Causes & Treatment of Tinnitus

Causes & Treatment of Tinnitus

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Description: An auditory perception due to aberrant spontaneous activity, arising from an altered state of excitation or inhibition within the auditory system. Large variability in prevalence stats: 10-15% of adults PST, 5% interferes with sleep or causes moderate-severe annoyance, and 0.5-1 % severe affect. 7% of UK population has consulted their GP specifically about tinnitus.

Prevalence increases with age, hearing loss & noise exposure. Defects at any point in the auditory system can induce tinnitus.

 
Author: Tony Kay (Fellow) | Visits: 2104 | Page Views: 2105
Domain:  Medicine Category: Therapy 
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Contents:
Tinnitus: Facts, causes & treatment
Tony Kay Aintree Tinnitus Support Group 6th May 2009

Boundaries
Audiologist not a medic Brief overview of a complex subject This talk is not a substitute for individual assessment Troublesome tinnitus, tinnitus in one ear or pulsatile tinnitus should be assessed in an appropriate clinic

Tinnitus Myths True of false?
Tinnitus is a disease? There is no treatment? Tinnitus is a sign of something terrible? Tinnitus means that I will go deaf? I will not be able to cope with tinnitus?

Simple definitions
Noises in the ears or head without an external origin Tinnitus is the perception of sound in the absence of an appropriate external sound source

Current definition
An auditory perception due to aberrant spontaneous activity, arising from an altered state of excitation or inhibition within the auditory system

History
The word Tinnitus stems from the Latin "tinnire" which means to ring Introduced by Pliny the Elder (AD2379) Roman scholar whose encyclopedia "Natural History" was a major source of scientific knowledge until 17th Century

History
Reference to tinnitus as "ringing in the ears" dates back in UK to the "Compendium" of 1240 First complete English medical text written by Glibertus Anglicus Tinnitus was referred to "bewitched ear" in the Ebers papyrus (2-3 millennium BC)

History
Early treatment included boiling earth worms in goose grease and inserting into the ear Cedar sap, rose oil, honey, vinegar, wine, cockroaches ground in rose oil Opium

News flash
Tinnitus has been around for a long time ! Treatment has improved !!

Prevalence
Large variability in prevalence statistics 10-15% of adults PST At least 5% interferes with sleep or causes moderate-severe annoyance 0.5-1 % severe affect

Prevalence
7% of UK population have consulted their GP specifically about tinnitus Prevalence increases with age, hearing loss & noise exposure But, can occur any age (including childhood) and with normal hearing

News Flash !!!
Relatively common symptom Most people that experience tinnitus are not troubled by it Whilst there is usually no definitive cure, there is treatment Most habituate over time

Causes
What causes tinnitus? What causes tinnitus distress?

Causes
Like pain (a symptom � not a disease) tinnitus (a symptom � not a disease) can be induced by many different conditions Defects at any point in the auditory system can induce tinnitus (ignition sites) General & neurological conditions But other factors play an important role in the annoyance of tinnitus

Causes

Hair cells

Stress Response of Body
Fight or flight response : cascade of bodily changes to prepare us when danger is sensed Stress hormones released Heart rate changes Blood vessels constrict Pupils dilate Blood sugars increase Senses on red alert Bodily processes not essential to immediate survival are suppressed

Mechanisms
Tinnitus is usually a consequence of altered spontaneous activity within the auditory system May just be simple compensatory changes due to slight hearing loss (not a sign of something terrible) Generation, maintenance and intrusiveness of tinnitus involves other central structures (e.g.. limbic & autonomic nervous systems)

But !
Heller & Bergman 1953 80 normal hearing individuals and no tinnitus Sound proof room for 5 minutes 94% described a tinnitus sound

Jastreboff Neurophysiological Model (JNM)

JNM
Developed in 1980s & published in 1990 Hearing, emotion & reaction are interlinked Limbic & ANS : conditioned response Directive counselling Categorising into one of five categories Sound enrichment Structured therapy Major influence on treatment Reasonably simple treatment model

Psychological Model
Hallam et al 1984 Natural history of tinnitus is habituation Distress is associated with failure to habituate Habituation is slowed by factors such as high autonomic arousal and by the tinnitus acquiring an emotive significance

Tinnitus distress
Arises through the perception of threat Often involves cognitive distortions (how we think about it) Usually gives rise to some action designed to reduce the distress

Negative counselling
"There is nothing that can be done to help" "You will have to learn to live with it" "Aunty Mary had tinnitus and she went mad" This causes a negative reinforcement Also, how we think about it can get in the way !

Thoughts
What thoughts do you have about your tinnitus? What caused you to have these thoughts?

Troublesome tinnitus
Mechanism causing the tinnitus signal

Mechanism causing the tinnitus distress

News Flash
Any new stimulus gets our attention initially but rapidly looses novelty Habituation should occur Unless there are roadblocks to habituation Parable : The country

Aims of tinnitus management
Diagnose & treat any associated pathology Facilitate habituation to the tinnitus and minimise the distress caused by the tinnitus

Objective of assessment
Exclude any significant pathology Acquire information necessary to plan treatment Identify the possible underlying mechanisms to allow appropriate counselling

Initial assessment
Full medical & drugs history Associated symptoms Listen to concerns Examination Investigations

Tinnitus Assessment
Onset Progression Characteristics Site Constant/intermittent/fluctuating Pulsatile/ non-pulsatile Tinnitus tests? Triggers Expectations Worries/fears/concerns Impact on life Handicap inventory Assess current coping strategies Explain findings clearly & discuss possible mechanisms

News flash
No simple cure in most cases But there is treatment in all cases Aim of treatment is to facilitate habituation to the tinnitus and reduce distress caused by it Most benefit from treatment Not all patients require the same approach

Treatment
�Treat any underlying pathology Information Support Lifestyle Self help: learn about your condition Counselling (knowing patient's concerns) Hearing aids Sound enrichment Wearable sound generators

Treatment
Relaxation/stress reduction techniques Sleep management Pillow speakers Tinnitus Retraining Therapy Cognitive Behavioural Therapy Refocus therapy Drugs Onward referral for any anxiety or depression Provide follow up Complimentary & alternative therapy

Review of Dr Dominic Bray's talk (October 2008) Consultant Clinical Health Psychologist The Solution-Focused Mentality: build on your strengths/resources

How do I make things better? What works for me? How do I get by/cope? When did I have my last slightly-less-bad day? Notice your strengths � keep noticing them If negative thoughts can spiral, why not positive ones !!

Research
Advanced imaging techniques Repetitive transcranial magnetic stimulation Direct electrical stimulation Drugs Neuronomics (filtered music therapy) Gene therapy Stem cells

News flash
How we think about things effects how we feel about things Outlook is invariably good Habituation/retraining is achievable Parable : New neighbour

Tinnitus Myths True of false?
Tinnitus is a disease? There is no treatment? Tinnitus is a sign of something terrible? Tinnitus means that I will go deaf? I will not be able to cope with the tinnitus?

Useful information
RNID Tinnitus Helpline 0808 808 6666 www.rnid.org www.tuneouttinnitus.org.uk British Tinnitus Association 0800 018 0527 www.tinnitus.org.uk

Main references
Stephens SDG. The treatment of tinnitus � a historical perspective. Journal of Laryngology and Otology. October 1984. Vol 98, 963-972 Davis A, El Rafaie A. Epedemiology of tinnitus. In Tyler RS, Tinnitus Handbook. San Diego:Thompson Learning;2000.1-23 Scott-Brown's Otolaryngology, Head and Neck Surgery. 7th Edition. 2008. Google images. Textbook of Audiological Medicine. First Edition, 2003. Edited by Linda Luxon Hallam RS, Rachman S, Hinchcliffe R. Psychological aspects of tinnitus. In: Rachman S, ed. Contributions to Medical Psychology. Oxford: Pergamon Press, Vol 3. 1984:31-53 Jastreboff PJ, Hazell J. A neurophysiological approach to tinnitus: clinical implications. Br J Audiol 1993;27:7-17 Provision of Services for Adults with Tinnitus: A Good Practice Guide. Department of Health. January 2009. McKenna L, Anderson G. Changing reactions to tinnitus, In The Consumer Handbook on Tinnitus, ed. Richard Tyler. Auricle Ink Publishers. 2008 Baguley DM. Mechanisms of tinnitus. British Medical Bulletin 2002;63:195-212 Tinnitus Update Lecture Course, University of Bristol, 2006

Thank you for listening

Some benefits of support group
Provision of information Reduces feeling of isolation Opportunities for sharing experiences and coping skills Gain inspiration & support from others experience Swap & learn new ways of dealing with the problem

Group boundaries
Respect confidentiality Respect any shared experiences Not a substitute for individual assessment & treatment

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