Hissing and Buzzing and Ringing, Oh My! The Diagnosis and Treatment of Tinnitus

1. Hissing and Buzzing and Ringing, Oh My!The Diagnosis and Treatment of Tinnitus Carol Rousseau, M.A., CCC-A Rochester Hearing and Speech Center Rochester, NY 12 May 2006

2. DEFINITION • The perception of sound in one or both ears or in the head when no external sound is present (American Tinnitus Association, 2006)

3. Po-TAY-to, Po-TAH-to…. • Both TINN-ni-tus and Tin-EYE-tis are acceptable pronunciations • Originated from the Latin verb “Tinnire” meaning to ring or tinkle • Geography • West Coast: Second syllable • Middle America: First syllable • East Coast: Evenly Divided

4. Some History… • First recorded appearance is about 2000 years ago by the Phoenicians • Noted in Egyptian hieroglyphics • Aristotle (384-322 B.C.) wrote of it • Physician Galen (129-199 B.C.) described it as “echoes” • Jean Marie Gaspard Itard in 1821 mentioned “True” and “False” Tinnitus, which we now refer as “Objective” and “Subjective”

5. More History… • 1975 Dr. Jack Vernon introduced the first wearable masker device • In 1990, Jastreboff introduced popular therapeutic approach called “Tinnitus Retraining Therapy (TRT)

6. Some Statistics… • Over 50 Million Americans experience Tinnitus to some degree • 12 Million severe enough to seek medical attention • 2 Million so seriously debilitated that they can not function on a normal basis (ATA, 2006)

7. More Statistics… • 6-20% of U.S. population describe noise as bothersome • 1% say it interferes with day-to-day activities (Gelfand, 1997)

8. Musicians Neil Young Pete Townsend Barbara Streisand Sting Eric Clapton Jeff Beck James Hatfield (Metallica) Lars Ulrich (Metallica) George Martin George Harrison Ted Nugent Bono (u2) The Edge (u2) Paul Schaffer Trent Rezner Dave Pirner (Soul Asylum) Huey Lewis Beethoven Famous People with Tinnitus

9. Actors William Shatner Leonard Nimoy Steve Martin Burt Reynolds Sylvester Stallone Tony Randall Jerry Stiller Florence Henderson Keanu Reeves Larry King David Letterman Cher Famous People with Tinnitus

10. Famous People with Tinnitus • Historical/Political • Jean-Jacques Rousseau • Thomas Edison • Dwight D. Eisenhower • Martin Luther • Alan Shepard • Vincent Van Gogh • Charles Darwin

11. Head Noise Ear Noise Ringing Buzzing Chirping Hissing Humming Pulsing Roaring Description

12. Characteristics of Tinnitus • Quality • Pitch • Loudness • Location

13. Characteristics of Tinnitus: Quality • 79% of patients described their tinnitus as a pure tone • Single, double, and tri-toned • 6% described it as noise • 15% mixture of pure tone and noise (Vernon, 1998)

14. Characteristics of Tinnitus: Pitch • Most frequently described pitch of the tone as 8000Hz (Vernon, 1998; Sandlin & Olsson, 2000)

15. Characteristics of Tinnitus: Loudness • 88% described loudness of 11 dB SL or less • Overall average loudness level as 5.7 dB SL

16. Characteristics of Tinnitus: Location • Both ears • 55% • One ear only • 20% • Head • 24% • Varied • 1%

17. Causes of Tinnitus • Mostly unknown • 47% • Noise Exposure • 25% • Head Injury/Brain Trauma • 8% • Ear Pathology • 7% • Ototoxic Medications and other • 13% (Vernon, 1998)

18. Causes of Tinnitus:Diet • May be related to food allergies or sensitivities • Salicylates naturally occurs in some foods may produce tinnitus • Almonds, cloves, gingerbread, mustard, mint flavors • Apples, Apricots, Blackberries, Grapes, Raisins, Oranges, Strawberries, Raspberries, avocados • Bell and green peppers, olives, cucumbers, white potatos • Processed foods • Alcohol, especially beer and gin

19. Causes of Tinnitus:Noise • 90% of ATA members also report hearing loss (ATA, 2006) • Many of those have high frequency hearing loss associated with noise • Effects of loud noise can worsen existing tinnitus

20. Mechanisms of Tinnitus: Just What is Going on in the Ear? • Vibrations • Phase-locked spontaneous discharge of cell bodies • Aberrant behavior of the efferent system • Involvement of Neurotransmitter substances • Central Origin (the brain) • Vascular Compression of the 7th nerve

21. Mechanisms of Tinnitus: Just What is Going on in the Ear? • CNS phenomenon dictated by peripheral activity • Something akin to Phantom Limb phenomenon • Lockwood (1998) theorized that tinnitus is based in the auditory cortex, and not the cochlea • Other theories state that it may be caused by alterations in the function of the inferior colliculus

22. Mechanisms of Tinnitus: Just What is Going on in the Ear? • Jastreboff (1995) theorized that tinnitus may involve a discordant dysfunction of OHC and IHC systems • One system becomes dysfunctional because of loss of cell population • Difference is created in the activity of the two different type of fibers • Many theorize that tinnitus is a symptom of many causes based on a number of different mechanisms

23. Medical Aspects of Tinnitus:Types of Tinnitus • Medical diseases and emotional factors may cause and/or affect severity of tinnitus • Two types • Objective • Subjective

24. Objective Tinnitus • Also called Audible Tinnitus • Can be heard by physician • Via external ear canal or mastoid bone • Corresponds to respiration or heartbeat

25. Objective Tinnitus: Corresponding to Respiration • May be caused by abnormally patent Eustachian Tube • Usually experienced short time • May be caused by extreme weight loss or after an extended illness • Symptoms relieved by lying down or putting head in lowered position

26. Objective Tinnitus: Sharp or Irregular Clicks • Heard for several seconds or minutes at a time • Contractions of soft palate or muscles of the middle ear • Cause unknown

27. Objective Tinnitus:Pulsatile Tinnitus • Synchronous with heartbeat/pulse • May indicate cardiac or vascular abnormalities • Abnormal vascular flow from arteries to veins somewhere in the head/neck • Also may be secondary to turbulence of major vessels from arteriosclerosis or narrowing of blood from artery to vein

28. Objective Tinnitus:Rushing or Flowing • Vascular tumors of the Middle Ear • Glomus Tumor • Rare

29. Subjective Tinnitus • More frequent than Objective Tinnitus • Most people experience this at some point • Various medical conditions cause or affect subjective tinnitus • Otologic disorders • Cardiovascular abnormalities • Metabolic diseases • Neurologic disorders • Drugs/Pharmaceuticals • Dental factors • Psychological/emotional factors

30. Subjective Tinnitus:Otologic Causes • Hearing Loss considered the most common cause of tinnitus • 90% have some form of ear disease • SNHL most frequent • Majority have a 30 dB or higher HL from 3 to 8 kHz • Mostly the result of aging or noise exposure • Often characterized as high-pitched • Usually described as mild

31. Subjective Tinnitus:Cardiovascular Disorders • 37% of tinnitus patients also have cardiovascular complaints (Schleuning, 1998) • Often characterized as low pitched pulsating sound • Alteration of blood flow in the head can be cause a low frequency hum • High blood pressure • Anemia • Arteriosclerosis

32. Subjective Tinnitus:Metabolic Disease • Rare, and may be associated with other disorders that may be causing tinnitus • Diabetes • Thyroid disease • High cholesterol levels • Vitamin deficiencies

33. Subjective Tinnitus:Neurologic Disease • Head trauma • 10% of tinnitus patients had skull fracture or severe closed head injury (Schleuning, 1998) • Result of damage to the internal structure of the inner ear with nerve or hair cell damage • Usually diminishes over time • Whiplash injury may involve nerve input from the neck and shoulders along with concussion damage to the inner ear • Meningitis • Multiple Sclerosis

34. Subjective Tinnitus:Pharmacological Factors • All types of drugs can be considered as a possible cause • Most frequent: • anti-inflammatory drugs • Aspirin and aspirin-containing medications • Percodan • Bufferin • Ecotrin • Nonsteroidal Anti-inflammatory drugs (not as severe as aspirin) • Naprosin • Ibuprophen

35. Subjective Tinnitus:Pharmacological Factors • Antibiotics • Aminoglycosides (tinnitus more pronounced when paired with diuretics) • Streptomycin • Kanamycin • Gentamicin • Sedatives or antidepressants • Quinine-containing medications for muscle cramps or arrhythmia • Heavy Metals • Mercury • Arsenic • Lead in high doses

36. Subjective Tinnitus:Pharmacological Factors • Stimulants • Tobacco • Caffeine • Constricts blood vessels • Make cells of the inner ear more irritable and more likely to randomly discharge

37. Subjective Tinnitus:Dental Factors • Temporomandibular-joint (TMJ) problems • Lower pitch • Related to jaw activity • Grinding and painful teeth and ear pain are other symptoms

38. Subjective Tinnitus:Psychological Factors • Stress and fatigue play a role in severity of complaint • Increases perception of problem more than causes tinnitus • Similar symptoms as depression • 15-20 of Tinnitus patients

39. Pulsatile Tinnitus • Can be objective or subjective • Characterized as a “thumping” sound that is often synchronous with heartbeat • Usually originates from vascular structures inside the head or neck • Arterial or venous • Other structures classified as non-vascular • Refer to ENT

40. Pulsatile Tinnitus • Glomus Tumor • Benign vascular tumors located usually in the ear • Red mass behind an intact TM • Hearing Loss • Hypertension • May start after starting medications to control blood pressure • Usually subsides after 4-6 weeks

41. Etiologies of Pulsatile Tinnitus:Arterial • Atherosclerotic Carotid Artery Disease • Tortuous (twisted) Arteries • Fibromuscular Dysplasia • Intracranial Arterio-venous Fistulae and Aneurysms • Vascular Compression fo the 8th Cranial Nerve • Aortic Murmurs • Paget’s Disease • Increased Cardiac Output (Amemia, Thyrotoxicosis, Pregnancy)

42. Etiologies of Pulsatile Tinnitus:Venous • Benign Intracranial Hypertension • Jugular Bulb Abnormalities • Abnormal Condylar and Mastoid Emissary Veins

43. Etiologies of Pulsatile Tinnitus:Nonvascular • Neoplasms of the skull and temporal bone • Palatal, Tensor Tympani, and Stapedial Muscle Myoclonus • Patulous Eustachian Tube • Cholesterol Granuloma of the Middle Ear

44. Otologic Causes for Tinnitus • Described as moderate or severe • Meniere’s disease • Chronic Suppurative Otitis Media • Viral Infections of the ear • Otoscleroris • Acoustic Neuroma • Unilateral • Sudden Hearing loss

45. Assessment of Tinnitus

46. Assessment of Tinnitus:Two Perspectives • Identify the source of the tinnitus • Assess of how the tinnitus affects the person

47. Assessment of Tinnitus • Psychoacoustic Measurements • Electophysical Measurements • Psychological Evaluation

48. Psychoacoustic Measurements • Audiolgical measurements of pitch and loudness • Audiometric evaluations • Pitch Matching • Loudness Matching • Minimum Masking Level • Residual Inhibition

49. Audimetric Evaluation • Basic test battery • Pure tone AC threshold frequencies from 250 to 12,000 Hz including half octaves

50. Pitch Matching • Can be done on a standard audimeter • Tinnitus synthesizer more accurate • Audiologist instructs patient to judge whether pitch of 1st or 2nd tones is close to the tinnitus sound • Bracket until find closest pitch • Patient then identifies type of sound (pure tone, narrow band noise, speech noise, or white noise) • If unilateral, then choose opposite ear