Tinnitus Tinnitus Grand Rounds Grand Rounds

Edward Buckingham, M. D.Edward Buckingham, M. D.Jeff Vrabec, M. D., Faculty SponcerJeff Vrabec, M. D., Faculty SponcerFrancis Quinn, M.D., Series Editor Francis Quinn, M.D., Series Editor

IntroductionIntroduction

Def. - Perception of sound produced Def. - Perception of sound produced involuntarily within the bodyinvoluntarily within the body

Sypmtom of threatening disease process or Sypmtom of threatening disease process or benign annoyancebenign annoyance

Psychological effects can be severe, even Psychological effects can be severe, even precipitate suicideprecipitate suicide

Definition and EpidemiologyDefinition and Epidemiology

Objective, paraauditory tinnitus - vascular Objective, paraauditory tinnitus - vascular or myoclonic sources, less prevalentor myoclonic sources, less prevalent

Subjective, sensorineural tinnitus - auditory Subjective, sensorineural tinnitus - auditory system, more prevalentsystem, more prevalent

Prevalence increases with age Prevalence increases with age Equal sex distributionEqual sex distribution Severity of symptoms increases with ageSeverity of symptoms increases with age

Objective TinnitusObjective Tinnitus

Stictly def. audible to physician or observerStictly def. audible to physician or observer Encompasses all paraauditory causesEncompasses all paraauditory causes Pulsatile or non-pulsatilePulsatile or non-pulsatile Vascular abnormalities - neoplasm, AVM, Vascular abnormalities - neoplasm, AVM,

arterial bruit, venous humsarterial bruit, venous hums PalatomyoclonusPalatomyoclonus

Objective Tinnitus - 2Objective Tinnitus - 2

H & PH & P Relation to the heart rate, light exerciseRelation to the heart rate, light exercise Thorough ENT exam, particulary otoscopyThorough ENT exam, particulary otoscopy Exam for retrotympanic massExam for retrotympanic mass Auscultate ext. canal, orbit, mastoid, skull, Auscultate ext. canal, orbit, mastoid, skull,

and neckand neck AudiogramAudiogram

Pulsatile TinnitusPulsatile Tinnitus

Many causesMany causes Possible algorithm from SismanisPossible algorithm from Sismanis H & P most important H & P most important BIH, ACAD, Glomus tumors 2/3 of causesBIH, ACAD, Glomus tumors 2/3 of causes

Benign Intracranial HypertensionBenign Intracranial Hypertension(pseudotumor cerebri) Syndrome (pseudotumor cerebri) Syndrome Most common cause in Sismanis’s studyMost common cause in Sismanis’s study Increased ICP, no focal neuro defecit except Increased ICP, no focal neuro defecit except

occas. 6th or 7th nerve palsyoccas. 6th or 7th nerve palsy Mech. systolic pulsation of CSF to medial Mech. systolic pulsation of CSF to medial

aspect of dural venous sinuses, compression of aspect of dural venous sinuses, compression of walls, turbulent blood flowwalls, turbulent blood flow

Head imaging, r/o IC lesionHead imaging, r/o IC lesion Diagnose by LP, ICP > 200 mm H2ODiagnose by LP, ICP > 200 mm H2O

BIH - 2BIH - 2

Female 20 - 50 yrs old and overweightFemale 20 - 50 yrs old and overweight Ipsilateral IJV digital pressure subsidesIpsilateral IJV digital pressure subsides Poss. blurred vision, fronto-occipital HA, Poss. blurred vision, fronto-occipital HA,

lightheadedness-disequilibuiumlightheadedness-disequilibuium Poss. LF HL with good discrimination, Poss. LF HL with good discrimination,

which nomalizes with IJV pressurewhich nomalizes with IJV pressure

BIH - TreatmentBIH - Treatment

Weight lossWeight loss Acetazolamide, furosemideAcetazolamide, furosemide Subarachnoid-peritoneal shuntSubarachnoid-peritoneal shunt Occas. gastric bypass for weight reductionOccas. gastric bypass for weight reduction

Vascular NeoplasmsVascular Neoplasms

Classic tumors - Glomus jugulare and Classic tumors - Glomus jugulare and tympanicumtympanicum

Bruit not altered by neck pressure, head Bruit not altered by neck pressure, head position, posture, or Valsalvaposition, posture, or Valsalva

Tympanometry - regular perturbationsTympanometry - regular perturbations Otoscopy - bluish or redish mass poss. Otoscopy - bluish or redish mass poss.

pulsation and paling with pos. pressurepulsation and paling with pos. pressure

Vascular Neoplasms - 2Vascular Neoplasms - 2

Dif. Diag. - hemotympanum, dehiscent Dif. Diag. - hemotympanum, dehiscent jugular bulb, carotid artery abnormalityjugular bulb, carotid artery abnormality

Radiograph prior to mryingotomyRadiograph prior to mryingotomy Check H & N for massesCheck H & N for masses Cranial nerve and cerebellar functionCranial nerve and cerebellar function If suspected CT scan, mass in ME or eroded If suspected CT scan, mass in ME or eroded

jugular spine.jugular spine.

Vascular Neoplasms - 3Vascular Neoplasms - 3

ArteriographyArteriography MRIMRI Treatment is usually surgicalTreatment is usually surgical

Arteriovenous MalformationsArteriovenous Malformations

Developemental abnormalitiesDevelopemental abnormalities Often larger than symptoms suggestOften larger than symptoms suggest May enlarge rapidly and tend to recurMay enlarge rapidly and tend to recur May inpinge on adjacent structuresMay inpinge on adjacent structures Posterior fossa occipital artery and transverse Posterior fossa occipital artery and transverse

sinus AVM most commonsinus AVM most common AVM of mandible uncommon but notorious AVM of mandible uncommon but notorious

cause of tinnituscause of tinnitus

AVM - 2AVM - 2

Carotid artery/cavernous sinus from traumaCarotid artery/cavernous sinus from trauma Pulsatile tinnitus often initial complaintPulsatile tinnitus often initial complaint HA, papilledema, bruit with thrill, HA, papilledema, bruit with thrill, Heart rate may slow with compressionHeart rate may slow with compression

AVM - TreatmentAVM - Treatment

SurgicalSurgical Preceeded by angiography with Preceeded by angiography with

embolizationembolization Tend to be larger than appear on angio.Tend to be larger than appear on angio. Max benefit if surgery follows within 72 hrsMax benefit if surgery follows within 72 hrs

Venous HumVenous Hum

Eddy currents in IJVEddy currents in IJV Normal in children, some adults, esp. young Normal in children, some adults, esp. young

womenwomen Attributed to Trans. proc. C2, increased Attributed to Trans. proc. C2, increased

CO (anemia, thyrotoxicosis, pregnancy)CO (anemia, thyrotoxicosis, pregnancy) Often presents with hearing lossOften presents with hearing loss

Venous Hum - 2Venous Hum - 2

Gentle ant. neck pressure may relieveGentle ant. neck pressure may relieve Head toward univolved side decreases and Head toward univolved side decreases and

to involved side increasesto involved side increases Deep breathing and Valsalva increaseDeep breathing and Valsalva increase Treat by reassurance, and correcting Treat by reassurance, and correcting

underlying causeunderlying cause

PalatomyoclonusPalatomyoclonus

Irregular clicking sound, 20-400 bpm Irregular clicking sound, 20-400 bpm Occurs intermittentlyOccurs intermittently Palatal musculature and ET mucous Palatal musculature and ET mucous

membrane membrane Also ear fullness, hearing distortionAlso ear fullness, hearing distortion May have other muscle spasmsMay have other muscle spasms Diagnose with Toynbee tube in ear canalDiagnose with Toynbee tube in ear canal

Palatomyoclonus -2Palatomyoclonus -2

Tympanogram movement synchronous with Tympanogram movement synchronous with contractioncontraction

EMG of palatal muscles confirmsEMG of palatal muscles confirms Observable palatal fasciculation - MRIObservable palatal fasciculation - MRI Hypertrophic degeneration inferior oliveHypertrophic degeneration inferior olive Differentiate from tensor tympani spasm, Differentiate from tensor tympani spasm,

usually transientusually transient

Palatomyoclonus -3Palatomyoclonus -3

Treatment - clonazepam, diazepam, warm Treatment - clonazepam, diazepam, warm liquids, stress mgmt.liquids, stress mgmt.

Botulinum toxin injection in severe casesBotulinum toxin injection in severe cases

Idiopathic Stapedial Muscle Idiopathic Stapedial Muscle SpasmSpasm

Rough, rumbling, or crackling noiseRough, rumbling, or crackling noise Triggered by external noisesTriggered by external noises Brief and intermittentBrief and intermittent Rarely disruptive and prolongedRarely disruptive and prolonged Variable intensity tympanometry to induce Variable intensity tympanometry to induce

spasmspasm

Idiopathic Stapedial Muscle Idiopathic Stapedial Muscle Spasm - 2Spasm - 2

Acoustic reflex - prolonged continued Acoustic reflex - prolonged continued increased impedance during and after sound increased impedance during and after sound stimulusstimulus

Treatment - clonazepam, diazepamTreatment - clonazepam, diazepam Symptoms may last only monthsSymptoms may last only months Surgery to divide tendon as last resortSurgery to divide tendon as last resort

Subjective TinnitusSubjective Tinnitus

Tinnitus originates within auditory systemTinnitus originates within auditory system More commonMore common Little known about physiologic mechanismLittle known about physiologic mechanism Hyperactive hair cells or nerve fibersHyperactive hair cells or nerve fibers Chemical imbalanceChemical imbalance Reduced suppressive influence of CNSReduced suppressive influence of CNS

Auditory PathwayAuditory Pathway

Cochlear hair cells, bipolar neurons of Cochlear hair cells, bipolar neurons of spiral ganglion make up 8th nerve, spiral ganglion make up 8th nerve, terminate on cochlear nucleusterminate on cochlear nucleus

Three pathways - dorsal acoustic stria, Three pathways - dorsal acoustic stria, intermediate acoustic stria, trapezoid bodyintermediate acoustic stria, trapezoid body

Superior olivary nucleiSuperior olivary nuclei Lateral lemniscusLateral lemniscus

Auditory Pathway - 2Auditory Pathway - 2

Bilateral auditory input from outsetBilateral auditory input from outset Central auditory lesions do not cause Central auditory lesions do not cause

monoaural disabilitymonoaural disability Inferior colliculus arranged tonotopicallyInferior colliculus arranged tonotopically Medial geniculate body, ipsilateralMedial geniculate body, ipsilateral Primary Auditory Cortex, Sup. Temp. Primary Auditory Cortex, Sup. Temp.

Gyrus (Brodmann’s areas 41 and 42)Gyrus (Brodmann’s areas 41 and 42)

Auditory Brainstem ResponseAuditory Brainstem Response

Auditory evoked responsesAuditory evoked responses Electrophysiologic recordings of response to Electrophysiologic recordings of response to

soundsound Can be recorded from all levels of auditory Can be recorded from all levels of auditory

pathwaypathway ABR most applied clinicallyABR most applied clinically Waves from 8th nerve, caudal and rostral Waves from 8th nerve, caudal and rostral

brainstembrainstem

ABR - 2ABR - 2

Wave I - synchronously stimulated compound Wave I - synchronously stimulated compound action potentials from distal (cochlear) end of action potentials from distal (cochlear) end of 8th nerve8th nerve

Wave II - Also 8th nerve but near brainstemWave II - Also 8th nerve but near brainstem Wave I & II - ipsilateral to ear stimulatedWave I & II - ipsilateral to ear stimulated Later waves have multiple generatorsLater waves have multiple generators Wave III - caudal pons with cont. cochlear Wave III - caudal pons with cont. cochlear

nuclei, trapezoid body, sup. olivary complexnuclei, trapezoid body, sup. olivary complex

ABR - 3ABR - 3

Wave V - most prominent and rostralWave V - most prominent and rostral Lateral lemniscus near inferior colliculus Lateral lemniscus near inferior colliculus

probably on contralateral side to ear probably on contralateral side to ear stimulatedstimulated

Little difference in ABR in tinnitusLittle difference in ABR in tinnitus

Evaluation - Subjective TinnitusEvaluation - Subjective Tinnitus

Etiologic factors - otologic, cardiovascular, Etiologic factors - otologic, cardiovascular, metabolic, neurologic, pharmacologic, metabolic, neurologic, pharmacologic, dental, psychologicaldental, psychological

H/O noise exposure and related symptoms - H/O noise exposure and related symptoms - hearing loss, vertigohearing loss, vertigo

Exact characterization of tinnitus qualityExact characterization of tinnitus quality Perceptual locationPerceptual location

Evaluation - Subjective TinnitusEvaluation - Subjective Tinnitus

Head injury, whiplash injury, meningitis, Head injury, whiplash injury, meningitis, multiple sclerosismultiple sclerosis

Medications - aspirin, aspirin compounds, Medications - aspirin, aspirin compounds, aminoglycoside antbiotics, NSAIDS, aminoglycoside antbiotics, NSAIDS, heterocycline antidepressantsheterocycline antidepressants

TMJ, dental abnormalities prevalentTMJ, dental abnormalities prevalent Psychologic factors, somatoform disorderPsychologic factors, somatoform disorder DepressionDepression

Evaluation - Subjective TinnitusEvaluation - Subjective Tinnitus

Audiometry - assymetrical hearing loss, Audiometry - assymetrical hearing loss, unilateral tinnitus - MRI r/o post fossa unilateral tinnitus - MRI r/o post fossa

Complete questionnaire for perceived Complete questionnaire for perceived severityseverity

Measurement of TinnitusMeasurement of Tinnitus

Pitch, loudness, minimum masking level, Pitch, loudness, minimum masking level, residual inhibition/post maskingresidual inhibition/post masking

Minimum masking level most clinical useMinimum masking level most clinical use Pitch - match most prominent pure tone, Pitch - match most prominent pure tone,

poor reliability, octave differencepoor reliability, octave difference Loudness - Adjust pure tone to tinnitusLoudness - Adjust pure tone to tinnitus Most < 7 dB SL, may be 2 dBMost < 7 dB SL, may be 2 dB

Measurement of TinnitusMeasurement of Tinnitus

Minimal masking level - number of Minimal masking level - number of decibels to cover tinnitusdecibels to cover tinnitus

Residual inhibition - response of patients Residual inhibition - response of patients tinnitus post maskingtinnitus post masking

Diagnostic TestsDiagnostic Tests

None available to objectively measure or None available to objectively measure or confirm tinnitusconfirm tinnitus

ABR, PET, SpOAE, magnetic activityABR, PET, SpOAE, magnetic activity

Otoacoustic EmissionsOtoacoustic Emissions

Low-intensity sounds produced by cochlea as Low-intensity sounds produced by cochlea as response to acoustic stimulusresponse to acoustic stimulus

Outer hair cell motility affects basilar membrane Outer hair cell motility affects basilar membrane - intracochlear amplification, cochlear tuning- intracochlear amplification, cochlear tuning

Generates mechanical energy propagated to ear Generates mechanical energy propagated to ear canalcanal

Vibration of TM produces acoustic signal Vibration of TM produces acoustic signal measured by sensitive microphonemeasured by sensitive microphone

Spontaneous Otoacoustic Spontaneous Otoacoustic EmissionsEmissions

Measurable without stimulationMeasurable without stimulation Present in 60% with normal hearingPresent in 60% with normal hearing Twice as common in femalesTwice as common in females No relationship yet in tinnitusNo relationship yet in tinnitus

Distortion Product Otoacoustic Distortion Product Otoacoustic EmissionsEmissions

Produced when two pure-tone simuli, Produced when two pure-tone simuli, different frequency simultaneouslydifferent frequency simultaneously

Present in all normal hearing Present in all normal hearing Damaged outer hair cells - no DPOAEDamaged outer hair cells - no DPOAE 30% damage without audiogram change30% damage without audiogram change Will have abnormal OAEWill have abnormal OAE No correlation in tinnitus yetNo correlation in tinnitus yet

DPOAEDPOAE

Norton - oscillating or prolonged evoked Norton - oscillating or prolonged evoked emission in 5/6 tinnitus patients and 0/2 emission in 5/6 tinnitus patients and 0/2 withoutwithout

They suggent that evoked emission and the They suggent that evoked emission and the tinnitus might be related to the same tinnitus might be related to the same underlying pathology, but the former is not underlying pathology, but the former is not the cause of the latterthe cause of the latter

Tinnitus Treatment - CounselingTinnitus Treatment - Counseling

Etiologic factorsEtiologic factors After work-up, unlikelihood of tumor or life-After work-up, unlikelihood of tumor or life-

endangering diseaseendangering disease 25% improve or go away, 50% decrease, 25% persist, 25% improve or go away, 50% decrease, 25% persist,

very small portion increasevery small portion increase Avoid loud noise, wear ear protectionAvoid loud noise, wear ear protection Avoid caffeinated beverages, stimulants (coffee, tea, Avoid caffeinated beverages, stimulants (coffee, tea,

colas, chocolate)colas, chocolate) Stop smokingStop smoking

Tinnitus Treatement - MedicationTinnitus Treatement - Medication

Avoid previously mentioned medicinesAvoid previously mentioned medicines Nicotinic acid (BNicotinic acid (B66), carbamazepine, ), carbamazepine,

baclofen, others; none beneficialbaclofen, others; none beneficial Lidocaine beneficial - IV, short 1/2 life, Lidocaine beneficial - IV, short 1/2 life,

poor side effectspoor side effects Oral analogs - tocainide, flecainide acetate - Oral analogs - tocainide, flecainide acetate -

no benefitno benefit

Tinnitus Treatment - MedsTinnitus Treatment - Meds

Melatonin - 3.0 mg qhs does not relieve tinnitusMelatonin - 3.0 mg qhs does not relieve tinnitus Sleep disturbance - 46.7% vs. 20% placebo Sleep disturbance - 46.7% vs. 20% placebo

benefit (p=0.04)benefit (p=0.04) Benzodiazepines - clonazepam, oxazepam, Benzodiazepines - clonazepam, oxazepam,

alprazolam may provide benefit esp. with alprazolam may provide benefit esp. with concurrent depressionconcurrent depression

Alprazolam - 76% had reduction in loudness Alprazolam - 76% had reduction in loudness 5% of placebo5% of placebo

Tinnitus Treatment - MedsTinnitus Treatment - Meds

Overall, meds should not be major strategy, Overall, meds should not be major strategy, certain sufferers may benefit in conjuntion certain sufferers may benefit in conjuntion with other therapywith other therapy

Environmental MaskingEnvironmental Masking

For mild tinnitus esp. bothersome in quietFor mild tinnitus esp. bothersome in quiet Home environmental maskersHome environmental maskers Broad-band noise, between FM stationsBroad-band noise, between FM stations Particularly useful at nightParticularly useful at night Required noise soft usually does not disturb Required noise soft usually does not disturb

family membersfamily members

Hearing Aids and Maskers Hearing Aids and Maskers

Saltzmann and Ersner (1947) - hearing aids Saltzmann and Ersner (1947) - hearing aids amplified background noise, mask tinnitusamplified background noise, mask tinnitus

If hearing loss try HA, less interference with If hearing loss try HA, less interference with speech, no noise to produce damage, improve speech, no noise to produce damage, improve speech understandingspeech understanding

Commercial tinnitus maskers with or without HACommercial tinnitus maskers with or without HA Complete or partial maskComplete or partial mask No clear guidelines for useNo clear guidelines for use

Hearing Aides and MaskersHearing Aides and Maskers

Narrowband noise (less 1/2 octave) tonal Narrowband noise (less 1/2 octave) tonal character, more annoyingcharacter, more annoying

Conservative approach - lowest level with Conservative approach - lowest level with adequate relief, need not be worn adequate relief, need not be worn continuouslycontinuously

No protocol which ear, unilateral, bilateralNo protocol which ear, unilateral, bilateral

Electrical StimulationElectrical Stimulation

DC (direct current) to round window or DC (direct current) to round window or promontory could reduce tinnituspromontory could reduce tinnitus

DC may produce permanent damage, cannot be DC may produce permanent damage, cannot be used clinicallyused clinically

AC (alternatig current) AC (alternatig current) External stim to tympanic membrane, External stim to tympanic membrane,

transtympanically on promontory, transtympanically on promontory, tanscutaneously in pre and post auricular regiontanscutaneously in pre and post auricular region

Electrical StimulationElectrical Stimulation

Ext. AC stim. results mixed, some Ext. AC stim. results mixed, some promisingpromising

One commercial extracochlear wearable One commercial extracochlear wearable device marketed 1985device marketed 1985

1986 Dobie 1 in 20 benefited 1986 Dobie 1 in 20 benefited

Intracochlear Electrical Intracochlear Electrical StimulationStimulation

Observations that cochlear-implant patients Observations that cochlear-implant patients reduction in tinnitus while listening to reduction in tinnitus while listening to speechspeech

Few received CI explicitly for tinnitusFew received CI explicitly for tinnitus 1984 House 5 patients severe to profound 1984 House 5 patients severe to profound

HL, CI placed for tinnitus relief, no stim. HL, CI placed for tinnitus relief, no stim. only one reported benefit listening to speech.only one reported benefit listening to speech.

Intracochlear Electrical Intracochlear Electrical StimulationStimulation

1989 Hazell - six totally deaf, CI implant and 1989 Hazell - six totally deaf, CI implant and trials with sinusoidal stim.trials with sinusoidal stim.

Able to reduce tinnitus in all 6 with 100 Hz Able to reduce tinnitus in all 6 with 100 Hz sinusoidsinusoid

Two forego speech processor and used just Two forego speech processor and used just for tinnitus relieffor tinnitus relief

One turn on current, turn off tinnitus “like a One turn on current, turn off tinnitus “like a light switch”light switch”

SurgerySurgery

Effective in treating conditions, tinnitus is Effective in treating conditions, tinnitus is symptom eg. otosclerosis, acoustic neuroma, symptom eg. otosclerosis, acoustic neuroma, glomus jugulareglomus jugulare

Lituratue discusses cochlear neurectomy and Lituratue discusses cochlear neurectomy and microvascular decompression of the cochlear nervemicrovascular decompression of the cochlear nerve

Results not consistentResults not consistent Few otologists advocate use of surgeryFew otologists advocate use of surgery Validates hypothesis tinnitus gen. centralValidates hypothesis tinnitus gen. central

Neurophysiological Approach to Neurophysiological Approach to Tinnitus and HabituationTinnitus and Habituation

New theoryNew theory Previous theories share belief that process Previous theories share belief that process

producing tinnitus restricted to auditory producing tinnitus restricted to auditory pathway and cochleapathway and cochlea

Models focused on tinnitus generation, Models focused on tinnitus generation, treated auditory pathway as passive, treated auditory pathway as passive, unchangeable transmitters of signal to unchangeable transmitters of signal to auditory cortexauditory cortex

Neurophysiological ModelNeurophysiological Model

Diagnostic efforts concentrated on Diagnostic efforts concentrated on psychoacoustical description (loudness, pitch, psychoacoustical description (loudness, pitch, maskability)maskability)

These no help in predicting treatment outcome, no These no help in predicting treatment outcome, no explaination why same descript produced drastic explaination why same descript produced drastic different annoyancedifferent annoyance

This model postulates - tinnitus results from This model postulates - tinnitus results from multiple interactions of a number of subsystems in multiple interactions of a number of subsystems in nervous systemnervous system

Neurophysiological ModelNeurophysiological Model

Auditory pathway role in development and Auditory pathway role in development and appearance of tinnitus as sound perceptionappearance of tinnitus as sound perception

Other systems, limbic system, tinnitus Other systems, limbic system, tinnitus annoyanceannoyance

Problem - perception becomes associated with Problem - perception becomes associated with neg. emotions, fear , and threatneg. emotions, fear , and threat

Limbic system activates autonomic nervous Limbic system activates autonomic nervous system resulting in annoyancesystem resulting in annoyance

Neurophysiologic ModelNeurophysiologic Model

Because annoyance primarily dependent on Because annoyance primarily dependent on limbic system which is a perception by the limbic system which is a perception by the individual and an associated emotional individual and an associated emotional state, psychoacoustical characterization of state, psychoacoustical characterization of tinnitus irrelevanttinnitus irrelevant

HabituationHabituation

Def. - The disappearance of reactions to sensory Def. - The disappearance of reactions to sensory stimulus because of repetitive exposition of a stimulus because of repetitive exposition of a subject to this stimulus and the lack of positive or subject to this stimulus and the lack of positive or negative reinforcement associated with this stimulusnegative reinforcement associated with this stimulus

Brain ordering of tasks 1) importance of signal esp. Brain ordering of tasks 1) importance of signal esp. if danger 2) noveltyif danger 2) novelty

If signal not assoc. with event or indicate danger, If signal not assoc. with event or indicate danger, not new, undergoes habituation, and after repetition not new, undergoes habituation, and after repetition in not perceivedin not perceived

HabituationHabituation

Accomplished by directive counseling - Accomplished by directive counseling - educate patient of potential mechanisms of educate patient of potential mechanisms of tinnitus, discuss results of all audiologic and tinnitus, discuss results of all audiologic and medical tests and relavancemedical tests and relavance

Once patient understands, level of annoyance Once patient understands, level of annoyance decreasesdecreases

Repetative visits reinforce and eliminate Repetative visits reinforce and eliminate negative association evoked by tinnitusnegative association evoked by tinnitus

HabituationHabituation

Directive counseling essential but not sufficient to Directive counseling essential but not sufficient to achieve permanent habituationachieve permanent habituation

Need to enhance auditory background ie. partial Need to enhance auditory background ie. partial masking, particularly in quiet envir.masking, particularly in quiet envir.

Increased background spontaneous and evoked Increased background spontaneous and evoked activity in auditory pathways, reduces contrast of activity in auditory pathways, reduces contrast of tinnitus to background noise facilitating habituationtinnitus to background noise facilitating habituation

Must avoid masking tinnitus completelyMust avoid masking tinnitus completely

HabituationHabituation By def. once signal is masked it cannot be By def. once signal is masked it cannot be

habituated tohabituated to Reconditioning of connections in subcortical Reconditioning of connections in subcortical

centers cannot occur if stimulus (tinnitus) is absentcenters cannot occur if stimulus (tinnitus) is absent Tinnitus masking 15 yrs no changes in tinnitus, Tinnitus masking 15 yrs no changes in tinnitus,

evidence of habituation, decreased annoyanceevidence of habituation, decreased annoyance One year habituation therapy - aware only small One year habituation therapy - aware only small

percent of time, annoyance decreasedpercent of time, annoyance decreased

Habituation - TechniqueHabituation - Technique

Fitted binaurally with broad-band noise Fitted binaurally with broad-band noise generatorgenerator

Use for at least 6 hrs per day, part. in quietUse for at least 6 hrs per day, part. in quiet If HL, HA are also used If HL, HA are also used Process requires 12 monthsProcess requires 12 months Jastreboff insists 6 more months to ensure Jastreboff insists 6 more months to ensure

plastic changes in brain establisedplastic changes in brain establised After that time noise generators discontinuedAfter that time noise generators discontinued

Habituation - ResultsHabituation - Results

Jabstreboff reports 83% of patients exhibit Jabstreboff reports 83% of patients exhibit significant improvement with combined significant improvement with combined therapytherapy

SummarySummary

Important to differentiate types of tinnitusImportant to differentiate types of tinnitus Must recognize when tinnitus part of Must recognize when tinnitus part of

symptomatology of underlying disease verses merely symptomatology of underlying disease verses merely auditory annoyanceauditory annoyance

Patience and understanding of patient’s experience Patience and understanding of patient’s experience importantimportant

Paraauditory tinnitus treatable by standard Paraauditory tinnitus treatable by standard medical/surgical therapymedical/surgical therapy

Subjective tinnitus treatment advancingSubjective tinnitus treatment advancing