Diagnosis and Treatment/Management of

TinnitusYongbing Shi, M.D., Ph.D.

Tinnitus ClinicOHSU Department of Otolaryngology Head &

Neck Surgery

What Tinnitus Is

• Definition: A perception of sound without external sound source

• A common symptom – 15% of population• Subjective and objective tinnitus

What Cause Tinnitus

• Changes in the auditory system: conductive hearing loss (outer and middle ear disorders), sensorineural hearing loss (inner ear/central auditory pathways)

• Systemic diseases: head/neck injury, anemia, renal diseases, hormonal disturbances

• Medications: ototoxic antibiotics, anti-inflammatories, quinine products, cytotoxic medications, and others

How Tinnitus Is Generated

• Altered neuronal activities along the auditory pathway: de-afferentation; loss of inhibition; enhanced spontaneous activities; rhythmic activities;

• Abnormal activation of auditory cortex• Self-sustaining and perpetuating activities• Neuroplasticity in chronic tinnitus

How Tinnitus Affects Patients

• In addition to annoying auditory perception

• Involvement of non-auditory neural structures in the CNS

• Interactions between auditory and non-auditory activities

• Non-auditory symptoms are a major part of the tinnitus problem

Evaluation of a Tinnitus Patient

• Establish the diagnoses• Look for treatable causes• Determine severity of tinnitus• Determine relations between tinnitus and

non-auditory complaints• Identify non-auditory factors that may

contribute to tinnitus complaints

Establish Tinnitus Diagnoses

• Is it tinnitus• Subjective or objective tinnitus• Other qualities of tinnitus: acute/chronic,

high/low pitches, unilateral/bilateral, constant/intermittent, pulsatile/non-pulsatile

• Possible causal/underlysing conditions• Associated non-auditory diagnoses

Determine Severity of Tinnitus

• Self-rated tinnitus loudness• Matched tinnitus loudness• Tinnitus severity evaluation questionnaires (THI, TSI,

TQ, TFI, etc)• Mild: education/reassurance/counseling, hearing

aids or masking devices• Moderate: plus habituation therapies, possibly

medications and follow up• Severe: plus referrals

Determine Relations between Tinnitus and Non-Auditory Complaints

• Sleep: how insomnia and tinnitus affect each other

• Mood disturbances: how anxiety, stress and other mood changes affect tinnitus and vice versa

• Cognitive dysfunction: does tinnitus affect the patient’s concentration, memory, learning and other abilities

• Vicious circle

Identify Non-Auditory Factors Contributing to Complaints

• Personality• Relational difficulties• Emotional difficulties• Economical difficulties• Behavioral problems

Tinnitus Treatment

• Treat causal conditions• Manage tinnitus and related problems when

there is no treatable causes

Management of Tinnitus with No Treatable Causes

• Reduce tinnitus perception• Promote tinnitus habituation• Improve sleep• Address mood disturbances• Counsel on life style changes and other related

issues• Judicious use of alternative medicine approaches• Management goal: minimal tinnitus impact on

patient, improved functioning and quality of life

Reduce Tinnitus Perception

• Sound therapy (masking): sound generators, personal listening devices, sound pillow, bed side sound machines, etc.

• Sound choices: band noises, tonal sounds, music, patterned sounds, etc

• Hearing aids: double benefits• Combination units• Cochlear implants• Ultrasound devices• Medications: benzodiazepines, etc.

Promote Tinnitus Habituation

• Acoustic stimulation (sound therapy): broadband noise (TRT), adjusted tonal sounds (Neuromoics)

• Patient education and counseling• Long term follow ups• Time• Management of other contributing factors:

sleep, anxiety, depression, stress, etc.

Improve Sleep

• Medications: alprazolam, zolpidem, melatonin receptor agonists, antidepressants, etc.

• Masking in bedroom: bed side machines, sound pillow, headband headphones

• Sleep hygiene: sleep habit, factors affecting sleep• Psychological conditions affecting sleep• Other medical conditions affecting sleep: OSA,

systemic medical diseases, etc.• Referral to specialty sleep clinic

Address Mood Disturbances

• First hand counseling• Medications: anti-depressants, anxiolytics,

other sedatives and anti-seizure medications• Referral to specialists: psychiatrist,

psychologist

Counsel on Other Related Issues

• Socioeconomic issues: job, finance, work-related stress, etc

• Relations: family issues, social activities, etc• Other activities: music, hunting, racing, etc• Life style changes: smoking, alcohol, diet, etc• Other medical issues potentially affecting

tinnitus: hypertension, diabetes, anemia, hypothyroidism, depression, etc

Judicious Use of Alternative Medicine Approaches

• Herbal medicine and supplements• Acupuncture• Chiropractic treatments, etc

Team Approach

• General practitioner• Otolaryngologist• Audiologist• Neurophysiologist• Psychiatrist/psychologist• Dentist• Other specialists• Social workers• Family members

Take Home Points

• Thorough evaluation including non-auditory issues

• Treat causes whenever possible• Management of chronic tinnitus (there is NO

cure) includes reducing tinnitus perception, habituation to tinnitus and management of related non-auditory issues

• Goal: reduced tinnitus impact and improved functioning and quality of life