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Tinnitus Diagnosis and Treatment

Tinnitus Diagnosis and Treatment. Hossein Talebi; PhD of Audiology Assistant Professor of Audiology Isfahan University of Medical Sciences. Introduction . Tinnitus is defined as sensations of hearing in the absence of external sounds. The burden of tinnitus. Introduction.

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Tinnitus Diagnosis and Treatment

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  1. Tinnitus Diagnosis and Treatment Hossein Talebi; PhD of Audiology Assistant Professor of Audiology Isfahan University of Medical Sciences

  2. Introduction • Tinnitus is defined as sensations of hearing in the absence of external sounds

  3. The burden of tinnitus

  4. Introduction • Prevalence increases with age • 80% of people don’t seek help • 6-8% of those affected are severe • 40% of patients experience depression • Can vary between barely perceptible noise to a deafening roar • Very little is understood about its cause or cure

  5. Sound features of tinnitus

  6. Tinnitus sufferers • Ludwig van Beethoven • Vincent van Gogh • Charles Darwin • Neil Young • Eric Clapton • Ronald Regan

  7. Types of Tinnitus • Objective: caused by sounds generated somewhere in the body • Subjective: perception of meaningless sounds without any physical sound being present • Auditory hallucinations: perceptions of meaningful sounds such as music or speech

  8. Causes

  9. Effects of Tinnitus • Concentration • Hearing • Insomnia • Psychological

  10. Ear Anatomy

  11. Ear Anatomy

  12. Mechanism of Hearing

  13. Mechanism of Hearing

  14. Mechanism of Hearing

  15. Pathophysiology • Poorly understood • Range of theories from loss of outer hair cell function to increased spontaneous activity of central nerves • Can be generated from any part of the auditory system from the ear to the Central Nervous System (CNS) • This then may become modified by the CNS

  16. Peripheral events lead to central neurological changes

  17. Brain response to auditory deprivation DECREASED SOUND INPUT • Patients with tinnitus exhibit enhanced auditory sensitivity • This is caused by hyperactivity of the auditory central nervous system • In patients with tinnitus and hearing loss, the tinnitus pitch and the hearing loss frequency spectrum are usually matched INCREASED SOUND SENSITIVITY

  18. Tinnitus is a balance of sensory input and spontaneous activity • The decreased input from the cochlea, due to outer hair cell damage, results in readjustments in the central auditory system resulting in abnormal neural activity including hyperactivity, bursting discharges and increases in neural synchrony. AUDITORY DEPRIVATION AND CENTRAL GAIN ALTERED SPONTANEOUS NEURONAL ACTIVITY TINNITUS

  19. Pathophysiology • When the perception of tinnitus is associated with negative reinforcement, the autonomic nervous system is activated. • Physiological and psychological reactions then lead to enhancement of the tinnitus signal • Often compared with chronic pain

  20. Pathophysiology

  21. Psychological associations with tinnitus

  22. A Team Approach • Thorough evaluation to rule out significant pathology • Treatment of other ear disorders eg. infection • Explanation of test results • Explanation of tinnitus mechanisms • Treatment options • Treatment of severe psychological disorders • Follow-up

  23. Differential Diagnosis • Idiopathic (most common) • Outer ear disease • Wax, foreign body, infection • Middle ear disease • Infection, perforated eardrum, ossicular problems, tumour

  24. Differential Diagnosis • Inner ear disease • Presbyacusis (older age hearing loss) • Meniere’s disease • Acoustic neuroma • Noise exposure • Drugs

  25. Evaluation of Tinnitus • Thorough history • Duration, nature, effects • Non vs. pulsatile • Noise exposure • Other ear symptoms • Ear examination • Rule out outer/middle ear disease • Tuning fork tests

  26. Normal Ear vs. Diseased Ear

  27. Evaluation of Tinnitus • Audiological (hearing) Tests • Audiogram, tympanogram • Specialized hearing tests: SOAE, ECochG, ABR • MRI • Associated symptoms • Asymmetric hearing loss

  28. Evaluation - Subjective Tinnitus • Audiometry - assymetrical hearing loss, unilateral tinnitus - MRI r/o post fossa • Complete questionnaire for perceived severity:THI

  29. Measurement of Tinnitus • Pitch, loudness, minimum masking level, residual inhibition/post masking • Minimum masking level most clinical use • Pitch - match most prominent pure tone, poor reliability, octave difference • Loudness - Adjust pure tone to tinnitus • Most < 7 dB SL, may be 2 dB

  30. Measurement of Tinnitus • Minimal masking level - number of decibels to cover tinnitus • Residual inhibition - response of patients tinnitus post masking

  31. ENT Referral ENT Referral

  32. Acoustic Neuroma

  33. Treatment • Aim to improve habituation rather than “cure” tinnitus • Most people don’t seek treatment • Multitude of potential treatments • Problems with scientific evidence

  34. Treatment • Basic advice • Hearing Aid • Tinnitus Masking Device • Tinnitus Instrument • Tinnitus Retraining Therapy • Psychological Treatment • Medication • Alternative Treatments

  35. Basic Advice • Reassurance • The first step is to understand the problem • Avoid aggravating factors eg. noise, NSAIDs • Decreased intake of stimulants eg. caffeine and nicotine • Relaxation • Avoiding silence • White noise eg. Detuned radio

  36. Treatment • Basic advice • Hearing Aid • Tinnitus Masking Device • Tinnitus Instrument • Tinnitus Retraining Therapy • Psychological Treatment • Medication • Alternative Treatments

  37. Hearing Aids • Essentially for poor hearing • Increases ambient noise • Decreases stress of poor hearing • Various shapes and sizes • Cost • Limitations • Up to 90% may benefit

  38. Hearing Aids

  39. Hearing aids are central to tinnitus management • Reports of the use of hearing aids in the management of tinnitus go back over 60 years • Because hearing loss is often associated with tinnitus, at least partial restoration of hearing should help to reduce the central gain in auditory perception that is a feature of tinnitus • A recent scoping review of studies of hearing aids in tinnitus revealed that 17/18 publications showed improvements in tinnitus symptoms by fitting hearing aids

  40. Treatment • Basic advice • Hearing Aid • Tinnitus Masking Device • Tinnitus Instrument • Tinnitus Retraining Therapy • Psychological Treatment • Medication • Alternative Treatments

  41. Tinnitus Masking Device • Essentially counteracts tinnitus • Generate noise bands • Tinnitus Instruments • Combination of hearing aid and masker

  42. Wide Band Noise Generators • Emit ‘white noise’ • Elimination of silence • White noise boring: tendency to ignore • Gives the tinnitus sufferer something tangible to work with • Reduce the starkness of the tinnitus signal

  43. Treatment • Basic advice • Hearing Aid • Tinnitus Masking Device • Tinnitus Instrument • Tinnitus Retraining Therapy • Psychological Treatment • Medication • Alternative Treatments

  44. Tinnitus Retraining Therapy • Based on evidence that a person can habituate to acoustic noise in the environment • Goal is to weaken or remove the functional connections between the auditory pathways • Key elements: counseling and sound therapy

  45. Normal Condition

  46. Tinnitus Condition

  47. Counseling alone

  48. Sound Therapy alone

  49. Counseling and Sound Therapy

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