Age 50-71 highest prevalence
• 12 men over 65
• 7 women over 65
• 64 adults with normal hearing perceive tinnitus
  in silence
• Tucker et al, Otol Head Neck Jan 2005

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Where is Tinnitus?

• Ear
• Brain
• Both

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What Causes Tinnitus?

• Uncoupled OHCs
• Aberrant afferent activity
• Loss of GABAergic inhibitory neurons

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Measuring Tinnitus

• Audiometric evaluation
• Outcome measures
• Tinnitus Outcome Profile
• Tinnitus Intensity Index
• Tinnitus Annoyance Index
• Tinnitus Stress Index
• Tinnitus Handicap Inventory
• Measurement of Depression Scale

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Animal Models of Tinnitus

• Jastreboff and the thirsty rat
• Bauer et al
• Chinchilla
• Food lever
• Sound-induced tinnitus
• Behavioral evidence
• Physiologic evidence
• Increased firing in DCN
• Bauer et al Otolaryngologic Clinics of North
  America2003(2)

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Treatment of Subjective Tinnitus

• Meniett
• Hyperbaric oxygen
• Acupuncture
• Benzodiazepines
• Lidocaine
• Steroids
• Stapedectomy
• Electrical stimulation
• Eighth nerve section

• Habituation
• Masking
• Cochlear implant
• Misoprostol
• Enoxaparin
• SSRIs
• Gabapentin
• Gentamicin
• Ginkgo Biloba

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Meniett Device

• Randomized ,double-blind, placebo-controlled
  study of tinnitus in Menieres disease
• NO EFFECT
• Thompsen et al Otol Neurotol Jan 2005

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Hyperbaric Oxygen

• Meta analysis
• 256 patients with SSNHL
• NO EFFECT
• Bennett et al, Cochrane Database Syst Rev. 2005
  Jan

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Acupuncture

• 2 unblinded studies showed improvement
• 4 blinded studies showed no effect
• NO EFFECT
• Park J et al Arch Otolaryngol Head Neck Surg 2000
  Apr
• Birch S J Altern Complement Med. 2004 Jun

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Benzodiazepines

• Tinnitus caused by reduction in inhibition
• GABA neurotransmitter of inhibition in auditory
  pathways
• Benzodiazepines enhance GABA effects
• Review of 3357 patients
• 32 control with clonazepam
• 67 control with alprazolam
• EFFECTIVE
• Vernon JA, Otolaryngol Clin North Am 200336(2)
• Shulman A et al, Int Tinnitus J 20028(1)

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Lidocaine

• Amide local anesthetic
• Axoplasmic sodium channel blockade
• Kroath 1960 IT Lidocaine
• Sakata 220 ears
• 34 resolved, 50 decreased, 10 unchanged
• Returned to baseline in 4 weeks
• Side effects vertigo, nausea vomiting
• EFFECTIVE
• Sakata E et al, Auris Nasus Larynx 198411(1)

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IT Steroids

• 50 patients
• Treated 3 times daily for 3 months
• 37 resolved or improved permanently
• Consistent with other studies showing an average
  of 70 improved
• EFFECTIVE
• Cesarani A et al Int Tinnitus J. 20028(2)

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Otosclerosis

• Stapedectomy 40 patients
• 85 improved
• 12 had no change
• 2.5 worse
• 52.5 complete resolution
• Prospective Study 48 patients 91 improved
• EFFECTIVE
• Sparano A et al, Int Tinnitus J. 200410(1)
• Sobrinho PG et al, Int Tinnitus J. 200410(2)

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Electrical Stimulation

• First used in 1800s
• Extradural implanted electrodes
• TENS
• Cochlear implants
• EFFECTIVE
• De Ridder D J Neurosurg. 2004 Mar100(3)

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Tinnitus Retraining Therapy

• Habituation exercises designed by Jastreboff
• 12-18 months
• Decouples tinnitus and the emotional response to
  tinnitus
• No more effective than directed counseling
• Possibly EFFECTIVE

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Masking

• Wearable Maskers
• Hearing aids
• Tinnitus maskers
• Tinnitus instruments
• High frequency bone conduction
• HiSonic Tinnitus Relief Device
• Environmental Maskers
• Recorded sound- Petroff Audio Technologies
• White noise
• EFFECTIVE

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Ultra High Frequency Muscle Vibration

• 15 patients
• Tactaid transducer
• 60 had relief after one treatment
• Effects lasted up to 4 months
• Possibly EFFECTIVE
• Lenhardt ML et al, Int Tinnitus J. 20039(1)

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Antidepressants

• Amitriptyline
• Selective serotonin reuptake inhibitors, SSRIs
• Tricyclic antidepressants
• EFFECTIVE

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Ginkgo Biloba

• Randomized placebo-controlled double-blind trial
  and meta-analysis of randomized trials
• NO EFFECT
• Rejali D et al, Clin Otolaryngol. 2004 Jun29(3)

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Electromagnetic therapy

• Randomized, prospective, double-blind,
  placebo-controlled pilot study
• 37 patients received 30-minute treatments with
  the Diapulse device three times a week for 1
  month
• NO EFFECT
• Ghossaini SN Laryngoscope. 2004 Mar114(3)

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Enoxaparin

• Anticoagulant, low molecular weight heparin
• Randomized, placebo-controlled study of 40
  patients
• Hospitalized for 10 days
• 2000 IU BID
• All patients had complete relief
• EFFECTIVE
• Mora R et al, Int Tinnitus J. 20039(2)

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Summary

• Probably Effective
• Lidocaine
• Benzodiazepines
• Antidepressants
• Electrical Stimulation
• Enoxaparin
• Dexamethasone

• Mixed Effects
• TRT
• Gentamicin
• Muscle vibration

• Likely Not Effective
• Acupuncture
• Carbamazepine
• Ginkgo Biloba
• Gabapentin
• Pulsed EM
• HB O2
• Meniett