This document provides an overview of tinnitus, including its definition, prevalence, classification, and potential etiologies. It then discusses various treatment options for tinnitus that have been studied, including counseling, sound therapy, transcranial direct current stimulation, hearing aids, music therapy, pharmacotherapy, transcutaneous electrical nerve stimulation, dental/orthodontic treatments, and osteopathic manipulative treatment. Many of the treatments discussed have limited or inconclusive evidence regarding their effectiveness for tinnitus, and more research is still needed to determine the best approaches.
HOW TO BROACH A MUSCLE TENSION DYSPHONIA CASE
Sachender Pal Singh (PGT), Aakanksha Rathor (PGT), Smrity Rupa Borah Dutta
ABSTRACT
Muscle Tension Dysphonia (MTD) is a condition where excessive muscular tension or
muscle misuse is associated with phonation. It has multifactorial etiologies. It can be a
primary or secondary Muscle Tension Dysphonia. While it can affect anyone, sufferers
usually belong to a particular group. It has very serious impact on sufferer's personal, social
& professional life. We are presenting here, our 1 year prospective study done in the
department of Otorhinolaryngology, Silchar Medical College & Hospital from June 2012 to
July 2013. Voice therapy was given to every patient whether primary or secondary muscle
tension dysphonia & Pre therapy-versus-post therapy comparisons were made of selfratings
of Voice Handicap Index, Auditory-Perceptual Ratings, as well as, Visual -
Perceptual Evaluations of laryngeal images. Outcome of voice therapy results in such
patients were found to be very good. As the disease is multifactorial so treatment approach
should be broad based involving multidisciplinary team
Mindfulness aplicada a la EPOC - Dr. Jordi Roig CutillasJordi Roig
Qué es el Mindfulness y cómo puede ayudar a los pacientes con enfermedades respiratorias como la EPOC.
Presentación del Dr. Jordi Roig Cutillas, doctor en medicina y especialista en neumología, durante el XVI Simposio sobre EPOC, dónde introduce el Mindfulness, la evidencia científica y su uso como complemento en la terapia de pacientes con enfermedades respiratorias crónicas.
Vídeo de la presentación: https://youtu.be/ivkwhxV2vVs?t=1362
Dr. Claudia Mghazli examines how osteopathic manual therapy can aid with tinnitus, a condition that affects an estimated 10-15% of the global population.
HOW TO BROACH A MUSCLE TENSION DYSPHONIA CASE
Sachender Pal Singh (PGT), Aakanksha Rathor (PGT), Smrity Rupa Borah Dutta
ABSTRACT
Muscle Tension Dysphonia (MTD) is a condition where excessive muscular tension or
muscle misuse is associated with phonation. It has multifactorial etiologies. It can be a
primary or secondary Muscle Tension Dysphonia. While it can affect anyone, sufferers
usually belong to a particular group. It has very serious impact on sufferer's personal, social
& professional life. We are presenting here, our 1 year prospective study done in the
department of Otorhinolaryngology, Silchar Medical College & Hospital from June 2012 to
July 2013. Voice therapy was given to every patient whether primary or secondary muscle
tension dysphonia & Pre therapy-versus-post therapy comparisons were made of selfratings
of Voice Handicap Index, Auditory-Perceptual Ratings, as well as, Visual -
Perceptual Evaluations of laryngeal images. Outcome of voice therapy results in such
patients were found to be very good. As the disease is multifactorial so treatment approach
should be broad based involving multidisciplinary team
Mindfulness aplicada a la EPOC - Dr. Jordi Roig CutillasJordi Roig
Qué es el Mindfulness y cómo puede ayudar a los pacientes con enfermedades respiratorias como la EPOC.
Presentación del Dr. Jordi Roig Cutillas, doctor en medicina y especialista en neumología, durante el XVI Simposio sobre EPOC, dónde introduce el Mindfulness, la evidencia científica y su uso como complemento en la terapia de pacientes con enfermedades respiratorias crónicas.
Vídeo de la presentación: https://youtu.be/ivkwhxV2vVs?t=1362
Dr. Claudia Mghazli examines how osteopathic manual therapy can aid with tinnitus, a condition that affects an estimated 10-15% of the global population.
Introduction
Epidemiology
Pathophysiology
Sign and symptoms
Complication and investigations
Evaluation
Diagnosis
Prevention and management
Treatment
PrognosisSudden
sensorineural hearing loss
It is one of three type of hearing loss
Hearing loss due to defect in the sensory apparatus cochlea (sensory)
Or in the pathway of conduction of nerve impulses to the brain (neural)
Neural causes can be
peripheral:8 nerve
Central:auditory pathway or cortex
Background: Perforated tympanic membrane and middle ear infection are among common complications treated by tympanoplasty. This study was aimed to compare the effects of underlay and overlay tympanoplasty on the improvement of hearing and tympanic membrane landmarks and post-operative complications as well.
This study was performed Department of Otor hinolaryngology, Jubilee Mission Medical College, thrissur, Kerala for a period of 2 years commencing from December 2012 to November 2014. To review our experience with deep neck space infections and to study changing trends. The objectives were to study clinical presentation, etiology, associated systemic diseases, bacteriology, radiology, management and outcome of deep neck space infections.40 Patients coming from both urban and rural areas irrespective of age and sex admitted in department of ENT with deep neck space infections which was confirmed either clinically or radiologically. Superficial skin abscesses and abscesses due to infections of external neck injuries were excluded from the study \r\n.
More Related Content
Similar to Crimson Publishers-Tinnitus: Diagnosis and Treatment Options
Introduction
Epidemiology
Pathophysiology
Sign and symptoms
Complication and investigations
Evaluation
Diagnosis
Prevention and management
Treatment
PrognosisSudden
sensorineural hearing loss
It is one of three type of hearing loss
Hearing loss due to defect in the sensory apparatus cochlea (sensory)
Or in the pathway of conduction of nerve impulses to the brain (neural)
Neural causes can be
peripheral:8 nerve
Central:auditory pathway or cortex
Background: Perforated tympanic membrane and middle ear infection are among common complications treated by tympanoplasty. This study was aimed to compare the effects of underlay and overlay tympanoplasty on the improvement of hearing and tympanic membrane landmarks and post-operative complications as well.
This study was performed Department of Otor hinolaryngology, Jubilee Mission Medical College, thrissur, Kerala for a period of 2 years commencing from December 2012 to November 2014. To review our experience with deep neck space infections and to study changing trends. The objectives were to study clinical presentation, etiology, associated systemic diseases, bacteriology, radiology, management and outcome of deep neck space infections.40 Patients coming from both urban and rural areas irrespective of age and sex admitted in department of ENT with deep neck space infections which was confirmed either clinically or radiologically. Superficial skin abscesses and abscesses due to infections of external neck injuries were excluded from the study \r\n.
Objectives: To determine the potential of“Black Bone” MRI as an alternative to CT in the maturation parameters of the palatine suture and identify the optimal time to perform orthodontic palatal expansion. Methods: two patients from 10.3 and 25.9 years underwent “Black Bone” MRI “, T1 and T2 weighted spin echo imaging were obtained in the axial plane in addition to routine cranial RMI. “Black Bone” datasets weresubsequently compared to T2 wheighted RMI for the visualisation medial palatine sutures by using a similarbased method to evaluate suture fusion stages. Results: Patient palatine sutures were consistently identified on “Black Bone” MRI as áreas with different signal intensity according to the maturation stage, from complete separation of the halves to total fusion, as also found in the T2 weighted protocol.“Black Bone” MRI can be considered as an alternative o CTBC to assess the maturation of medial palatine suture for orthodontic purposes. Conclusions “Black Bone” MRI has considerable clinical potential as a nonionising alternative to CT in the assessement of the medial palatine suture.
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The Utility of the Bird’s Eye View in Rhinoplasty by Anil R Shah in Experiments in Rhinology & Otolaryngology
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Metastatic Atypical Fibroxanthoma: Case Report of an Uncommon Pathology in the Head and Neck by Luis Boccalatte in Experiments in Rhinology & Otolaryngology
Atypical fibroxanthoma (AFX) is an uncommon skin neoplasm developed mainly in the head and neck region in older senior patients. Prolonged sun exposure, actinic damaged, history of previous neoplasms and immunosuppressant are considered the most important risks factors. Subcutaneous extension of these tumors is related to a more aggressive biology.
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The Role of the Nasal Inspiratory Flow Peak, the Clinical and of the Visual Analogue Scale in the Evaluation of Allergic Rhinitis by Ana Carolina Gonçalves Ribeiro de Carvalho in Experiments in Rhinology & Otolaryngology
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Premalignant Lesions of Oral Cavity - A Clinicopathological Study by Mohit Srivastava in Experiments in Rhinology & Otolaryngology
We conducted a study on a total of 360 patients to find out the incidence of premalignant disorders in the oral cavity who attended the ENT opd of Saraswathi Institute of Medical Sciences, Hapur. The study design was cross sectional in nature. Out of all the 360 patients who were suspected to have premalignant disorders of oral cavity were subjected to biopsy and 87 of them were found to be premalignant. Incidence was found to be 24.53% in males and 23.6% in females. Buccal mucosa was most common site of involvement.
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A Rare Case of Nasal Inferior Meatus Polyps by George MV in Experiments in Rhinology & Otolaryngology
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Management Outcomes of Post-Thyroidectomy Bilateral Recurrent Laryngeal Nerve Paralysis at National Hospital Abuja by Olusesi Abiodun Daud in Experiments in Rhinology & Otolaryngology
Bilateral recurrent laryngeal paralysis is an uncommon complication of total or subtotal thyroidectomy, observed in approximately 0.4 per cent of cases. This paralysis could be temporary or permanent. An audit of 5 cases referred to the ENT Department of National Hospital Abuja, between January 2010 and July 2017 is presented. All cases were referred already on tracheostomy tubes and were females aged 11 to 59 years. 4 of the cases had external arytenoidectomy, bilateral in 2 cases, and unilateral in 2 cases. 4 out of the 5 cases were successfully decannulated. The preferred approach to cases of post-thyroidectomy bilateral recurrent laryngeal nerve paralysis referred to ENT Specialists in resource-poor economy like ours is not very clear from existing literature and we discuss our adopted protocol for management of such cases in this case series.
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An Unusual Presentation of Squamous Cell Carcinoma of Bilateral Temporal Bones by Titas Kar in Experiments in Rhinology & Otolaryngology
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Post-Thyroidectomy Laryngeal Diplegia in Mali: What Therapeutic Challenge? by Kone Fatogoma Issa in Experiments in Rhinology & Otolaryngology
Post-thyroidectomy laryngeal diplegia is the most common and most feared complication [1]. It occurs following a recurrent nerve lesion in 26 to 59% of cases [1,2]. Tracheotomy was considered until 1922 as the only reference treatment [3,4]. Therapeutic approaches have evolved over time, ranging from convention altranslaryngeal or extralaryngeal therapy to endoscopic laser approaches [5]. These endoscopic methods emphasized endoscopicary tenoidectomy and posterior transverse cordotomy [4,6]. Laser transverse posterior cordotomy has proved its efficacy, illustrated by the work of Denis and Kashima and Laccoureye & Merite Drancy [4,7].
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2. How to cite this article: Roya Vahdatinia, James Keane, Victoria Troncoso, Leonard B G. Tinnitus: Diagnosis and Treatment Options. Exp Rhinol Otolaryngol.
1(1). ERO.000502. 2017. DOI: 10.31031/ERO.2017.01.000502
Experiments in Rhinology & Otolaryngology
2/5
Exp Rhinol Otolaryngol
Tinnitus counseling: The goal of counseling is to educate the
patient on the anatomy and physiology of the ear and tinnitus,
and how to cope with tinnitus [21]. The effectiveness of tinnitus
counseling has only been addressed in conjunction with other
procedures such as cognitive behavioral therapy. There have been
no studies of the effectiveness of counseling alone [22].
Acoustic therapy: Acoustic, or sound therapy is using
external sounds to provide relief from tinnitus. The rationale is
that the increase in the level of external sounds in the patient’s
environment will decrease the patient’s perception of tinnitus.
By increasing the level of background sound, we will decrease the
tinnitus signal-to-noise ratio. Acoustic therapy is non-invasive, and
has no side effects. Patients will often obtain immediate relief from
the tinnitus. The patient can exert some control over the tinnitus,
utilizing external sounds which can result in reduced anxiety
and frustration. Also, increased exposure to external sounds can
contribute to reorganization of neural pathways responsible for
tinnitus perception. Acoustic therapy can be a vital component of an
effective tinnitus management program when used in conjunction
with other strategies [23].
Transcranial direct current stimulation (tDCS) with
tinnitus retraining therapy (TRT): TRT has a counseling and
sound enrichment component (discussed above). TDCS involves
two electrodes sending a low current through the brain. Some
studies have shown tinnitus relief after tDCS for 82% [24] of the
cohort studied while others have only shown improvement for
39.5% [25]. A study by Rabau et al examined the effect of tDCS
in combination with TRT. In this study, the tDCS treatment group
received a constant current of 2mA for 20 minutes with a fade-
in and fade-out of 10 seconds. The sham tDCS group received 10
seconds of 1mA current. The results of this study are yet to be
published [26].
Hearing aids: Hearing aids are another form of acoustic
therapy that can be beneficial to the tinnitus patient who may also
have significant hearing loss. However, tinnitus does not cause
hearing loss, but hearing loss makes it more likely for a person to
hear tinnitus. Hearing aids do NOT amplify tinnitus. Hearing aids
usually reduce the loudness of tinnitus by amplifying external
sounds. Using hearing aids to stimulate the auditory system can
contribute to permanent reduction in neural activity responsible
for tinnitus generation and perception [27].
Music therapy: Active Music Therapy is conducted under
the guidance of a music therapist. This is a standardized therapy
consisting of nine (9) fifty (50) minute sessions attended on five (5)
consecutive days [28,29].
Pharmacotherapy: Pharmacotherapy to treat tinnitus includes
antidepressants such as nortriptyline and amitriptyline and
benzodiazepinessuchasclonazepamandoxazepam;however,these
medications have limited benefits and chronic benzodiazepines
should be used cautiously especially for patients being treated
with opioids. Gabapentin is another medication which has had
inconclusive results; while it helps some patients, in those with
tinnitus secondary to trauma this effect is variable [30]. Melatonin
and niacin have not been found to be effective. Zinc deficiency may
increase the risk of cochlear hair cell death (in animal models) but
zinc supplementation has yet to be found helpful [31].
Transcutaneous electrical nervous stimulation (TENS): Due
to the similarities between tinnitus and central neuropathic pain,
TENS may be a useful treatment by interfering with the somatic
components of tinnitus. In one study, 20 healthy individuals aged
18-65 were treated with InteriX (a TENS unit modified to sense
difference in skin potential and adapt accordingly to prevent
overstimulation) for 60 minutes once a week for 2 months at 70Hz.
The tinnitus handicap inventory (THI) index decreased by 15.1
points (-27%, p<0.0007); the visual analog score (VAS) decreased
1.45 points (p<0.006). The quality of life improved (2.4 point
reduction; p<0.0006). In other studies, however, there has been
both improvement and worsening of symptoms. This may be due to
the parameters used for stimulation and/or placement. InteriX may
be a better instrument versus traditional TENS due to its ability to
adjust the amount of stimulation based on cutaneous feedback [32].
Dental/Orthodontic treatment: TMJ treatments including
splints, occlusal adjustments, and jaw exercises have been shown
to be more effective than no treatment but just as effective as
biofeedback therapy, progressive relaxation, and counseling [33].
One study examined the relationship between tinnitus and
TMD therapy in 40 participants with moderate or severe tinnitus.
The TMD therapy included a dental splint, a six hour class on
coping skills and how to reduce oral habits such as clenching,
physical therapy which included stretching exercises and posture
training, and/or medications (for three of the subjects). 21 subjects
had resolved tinnitus, 12 had significant improvement, 7 had
unchanged symptoms, and no subjects developed worse symptoms.
Participants who were younger (20-40 years old) were more likely
to improve, as were patients who experienced moderate rather
than severe tinnitus [34].
Osteopathic Manipulative Treatment (OMT): OMT is an
established treatment option to address the underlying structural
and functional imbalances which may contribute to peripheral
tinnitus. Somatic dysfunction of the head, neck, and shoulders,
similar to the cervicogenic somatosesory tinnitus mentioned
above, has long been clinically observed as an etiology of tinnitus.
A complete and discerning osteopathic physical exam including
placatory findings of restricted motion can identify structural
etiologies of tinnitus. Gentle osteopathic modalities addressing
somatic dysfunction in the cranial and cervical regions may improve
or restore the normal functions of delicate neurovascular structures
resulting in clinical improvement. In general, an osteopathic
approach to tinnitus will include a thorough history and evaluation
with the added skill of discerning palpation.
This added dimension of placatory findings of disturbances
in the soma that affect function may be of particular benefit not
only in amelioration of symptoms (treatment) but in elucidating
cause (diagnosis). The goal of an osteopathic approach is always
3. How to cite this article: Roya Vahdatinia, James Keane, Victoria Troncoso, Leonard B G. Tinnitus: Diagnosis and Treatment Options. Exp Rhinol Otolaryngol.
1(1). ERO.000502. 2017. DOI: 10.31031/ERO.2017.01.000502
3/5
Exp Rhinol OtolaryngolExperiments in Rhinology & Otolaryngology
to restore structure and function as much as possible back to the
homeostatic baseline. This approach does not preclude other
modalities but rather encompasses them as part of a whole person
approach. In addition to tinnitus, chronic somatic dysfunction
can mimic a spectrum of conditions including Meniere’s disease,
Temporomandibular Joint Disorder,Trigeminal Neuralgia, vision
changes, headache, otitis media, chronic sinusitis and other
conditions [35]. Myofascial pain syndrome has also been reported
as a specific etiology of tinnitus. A double blinded, randomized
study in Brazil of 75 individuals with tinnitus and myofascial pain
syndrome showed effective relief with trigger point injections.
The treatment arm had 10 sessions of myofascial trigger point
deactivation/injections around the ear and in the cervical spine
which resulted in statistically significant improvement in symptoms
(p<0.001) and revealed a statistically significant relationship
between pain relief and tinnitus relief (p<0.013). The severity or
intensity of tinnitus symptoms was also noted to frequently be
affected by physical manipulation [36]. As traditionally described
in the cranial osteopathic arena, tinnitus develops due to general
dysfunction of the vestibulocochlear nerve (eighth cranial nerve),
the trigeminal nerve (fifth cranial nerve) and/or Eustachian tube
(ET) often attributed to the abnormal rotation of one or both
temporal bones. One structural explanation for the auditory
symptoms of tinnitus has been attributed in part to the “friction
of blood rushing around the elbow bend in the carotid artery,
immediately adjacent...” to the ET. With external rotation of the
temporal bone, the ET is held continuously open resulting in “a low-
pitched roar.”
With internal rotation, the ET may be continuously closed
accompaniedbya“...high-pitchedhummingorbuzzing[37].”Several
other mechanisms of tinnitus have also been offered generally
grouped as “Eustachian tube dysfunction” (ETD). ETD is thought
to involve abnormal pressure differentials within the ET that affect
the function of the middle ear including the tympanic membrane.
Etiologies of ETD beyond cranial/temporal somatic dysfunction
include mass effect from neoplasms, chronic sinusitis whether
infectious or related to airborne allergens, upper respiratory tract
infections, rapid changes in surrounding pressure (i.e. air travel,
scuba diving, etc.), adenoid tonsillar hypertrophy and others.
In addition, dysfunction of the pharyngeal musculature
including the tensor veli palatini muscle which controls the medial
opening of the ET within the nasopharynx and the tensor tympani
muscle related to tympanic membrane function is another possible
cause of ETD and tinnitus. The tensor veli palatini muscle and the
tensor tympani muscle share innervations by the medial pterygoid
branch of the mandibular nerve, the third branch of trigeminal
cranial nerve (V).
OMT of the temporal bones, the occipitomastoid sutures
and the temporomandibular joints are the general basis for the
cranial approach to OMT of tinnitus. Several specific techniques
have evolved to treat ETD including the Gal breath Technique and
Muncie/Modified Muncie Technique. The Gal breath technique, first
described in 1929 by William Otis Gal breath, DO, involves turning
the affected side of the head away from the examiner who then
applies a gentle pumping force to the mandible on the affected side
drawing the mandible inferiorly and medially to drain accumulated
fluid from the ET.
The Muncie or Modified Muncie Technique treats the
nasopharyngeal opening of the Eustachian tube (and tensor veli
palatini muscle) through intra-oral OMT with a gloved finger. In
one study, 20 healthy patients 18-65 years old were treated once
a week for 2 months with OMT. The THI index decreased by 8.5
points (-16.2%, p<0.037); the VAS decreased by 0.45 points. The
perceived quality of life did not change. Regarding cervicogenic
somatosensory tinnitus, researchers in the Netherlands were
able to show a statistically significant reduction in the tinnitus
intensity Visual Analog Scale (VAS) after manual treatment. Over
120 individuals were treated between 7 and thirteen times for 30-
60 minutes. The results showed statistically significant reductions
in VAS scores for patients with both cervicogenic somatosensory
tinnitus and tinnitus sensitization. (CST alone, P=.01; CST and TS,
P<.001), and the differences between the groups was clinically
significant (P<.001).
Discussion
Though the benefit of acupuncture, hyperbaric oxygen, and
tinnitus counseling alone have yet to be illustrated, studies exist
showing benefit for acoustic therapy, hearing aids, music therapy,
transcutaneous electrical nervous stimulation, dental treatment,
pharmacotherapy, and osteopathic manipulative treatment.
Conclusion
The soundest approach to treating tinnitus is elucidating cause
which will then dictate therapeutics. Once cause is determined,
specific individualized treatments may follow. Tinnitus etiologies,
treatment modalities, and success rates are widely varied thus
proving troublesome to clinicians of all health disciplines. With so
many cases of tinnitus ultimately categorized as idiopathic, diverse
treatments are often applied toward multiple therapeutic targets
that may or may not yield results.
As hinted above, each etiology of tinnitus may exist within a
multifactorial spectrum thus exacerbating treatment coordination
especially when symptomatic patients seek relief from non-
medical modalities and practitioners. The profound impact on
the patient and the inherent difficulties in efficiently finding a
specific etiology can exacerbate the condition’s morbidity and lead
to clinical frustration. While an active area of research with the
potential for significant advances, the current efficacy of the most
commonly used primary care options, pharmaceutical treatment
and subspecialty management, is less than optimal.
To better serve those patients who have not responded to
pharmaceutical treatment or who return to clinic after subspecialty
evaluation with unchanged symptoms, an awareness of the
treatment options available outside of one’s field will likely lead to
a greater understanding the role that other practitioners can play
in managing the patient and possibly better outcomes. In cases of
4. How to cite this article: Roya Vahdatinia, James Keane, Victoria Troncoso, Leonard B G. Tinnitus: Diagnosis and Treatment Options. Exp Rhinol Otolaryngol.
1(1). ERO.000502. 2017. DOI: 10.31031/ERO.2017.01.000502
Experiments in Rhinology & Otolaryngology
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objective tinnitus, identifying and treating the underlying condition
(whether hypertension, multiple sclerosis, or arteriovenous shunts)
will likely resolve the tinnitus.
The diagnosis and treatment of these conditions are described
elsewhere and outside the scope of this paper. Though options for
healing central tinnitus and tinnitus resulting from neural damage
are currently limited, treating any peripheral dysfunctions that
compound the symptomatology may result in the reduction of
symptoms. For peripheral tinnitus, a multidisciplinary treatment
approach addresses the various possible components of the
underlyingdiseaseprocessandismostlikelytoleadtothereduction
or resolution of symptoms. In both OMT and dental/orthodontic
approaches, structural components such as the position of the
temporal bones or the occlusal surface can be addressed with
positive outcome.
Cervicogenic somatosensory tinnitus has a definite structural
component that may be addressed with osteopathic treatment of
the cervical and cranial dysfunctions. For patients with idiopathic
tinnitus, clinicians can encourage patients to pursue a diverse range
of therapeutic options beyond pharmacology and subspecialty
evaluation. While an evidence-based approach should underly all
clinical actions, the response of an idiopathic condition to unknown
therapeutic mechanisms should not preclude their use.
Referral to dentists or orthodontists, referral to audiologists,
utilization of hearing aids or tinnitus dampening devices, tinnitus
retaining therapy (with and without transcranial direct current
stimulation), music therapy, behavioral therapy related to reducing
factors that lead to jaw clenching and bruxism and osteopathic
manipulative treatment are all therapeutic options that can be
considered. In addition, therapeutic options with less of an evidence
basis such as acupuncture, tinnitus therapy, hyperbaric oxygen and
others may also be considered for patients who have not responded
to other modalities.
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5. How to cite this article: Roya Vahdatinia, James Keane, Victoria Troncoso, Leonard B G. Tinnitus: Diagnosis and Treatment Options. Exp Rhinol Otolaryngol.
1(1). ERO.000502. 2017. DOI: 10.31031/ERO.2017.01.000502
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