TinnitusTinnitusGrand Rounds Grand Rounds

January 22, 2003January 22, 2003Gordon Shields, MDGordon Shields, MDFrancis Quinn, MD Francis Quinn, MD

“…“…only my ears whistle and buzz only my ears whistle and buzz continuously day and night. I can continuously day and night. I can

say I am living a wretched life.”say I am living a wretched life.”

Ludwig Von Beethoven - 1801Ludwig Von Beethoven - 1801

TinnitusTinnitus

• DefinitionDefinition• ClassificationClassification• Objective tinnitus – pulsatile Objective tinnitus – pulsatile • Subjective tinnitusSubjective tinnitus• TheoriesTheories• EvaluationEvaluation• TreatmentTreatment

IntroductionIntroduction

• Tinnitus -“The perception of sound Tinnitus -“The perception of sound in the absence of external stimuli.”in the absence of external stimuli.”

• Tinnere Tinnere – means “ringing” in Latin– means “ringing” in Latin• Includes Buzzing, roaring, clicking, Includes Buzzing, roaring, clicking,

pulsatile soundspulsatile sounds

TinnitusTinnitus

• May be perceived as unilateral or May be perceived as unilateral or bilateralbilateral

• Originating in the ears or around the Originating in the ears or around the headhead

• First or only symptom of a disease First or only symptom of a disease process or auditory/psychological process or auditory/psychological annoyanceannoyance

TinnitusTinnitus

• 40 million affected in the United 40 million affected in the United StatesStates

• 10 million severely affected10 million severely affected• Most common in 40-70 year-oldsMost common in 40-70 year-olds• More common in men than womenMore common in men than women

ClassificationClassification

• Objective tinnitusObjective tinnitus – sound produced – sound produced by paraauditory structures which by paraauditory structures which may be heard by an examinermay be heard by an examiner

• Subjective tinnitusSubjective tinnitus – sound is only – sound is only perceived by the patient (most perceived by the patient (most common)common)

TinnitusTinnitus

• Pulsatile tinnitus – matches pulse or Pulsatile tinnitus – matches pulse or a rushing sound a rushing sound – Possible vascular etiologyPossible vascular etiology– Either objective or subjectiveEither objective or subjective– Increased or turbulent bloodflow Increased or turbulent bloodflow

through paraauditory structuresthrough paraauditory structures

Objective -Pulsatile Objective -Pulsatile tinnitustinnitus

• Arteriovenous Arteriovenous malformationsmalformations

• Vascular tumorsVascular tumors• Venous humVenous hum• AtherosclerosisAtherosclerosis• Ectopic carotid arteryEctopic carotid artery• Persistent stapedial Persistent stapedial

arteryartery• Dehiscent jugular Dehiscent jugular

bulbbulb• Vascular loopsVascular loops

• Cardiac murmursCardiac murmurs• PregnancyPregnancy• AnemiaAnemia• ThyrotoxicosisThyrotoxicosis• Paget’s diseasePaget’s disease• Benign intracranial Benign intracranial

hypertensionhypertension

Arteriovenous Arteriovenous malformationsmalformations

• Congenital lesionsCongenital lesions• Occipital artery and transverse Occipital artery and transverse

sinus, internal carotid and vertebral sinus, internal carotid and vertebral arteries, middle meningeal and arteries, middle meningeal and greater superficial petrosal arteriesgreater superficial petrosal arteries

• MandibleMandible• Brain parenchymaBrain parenchyma• DuraDura

Arteriovenous Arteriovenous malformationsmalformations

• Pulsatile tinnitusPulsatile tinnitus• HeadacheHeadache• PapilledemaPapilledema• Discoloration of skin or mucosaDiscoloration of skin or mucosa

Vascular tumorsVascular tumors

• Glomus tympanicumGlomus tympanicum– Paraganglioma of middle ear Paraganglioma of middle ear – Pulsatile tinnitus which may decrease Pulsatile tinnitus which may decrease

with ipsilateral carotid artery with ipsilateral carotid artery compressioncompression

– Reddish mass behind tympanic Reddish mass behind tympanic membrane which blanches with positive membrane which blanches with positive pressurepressure

– Conductive hearing lossConductive hearing loss

Vascular tumorsVascular tumors

• Glomus jugulareGlomus jugulare– Paraganlioma of jugular fossaParaganlioma of jugular fossa– Pulsatile tinnitusPulsatile tinnitus– Conductive hearing loss if into middle Conductive hearing loss if into middle

earear– Cranial neuropathiesCranial neuropathies

Venous humVenous hum

• Benign intracranial hypertensionBenign intracranial hypertension• Dehiscent jugular bulbDehiscent jugular bulb• Transverse sinus partial obstructionTransverse sinus partial obstruction• Increased cardiac output from Increased cardiac output from

– PregnancyPregnancy– ThyrotoxicosisThyrotoxicosis– AnemiaAnemia

Benign Intracranial Benign Intracranial HypertensionHypertension

• Young, obese, female patientsYoung, obese, female patients• Hearing lossHearing loss• Aural fullnessAural fullness• DizzinessDizziness• HeadachesHeadaches• Visual disturbanceVisual disturbance• Papilledema, pressure >200mm H20 Papilledema, pressure >200mm H20

on LPon LP

Benign Intracranial Benign Intracranial HypertensionHypertension

• Sismanis and Smoker 1994Sismanis and Smoker 1994– 100 patients with pulsatile tinnitus100 patients with pulsatile tinnitus– 42 found to have BIH syndrome42 found to have BIH syndrome– 16 glomus tumors16 glomus tumors– 15 atherosclerotic carotid artery 15 atherosclerotic carotid artery

diseasedisease

BIH SyndromeBIH Syndrome

• TreatmentTreatment– Weight lossWeight loss– DiureticsDiuretics– Subarachnoid-peritoneal shuntSubarachnoid-peritoneal shunt– Gastric bypass for weight reductionGastric bypass for weight reduction

Muscular Causes of Muscular Causes of TinnitusTinnitus

• Palatal myoclonusPalatal myoclonus– Clicking soundClicking sound– Rapid (60-200 beats/min), intermittentRapid (60-200 beats/min), intermittent– Contracture of tensor palantini, levator Contracture of tensor palantini, levator

palatini, levator veli palatini, tensor palatini, levator veli palatini, tensor tympani, salpingopharyngeal, superior tympani, salpingopharyngeal, superior constrictorsconstrictors

– Muscle spasm seen orally or transnasallyMuscle spasm seen orally or transnasally– Rhythmic compliance change on Rhythmic compliance change on

tympanogram tympanogram

MyoclonusMyoclonus

• Palatal myoclonus associations:Palatal myoclonus associations:– Multiple Sclerosis and other Multiple Sclerosis and other

degenerative neurological disordersdegenerative neurological disorders– Small vessel diseaseSmall vessel disease– TumorsTumors

• treatments: muscle relaxants, treatments: muscle relaxants, botulinum toxin injectionbotulinum toxin injection

Stapedius Muscle SpasmStapedius Muscle Spasm

• Idiopathic stapedial muscle spasmIdiopathic stapedial muscle spasm– Rough, rumbling, crackling soundRough, rumbling, crackling sound– Exacerbated by outside soundsExacerbated by outside sounds– Brief and intermittentBrief and intermittent– May be able to see tympanic membrane May be able to see tympanic membrane

movementmovement– Treatments: avoidance of stimulants, Treatments: avoidance of stimulants,

muscle relaxants, sometimes surgical muscle relaxants, sometimes surgical division of tensor tympani and stapedius division of tensor tympani and stapedius musclesmuscles

Patulous Eustachian Patulous Eustachian TubeTube

• Eustachian tube remains open Eustachian tube remains open abnormallyabnormally

• Ocean roar soundOcean roar sound• Changes with respirationChanges with respiration• Lying down or head in dependent Lying down or head in dependent

position provides reliefposition provides relief

Patulous Eustachian Patulous Eustachian TubeTube

• Tympanogram will show changes in Tympanogram will show changes in compliance with respirationcompliance with respiration

• Significant weight loss, radiation to the Significant weight loss, radiation to the nasopharynxnasopharynx

• Previous treatments: caustics, mucosal Previous treatments: caustics, mucosal irritants, saturated solution of irritants, saturated solution of potassium iodide, Teflon or gelfoam potassium iodide, Teflon or gelfoam injection around torus tubariusinjection around torus tubarius

Subjective TinnitusSubjective Tinnitus• Much more common than Much more common than

objectiveobjective• Usually nonpulsatileUsually nonpulsatile

• PresbycusisPresbycusis• Noise exposureNoise exposure• Meniere’s diseaseMeniere’s disease• OtosclerosisOtosclerosis• Head traumaHead trauma• Acoustic neuromaAcoustic neuroma• DrugsDrugs• Middle ear effusionMiddle ear effusion• TMJ problemsTMJ problems• DepressionDepression• HyperlipidemiaHyperlipidemia• MeningitisMeningitis• SyphilisSyphilis

Conductive hearing lossConductive hearing loss

• Conductive hearing loss decreases Conductive hearing loss decreases level of background noiselevel of background noise

• Normal paraauditory sounds seem Normal paraauditory sounds seem amplifiedamplified

• Cerumen impaction, otosclerosis, Cerumen impaction, otosclerosis, middle ear effusion are examplesmiddle ear effusion are examples

• Treating the cause of conductive Treating the cause of conductive hearing loss may alleviate the tinnitushearing loss may alleviate the tinnitus

Other subjective tinnitusOther subjective tinnitus

• Poorly understood mechanisms of Poorly understood mechanisms of tinnitus productiontinnitus production

• Abnormal conditions in the cochlea, Abnormal conditions in the cochlea, cochlear nerve, ascending auditory cochlear nerve, ascending auditory pathways, auditory cortexpathways, auditory cortex

• Hyperactive hair cellsHyperactive hair cells• Chemical imbalanceChemical imbalance

CNS MechanismsCNS Mechanisms

• Reorganization of central pathways Reorganization of central pathways with hearing loss (similar to with hearing loss (similar to phantom limb pain)phantom limb pain)

• Disinhibition of dorsal cochlear Disinhibition of dorsal cochlear nucleus with increase in nucleus with increase in spontaneous activity of central spontaneous activity of central auditory systemauditory system

Neurophysiologic ModelNeurophysiologic Model

• Proposed by JastreboffProposed by Jastreboff• Result of interaction of subsystems in Result of interaction of subsystems in

the nervous systemthe nervous system• Auditory pathways playing a role in Auditory pathways playing a role in

development and appearance of tinnitusdevelopment and appearance of tinnitus• Limbic system responsible for tinnitus Limbic system responsible for tinnitus

annoyanceannoyance• Negative reinforcement enhances Negative reinforcement enhances

perception of tinnitus and increases perception of tinnitus and increases time it is perceivedtime it is perceived

Role of DepressionRole of Depression

• Depression is more prevalent in Depression is more prevalent in patients with chronic tinnitus than in patients with chronic tinnitus than in those without tinnitusthose without tinnitus

• Folmer et al (1999) reported patients Folmer et al (1999) reported patients with depression rated the severity of with depression rated the severity of their tinnitus higher although their tinnitus higher although loudness scores were the sameloudness scores were the same

• Which comes first, depression or Which comes first, depression or tinnitus?tinnitus?

Drugs that cause tinnitusDrugs that cause tinnitus

• AntinflammatoriesAntinflammatories• Antibiotics Antibiotics

(aminoglycosides)(aminoglycosides)• Antidepressants Antidepressants

(heterocyclines)(heterocyclines)

• AspirinAspirin• QuinineQuinine• Loop diureticsLoop diuretics• Chemotherapeutic Chemotherapeutic

agents (cisplatin, agents (cisplatin, vincristine)vincristine)

Evaluation - HistoryEvaluation - History

• Careful historyCareful history• QualityQuality• PitchPitch• LoudnessLoudness• Constant/intermittentConstant/intermittent• OnsetOnset• Alleviating/aggravating factorsAlleviating/aggravating factors

Evaluation - HistoryEvaluation - History

• InfectionInfection• TraumaTrauma• Noise exposureNoise exposure• Medication usageMedication usage• Medical historyMedical history• Hearing lossHearing loss• VertigoVertigo• PainPain• Family historyFamily history• Impact on patientImpact on patient

Evaluation – Physical Evaluation – Physical ExamExam

• Complete head & neck examComplete head & neck exam• General physical examGeneral physical exam• Otoscopy (glomus tympanicum, dehiscent Otoscopy (glomus tympanicum, dehiscent

jugular bulb)jugular bulb)• Search for audible bruit in pulsatile Search for audible bruit in pulsatile

tinnitustinnitus– Auscultate over orbit, mastoid process, skull, Auscultate over orbit, mastoid process, skull,

neck, heart using bell and diaphragm of neck, heart using bell and diaphragm of stethoscopestethoscope

– Toynbee tube to auscultate EACToynbee tube to auscultate EAC

Evaluation – Physical Evaluation – Physical ExamExam

• Light exercise to increase pulsatile Light exercise to increase pulsatile tinnitustinnitus

• Light pressure on the neck Light pressure on the neck (decreases venous hum)(decreases venous hum)

• Valsalva maneuver (decrease venous Valsalva maneuver (decrease venous hum)hum)

• Turning the head (decrease venous Turning the head (decrease venous hum)hum)

Evaluation - AudiometryEvaluation - Audiometry

• PTA, speech descrimination scores, PTA, speech descrimination scores, tympanometry, acoustic reflexestympanometry, acoustic reflexes

• Pitch matchingPitch matching• Loudness matchingLoudness matching• Masking levelMasking level

Evaluation - AudiometryEvaluation - Audiometry

• Vascular or palatomyoclonus induced Vascular or palatomyoclonus induced tinnitus – graph of compliance vs. tinnitus – graph of compliance vs. timetime

• Patulous Eustachian tube – changes Patulous Eustachian tube – changes in compliance with respirationin compliance with respiration

• Asymmetric sensorineural hearing Asymmetric sensorineural hearing loss or speech discrimination, loss or speech discrimination, unilateral tinnitus suggests possible unilateral tinnitus suggests possible acoustic neuroma - MRIacoustic neuroma - MRI

From: Tyler RS, Babin RW. Tinnitus. In: Cummings CW, ed. Otolaryngology-Head and Neck Surgery, second edition. St. Louis, Mosby-Year Book, 1993:3032.

Laboratory studiesLaboratory studies

• As indicated by history and physical As indicated by history and physical examexam

• Possibilities include:Possibilities include:– HematocritHematocrit– FTA absorption testFTA absorption test– Blood chemistriesBlood chemistries– Thyroid studiesThyroid studies– Lipid batteryLipid battery

ImagingImaging

• Pulsatile tinnitusPulsatile tinnitus• Reviewed by Weissman and Hirsch Reviewed by Weissman and Hirsch

(2000)(2000)• Contrast enhanced CT of temporal Contrast enhanced CT of temporal

bones, skull base, brain, calvaria as bones, skull base, brain, calvaria as first-line studyfirst-line study

• Sismanis and Smoker (1994) Sismanis and Smoker (1994) recommended CT for retrotympanic recommended CT for retrotympanic mass, MRI/MRA if normal otoscopymass, MRI/MRA if normal otoscopy

• Glomus tympanicum – bone Glomus tympanicum – bone algorithm CT scan best shows extent algorithm CT scan best shows extent of massof mass

• May not be able to see enhancement May not be able to see enhancement of small tumorof small tumor

• Tumor enhances on T1-weighted Tumor enhances on T1-weighted images with gadolinium or on T2-images with gadolinium or on T2-weighted imagesweighted images

Glomus TympanicumGlomus Tympanicum

From: Weissman JL, Hirsch BE. Imaging of tinnitus: a review. Radiology 2000;216:343.

Glomus TympanicumGlomus Tympanicum

From: Weissman JL, Hirsch BE. Imaging of tinnitus: a review. Radiology 2000;216:343.

ImagingImaging

• Glomus jugulareGlomus jugulare– Erosion of osseous jugular fossaErosion of osseous jugular fossa– Enhance with contrast, may not be able Enhance with contrast, may not be able

to differentiate jugular vein and tumorto differentiate jugular vein and tumor– Enhance with T1-weighted MRI with Enhance with T1-weighted MRI with

gadolinium and on T2-weighted imagesgadolinium and on T2-weighted images– Characteristic “salt and pepper” Characteristic “salt and pepper”

appearance on MRIappearance on MRI

Glomus jugulareGlomus jugulare

From: Weissman JL, Hirsch BE. Imaging of

tinnitus: a review. Radiology 2000;216:344.

Glomus jugulareGlomus jugulare

“salt and pepper appearance”

From: Weissman JL, Hirsch BE. Imaging of tinnitus: a review. Radiology 2000;216:344.

ImagingImaging

• Arteriovenous malformations – readily Arteriovenous malformations – readily apparent on contrasted CT and MRIapparent on contrasted CT and MRI

• Normal otoscopic exam and pulsatile Normal otoscopic exam and pulsatile tinnitus may be dural arteriovenous tinnitus may be dural arteriovenous fistulafistula– Often invisible on contrasted CT and Often invisible on contrasted CT and

MRI/MRAMRI/MRA– Angiography may be only diagnostic testAngiography may be only diagnostic test

ImaginingImagining

• Shin et al (2000)Shin et al (2000)– MRI/MRA initially if subjective pulsatile MRI/MRA initially if subjective pulsatile

tinnitustinnitus– Angiography if objective with audible Angiography if objective with audible

bruit in order to identify dural bruit in order to identify dural arteriovenous fistulaarteriovenous fistula

ImagingImaging

• Other contrast enhanced CT diagnosesOther contrast enhanced CT diagnoses• Aberrant carotid arteryAberrant carotid artery• Dehiscent carotid arteryDehiscent carotid artery• Dehiscent jugular bulbDehiscent jugular bulb• Persistent stapedial arteryPersistent stapedial artery

– Soft tissue on promontorySoft tissue on promontory– Enlargement of facial nerve canalEnlargement of facial nerve canal– Absence of foramen spinosumAbsence of foramen spinosum

Persistent Stapedial ArteryPersistent Stapedial Artery

From: Araujo MF et al. Radiology quiz case I: persistent stapedial artery. Arch Otolaryngol Head Neck Surg 2002;128:456.

ImagingImaging

• Acoustic NeuromaAcoustic Neuroma– Unilateral tinnitus, asymmetric Unilateral tinnitus, asymmetric

sensorineural hearing loss or speech sensorineural hearing loss or speech descrimination scoresdescrimination scores

– T1-weighted MRI with gadolinium T1-weighted MRI with gadolinium enhancement of CP angle is study of enhancement of CP angle is study of choicechoice

– Thin section T2-weighted MRI of Thin section T2-weighted MRI of temporal bones and IACs may be temporal bones and IACs may be acceptable screening testacceptable screening test

Acoustic NeuromaAcoustic Neuroma

From: Weissman JL, Hirsch BE. Imaging of tinnitus: a review. Radiology 2000;216:348.

Acoustic NeuromaAcoustic Neuroma

From: Weissman JL, Hirsch BE. Imaging of tinnitus: a review. Radiology 2000;216:348.

ImagingImaging

• Benign intracranial hypertensionBenign intracranial hypertension– MRIMRI– Small ventriclesSmall ventricles– Empty sella Empty sella

BIH – Empty SellaBIH – Empty Sella

Sismanis A, Smoker W. Pulsatile tinnitus: recent advances in diagnosis. Laryngoscope 1994;104:685.

TreatmentsTreatments

• Multiple Multiple treatmentstreatments

• Avoidance of Avoidance of dietary stimulants: dietary stimulants: coffee, tea, cola, coffee, tea, cola, etc.etc.

• Smoking cessationSmoking cessation• Avoid medications Avoid medications

known to cause known to cause tinnitustinnitus

• ReassuranceReassurance• White noise from White noise from

radio or home radio or home masking machinemasking machine

Treatments - MedicinesTreatments - Medicines

• Many medications have been Many medications have been researched for the treatment of researched for the treatment of tinnitus:tinnitus:– Intravenous lidocaine suppresses tinnitus Intravenous lidocaine suppresses tinnitus

but is impractical to use clinicallybut is impractical to use clinically– Tocainide is oral analog which is Tocainide is oral analog which is

ineffectiveineffective– Carbamazepine ineffective and may Carbamazepine ineffective and may

cause bone marrow suppressioncause bone marrow suppression

Treatments - MedicinesTreatments - Medicines

• Alprazolam (Xanax)Alprazolam (Xanax)– Johnson et al (1993) found 76% of 17 Johnson et al (1993) found 76% of 17

patients had reduction in the loudness patients had reduction in the loudness of their tinnitus using both a tinnitus of their tinnitus using both a tinnitus synthesizer and VAS (dose 0.5mg-1.5 synthesizer and VAS (dose 0.5mg-1.5 mg/day)mg/day)

– Dependence problem, long-term use is Dependence problem, long-term use is not recommendednot recommended

Treatments - MedicinesTreatments - Medicines

• Nortriptyline and amitriptylineNortriptyline and amitriptyline– May have some benefitMay have some benefit– Dobie et al reported on 92 patients Dobie et al reported on 92 patients – 67% nortriptlyine benefit, 40%placebo67% nortriptlyine benefit, 40%placebo

• Ginko bilobaGinko biloba– Extract at doses of 120-160mg per day Extract at doses of 120-160mg per day – Shown to be effective in some trials and Shown to be effective in some trials and

not in othersnot in others– Needs further studyNeeds further study

TreatmentsTreatments

• Hearing aids – amplification of Hearing aids – amplification of background noise can decrease background noise can decrease tinnitustinnitus

• Maskers – produce sound to mask Maskers – produce sound to mask tinnitustinnitus

• Tinnitus instrument – combination of Tinnitus instrument – combination of hearing aid and maskerhearing aid and masker

TreatmentsTreatments

• Tinnitus Retraining TherapyTinnitus Retraining Therapy– Based on neurophysiologic modelBased on neurophysiologic model– Combination of masking with low level Combination of masking with low level

broadband noise for several hours per broadband noise for several hours per day and counseling to achieve day and counseling to achieve habituation of the reaction to tinnitus habituation of the reaction to tinnitus and perception of the tinnitus itselfand perception of the tinnitus itself

TreatmentsTreatments

• Electrical stimulation of the cochleaElectrical stimulation of the cochlea– Transcutaneous, round window, Transcutaneous, round window,

promontory stimulation have all been promontory stimulation have all been triedtried

– Direct current can cause permanent Direct current can cause permanent damagedamage

– Steenersen and Cronin have used Steenersen and Cronin have used transcutaneous stimulation of the auricle transcutaneous stimulation of the auricle and tragus decreasing tinnitus in 53% of and tragus decreasing tinnitus in 53% of 500 patients500 patients

TreatmentsTreatments

• Cochlear implantsCochlear implants– Have shown some promise in relief of Have shown some promise in relief of

tinnitustinnitus– Ito and Sakakihara (1994) reported that Ito and Sakakihara (1994) reported that

in 26 patients implanted who had in 26 patients implanted who had tinnitus 77% reported either tinnitus tinnitus 77% reported either tinnitus was abolished or suppressed, 8% was abolished or suppressed, 8% reported worseningreported worsening

TreatmentsTreatments

• SurgerySurgery– Used for treatment of arteriovenous Used for treatment of arteriovenous

malformations, glomus tumors, malformations, glomus tumors, otosclerosis, acoustic neuromaotosclerosis, acoustic neuroma

– Some authors have reported success Some authors have reported success with cochlear nerve section in patients with cochlear nerve section in patients who have intractable tinnitus and have who have intractable tinnitus and have failed all other treatments, this is not failed all other treatments, this is not widely acceptedwidely accepted

TreatmentsTreatments

• BiofeedbackBiofeedback• HypnosisHypnosis• Magnetic stimulationMagnetic stimulation• AcupunctureAcupuncture• Conflicting reports of benefitConflicting reports of benefit

ConclusionsConclusions

• Tinnitus is a common problem with an Tinnitus is a common problem with an extensive differentialextensive differential

• Need to identify medical process if Need to identify medical process if involvedinvolved

• Pulsatile/Nonpulsatile is important Pulsatile/Nonpulsatile is important distinctiondistinction

• Will only become more common with aging Will only become more common with aging of our populationof our population

• Research into mechanism and treatments Research into mechanism and treatments is needed to better help our patientsis needed to better help our patients