diagnosis and treatment/management of tinnitus yongbing shi, m.d., ph.d. tinnitus clinic ohsu...
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Diagnosis and Treatment/Management of
TinnitusYongbing Shi, M.D., Ph.D.
Tinnitus ClinicOHSU Department of Otolaryngology Head &
Neck Surgery
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What Tinnitus Is
• Definition: A perception of sound without external sound source
• A common symptom – 15% of population• Subjective and objective tinnitus
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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
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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
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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
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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
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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
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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
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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
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Identify Non-Auditory Factors Contributing to Complaints
• Personality• Relational difficulties• Emotional difficulties• Economical difficulties• Behavioral problems
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Tinnitus Treatment
• Treat causal conditions• Manage tinnitus and related problems when
there is no treatable causes
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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
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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.
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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.
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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
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Address Mood Disturbances
• First hand counseling• Medications: anti-depressants, anxiolytics,
other sedatives and anti-seizure medications• Referral to specialists: psychiatrist,
psychologist
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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
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Judicious Use of Alternative Medicine Approaches
• Herbal medicine and supplements• Acupuncture• Chiropractic treatments, etc
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Team Approach
• General practitioner• Otolaryngologist• Audiologist• Neurophysiologist• Psychiatrist/psychologist• Dentist• Other specialists• Social workers• Family members
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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