1. TINNITUS
Dr. Mohammed Subhan Hawramy
Otolaryngologist
Ph.D. candidate in Neuro-otology
2022-2023
5/28/2023
Tinnitus/ University of Sulaimani
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2. INTRODUCTION
• Tinnitus is defined as sensations of hearing in the absence of external sounds
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4. THE BURDEN OF TINNITUS
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5. PREVALENCE
• Prevalence increases with age
• 1/3 of the population have had tinnitus at some stage in their lives
• Up to 15% of the population currently experience tinnitus
• 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
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6. SOUND FEATURES OF TINNITUS
NOISE CRITERIA POSSIBLE FEATURES
Onset Sudden, gradual
Pattern Pulsatile, intermittent, constant, fluctuating
Site Right or left ear, both ears, within head
Loudness Wide range, varying over time
Quality Pure tone, noise, polyphonic
Pitch Very high, high, medium, low
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7. TINNITUS SUFFERERS
• Ludwig van Beethoven
• Vincent van Gogh
• Charles Darwin
• Neil Young
• Eric Clapton
• Ronald Regan
• Keanu Reeves
• Sylvester Stallone
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Tinnitus/ University of Sulaimani
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8. 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
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9. CAUSES
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10. EFFECTS OF TINNITUS
• Concentration
• Hearing
• Insomnia
• Psychological
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11. EAR ANATOMY
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12. MECHANISM OF HEARING
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13. MECHANISM OF HEARING
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14. PATHOPHYSIOLOGY OF TINNITUS
• 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.
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Tinnitus/ University of Sulaimani
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15. PERIPHERAL EVENTS LEAD TO CENTRAL
NEUROLOGICAL CHANGES
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16. BRAIN RESPONSE TO AUDITORY DEPRIVATION
• 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
• 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.
DECREASED
SOUND INPUT
INCREASED SOUND
SENSITIVITY
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17. • 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
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18. PSYCHOLOGICAL ASSOCIATIONS
WITH TINNITUS
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19. DIFFERENTIAL DIAGNOSIS
• Idiopathic (most common)
• Outer ear disease
– Wax, foreign body, infection
• Middle ear disease
– Infection, perforated eardrum, ossicular problems, tumour
• Inner ear disease
– Presbyacusis (older age hearing loss)
– Meniere’s disease
– Acoustic neuroma
– Noise exposure
– Drugs
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Tinnitus/ University of Sulaimani
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20. 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
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21. NORMAL EAR VS. DISEASED EAR
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22. EVALUATION OF TINNITUS
• Audiological (hearing) Tests
• Audiogram, tympanogram
• Specialized hearing tests: SOAE, ECochG, ABR
• MRI
• Associated symptoms
• Asymmetric hearing loss
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23. EVALUATION OF SUBJECTIVE TINNITUS
• Audiometry - assymetrical hearing loss, unilateral tinnitus - MRI r/o post fossa
• Complete questionnaire for perceived severity:THI, IOWA, TFI
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24. MEASUREMENT OF TINNITUS
• Pitch
• Loudness
• minimum masking level
• residual inhibition/post masking
• Minimum masking level most clinical use
• Minimal masking level - number of decibels to cover tinnitus
• Residual inhibition - response of patients tinnitus post masking
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Tinnitus/ University of Sulaimani
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25. ENT Referral
ENT Referral
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26. ACOUSTIC NEUROMA
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27. TREATMENT
• Aim to improve habituation rather than “cure” tinnitus
• Most people don’t seek treatment
• Multitude of potential treatments
• Problems with scientific evidence
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28. TREATMENT
• Basic advice
• Hearing Aid
• Tinnitus Masking Device
• Tinnitus Instrument
• Tinnitus Retraining Therapy
• Psychological Treatment
• Medication
• Alternative Treatments
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29. 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
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Tinnitus/ University of Sulaimani
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30. TREATMENT
• Basic advice
• Hearing Aid
• Tinnitus Masking Device
• Tinnitus Instrument
• Tinnitus Retraining Therapy
• Psychological Treatment
• Medication
• Alternative Treatments
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Tinnitus/ University of Sulaimani
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31. 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
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32. PSYCHOLOGICAL AND
BEHAVIOURAL SUPPORT
INTERVENTION DESCRIPTION
Counselling and
education
• Delivered in person, to groups and via the internet
• Variable results may depend on personal characteristics
Cognitive behavioural
therapy
• Designed to modify maladaptive behavioural and emotional responses
• One-to-one and group settings, delivered by psychologists or psychiatrists, or
via internet
• Statistically significant reductions in severity of tinnitus symptoms (P<0.05)
Relaxation therapy • May help reduce tinnitus symptoms and depressive symptoms
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Tinnitus/ University of Sulaimani
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33. MEDICATIONS
• No approved drugs (European Medicines Agency [EMA] or US Food and Drug Administration [FDA])
• Some psychopharmacological agents may help reduce the severity of psychological issues associated with
tinnitus, and some may also lessen tinnitus symptoms
DRUG CLASS EXAMPLES OF DRUGS USED IN TINNITUS
Antidepressants tricyclics, selective serotonin reuptake inhibitors
Antipsychotics sulpiride
Mood stabilisers gabapentin, valproate
Sedatives/hypnotics benzodiazepines
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Tinnitus/ University of Sulaimani
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34. ALTERNATIVE THERAPIES
• Vitamins
• B1, B3, B6, B12, zinc, calcium, Mg
• Laser Therapy
• Germany
• Thought to increase ATP in cochlea
• Hypnotherapy
• Acupuncture
• Ear canal magnets
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