Tinnitus – An ENT Perspective

Mr. Marcus Choo

Introduction      Tinnitus is defined as sensations of hearing in the absence of external sounds 155 million Americans have sought treatment 1/3 of the population have had tinnitus at some stage in their lives Up to 20% of the population currently experience tinnitus “Google” search for tinnitus identified 4.2 million sites!

Introduction       Prevalence increases with age 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 Very little is understood about its cause or cure

Tinnitus sufferers             Ludwig van Beethoven Joan of Arc Oscar Wilde Vincent van Gogh Charles Darwin Neil Young Eric Clapton Bono Sting Barbara Streisand William Shatner Ronald Regan

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

Causes         Noise exposure Medication Infection Older age hearing loss Meniere’s Disease Outer/Middle ear disease Acoustic neuroma Unknown (by far the most common)

Effects of Tinnitus     Concentration Hearing Insomnia Psychological

Ear Anatomy

Mechanism of Hearing

Pathophysiology  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

Pathophysiology  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  Often compared with chronic pain

Pathophysiology

An ENT Surgeons Approach        Thorough evaluation to rule out significant pathology Treatment of other ear disorders eg. infection Explanation of test results Explanation of tinnitus mechanisms Treatment options Treatment of severe psychological disorders Follow-up

Differential Diagnosis  Idiopathic (most common)  – Outer ear disease Wax, foreign body, infection  – Middle ear disease Infection, perforated eardrum, ossicular problems, tumour

Differential Diagnosis  – – – – – Inner ear disease Presbyacusis (older age hearing loss) Meniere’s disease Acoustic neuroma Noise exposure Drugs

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

Normal Ear

Diseased ear

Evaluation of Tinnitus  Audiological (hearing) Tests  Audiogram, tympanogram  Specialised hearing tests  MRI  Associated symptoms  Asymmetric hearing loss

Audiogram

MRI

Treatment  Aim to improve habituation rather than “cure” tinnitus    Most people don’t seek treatment Multitude of potential treatments Problems with scientific evidence