Tinnitus Lianne Beck, MD Assistant Professor Emory Family Medicine
Tinnitus <ul><li>Definition </li></ul><ul><li>Classification </li></ul><ul><li>Objective tinnitus  </li></ul><ul><li>Subje...
Introduction <ul><li>Tinnitus -“The perception of sound in the absence of external stimuli.” </li></ul><ul><li>Tinnire  – ...
Tinnitus <ul><li>May be perceived as unilateral or bilateral </li></ul><ul><li>Originating in the ears or around the head ...
Tinnitus <ul><li>40 million affected in the United States </li></ul><ul><li>10 million severely affected </li></ul><ul><li...
Classification <ul><li>Objective tinnitus  – sound produced by paraauditory structures which may be heard by an examiner, ...
Tinnitus <ul><li>Pulsatile tinnitus – matches pulse or a rushing sound  </li></ul><ul><ul><li>Possible vascular etiology <...
Objective tinnitus <ul><li>Vascular (pulsatile) </li></ul><ul><ul><li>A/V malformations </li></ul></ul><ul><ul><li>Vascula...
Arteriovenous Malformations <ul><li>Congenital lesions </li></ul><ul><li>Occipital artery and transverse sinus, internal c...
Arteriovenous Malformations <ul><li>Pulsatile tinnitus </li></ul><ul><li>Headache </li></ul><ul><li>Papilledema </li></ul>...
Vascular tumors <ul><li>Glomus tympanicum </li></ul><ul><ul><li>Paraganglioma of middle ear  </li></ul></ul><ul><ul><li>Lo...
Vascular tumors <ul><li>Glomus jugulare </li></ul><ul><ul><li>Paraganglioma of jugular fossa </li></ul></ul><ul><ul><li>Lo...
Venous hum <ul><li>Benign intracranial hypertension </li></ul><ul><li>Dehiscent jugular bulb </li></ul><ul><li>Transverse ...
Benign Intracranial Hypertension <ul><li>Also called pseudotumor cerebri </li></ul><ul><li>Young, obese, female patients <...
Benign Intracranial Hypertension <ul><li>Sismanis and Smoker 1994 </li></ul><ul><ul><li>100 patients with pulsatile tinnit...
Benign Intracranial Hypertension <ul><li>Treatment </li></ul><ul><ul><li>Weight loss </li></ul></ul><ul><ul><li>Diuretics ...
Neuromuscular Causes <ul><li>Palatal myoclonus </li></ul><ul><ul><li>Clicking sound </li></ul></ul><ul><ul><li>Rapid (60-2...
Myoclonus <ul><li>Palatal myoclonus associations: </li></ul><ul><ul><li>Multiple Sclerosis and other degenerative neurolog...
Stapedius Muscle Spasm <ul><li>Idiopathic stapedial muscle spasm </li></ul><ul><ul><li>Rough, rumbling, crackling sound </...
Patulous Eustachian Tube <ul><li>Eustachian tube remains open abnormally </li></ul><ul><li>Ocean roar sound </li></ul><ul>...
Subjective Tinnitus <ul><li>Otologic </li></ul><ul><ul><li>Hearing loss (presbycusis, noise exposure, otosclerosis, middle...
Conductive hearing loss <ul><li>Conductive hearing loss decreases level of background noise </li></ul><ul><li>Normal paraa...
Sensorineural hearing loss <ul><li>Indicates abnormality of the inner ear or cochlear portion of the 8 th  CN </li></ul><u...
Other subjective tinnitus <ul><li>Poorly understood mechanisms of tinnitus production </li></ul><ul><li>Abnormal condition...
CNS Mechanisms <ul><li>Reorganization of central pathways with hearing loss (similar to phantom limb pain) </li></ul><ul><...
Neurophysiologic Model <ul><li>Proposed by Jastreboff </li></ul><ul><li>Result of interaction of subsystems in the nervous...
Role of Depression <ul><li>Depression is more prevalent in patients with chronic tinnitus than in those without tinnitus <...
Ototoxic Drugs <ul><li>Analgesic </li></ul><ul><ul><li>ASA, NSAIDs </li></ul></ul><ul><li>Antibiotics  </li></ul><ul><ul><...
Evaluation - History <ul><li>Careful history </li></ul><ul><li>Quality </li></ul><ul><li>Pitch </li></ul><ul><li>Loudness ...
Evaluation - History <ul><li>Infection </li></ul><ul><li>Trauma </li></ul><ul><li>Noise exposure </li></ul><ul><li>Medicat...
Evaluation – Physical Exam <ul><li>Complete head & neck exam </li></ul><ul><li>General physical exam </li></ul><ul><li>Oto...
Evaluation – Physical Exam <ul><li>Light exercise to increase pulsatile tinnitus </li></ul><ul><li>Light pressure on the n...
Evaluation - Audiometry <ul><li>Pure tone air, bone and speech descrimination scores, tympanometry, acoustic reflexes </li...
Evaluation - Audiometry <ul><li>Vascular or palatomyoclonus induced tinnitus – graph of compliance vs. time </li></ul><ul>...
Laboratory studies <ul><li>As indicated by history and physical exam </li></ul><ul><li>Possibilities include: </li></ul><u...
Imaging <ul><li>Pulsatile tinnitus </li></ul><ul><li>Reviewed by Weissman and Hirsch (2000) </li></ul><ul><li>Contrast enh...
<ul><li>Glomus tympanicum – bone algorithm CT scan best shows extent of mass </li></ul><ul><li>May not be able to see enha...
Glomus Tympanicum From: Weissman JL, Hirsch BE.  Imaging of tinnitus: a review.  Radiology  2000;216:343.
Glomus Tympanicum From: Weissman JL, Hirsch BE.  Imaging of tinnitus: a review.  Radiology  2000;216:343.
Imaging <ul><li>Glomus jugulare </li></ul><ul><ul><li>Erosion of osseous jugular fossa </li></ul></ul><ul><ul><li>Enhance ...
Glomus jugulare From: Weissman JL, Hirsch BE.  Imaging of tinnitus: a review.  Radiology  2000;216:344 .
Glomus jugulare “ salt and pepper appearance” From: Weissman JL, Hirsch BE.  Imaging of tinnitus: a review.  Radiology  20...
Imaging <ul><li>Arteriovenous malformations – readily apparent on contrasted CT and MRI </li></ul><ul><li>Normal otoscopic...
Imaging <ul><li>Shin et al (2000) </li></ul><ul><ul><li>MRI/MRA initially if subjective pulsatile tinnitus </li></ul></ul>...
Imaging <ul><li>Acoustic Neuroma </li></ul><ul><ul><li>Unilateral tinnitus, asymmetric sensorineural hearing loss or speec...
Acoustic Neuroma From: Weissman JL, Hirsch BE.  Imaging of tinnitus: a review.  Radiology  2000;216:348.
Acoustic Neuroma From: Weissman JL, Hirsch BE.  Imaging of tinnitus: a review.  Radiology  2000;216:348.
Collins RD. Algorithmic diagnosis of symptoms and signs: a cost-effective approach. 2d ed. Philadelphia: Lippincott Willia...
Treatments <ul><li>Multiple treatments </li></ul><ul><li>Avoidance of dietary stimulants: coffee, tea, cola, etc. </li></u...
Treatments - Medicines <ul><li>Many medications have been researched for the treatment of tinnitus: </li></ul><ul><ul><li>...
Treatments - Medicines <ul><li>Alprazolam (Xanax) </li></ul><ul><ul><li>Johnson et al (1993) found 76% of 17 patients had ...
Treatments - Medicines <ul><li>Nortriptyline and amitriptyline </li></ul><ul><ul><li>May have some benefit </li></ul></ul>...
Treatments <ul><li>Hearing aids – amplification of background noise can decrease tinnitus </li></ul><ul><li>Maskers – prod...
Treatments <ul><li>Tinnitus Retraining Therapy </li></ul><ul><ul><li>Based on neurophysiologic model </li></ul></ul><ul><u...
Treatments <ul><li>Electrical stimulation of the cochlea </li></ul><ul><ul><li>Transcutaneous, round window, promontory st...
Treatments <ul><li>Cochlear implants </li></ul><ul><ul><li>Have shown some promise in relief of tinnitus </li></ul></ul><u...
Treatments <ul><li>Surgery </li></ul><ul><ul><li>Used for treatment of arteriovenous malformations, glomus tumors, otoscle...
Treatments <ul><li>Biofeedback </li></ul><ul><li>Hypnosis </li></ul><ul><li>Magnetic stimulation </li></ul><ul><li>Acupunc...
Conclusions <ul><li>Tinnitus is a common problem with an extensive differential </li></ul><ul><li>Need to identify medical...
References <ul><li>Crummer R, Ghinwa H.  Diagnostic Approach to Tinnitus . American Family Physician. 2004; 69: 120-126. <...
Upcoming SlideShare
Loading in...5
×

Tinnitus*

2,212

Published on

0 Comments
2 Likes
Statistics
Notes
  • Be the first to comment

No Downloads
Views
Total Views
2,212
On Slideshare
0
From Embeds
0
Number of Embeds
0
Actions
Shares
0
Downloads
92
Comments
0
Likes
2
Embeds 0
No embeds

No notes for slide
  • Much more common, nonpulsatile
  • Tinnitus*

    1. 1. Tinnitus Lianne Beck, MD Assistant Professor Emory Family Medicine
    2. 2. Tinnitus <ul><li>Definition </li></ul><ul><li>Classification </li></ul><ul><li>Objective tinnitus </li></ul><ul><li>Subjective tinnitus </li></ul><ul><li>Theories </li></ul><ul><li>Evaluation </li></ul><ul><li>Treatment </li></ul>
    3. 3. Introduction <ul><li>Tinnitus -“The perception of sound in the absence of external stimuli.” </li></ul><ul><li>Tinnire – means “ringing” in Latin </li></ul><ul><li>Includes buzzing, hissing, roaring, clicking, pulsatile sounds </li></ul><ul><li>For some, an unbearable sound that drives them to contemplate suicide. </li></ul>
    4. 4. Tinnitus <ul><li>May be perceived as unilateral or bilateral </li></ul><ul><li>Originating in the ears or around the head </li></ul><ul><li>First or only symptom of a disease process or auditory/psychological annoyance </li></ul>
    5. 5. Tinnitus <ul><li>40 million affected in the United States </li></ul><ul><li>10 million severely affected </li></ul><ul><li>Most common in 40-70 year-olds </li></ul><ul><li>Roughly equal prevalence in men and women </li></ul>
    6. 6. Classification <ul><li>Objective tinnitus – sound produced by paraauditory structures which may be heard by an examiner, often pulsatile </li></ul><ul><li>Subjective tinnitus – sound is only perceived by the patient (most common) </li></ul>
    7. 7. Tinnitus <ul><li>Pulsatile tinnitus – matches pulse or a rushing sound </li></ul><ul><ul><li>Possible vascular etiology </li></ul></ul><ul><ul><li>Objective or subjective </li></ul></ul><ul><ul><li>Increased or turbulent blood flow through paraauditory structures </li></ul></ul>
    8. 8. Objective tinnitus <ul><li>Vascular (pulsatile) </li></ul><ul><ul><li>A/V malformations </li></ul></ul><ul><ul><li>Vascular tumors </li></ul></ul><ul><ul><li>Venous hum (cardiac murmurs, anemia, BIH, thyrotoxicosis, pregnancy, dehiscent jugular bulb) </li></ul></ul><ul><ul><li>Atherosclerosis </li></ul></ul><ul><ul><li>Ectopic carotid artery </li></ul></ul><ul><ul><li>Persistent stapedial artery </li></ul></ul><ul><ul><li>Vascular loops </li></ul></ul><ul><li>Neuromuscular </li></ul><ul><ul><li>Palatomyclonus </li></ul></ul><ul><ul><li>Stapedial muscle spasm </li></ul></ul><ul><li>Patulous eustachian tube </li></ul>
    9. 9. Arteriovenous Malformations <ul><li>Congenital lesions </li></ul><ul><li>Occipital artery and transverse sinus, internal carotid and vertebral arteries, middle meningeal and greater superficial petrosal arteries </li></ul><ul><li>Mandible </li></ul><ul><li>Brain parenchyma </li></ul><ul><li>Dura </li></ul>
    10. 10. Arteriovenous Malformations <ul><li>Pulsatile tinnitus </li></ul><ul><li>Headache </li></ul><ul><li>Papilledema </li></ul><ul><li>Discoloration of skin or mucosa </li></ul>
    11. 11. Vascular tumors <ul><li>Glomus tympanicum </li></ul><ul><ul><li>Paraganglioma of middle ear </li></ul></ul><ul><ul><li>Loud pulsatile tinnitus which may decrease with ipsilateral carotid artery compression </li></ul></ul><ul><ul><li>Reddish mass behind tympanic membrane which blanches with positive pressure </li></ul></ul><ul><ul><li>Conductive hearing loss </li></ul></ul>
    12. 12. Vascular tumors <ul><li>Glomus jugulare </li></ul><ul><ul><li>Paraganglioma of jugular fossa </li></ul></ul><ul><ul><li>Loud pulsatile tinnitus </li></ul></ul><ul><ul><li>Conductive hearing loss if into middle ear </li></ul></ul><ul><ul><li>Cranial neuropathies </li></ul></ul>
    13. 13. Venous hum <ul><li>Benign intracranial hypertension </li></ul><ul><li>Dehiscent jugular bulb </li></ul><ul><li>Transverse sinus partial obstruction </li></ul><ul><li>Increased cardiac output from </li></ul><ul><ul><li>Pregnancy </li></ul></ul><ul><ul><li>Thyrotoxicosis </li></ul></ul><ul><ul><li>Anemia </li></ul></ul>
    14. 14. Benign Intracranial Hypertension <ul><li>Also called pseudotumor cerebri </li></ul><ul><li>Young, obese, female patients </li></ul><ul><li>Hearing loss </li></ul><ul><li>Aural fullness </li></ul><ul><li>Dizziness </li></ul><ul><li>Headaches </li></ul><ul><li>Visual disturbance </li></ul><ul><li>Papilledema, pressure >200mm H20 on LP </li></ul>
    15. 15. Benign Intracranial Hypertension <ul><li>Sismanis and Smoker 1994 </li></ul><ul><ul><li>100 patients with pulsatile tinnitus </li></ul></ul><ul><ul><li>42 found to have BIH syndrome </li></ul></ul><ul><ul><li>16 glomus tumors </li></ul></ul><ul><ul><li>15 atherosclerotic carotid artery disease </li></ul></ul>
    16. 16. Benign Intracranial Hypertension <ul><li>Treatment </li></ul><ul><ul><li>Weight loss </li></ul></ul><ul><ul><li>Diuretics </li></ul></ul><ul><ul><li>Subarachnoid-peritoneal shunt </li></ul></ul><ul><ul><li>Gastric bypass for weight reduction </li></ul></ul>
    17. 17. Neuromuscular Causes <ul><li>Palatal myoclonus </li></ul><ul><ul><li>Clicking sound </li></ul></ul><ul><ul><li>Rapid (60-200 beats/min), intermittent </li></ul></ul><ul><ul><li>Contracture of tensor palantini, levator palatini, levator veli palatini, tensor tympani, salpingopharyngeal, superior constrictors </li></ul></ul><ul><ul><li>Muscle spasm seen orally or transnasally </li></ul></ul><ul><ul><li>Rhythmic compliance change on tympanogram </li></ul></ul>
    18. 18. Myoclonus <ul><li>Palatal myoclonus associations: </li></ul><ul><ul><li>Multiple Sclerosis and other degenerative neurological disorders </li></ul></ul><ul><ul><li>Small vessel disease </li></ul></ul><ul><ul><li>Brain stem tumors </li></ul></ul><ul><ul><li>Treatments: muscle relaxants, botulinum toxin injection </li></ul></ul>
    19. 19. Stapedius Muscle Spasm <ul><li>Idiopathic stapedial muscle spasm </li></ul><ul><ul><li>Rough, rumbling, crackling sound </li></ul></ul><ul><ul><li>Exacerbated by outside sounds </li></ul></ul><ul><ul><li>Brief and intermittent </li></ul></ul><ul><ul><li>May be able to see tympanic membrane movement </li></ul></ul><ul><ul><li>Treatments: avoidance of stimulants, muscle relaxants, sometimes surgical division of tensor tympani and stapedius muscles </li></ul></ul>
    20. 20. Patulous Eustachian Tube <ul><li>Eustachian tube remains open abnormally </li></ul><ul><li>Ocean roar sound </li></ul><ul><li>Changes with respiration </li></ul><ul><li>Lying down or head in dependent position provides relief </li></ul><ul><li>Tympanogram will show changes in compliance with respiration </li></ul><ul><li>Associated with significant weight loss, radiation to the nasopharynx </li></ul>
    21. 21. Subjective Tinnitus <ul><li>Otologic </li></ul><ul><ul><li>Hearing loss (presbycusis, noise exposure, otosclerosis, middle ear effusion) </li></ul></ul><ul><ul><li>Meniere’s disease </li></ul></ul><ul><ul><li>Acoustic neuroma </li></ul></ul><ul><li>Ototoxic drugs or substances </li></ul><ul><li>Neurologic </li></ul><ul><ul><li>MS </li></ul></ul><ul><ul><li>Head trauma </li></ul></ul><ul><li>Metabolic </li></ul><ul><ul><li>Thyroid disorders </li></ul></ul><ul><ul><li>Hyperlipidemia </li></ul></ul><ul><ul><li>B12 def </li></ul></ul><ul><li>Psych </li></ul><ul><ul><li>Depression/anxiety </li></ul></ul><ul><li>Infectious </li></ul><ul><ul><li>Syphilis </li></ul></ul><ul><ul><li>Meningitis </li></ul></ul>
    22. 22. Conductive hearing loss <ul><li>Conductive hearing loss decreases level of background noise </li></ul><ul><li>Normal paraauditory sounds seem amplified </li></ul><ul><li>Cerumen impaction, otosclerosis, middle ear effusion, otosclerosis, perforated TM, EAC swelling are examples </li></ul><ul><li>Treating the cause of conductive hearing loss may alleviate the tinnitus </li></ul>
    23. 23. Sensorineural hearing loss <ul><li>Indicates abnormality of the inner ear or cochlear portion of the 8 th CN </li></ul><ul><li>NIHL and presbycusis most common </li></ul>
    24. 24. Other subjective tinnitus <ul><li>Poorly understood mechanisms of tinnitus production </li></ul><ul><li>Abnormal conditions in the cochlea, cochlear nerve, ascending auditory pathways, auditory cortex </li></ul><ul><li>Hyperactive hair cells </li></ul><ul><li>Chemical imbalance </li></ul>
    25. 25. CNS Mechanisms <ul><li>Reorganization of central pathways with hearing loss (similar to phantom limb pain) </li></ul><ul><li>Disinhibition of dorsal cochlear nucleus with increase in spontaneous activity of central auditory system </li></ul>
    26. 26. Neurophysiologic Model <ul><li>Proposed by Jastreboff </li></ul><ul><li>Result of interaction of subsystems in the nervous system </li></ul><ul><li>Auditory pathways playing a role in development and appearance of tinnitus </li></ul><ul><li>Limbic system responsible for tinnitus annoyance </li></ul><ul><li>Negative reinforcement enhances perception of tinnitus and increases time it is perceived </li></ul>
    27. 27. Role of Depression <ul><li>Depression is more prevalent in patients with chronic tinnitus than in those without tinnitus </li></ul><ul><li>Folmer et al (1999) reported patients with depression rated the severity of their tinnitus higher although loudness scores were the same </li></ul><ul><li>Which comes first, depression or tinnitus? </li></ul>
    28. 28. Ototoxic Drugs <ul><li>Analgesic </li></ul><ul><ul><li>ASA, NSAIDs </li></ul></ul><ul><li>Antibiotics </li></ul><ul><ul><li>Aminoglycosides </li></ul></ul><ul><ul><li>Erthyromycin </li></ul></ul><ul><ul><li>Vancomycin </li></ul></ul><ul><ul><li>Chloramphenicol </li></ul></ul><ul><ul><li>Tetracycline </li></ul></ul><ul><li>Loop diuretics </li></ul><ul><li>Chemotherapeutic agents </li></ul><ul><ul><li>Cisplatin </li></ul></ul><ul><ul><li>Vincristine </li></ul></ul><ul><ul><li>Methotrexate </li></ul></ul><ul><ul><li>Bleomycin </li></ul></ul><ul><li>Others </li></ul><ul><ul><li>Chloroquine </li></ul></ul><ul><ul><li>Heavy metals </li></ul></ul><ul><ul><li>Quinine </li></ul></ul><ul><ul><li>Heterocyclic antidepressants </li></ul></ul>
    29. 29. Evaluation - History <ul><li>Careful history </li></ul><ul><li>Quality </li></ul><ul><li>Pitch </li></ul><ul><li>Loudness </li></ul><ul><li>Unilateral vs Bilateral </li></ul><ul><li>Constant/intermittent </li></ul><ul><li>Onset </li></ul><ul><li>Alleviating/aggravating factors </li></ul>
    30. 30. Evaluation - History <ul><li>Infection </li></ul><ul><li>Trauma </li></ul><ul><li>Noise exposure </li></ul><ul><li>Medication usage </li></ul><ul><li>Medical history </li></ul><ul><li>Hearing loss </li></ul><ul><li>Vertigo </li></ul><ul><li>Pain </li></ul><ul><li>Family history </li></ul><ul><li>Impact on patient </li></ul>
    31. 31. Evaluation – Physical Exam <ul><li>Complete head & neck exam </li></ul><ul><li>General physical exam </li></ul><ul><li>Otoscopy (glomus tympanicum, dehiscent jugular bulb) </li></ul><ul><li>Search for audible bruit in pulsatile tinnitus </li></ul><ul><ul><li>Auscultate over orbit, mastoid process, skull, neck, heart using bell and diaphragm of stethoscope </li></ul></ul><ul><ul><li>Toynbee tube to auscultate EAC </li></ul></ul>
    32. 32. Evaluation – Physical Exam <ul><li>Light exercise to increase pulsatile tinnitus </li></ul><ul><li>Light pressure on the neck (decreases venous hum) </li></ul><ul><li>Valsalva maneuver (decrease venous hum) </li></ul><ul><li>Turning the head (decrease venous hum) </li></ul>
    33. 33. Evaluation - Audiometry <ul><li>Pure tone air, bone and speech descrimination scores, tympanometry, acoustic reflexes </li></ul><ul><li>Weber and Rinne tests </li></ul><ul><li>Pitch matching </li></ul><ul><li>Loudness matching </li></ul><ul><li>Masking level </li></ul>
    34. 34. Evaluation - Audiometry <ul><li>Vascular or palatomyoclonus induced tinnitus – graph of compliance vs. time </li></ul><ul><li>Patulous Eustachian tube – changes in compliance with respiration </li></ul><ul><li>Asymmetric sensorineural hearing loss or speech discrimination, unilateral tinnitus suggests possible acoustic neuroma - MRI </li></ul>
    35. 35. Laboratory studies <ul><li>As indicated by history and physical exam </li></ul><ul><li>Possibilities include: </li></ul><ul><ul><li>Hematocrit </li></ul></ul><ul><ul><li>FTA-ABS </li></ul></ul><ul><ul><li>Blood chemistries </li></ul></ul><ul><ul><li>Thyroid studies </li></ul></ul><ul><ul><li>Lipid panel </li></ul></ul><ul><ul><li>B12, zinc ? </li></ul></ul>
    36. 36. Imaging <ul><li>Pulsatile tinnitus </li></ul><ul><li>Reviewed by Weissman and Hirsch (2000) </li></ul><ul><li>Contrast enhanced CT of temporal bones, skull base, brain, calvaria as first-line study </li></ul><ul><li>Sismanis and Smoker (1994) recommended CT for retrotympanic mass, MRI/MRA if normal otoscopy </li></ul>
    37. 37. <ul><li>Glomus tympanicum – bone algorithm CT scan best shows extent of mass </li></ul><ul><li>May not be able to see enhancement of small tumor </li></ul><ul><li>Tumor enhances on T1-weighted images with gadolinium or on T2-weighted images </li></ul>
    38. 38. Glomus Tympanicum From: Weissman JL, Hirsch BE. Imaging of tinnitus: a review. Radiology 2000;216:343.
    39. 39. Glomus Tympanicum From: Weissman JL, Hirsch BE. Imaging of tinnitus: a review. Radiology 2000;216:343.
    40. 40. Imaging <ul><li>Glomus jugulare </li></ul><ul><ul><li>Erosion of osseous jugular fossa </li></ul></ul><ul><ul><li>Enhance with contrast, may not be able to differentiate jugular vein and tumor </li></ul></ul><ul><ul><li>Enhance with T1-weighted MRI with gadolinium and on T2-weighted images </li></ul></ul><ul><ul><li>Characteristic “salt and pepper” appearance on MRI </li></ul></ul>
    41. 41. Glomus jugulare From: Weissman JL, Hirsch BE. Imaging of tinnitus: a review. Radiology 2000;216:344 .
    42. 42. Glomus jugulare “ salt and pepper appearance” From: Weissman JL, Hirsch BE. Imaging of tinnitus: a review. Radiology 2000;216:344.
    43. 43. Imaging <ul><li>Arteriovenous malformations – readily apparent on contrasted CT and MRI </li></ul><ul><li>Normal otoscopic exam and pulsatile tinnitus may be dural arteriovenous fistula </li></ul><ul><ul><li>Often invisible on contrasted CT and MRI/MRA </li></ul></ul><ul><ul><li>Angiography may be only diagnostic test </li></ul></ul>
    44. 44. Imaging <ul><li>Shin et al (2000) </li></ul><ul><ul><li>MRI/MRA initially if subjective pulsatile tinnitus </li></ul></ul><ul><ul><li>Angiography if objective with audible bruit in order to identify dural arteriovenous fistula </li></ul></ul>
    45. 45. Imaging <ul><li>Acoustic Neuroma </li></ul><ul><ul><li>Unilateral tinnitus, asymmetric sensorineural hearing loss or speech descrimination scores </li></ul></ul><ul><ul><li>T1-weighted MRI with gadolinium enhancement of CP angle is study of choice </li></ul></ul><ul><ul><li>Thin section T2-weighted MRI of temporal bones and IACs may be acceptable screening test </li></ul></ul>
    46. 46. Acoustic Neuroma From: Weissman JL, Hirsch BE. Imaging of tinnitus: a review. Radiology 2000;216:348.
    47. 47. Acoustic Neuroma From: Weissman JL, Hirsch BE. Imaging of tinnitus: a review. Radiology 2000;216:348.
    48. 48. Collins RD. Algorithmic diagnosis of symptoms and signs: a cost-effective approach. 2d ed. Philadelphia: Lippincott Williams & Wilkins, 2003:568-9. ENT Referral ENT Referral
    49. 49. Treatments <ul><li>Multiple treatments </li></ul><ul><li>Avoidance of dietary stimulants: coffee, tea, cola, etc. </li></ul><ul><li>Smoking cessation </li></ul><ul><li>Avoid medications known to cause tinnitus </li></ul><ul><li>Reassurance </li></ul><ul><li>White noise from radio or home masking machine </li></ul>
    50. 50. Treatments - Medicines <ul><li>Many medications have been researched for the treatment of tinnitus: </li></ul><ul><ul><li>Intravenous lidocaine suppresses tinnitus but is impractical to use clinically </li></ul></ul><ul><ul><li>Tocainide is oral analog which is ineffective </li></ul></ul><ul><ul><li>Carbamazepine ineffective and may cause bone marrow suppression </li></ul></ul>
    51. 51. Treatments - Medicines <ul><li>Alprazolam (Xanax) </li></ul><ul><ul><li>Johnson et al (1993) found 76% of 17 patients had reduction in the loudness of their tinnitus using both a tinnitus synthesizer and VAS (dose 0.5mg-1.5 mg/day) </li></ul></ul><ul><ul><li>Dependence problem, long-term use is not recommended </li></ul></ul>
    52. 52. Treatments - Medicines <ul><li>Nortriptyline and amitriptyline </li></ul><ul><ul><li>May have some benefit </li></ul></ul><ul><ul><li>Dobie et al reported on 92 patients </li></ul></ul><ul><ul><li>67% nortriptlyine benefit, 40%placebo </li></ul></ul><ul><li>SSRI’s </li></ul><ul><li>Ginko biloba </li></ul><ul><ul><li>Extract at doses of 120-160mg per day </li></ul></ul><ul><ul><li>Shown to be effective in some trials and not in others </li></ul></ul><ul><ul><li>Needs further study </li></ul></ul><ul><li>Niacin </li></ul>
    53. 53. Treatments <ul><li>Hearing aids – amplification of background noise can decrease tinnitus </li></ul><ul><li>Maskers – produce sound to mask tinnitus </li></ul><ul><li>Tinnitus instrument – combination of hearing aid and masker </li></ul>
    54. 54. Treatments <ul><li>Tinnitus Retraining Therapy </li></ul><ul><ul><li>Based on neurophysiologic model </li></ul></ul><ul><ul><li>Combination of masking with low level broadband noise for several hours per day and counseling to achieve habituation of the reaction to tinnitus and perception of the tinnitus itself </li></ul></ul>
    55. 55. Treatments <ul><li>Electrical stimulation of the cochlea </li></ul><ul><ul><li>Transcutaneous, round window, promontory stimulation have all been tried </li></ul></ul><ul><ul><li>Direct current can cause permanent damage </li></ul></ul><ul><ul><li>Steenersen and Cronin have used transcutaneous stimulation of the auricle and tragus decreasing tinnitus in 53% of 500 patients </li></ul></ul>
    56. 56. Treatments <ul><li>Cochlear implants </li></ul><ul><ul><li>Have shown some promise in relief of tinnitus </li></ul></ul><ul><ul><li>Ito and Sakakihara (1994) reported that in 26 patients implanted who had tinnitus 77% reported either tinnitus was abolished or suppressed, 8% reported worsening </li></ul></ul>
    57. 57. Treatments <ul><li>Surgery </li></ul><ul><ul><li>Used for treatment of arteriovenous malformations, glomus tumors, otosclerosis, acoustic neuroma </li></ul></ul><ul><ul><li>Some authors have reported success with cochlear nerve section in patients who have intractable tinnitus and have failed all other treatments, this is not widely accepted </li></ul></ul>
    58. 58. Treatments <ul><li>Biofeedback </li></ul><ul><li>Hypnosis </li></ul><ul><li>Magnetic stimulation </li></ul><ul><li>Acupuncture </li></ul><ul><li>Conflicting reports of benefit </li></ul>
    59. 59. Conclusions <ul><li>Tinnitus is a common problem with an extensive differential </li></ul><ul><li>Need to identify medical process if involved </li></ul><ul><li>Pulsatile/Nonpulsatile is important distinction </li></ul><ul><li>Unilateral vs Bilateral </li></ul><ul><li>Associated hearing loss, vertigo </li></ul><ul><li>Thorough head and neck physical exam and audiometry testing is necessary for all patients </li></ul><ul><li>In general, tinnitus that is pulsatile, unilateral, and assoc w/ other unilateral otologic symptoms is more worrisome and should warrant ENT referral. </li></ul>
    60. 60. References <ul><li>Crummer R, Ghinwa H. Diagnostic Approach to Tinnitus . American Family Physician. 2004; 69: 120-126. </li></ul>
    1. A particular slide catching your eye?

      Clipping is a handy way to collect important slides you want to go back to later.

    ×