Tinnitus and its What is tinnitus ?

therapy Tinnitus is a sound in the ears of head that is not

coming from an identifable source

Jukka Ylikoski MD
Department of ORL, University of
Helsinki

Tinnitus sound Diagnostics and therapy I

Soiva, kilisevä Ringing ”There is nothing that can be done”

Viheltävä Whistling
”You just to have to learn to live with it”
Sykkivä Pulsing
Suriseva Humming
Suhiseva Buzzing

Diagnostics and therapy III

Diagnostics and therapy II
1. Careful diagnostic workup leads to exclusion of serious
diseases (acoustic tumour)
There is no magic pill or surgery for tinnitus. This does
2. Results of examinations must be thorougly explained for
not mean that patients with tinnitus cannot be helped !! the patient

3. Short and simple education of the structure and function

of the ear and auditory system

4. Positive and emphatic attitude

”Drugs”: 1. ”reassurance” ;
2. ”giving hope”

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TINNITUS

Necessary diagnostics
Heller & Bergman 1953 (=everybody has tinnitus)
all do not hear it because it is blocked by the filters
of the auditory pathway
tinnitus = functional change in the auditory pathway
processing of tinnitus Î the meaning of sounds
z+: no problems (”God is speaking”)

z- : problem (illness, rings the rest of life?”)

1. Clinical ENT-examination, structured symptom
Subcortical connexions: annoyance
zlimbic system:anxiety, fear
history (tinnitus handicap index, THI),
zautonomic nervous system: sweating, palpitations
otomikroscopy
Auditory pathway
tinnitus 2. Auscultation of carotic artery and mastoid region
•not a passive ”sound transporter”
•able to amplify any stimulus negative assosiation 3. Pure tone audiometry
(conditioning) anxiety, fear, depression
•able to reduce response to repeated stimuli tinnitus disturbs more 4. LDL, loudness discorfort level
filters are fokused
(habituation); 5. Loudness matching of tinnitus VAS
•can change (plasticity/synapses)
the problem is not tinnitus but the reaction from it 6. Frequency matching of tinnitus
sound engram
7. Tympanometry ja stapediusreflex
auditory nerve = raw data 8. Auditory brainstem responses (ABR)
•processing (auditory tract)
•empty at beginning, ”tabula rasa”
•classfication
•Î ”label”
•Î reaction varies
–alarm sound
–tranqulizing sound

Tinnitus classification

Therapy; acute tinnitus

a) objective – subjective
-antioxidants
b) where tinnitus arises: C-, E-vitamine, melatonine,
external, middle, inner ear, auditory nerve, central auditory carbocystein, thioctane
pathway
-blood circulation enhancers
c) duration: acute (< 3 months) – subacute (3-12 mos) – chronic (> 1 yr) hydergin, betahistine (Betaserc – no benefit
for the patient. For the medical industry yes)
d) additional symptoms: compensated -decompensated
-NMDA-reseptor-antagonists
compensated : the person is awared of tinnitus, but manages it well, no caroverine, memantine
sleep disturbances, quality of life (QoL) normal
-tranquilizers
decompensated : Tinnitus causes massive additional symptoms like sleep
problems, anxiety, depression
QoL greatly affected

Therapy; acute tinnitus;

Guidelines in Germany
stereocilia
Therapy should be started immediately- optimally the
day when tinnitus has started – or at least when
the patient visits doctor for the first time

1. Rheologic infusions with plasmaexpanders &

vasodilators (Dextran, HAES, Prokaine,
Pentoxiphylline), for 10 days
2. Procaine in increasing dosages Noise exposure (discovisit)
Æ Temporary threshold shift (TTS)=
3. Cortisone for 10 days
stereocilia damage
4. Manipulationtherapy in cervical tinnitus
new stereocilia in 48 hours
= spontaneous recovery

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 SubacuteTinnitus
HyperBaric Oxygenation, HBO Careful diagnostics, after that “Tinnitus-Counselling”

medical treatment in which thge patients breathes
100 oxygen in pressure chamber in 1.4 bar
overpressure (14 m diving) .
oxygen content of extracellular fluids (also in
inner ear) increases 10-20 times
useful if question about oxygen deprivation
• Add instructions how the patients best would manage
in everyday situations with his tinnitus.
• Instructions could include psychotherapeutic means
such as relaxation excercises (biofeedback, autogenic
training modo Jakobsen etc).

Chronic, compensated tinnitus

•The following list might make sense:
Saying ”therapeutically there is nothing to be done”
is certainly wrong – may cause the patients to surrender
1. Hearing aid fitting or resign and they may seek help from ”miracle therapies”
2. Sound generator/tinnitusmasker (at least a trial)
(in connexion with TRT) Important that the patient is seeing his tinnitus critically
3. Lidocain-Test: (plus therapy trial with Tocainid) and understand the principles of habituation.
4. Advice how to avoid noise exposures
The aim si that the patient accepts the presence of tinnitus.
5. Manipulatiotherapy in cervical tinnitus
6. Orthognathic diagnostics and terapy A good patient-doctor relationship most important.
7. Alternative therapies: Neuraltherapy, Acupuncture

Dekompensated, chronic Secondary central tinnitus

complex tinnitus
TDT =tinnitus desensitization
1. Tinnitus Retraining-program
(=habituation)
2. Sound generator/tinnitusmasker (at least a trial)
(in connexion with TRT) T signaalin negat tinnitus -> not-wanted sensitization
3. Lidocain-Test: (plus therapy trial with Tocainid)
patologinen
vahvistuminen competing stimuli -> wanted --”--
4. Advice how to avoid noise exposures
5. Manipulatiotherapy in cervical tinnitus
6. Orthognathic diagnostics and terapy Tinnitus modification/elimination
7. Alternative therapies: Neuraltherapy, Acupuncture

8. Habituation training e.g. in groups (relaxation training) ”limited capacity control system LCCS”
9. Sleep hygiene competitive inhibition possible
10. Anxiety treatment (drugs) Inhibitors:
11. Depression treatment with drugs 1. cognitive tinnitus modification
2. Exogenic antagonists (e.g. positive
imagination)

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 About treatment of tinnitus I About treatment of tinnitus II

if hearing impairment: hearing aid is the Ist

Until 1980s: tinnitus =inner ear problem; therapy=
treatment of the inner ear
therapy
no pill or surgery which eliminates tinnitus
electrical stimulation since 1800s, transient help, not in
use today
when additional symptoms: psychotherapy,
little or no attention was earlier paid to adjunctive cognitive therapy, hypnosis, meditation, group
symptoms (sleeping problems, depression; psychiatric
therapies separately therapies
concentration-demanding exercises
masking of tinnitus sounds since antics; 1900-1990 keskittymistä
tinnitusmasker; white noise or tinnitus matching sound physical therapy, orthognathics, physical
training
external sound sources: music, nature sounds, water
sounds, traffic, maskins etc.

About treatment of tinnitus III

tinnitus usually arises in the cochlea but arise anywhere
in the auditory pathway About treatment of tinnitus IV
most people habituate and tolerate tinnitus (more than if it were possible to reduce tinnitus percepted in
500.000 in Finland) the auditory cortex, it would be easier to accept
occasionally occurring milder tinnitus
about 50.000 individuals develop additional symptoms
from auditory pathway communicating neuronal tracts
this is the aim of TRT (tinnitus retraining therapy)
because there are no drugs, surgeries or electricity
which eliminates tinnitus, focus has been moved to
reduce neuropsychological reactions aiming to reduce
invalidity as well

TRT- tinnitus retraining therapy

Vicious circle
Tinnituksen poisoppimishoito
negative associations
anxiety, fear, depression
tinnitus disturbs more Pawel Jastreboff, Jonathan Hazell

tinnitus is not the problem but the aim: to eliminate the unwanted
REACTION caused by it conditioned reflex by habituation

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 TRT- tinnitus retraining therapy
TPH-tinnituksen poisoppimishoito
TRT principle
means (main elements)

Problem 1. Diagnostics
-careful history
-audiological tests
z the reaction induced by tinnitus -diagnostic categorization (0-4)
-announcement: not a serious disease

2. Teaching, education & information; isnpiration of positive attitude

Goal
3. Sound therapy (masking, sound habituation)
z HABITUATION of the reaction
4. Physical training
(reduced response to repeated stimulation)
5. Elimination of tinnitus causing elements

6. Audiologic treatment (hearing aid, masking)

Tinnitus -->brain stem--> inf colliculus-->lat lemnisc--> CORTEX Changes in daily life
general life situation
- what worsens, what improves, write down
Posit. stimulus
situation at work
z burn out, stresssituations, conflicts, noise
z NO SICK LEAVE, everything as before
private life
”limited capacity control system LCCS” z parisuhdeongelmat useinÆdepressios and tinnitus increases,
social life should contnue as before
competitiivinen inhibition possible hobbies
- concentration demanding but entertaining hobbies
habits
z sofa is the best friend of tinnitus, avoid tobacco, alcohol,
kofein

May 17, 1999 -- An investigational treatment employing

NEW TINNITUSTHERAPY I
Chronic central tinnitus
-- Electrical activity of the auditory tract is increased
(Kaltenbach Am Acad Audiol 11: 125-137, 2000; (Lockwood et al Scand Audiol Suppl
51:47-52, 1999; Mirz et al Acta Otolaryngol Suppl 543:241-3, 2000).
-- metabolic activity of the auditory cortex is increased
(Arnold et al ORL J Otorhinolaryngol 58: 195-100, 1996).
electromagnetic stimulation relieved depression
in 25 patients whose depression failed to respond
to conventional treatment, report Emory University
researchers.
Scores on depression rating scales administered to study
subjects before, during and after the new treatment were
significantly improved at all time points compared to baseline,

-- tinnitus = phantom exprience in the auditory cortex

(Muhlnickel et al PNAS 95: 10340-3, 1998).

Chronic central tinnitus is difficult to treat because it is caused

by hyperexcitability of the neurons in the auditoyr cortex.

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 NEW TINNITUSTHERAPY II
Electromagnetic
Stimulation Shows
1. Low frequency (1 Hz) repetitive transcranial
Promise For magnetic stimulation (rTMS) give for more than 15 min effectively reduces
Treatment-Resistant auditory cortex activation (Chen et al Neurology 48: 1398-1403, 1997) therefore, rTMS has been
Depression proposed as treatment of brain hyperaxcitability conditions

2. In animal experiments rTMS-induced activity reduction in the auditory cortex

lasted for more than 24 hours (Wang et al Neuroreport 7: 521-5, 1996).

3. Recently, rTMS of the temporoparietal cortex reduced

tinnitus in patients (Plewnia et al Ann Neurol 7: 376-81, 2003).
TMS was also shown to reduce auditory hallucinations in patients with schizophrenia when applied as low frequency rTMS to
the left temporoparietal cortex (Hoffman et al Lancet 355: 1073-5, 2000).

4. Neuronavigational 1 Hz rTMS to auditory cortex reduced

significantly activity of the auditory cortex in 2 of 3 tinnitus
patients (Langguth et al Neuroreport 14: 977-80, 2003; Eichhammer et al Biol Psychiatr 54: 862-5, 2003).

Essential messages in tinnitus treatment

HOW TRT in practice ?
physiology of hearing/tinnitus
1. Doing nothing is not an option (demystification)
reaction exercises (not too much)
z identification of reaction
2. Avoid silence z 10 sec without reaction, relaxation
z sound therapy to everybody
z contrast È
3. Future ? z no masking !
z ”environmental sound enrichment”
sound generators (wearable sound generators,
TMS ?? z
WSG)

AUDITORY
PATHWAY
not a passive transporter ei passiivinen
”äänenkuljetin”
ability to amplify the response even to a
minimal stimulation (e.g. warning
signals; conditioning)
ability to reduce the response to
repeated stimulation (habituation)
can change (plasticity/synapses)