Tinnitus

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  • http://www.youtube.com/watch?v=0n68WU5ptbw

    Nice set of slides!
    My elderly Mohter suffered with tinnitus for years and it was the bane of her life.
    She has now passed away now but I found this interesting ebook via You tube explaining how this condition can be cured.
    Thank you.
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Tinnitus

  1. 1. Tinnitus<br />Alexandra D. Costlow, B.S.<br />
  2. 2. According to Merriam-Webster<br />From Latin, tinnire, to ring<br />Of imitative origin<br />First Known<br /> Use: 1843<br />http://www.merriam-webster.com/dictionary/tinnitus<br />
  3. 3. The Many Sounds of Tinnitus<br />Ringing<br />Hissing<br />Roaring<br />Whistling<br />Swishing<br />Buzzing<br />Chirping, crickets<br />Clicking<br />“It goes along with my heartbeat.”*<br />
  4. 4. Hear, Neuromonics Will Show You<br />http://www.neuromonics.com/patient/treatment/index.aspx?id=50<br />
  5. 5. Common Audiological Causes<br />Hearing loss<br />Cerumen accumulation/occlusion<br />Eustachian tube blockage<br />Otitis media<br />Exposure to loud noise<br />Ototoxic chemicals*<br />Otosclerosis - frequently<br />Meniere’s Disease (episodic tinnitus along with hearing loss, dizziness, and aural fullness)<br />Acoustic neuroma – Even when the tumor is removed, 50% of pts continue to experience tinnitus (Benson et al., 2009)<br />http://www.emedicinehealth.com/tinnitus/page2_em.htm<br />
  6. 6. …So Who’s Hearing Things Now?<br />Subjective Tinnitus <br />Only the patient perceives head noise<br />This is the more common form<br />Objective tinnitus<br />Head noise is audible to the patient and to the professional<br />Relatively rare <br />Originates in the ear, head, or neck<br />Muscular or vascular etiology<br />Myoclonus is found in pts with degenerative diseases*<br />Benson, A.G., McGuire, J.F., Djalilian, H.R., Hanks, K.M., Robbins, W.K. (2009)<br />
  7. 7. Myoclonus<br />The neuromuscular control over ear muscles deteriorates in an individual with good very good sensory perception.<br />The stapedius and/ or tensor tympani muscles repeatedly contract and relax.<br />This results in audible click noises arising from the ear.<br />Can be unilateral or bilateral.<br />Treatment is lysis of the muscle/s through tympanotomy incision.<br />Benson, A.G., McGuire, J.F., Djalilian, H.R., Hanks, K.M., Robbins, W.K. (2009)<br />
  8. 8. Other Causes of “Click” Tinnitus<br />Jaw joint misalignment <br />i.e. the tempero-<br />mandibular<br /> joint (TMJ)<br />http://www.emedicinehealth.com/tinnitus/page2_em.htm<br />
  9. 9. Cardiological Etiology<br />Carotid artery<br />Injury due to aging or surgery<br />Ectasia: Dilation, expansion, distentsion, bulging<br />Blood flow through the artery is tumultuous<br />Follows the pt’s heartbeat <br />Can be ausculated by the examiner<br />Jugular Vein and bulb<br />More common than the 2 other objective etiologies<br />Produces a “Venous hum”<br />Pt describes a vibratory or low-pitched sound<br />Benson, A.G., McGuire, J.F., Djalilian, H.R., Hanks, K.M., Robbins, W.K. (2009)<br />
  10. 10. Anatomical Reference – Jugular Vein (External)<br />http://www.frca.co.uk/article.aspx?articleid=100030<br />
  11. 11. Anatomical Reference – Carotid Artery <br />http://www.nlm.nih.gov/medlineplus/ency/presentations/100124_1.htm<br />
  12. 12. Causes of Pulsatile Tinnitus <br />Suggests involvement of blood flow through vessels near the ear<br />May be normal or pathological<br />Space-occupying lesions<br />Anemia* (Contributing cause)<br />Overactive thyroid<br />Hypertension<br />Benign intracranial pressure<br />http://www.emedicinehealth.com/tinnitus/page2_em.htm<br />
  13. 13. Red Flags<br />Sudden onset tinnitus (with or without hearing loss)<br />Sudden onset hearing loss and tinnitus<br />Unilateral tinnitus<br />Pulsatile tinnitus<br />Report of tinnitus + symptoms of a stroke<br />Sudden difficulty communicating, movement disorders, personality changes<br />http://www.emedicinehealth.com/tinnitus/page4_em.htm<br />
  14. 14. Getting to the Crux<br />Tinnitus is a symptom, NOT a disease.<br />The pathology causing tinnitus may be outside of the scope of audiologists.<br />The actual “cause” of tinnitus depends on pathophysiology.<br />Understanding the pathophysiology will help us (AuDs, PhDs, MDs, DOs, neurologists, neurosurgeons, etc…) to better treat people who experience tinnitus.<br />
  15. 15. A Familiar Scenario <br />Patient: I’ve had this ringing in my ears for years. My doctor told me that there’s no cure for it. Is that true? <br />Audiologist: <br />
  16. 16. Pathophysiology<br />Nuerophysiologically, “ … Tinnitus is the consequence of the brain’s response to input deprivation from the auditory periphery” (Benson et al., 2009).<br />Leaver et al. (2011) suggest that tinnitus occurs due to abnormal function of the limbic system, which controls emotion.<br />Suggests link to depression, anxiety?<br />
  17. 17. Pathophysiology<br />In a healthy cochlea, there is a tonotopic organization (peripheral).<br />Signal travels from the cochlea to the midbrain to the auditory cortex.<br /><br />
  18. 18. Pathophysiology<br />In a damaged cochlea, cortical and subcortical pathways adapt to lack of stimulation (plasticity) and the tonotopic organization (not just of the cochlea, but rather of the projections from the cochlea mesencephalon cortex) is altered (Benson et al., 2009).<br />Neuroplasticity may take the form of:<br />Creation or elimination of synapses, including their axons and dendrites, causing changes in how effectively the electrical signal is transmitted (Moller). <br />
  19. 19. Anatomical Reference - Synapse<br />http://hshgp.genome.washington.edu/teacher_resources/modules-view.htm<br />
  20. 20. Pathophysiology<br />In the auditory cortex, the area that no longer receives stimulation due to cochlear injury is called the lesion projection zone (LPZ). <br />Following cochlear injury, neurons in the LPZ change in two ways:<br />Increase in spontaneous firing rate<br />Neurons that are adjacent to the LPZ represent a larger frequency range<br />(Benson et al., 2009)<br />
  21. 21. Pathophysiology<br />This mechanism is believed to be the neurophysiological correlate of tinnitus (Benson et al., 2009).<br />A key understanding in tinnitus research over the years was that although tinnitus presents in the ear, it is a neurological phenomenon.<br />As evidenced by the fact that if the auditory nerve was severed, tinnitus was yet able to persist (Moller). <br />
  22. 22. How is Tinnitus Quantified?<br />May use pitch and loudness mapping<br />90% of pts report tinnitus at an intensity level of <20 dB<br />84% of pts report tinnitus at an intensity level of <9 dB<br />These measures are useful for masking devices <br />Do these measures match subjective reports of tinnitus severity?<br />(Benson et al., 2009)<br />
  23. 23. How is Tinnitus Quantified?<br />The Tinnitus Handicap Inventory<br />Self-report measure<br />Validated in 1996<br />Measures how tinnitus affects daily life<br />Functional, Emotional, and Catastrophic subscales<br />(Newman, Jacobson, & Spitzer, 1996)<br />
  24. 24. Tinnitus’ Kissing Cousins<br />If the patient has tinnitus:<br />Sound may be distorted.<br />Patient may also have hyperacusis and/or phonphobia (Moller).<br />The patient may have anxiety, isolation, and/or depression. <br />
  25. 25. Treatment<br />May depend on etiology<br />Glomus tumor: Surgical removal<br />Meniere’s Disease: Endolymphatic shunt, labyrinthectomy, antibiotic injection<br />Courtesy of Hood Labs<br />www.earassociates.com<br />
  26. 26. Treatment<br />Let’s hear from Roger Miller, PhD, Director for Hearing and Balance at NIDCD<br />http://ocplmedia.od.nih.gov/nihradio/20110113NIDCDtinnitus.mp3?utm_source=twitterfeed&utm_medium=twitter<br />Behavioral: Tinnitus Feedback Retraining, Support Groups, Counseling (informational and affective)<br />Masking <br />Vagal Nerve Stimulation: Like pressing “Reset” button in the brain<br />
  27. 27. Treatment<br />Pharmacologic: Treat symptoms related to tinnitus, such as depression and anxiety.<br />Nortriptyline (50 mg): Most effective drug, although it causes dry mouth and takes 3-4 weeks to build up summative effect for benefit.<br />SSRIs<br />Paroxetine (10 mg) AKA Paxil<br />Sertraline (50 mg/d) AKA Zoloft: Reduced tinnitus severity, as well as symptoms of depression and anxiety<br />Benzodiazepines: Treats tinnitus as an anxiety disorder BUT should not use these if depression is present (and often it is).<br />(Benson et al., 2009)<br />
  28. 28. Non-Traditional Treatment<br />Electrical Stimulation<br />Overall, mixed success<br />Stimulation may only be effective during stimulus presentation<br />First attempted by Volta in the 1800s<br />Types:<br />Cutaneous, brain stimulation, promontory stimulation<br />New: Repetitive transcranial magnetic stimulation (rTMS)<br />(Benson et al., 2009)<br />
  29. 29. Repetitive Transcranial Magnetic Stimulation (rTMS)<br />The Society for Neuroscience<br />www.sfn.org<br />
  30. 30. Non-Traditional Treatment<br />Biofeedback<br />Commonly used for the management of pain<br />Pt monitors involuntary bodily processes such as heart rate, blood pressure, and muscle tension through electromyography (EMG) and electroencephalography (EEG) (UMMC, 2011).<br />Goal is to reduce anxiety and/or stress that may aggravate tinnitus<br />Conducted by a psychologist<br /><80% of pts report reduction in tinnitus symptoms (Benson et al., 2009).<br />
  31. 31. Non-Traditional Treatment<br />Homeopathic Therapy<br />GinkoBiloba: Antioxidant that inhibits platelet aggregation  promotes circulation to small blood vessels such as those that supply the cochlea.<br />Niacin: May provide smooth muscle relaxation and promote circulation to small blood vessels.<br />Pts may report that Niacin reduces severity of tinnitus (Benson et al., 2009).<br />
  32. 32. Pediatrics<br />Prevalence varies <br />Shetye and Kennedy (2010) noted it occurs in 12 - 36% of children with normal hearing and in <66% of children with hearing loss.<br />Shetye and Kennedy (2010) noted that 3 – 10% of children are significantly affected by it.<br />May be more difficult to identify in children<br />Might pediatric tinnitus become more prevalent due to environment?<br />(Shetye & Kennedy, 2010).<br />
  33. 33. Areas of Further Research – Moving from Anecdotal to Evidence-Based Practice<br />Caffeine: Anecdotal evidence tells us that caffeine consumption exacerbates tinnitus.<br />St. Claire et al. (2010) found that caffeine consumption had no effect on tinnitus severity but that caffeine withdrawal symptoms were observed.<br />Heritability: Anecdotally, tinnitus may “Run in families.”<br />Kvestad et al. (2010) found low heritability of tinnitus.<br />
  34. 34. Works Cited<br />American Tinnitus Association (ATA). What you should know about tinnitus. Retrieved from http://www.ata.org/sites/ata.org/files/pdf/ATA%20Facts% 20About%20Tinnitus.pdf<br />AnaesthesiaUK. (2010). Cannulation of the internal jugular vein. [Graphic].<br />Benson, A.G., McGuire, J.F., Djalilian, H.R., Hanks, K.M., Robbins, W.K. (2009). Inner Ear, tinnitus. MedScape online encyclopedia. Retrieved from http://emedicine. medscape.com/article/856916-overview<br />Gurr, P., Owen, G. Reid, A. & Canter, R. (1993). Tinnitus in pregnancy. Clinical Otolaryngology, 18(4), 294-297.<br />Kvestad, E., Czajkowski, N., Engdahl, B., Hoffman, H., & Tambs, K. (2010). Low heritability of tinnitus: Results from the second Nord-Trandelag study. Archives of Otolaryngology, Head and Neck Suergery, 136(2), 178-182. <br />Leaver, A.M., Renier, L., Chevillet, M.A., Morgan, S., Kim, H.J., Rauschecker, J.P.
(2011). 
 Dysregulation of limbic and auditory networks in tinnitus. Neuron, 69(1), 33-43.<br /> <br />Moller, A. R. Pathophysiology of tinnitus. [Powerpoint slides] presented at the University of Texas at Dallas, School of Behavioral and Brain Sciences. Retrieved from http://www.slideworld.org/slideshow.aspx/Pathophysiology-of-tinnitus-ppt-4329<br />
  35. 35. Works Cited<br />Neuromonics Inc. (2011). What tinnitus sounds like. Retrieved from http://www.neuromonics.com/patient/treatment/index.aspx?id=50<br />Newman, C.W., Jacobson, G.P., & Spitzer, J.B. (1996). Development of the tinnitus handicap inventory. Archives of Otolaryngology, Head and Neck Surgery, 122(2), 143-8.<br />Shetye, A., & Kennedy, V. (2010). Tinnitus in children: An uncommon symptom? Archives in disease in childhood, 95(8), 645-648.<br />St. Claire, L., Stothart, G., McKenna, L., & Rogers, P.J. (2010) Caffeine abstinence: An ineffective and potentially distressing tinnitus therapy. International Journal of Audiology, 49(1), 24–29.<br />The Society for Neuroscience. (2011). Obsessive-compulsive disorder. Retrieved from http://www.sfn.org/index.aspx?pagename=brainbriefings_obsessivecompulsivedisorder<br />University of Maryland Medical Center. (2011). Biofeedback. Retrieved from http://www.umm.edu/altmed/articles/biofeedback-000349.htm<br />U.S. Department of Health and Human Services National Institutes of Health. (2011). Carotid artery surgery – series. In MedLine Plus. Retrieved from http:// www.nlm.nih.gov/medlineplus/ency/presentations/100124_1.htm<br />

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