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Tinnitus A Clinical Update

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Notes

Show Notes

Slide 1 :

TinnitusA Clinical Update Jennifer L Smullen, MD Fred F Telischi, MD MEE FACS February 17, 2005

Slide 2 :

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

Slide 3 :

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

Slide 4 :

Definitions Objective Subjective Pulsatile

Slide 5 :

Pulsatile Tinnitus Etiology Evaluation Management

Slide 6 :

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

Slide 9 :

Evaluation of Pulsatile Tinnitus History Otoscopy Auscultation Palpation and IJ compression Complete ENT exam Ophthalmology and Neurology as indicated

Slide 10 :

Evaluation of Pulsatile Tinnitus Audiogram Impedance audiometry ABR if Pseudotumor cerebri suspected CBC, TSH Duplex carotid US MRI/MRA CT

Slide 11 :

Management of Pulsatile Tinnitus Arterial Atherosclerosis AV malformation or fistula High flow states Vascular loop Glomus tumors Aberrant carotid artery Persistent stapedial artery

Slide 12 :

Management of Pulsatile Tinnitus Venous Dehiscent jugular bulb Sigmoid sinus thrombosis Pseudotumor cerebri Diamox Weight loss VP shunt

Slide 13 :

Management of Pulsatile Tinnitus Nonvascular Palatal myoclonus Middle ear myoclonus Patulous ET

Slide 14 :

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

Slide 15 :

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

Slide 16 :

Where is Tinnitus? Ear Brain Both

Slide 17 :

What Causes Tinnitus? Uncoupled OHC’s Aberrant afferent activity Loss of GABAergic inhibitory neurons

Slide 18 :

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

Slide 19 :

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)

Slide 20 :

Treatment of Subjective Tinnitus Meniett Hyperbaric oxygen Acupuncture Benzodiazepines Lidocaine Steroids Stapedectomy Electrical stimulation Eighth nerve section Habituation Masking Cochlear implant Misoprostol Enoxaparin SSRI’s Gabapentin Gentamicin Ginkgo Biloba

Slide 21 :

Meniett Device Randomized ,double-blind, placebo-controlled study of tinnitus in Meniere’s disease NO EFFECT Thompsen et al Otol Neurotol Jan 2005

Slide 22 :

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

Slide 23 :

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

Slide 24 :

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 2003;36(2) Shulman A et al, Int Tinnitus J 2002;8(1)

Slide 25 :

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 1984;11(1)

Slide 26 :

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. 2002;8(2)

Slide 27 :

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. 2004;10(1) Sobrinho PG et al, Int Tinnitus J. 2004;10(2)

Slide 28 :

Electrical Stimulation First used in 1800’s Extradural implanted electrodes TENS Cochlear implants EFFECTIVE De Ridder D J Neurosurg. 2004 Mar;100(3)

Slide 29 :

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

Slide 30 :

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

Slide 31 :

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. 2003;9(1)

Slide 32 :

Antidepressants Amitriptyline Selective serotonin reuptake inhibitors, SSRI’s Tricyclic antidepressants EFFECTIVE

Slide 33 :

Ginkgo Biloba Randomized placebo-controlled double-blind trial and meta-analysis of randomized trials NO EFFECT Rejali D et al, Clin Otolaryngol. 2004 Jun;29(3)

Slide 34 :

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 Mar;114(3)

Slide 35 :

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. 2003;9(2)

Slide 36 :

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

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Park J et al Arch Otolaryngol Head Neck Surg 2000 Apr. Birch S J Altern Complement Med. 2004 JunVer more Park J et al Arch Otolaryngol Head Neck Surg 2000 Apr. Birch S J Altern Complement Med. 2004 JunVernon JA, Otolaryngol Clin North Am 2003;36(2) …otolaryngology.med.miami.edu/documents/Tinnitus.ppt less

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