Update in Tinnitus

Educational Objectives

The goals of this lecture are to improve diagnosis and treatment of otologic disorders. After hearing and assimilating this lecture, the clinician will be better able to:

1. Counsel a patient considering biofeedback for tinnitus.

2. Select appropriate treatments for patients with tinnitus.

Summary

Types of tinnitus: objective tinnitus heard by examiner; subjective tinnitus heard only by patient; tinnitus typically in higher frequencies (similar to frequency at which hearing loss detected); chronic tinnitus often high-frequency, but acute tinnitus occurs at any frequency; tinnitus usually 5 to 8 dB above hearing threshold; patients vary in degree to which they find tinnitus disturbing; explanation and reassurance important (patients often concerned about becoming deaf); 80% of patients with any degree of hearing loss have tinnitus

Electrical stimulation: patients receiving early CI reported that tinnitus improved, prompting idea that electrical stimulation might cure tinnitus; electrical stimulation applied at same frequency as CI improves tinnitus in some patients

Biofeedback: used to help patients relax frontalis muscles (muscular tension makes tinnitus louder); patients gain understanding of relationship between stress and tinnitus, practice relaxation techniques, and learn to control autonomic function; psychometric testing — in speaker’s study, patients with severe tinnitus had abnormal Minnesota Multiphasic Personality Inventory (MMPI) scores, with high scores related to depression, anxiety, and psychosomatic disorders; MMPI scores normal in control group of individuals who did not feel disturbed by their tinnitus; however, study does not reveal whether abnormalities on MMPI caused by or result of tinnitus; among 132 patients treated with weekly biofeedback for 12 wk, 15% had complete relief, 29% showed improvement, one-third derived some benefit, and none reported worsening of tinnitus

Medications: lidocaine (Xylocaine) — favorable effect on tinnitus lasts only few minutes; psychotropic medications — small doses of alprazolam (eg, Niravam, Xanax) or diazepam (Valium) may help anxious patient fall asleep; patients with early-morning awakening (suggesting depression) may benefit from small doses of amitriptyline (Elavil) or nortriptyline; small doses do not address depression but may act centrally to improve tinnitus; intratympanic (IT) dexamethasone — may improve acute tinnitus and sudden hearing loss, but not chronic tinnitus; alternatives — lipoflavonoids and several vitamins have been suggested; double-blind, crossover study evaluated Ginkgo, vitamin B12, and magnesium in 20 patients; this study and others showed large placebo effect and no difference between groups; low-dose amitriptyline probably more effective than Ginkgo

Other treatments: laser — transtympanic low-power laser reported to cure tinnitus, but subsequent study found no benefit; misoprostol — not beneficial; transcranial magnetic stimulation — tried because tinnitus central problem related to specific areas in brain; however, studies found no difference between controls and treated patients; masking — in study, 27 patients advised to try masking, but only 13 did so; of these, 7 purchased masker, suggesting treatment not panacea; HA — strongly recommended, even if hearing loss mild; HA may be used for patients bothered by tinnitus during day, and masking devices for those troubled at night

Surgery: CI used in Europe for severe tinnitus; cochlear nerve section not effective; acoustic neuroma — among 500 patients treated for acoustic neuroma, 83% had tinnitus; unilateral tinnitus rarely presenting symptom of acoustic neuroma (hearing loss more common); size of tumor not related to presence of tinnitus; after surgery, 40% of patients reported improvement of tinnitus, 10% noted no change, and 50% had worsening; however, many patients with improvement found that tinnitus increased back to preoperative level in few weeks; stapedectomy — 69% of 166 patients had tinnitus; tinnitus mild in 45%, moderate in 46%, and severe in 7%; after stapedectomy, tinnitus cured in 37%, improved in 39%, unchanged in 20%, and worse in 4%; other studies have reported similar results; CI — in early study, 53% of patients had improvement in tinnitus, 2 had worsening, and 36% unchanged

Auditory desensitization: for several hours daily, patient listens to music tuned to their tinnitus; treatment works by reducing overstimulation of amygdala and limbic system that causes tinnitus; interactions with therapist take time; among 29 patients, 14 who completed treatment reported improvement (reduction in tinnitus score from 46 to 17); another study reported success rate of 86% and showed that use of Neuromonics device plus counseling better than masker plus counseling or counseling alone

Readings

Folmer RL et al: Experimental, controversial, and futuristic treatments for chronic tinnitus. J Am Acad Audiol 2014 Jan;25(1):106-25; Goddard JC et al: Recent experience with the neuromonics tinnitus treatment. Int Tinnitus J 2009;15(2):168-73; Hilton MP et al: Ginkgo biloba for tinnitus. Cochrane Database Syst Rev 2013 Mar 28;3:CD003852; Hoare DJ et al: Recent technological advances in sound-based approaches to tinnitus treatment: a review of efficacy considered against putative physiological mechanisms. Noise Health 2013 Mar-Apr;15(63):107-16; Nakashima T et al: Transmeatal low-power laser irradiation for tinnitus. Otol Neurotol 2002 May;23(3):296-300.

Disclosures

For this lecture, members of the faculty and planning committee reported nothing to disclose.

Acknowledgements

Dr. House was recorded at Recent Advances in Otolaryngology, the 84th Midwinter Conference of the Research Study Club of Los Angeles, held January 29-30, 2016, in Los Angeles, CA. For information about the Research Study Club of Los Angeles, visit researchstudyclub.com. The Audio Digest Foundation thanks the speakers and the sponsors for their cooperation in the production of this lecture.

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 0 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 0 CE contact hours.

Lecture ID:

OT490802

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.