Journal Home     Contents    Preview    Next

Tinnitus: Advances in Diagnosis and Management

Aristides Sismanis

Department of Otolaryngology - Head and Neck Surgery
Medical College of Virginia, Virginia Commonwealth University
Richmond, Virginia, USA

ABSTRACT

Objective: Tinnitus is a common otologic symptom secondary to numerous etiologies such as noise exposure, otitis, Meniere’s disease, otosclerosis, trauma, medications, and presbycusis. A thorough evaluation is necessary to rule out less common causes which may include acoustic neuromas, glomus tumors, atherosclerosis of the carotid arteries, arteriovenous fistulae (AVFs) / malformations (AVMs) and intracranial hypertension.
Data sources: The literature used for the investigation is from the last 25 years.
Conclusion: Treating physicians need to have a very compassionate attitude towards these patients and statements such as “ there is nothing that can be done” are very inappropriate and should be strongly condemned. Reassurance, hearing aids, masking devices, tinnitus retraining therapy, antidepressants, intratympanic medications and management of underlying pathologies such as carotid artery atherosclerosis, skull base tumors, intracranial hypertension and AVMs/AVFs provide relief for the majority of these patients.
Key words: Tinnitus, Diagnosis, Management.
Pro Otology 3: 99-103, 2002

INTRODUCTION

Tinnitus is a common otologic symptom secondary to numerous etiologies. Based upon sound characteristics, tinnitus can be classified as non-pulsatile (or continuous) which is the most common type and pulsatile. Since these two types of tinnitus have very diverse etiologies, pathophysiology as well as treatment, they will be described as separate entities.


Table 1. Common etiologies of tinnitus.

Table 2. Medications associated with tinnitus.

I. NON-PULSATILE TINNITUS

Non-pulsatile tinnitus (henceforth referred as tinnitus) is more common than the pulsatile type and is prevalent in patients between the ages of 50 and 71 years, although it can occur in younger individuals (1). This type of tinnitus can be differentiated into a mild form, audible occasionally or only when in a quiet environment and a severe form, audible at all times and usually very disturbing and affecting patient’s quality of life (2). It has been estimated that 36 million people in the United States have tinnitus, and between 7.2 to 11.25 million have the severe form (3). The majority of tinnitus patients have an associated otologic pathology, however, many other factors and medical conditions can be responsible for this symptom. An average of 30-decibel (dB) hearing loss between 3 and 8 kilohertz (KHz) has been reported in 75 percent of tinnitus patients (4). Noise exposure is a very common etiology of tinnitus. Side effects from medications, especially aspirin, aspirin containing compounds and anti-inflammatory agents also can cause tinnitus. Tinnitus etiologies and medications associated with tinnitus are summarized in Tables 1 and 2.

Psychological factors, such as depression and anxiety, are related to tinnitus. Between 28 and 60 percent of patients with severe tinnitus have been reported as clinically depressed (5). Depressed tinnitus patients are usually individuals with predilection to depression (5).

PATHOPHYSIOLOGY

There is evidence that tinnitus can arise not only from disease processes affecting the cochlea, but also from disorders affecting the central auditory pathways. It has been speculated that peripheral pathologies can sensitize central structures resulting in hyperactivity and tinnitus (6).

EVALUATION

History

The time of onset and any possible causative factors, such as exposure to noise, medications, viral infections, or head trauma, should be elicited from the history. The psychological impact of tinnitus also should be determined by seeking symptoms of depression, anxiety, sleep disturbances, and inability to concentrate.

Examination

This should include otoscopic and neuro-otologic examination for patients suspected of retrocochlear lesions.

Audiologic Evaluation

Audiogram (air conduction, bone conduction, speech discrimination) should be obtained in all patients.

Impedance audiometry (tympanometry, acoustic reflexes, acoustic reflex decay) should be considered in selected cases.

Electrophysiologic testing

Auditory evoked responses (ABR), instead of imaging studies, should be considered for patients with a low index of suspicion for an acoustic neuroma. Electrocochleography can be helpful in patients suspected for endolymphatic hydrops.

Electronystagmography (ENG) can be helpful in patients with associated vestibular symptoms.

Radiologic Evaluation

Head magnetic resonance imaging (MRI) with gadolinium enhancement should be obtained in patients with:

Unilateral unexplained tinnitus with or without hearing loss

Bilateral symmetrical or asymmetrical hearing loss suspicious for retrocochlear pathology (poor discrimination, absent acoustic reflexes, acoustic reflex decay, abnormal ABR)

Computed tomography (CT) of the temporal bones should be considered for patients suspected of otic capsule pathology (otosclerosis, Paget’s disease, marble bone disease).

Tinnitus Analysis

Tinnitus analysis by an experienced audiologist for pitch and loudness matching, minimum masking level and residual inhibition should be considered in patients with severe tinnitus affecting their life styles (1).

MANAGEMENT

A very positive and compassionate attitude is imperative in treating tinnitus patients. Negative statements, such as “There is nothing much that can be done” and “you just have to live with it,” should be strongly avoided. Symptoms of anxiety or depression should be detected early on and properly addressed. I usually treat these patients with Nortryptiline 30 mg at bed time. Evaluation and therapy by a psychiatrist should be considered for severely depressed patients.

The test results should be given to the patient and an overview of the anatomy and physiology of the auditory system should be made. It is believed that a vicious cycle exists between tinnitus and fear/anxiety, and the latter can enhance the perception level and duration of tinnitus awareness (7). Once serious pathology has been eliminated, the patient should be appropriately informed and reassured. Many of these patients are very concerned about having a life threatening condition such as a brain tumor, or fear that are becoming deaf. The majority of these patients has the mild form of tinnitus and responds quite well to reassurance. Patients are advised to avoid noise and intake of stimulants, such as caffeine and nicotine. They also need to be reminded that caffeine is contained not only in coffee, but also in tea, colas, and chocolate. Intake of aspirin-containing medications and non-steroidal anti-inflammatory drugs should be avoided. Home masking techniques, such humidifiers, fans, music, or broadband noise by tuning the radio between FM stations are often helpful. They also should be told that most likely the intensity of tinnitus will lessen with time and the chance of worsening is small.

For patients with severe and disabling tinnitus, the following modalities of management are available:

Masking

Tinnitus masking denotes applying an external sound to cover up the tinnitus. Masking of tinnitus can be achieved with one of the following modalities:

1. Hearing Aids. Hearing aids can provide a form of masking by amplifying ambient environmental sounds. Hearing aids are useful for patients with hearing loss and tinnitus pitch at or below about 4 KHz, because normal ambient environmental sounds are below this frequency.

2. Tinnitus Maskers. These noise-producing devices should be considered for patients with normal or near normal hearing (1).

3. Tinnitus instruments. These devices are a combination of a hearing aid and a tinnitus masker and are available as either in-the-ear or behind-the-ear unit.

The overall success rate of masking devices has been very good (8).

Tinnitus retraining or habituation therapy

This technique involves a process by which using specific protocols, patients can reach a state of being unaware of the presence of tinnitus except when they deliberately concentrate their attention on it. Tinnitus retraining is a different t from masking and is thought to be a reconditioning of connections within subcortical centers (7). This method involves extensive counseling and use of binaural broadband noise generators. Tinnitus habituation requires at least 12 months of treatment, and it is recommended that patients continue for an additional 6 months (9). This technique also has been found helpful for patients with associated hyperacusis.

Significant improvement of tinnitus has been reported in 75 percent of patients (9). Controlled studies are needed, however, to validate the results of this very promising technique.

Electrical Stimulation

Transcutaneous electrical stimulation has been reported to decrease tinnitus in 53 percent of patients (10). This method also needs further critical evaluation.

Tinnitus reduction has been reported up to 75 percent of patients undergoing cochlear implantation (11).

Biofeedback

Biofeedback should be considered for patients with associated anxiety/stress, tension headaches and temporomandibular joint disorders.

Medical Treatment

Antidepressants such as Nortriptyline (Pamelor) and Amitriptyline (Elavil) have been found useful for patients with severe tinnitus and associated depression (5,12). For patients with severe depression, psychiatric evaluation should be considered.

Systemic and intratympanic administration of lidocaine has been used with controversial results (13-16).

For patients experiencing improvement of tinnitus following intravenous administration of lidocaine, carbamazepine has been reported to be effective in maintaining improvement (17).

Melatonin has recently been found helpful for patients with tinnitus especially for those with associated insomnia (18).

Alprazolam (Xanax) has a beneficial effect on tinnitus (19). This is potentially a habit-forming medication and should be used in cases that have failed other modalities of treatments.

Intratympanic injection of Gentamicin in patients with Meniere’s disease has been reported to be effective in reducing tinnitus in 65 percent of patients (20). Intratympanic injections of dexamethasone has also been found to be helpful in patients with low tone tinnitus and associated endolymphatic hydrops (21).

Nimodipine, an L-Calcium channel antagonist, has been reported to provide relief for a small number of tinnitus sufferers (22).

Anti-convulsive medications such as Primidone (Mysoline), Phenytoin (Dilantin), and Carbamazepine (Tegretol), have been used without any significant success (23). The effectiveness of medications with gamma-amino butyric acid (GABA) or GABA-like effects such as Baclofen are promising, however, they remain investigational (23).

Table 3 is a summary of medications that have been reported for treating tinnitus. The effectiveness of these medications, however, has not been established with controlled studies.

Surgical Treatment

Labyrinthectomy and translabyrinthine section of the eighth nerve have been reported to provide relief of tinnitus in up to 70 percent of cases (24).

Cochleovestibular neurectomy, vestibular neurectomy, and labyrinthectomy have been reported to improve tinnitus in 31 to 76 percent of patients (24-32).

Of 18 tinnitus patients undergoing microvascular decompression of the eighth nerve, tinnitus subsided in 8 and decreased in 9 (33).

Tinnitus associated with otosclerosis subsided following successful stapedectomy in 64 percent and improved in 16 percent of cases (34).

End of the first part.

REFERENCES

  1. Vernon J: Tinnitus causes, evaluation and treatment in otolaryngology (ed) G.M. English. Philadelphia: Lippincott Company, 1992.

  2. Vernon J: Tinnitus 1989: current knowledge and treatment therapy. The Hearing Journal 1989;42(11):7-11.

  3. National Center for Health Statistics: Basic data on hearing levels of adults 25-74 years, United States 1971-1975. Vital and Health Statistics Publication Series 11, No. 215. Hyattsville, Maryland, US Dept of Health Education and Welfare, 1980.

  4. Schleuning A: Medical aspects of tinnitus. The Hearing Journal 1989;42(11):12-5.

    5. Dobie RA: Tinnitus and depression. The International Tinnitus Journal 1997;3(1):33-4.

  5. Moller AR. Similarities between chronic pain and tinnitus. American Journal of Otolaryngology 1997;18:577-85.

  6. Jastreboff PJ, Gray WC, Gould SL. Neurophysiological approach to tinnitus patients. American Journal of Otolaryngology 1996;17:236-40.

    8. Schleuning AJ, Johnson RM. Use of Masking for Tinnitus. International Tinnitus Journal 1997;3(1):25-9.

    9. Jastreboff PJ, Jastreboff MM. Tinnitus Retraining Therapy (TRT) as a method for treatment of tinnitus and hyperacusis patients. Journal of the American Academy of Audiology 2000;11(3):162-77.

    10. Steenerson RL, Cronin GW. Treatment of tinnitus with electrical stimulation. Otolaryngology Head and Neck Surgery 1999;121(5):511-3.

  7. Aschendorff A, Pabst G, Klenzner T, et al. Tinnitus in Cochlear Implant Users: The Freiburg Experience. The International Tinnitus Journal 1998;4(2):162-4.

    12. Sullivan M, Katon W, Russo J. A randomized trial of nortriptyline for severe chronic tinnitus. Archives of Internal Medicine 1993;153:2251-9.

  8. Israel JM, Connelly JS, McTigue ST, et al. Lidocaine in the treatment of Tinnitus Aurium. Archives of Otolaryngology 1982;108:471-3.

  9. Coles RR, Thompson AC, O’Donoghue GM. Intra-tympanic injections in the treatment of Tinnitus. Clinical Otolaryngology 1992;17(3):240-2.

  10. Podoshin L, Fradis M, David YB. Treatment of tinnitus by intratympanic instillation of lignocaine (lidocaine) 2 per cent through ventilation tubes. Journal of Laryngology and Otology 1992;106(7):603-6.

  11. Rudack C, Hillebrandt M, Wagenmann M, et al. Treatment of tinnitus with lidocaine? A report of clinical experiences. HNO 1997;45(2):69-73.

  12. Sanchez TG, Balbani AP, Bittar RS, et al. Lidocaine test in patients with tinnitus: rationale of accomplishment and relation to the treatment with carbamazepine. Auris Nasus Larynx 1999;26(4):411-7.

  13. Rosenberg SI, Silverstein H, Rowan PT, et al. The effect of melatonin tinnitus. Laryngoscope 1998;108(3):305-10.

  14. Johnson RM, Brummett R, Schleuning A. Use of Alprazolam for relief of tinnitus: A double-blind study. Archives of Otolaryngology Head & Neck Surgery 1993;119:842-5.

  15. Kaasinen S, et al. Effect of intratympanically administered gentamycin on hearing and tinnitus in Ménière’s disease. Acta Otolaryngol (Stockh) Suppl 1995;520:184-5.

  16. Sakata E, Ito Y, Itoh A. Clinical Experiences of Steroid Targeting Therapy to Inner Ear for Control of Tinnitus. International Tinnitus Journal 1997;3(2):117-21.

  17. Davies E, Knox E, Donaldson I. The usefulness of nimodipine, an L-calcium channel antagonist, in the treatment of tinnitus. Br J Audio 1994;28:125-9.

  18. Moller AR. Tinnitus. In: Jackler RK, Brackmann DE, eds. Neurotology. St. Louis: Mosby-Year Book, 1994;153-65.

  19. Pulec JL. Tinnitus: surgical therapy. American Journal Otology 1984;5:479-80.

  20. Fisch J. Surgical treatment of vertigo. Journal of Laryngology and Otology 1976;90:75-86.

    26. Silverstein H: Transmental Labyrinthectomy with and without cochleovestibular neurectomy. Laryngoscope 1976;86:1777-91.

    27. House JW, Brackmann DE. Tinnitus, Surgical Management. Ciba Found Symp 1981;85:204-16.

  21. Gardner G. Neurologic Surgery and tinnitus. Journal of Otolaryngology (Suppl) 1984;9:311-8.

  22. Barrs DM, Brackmann DE. Translabyrinthine nerve section: Effect of tinnitus. Journal of Laryngology and Otology 1984;9:287-93.

  23. Silverstein H, Haberkamp T, Smouha E. The state of tinnitus after inner ear surgery. Otolaryngology Head and Neck Surgery 1986;95:438-41.

  24. Glasscock MC, Thedinger BA, Cueva RA. An analysis of the retrolabyrinthine vs the retrosigmoid vestibular nerve section. Otolaryngology Head and Neck Surgery 1991;104:88-95.

  25. Wazen JJ, Caruso M. Tinnitus outcome in surgery for vertigo. International Tinnitus Journal 1997;3(1):51-3.

  26. Okamura T, Kurokawa Y, Ikeda N, et al. Microvascular decompression for cochlear symptoms Journal of Neurosurgery 2000;93(3):421-6.

  27. Gersdorff M, Nouwen J, Gilain C, et al. Tinnitus and otosclerosis. Eur Arch Otorhinolaryngol 2000;257(6):314-6.

  28. Sismanis A. Otologic manifestations of benign intracranial hypertension syndrome: diagnosis and management. Laryngoscope 1987;42(97):1-17.

  29. Sismanis A, Stamm MA, Sobel M. Objective tinnitus in patients with atherosclerotic carotid artery disease. American Journal of Otology 1994;15:404-7.

  30. Sismanis A. Pulsatile tinnitus. A 15-year experience. American Journal of Otology 1998;19(4):472-7.

  31. Spence JD, Amacher AL, Willis NR. Benign intracranial hypertension without papilledema: Role of 24-hour cerebrospinal fluid pressure. Neurosurgery 1980;7(4):326-36

  32. Sismanis A, Callari RH, Slomka WS, Butts FM: Auditory evoked responses in benign intracranial hypertension syndrome. Laryngoscope 1990;100:1152-5.

  33. Hentzer E. Objective tinnitus of vascular type. Acta Otolaryngol 1968;66:273-81.

  34. Heller MF. Vibratory tinnitus and palatal myoclonus. Acta Otolaryngol (Stockh) 1962;55:292-8.

  35. Zipfel TE, Kaza SR, Greene JS. Middle-ear myoclonus. Journal of Laryngology and Otology 2000;114(3):207-9

  36. Wells RP, Smith RR. Fibromuscular dysplasia of the internal carotid artery: a long follow-up. Neurosurgery 1982;10:39-43.

  37. Saeed SR, Hinton AE, Ramsden RT, et al. Spontaneous dissection of the intrapetrous internal carotid artery. Journal of Laryngology and Otology 1990;104:491-3.

  38. Sismanis A, Butts, FM. A practical device for detection and recording of objective tinnitus. Otolaryngology Head and Neck Surgery 1994;110:459-62.

  39. Shin EJ, Lalwani AK, Dowd CF. Role of Angiography in the Evaluation of Patients with Pulsatile Tinnitus. Laryngoscope 2000;110:1916-20.

  40. Sismanis A, Smoker WRK. Pulsatile Tinnitus: Recent Advances in Diagnosis. Laryngoscope 1994;104:681-8.

  41. Michaelides EM, Sismanis A, Sugerman HJ, et al.: Pulsatile tinnitus in patients with morbid obesity: the effectiveness of weight reduction surgery. American Journal of Otology 2000;21(5):682.

  42. Jero J, Salmi T. Palatal myoclonus and clicking tinnitus in a 12-year-old girl - case report. Acta Otolaryngol Suppl 2000;543:61-2.

  43. Sismanis A, Butts FM, Hughes GB. Objective tinnitus in benign intracranial hypertension: an update. Laryngoscope 1990;100:33-6.

  Journal Home     Contents    Preview    Next