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Tinnitus

1. Introduction

Tinnitus is abnormal sounds, such as buzzing or whistling in the ears, that the patient hears intermittently or all the time, in the absence of any source of environmental noise. Affecting one ear or both, tinnitus can be simple or complex and may or may not be accompanied by deafness. Tinnitus is a genuine public health problem. Based on the different epidemiological studies, its prevalence is evaluated as 1% to 8% of the adult population. A study involving over 600 tinnitus patients has also demonstrated that 26% suffer from a significant deterioration in their quality of life, with substantial behavioural changes such as irritability, anxiety, tension and sleep deprivation. The lack of success of several treatments, particularly drug therapies, has led teams to propose therapies using radically different concepts.


All tinnitus patients require a careful otoneurological assessment conducted by an ENT specialist to try to:
1. find the cause
2. find the most suitable treatment.

 

2. Pathophysiology

Two hypotheses have been offered as to the cause of tinnitus: a peripheral cause and a central cause.
>> publications

 

3. Interview

Different questionnaires have been developed to determine the functional, physical and psychological consequences of tinnitus. They can also be used to assess the impact of a given treatment. There are several types. The following are most often used:

1. The Tinnitus Handicap Inventory (THI) (Newman, Jacobson and Spitzer, 1996), developed specifically in English-speaking countries to determine the debilitating effects of tinnitus (25 questions subdivided into functional, emotional and catastrophic consequences).

2. The THQ: tinnitus handicap questionnaire, is the one most widely used in France.
It includes 27 questions (with a score of 0 to 100).

 

 

4. Audiometry

The pure tone and speech audiometry, accompanied by a tympanometry and an impedance measurement, is an essential examination. The majority of tinnitus cases are accompanied by hearing loss but 20 to 30% of patients have normal hearing. Tinnitus is often found with age-related high frequency hearing loss but also hearing loss caused by exposure to noise through the person’s occupation or leisure activities (such as hunting or concerts).


During this examination, the ENT specialist also tries to determine the predominant frequency of the tinnitus (tinnitus frequency test). This test helps to diagnose the cause. When the tinnitus is predominant in the lower frequencies, this indicates a condition involving the secretion of endolymphatic fluids. When the tinnitus affects high frequencies, it is often associated with a unilateral scotoma (asymmetrical hearing loss on one frequency) for which the cause must be determined.

Auditory evoked potentials may also be necessary to detect a problem with the auditory nerve, such as that caused by an acoustic neuroma.  Otolithic evoked potentials induced by loud noises can indicate a canal dehiscence when early waves (P13-N23) are asymmetrical in amplitude.

5. Radiology

An MRI focusing on the internal auditory canals must be conducted in the event of unilateral tinnitus with or without unilateral deafness, in order to detect damage to the auditory nerve. In certain cases of conductive hearing loss, a thin section scan of the petrous temporal bones can be useful to detect otosclerosis, a traumatic impairment or a canal dehiscence.

Figure: acoustic neuroma


Blood work is necessary, including FBC, SR, lipid profile, and zinc and thyroid hormone assays. It is also vital to measure blood pressure.

 

6. Treatments

Different types of treatment can be offered:

 

Medical

Medications used to stimulate blood flow such as trimetazidine and ginkgo bilboa (Tanakan) can be useful. Gaba agonists (neurontin) and dopamine agonists (piribedil) specifically affect the efferent auditory system. Afferent neural pathway inhibitors, such as carbamazepine (Tegretol), are also recommended as they reduce the hypersensitivity of the auditory centres.  Tranquilisers or antidepressants reducing serotonin reuptake may also be prescribed.  Lastly, recent studies have shown that acamprosate (an NMDA receptor blocker and Gaba agonist) has been effective in some cases.  

 

Relaxation techniques

Techniques used to reduce autonomic nervous system activity (sophrology, yoga) can be beneficial.

 

Cognitive therapy

Cognitive behavioural therapy (CBT) has progressed considerably over recent years. It is based on a pragmatic and short-term approach, using optimum adaptation and coping strategies both in terms of cognitive aspects (by modifying unhelpful thought patterns) and in terms of behavioural aspects (by modifying inappropriate behaviour). The goal is to help patients who are disabled by their tinnitus to reach the state of neglect that most tinnitus patients reach spontaneously. The auditory pathways project not only to the auditory cortex but also to the limbic system, which is responsible for the patient’s state of anxiety. CBT is also effective for anxiety or depressive states preceding or induced by the onset of tinnitus.

 

Cognitive Behavioural Therapy to relieve tinnitus

Cognitive behavioural therapy is a short-term scientific therapy based on modern psychology.
It has been indicated for the treatment of tinnitus for many years.

 

The therapist actively works with the patient throughout treatment to reduce or even eradicate the symptoms by adjusting cognitive behavioural attitudes, even when deeply entrenched.
This therapy is used to evaluate patients to effectively alleviate psychological suffering and reduce the stress of tinnitus.

 

What is also specific about CBT is that patients are given therapeutic tasks between sessions to help them become autonomous over a short time.
This effective technique allows patients to “regain control of their lives.”

 

For information:
The length of treatment varies depending on the individual needs of each patient
(on average 8 to 10 one-hour sessions).

 

Key points:
- It is a scientific short-term therapy
- There is significant interaction between the therapist and patient
- The patient’s progress is continuously assessed
- Focus is taken away from the tinnitus and the patient learns to accept their condition.

 

Sophrology to relieve tinnitus:

SOS:  Harmony           PHREN: Consciousness           LOGOS: Study
Sophrology was invented in 1960 by a Neuropsychiatrist, Dr Alfonso Caycedo. It is a mind-body therapy that studies human consciousness. A range of specific techniques are used throughout the therapy.
It is a short-term educational, prophylactic and humanist therapy, which helps to harmonize body and mind by balancing emotions, thoughts and behaviour.

 

Sophrologists are trained to help patients by adapting the clinical protocol to the problem, such as tinnitus.
The therapy involves discussions between the patient and therapist, breathing exercises, mental imagery, relaxation, and significant work on body mapping.

 

Sophrology is very effective in treating tinnitus and stress management.
Patients rapidly feel better and become autonomous, regaining control of their lives.

 

For information:
The length of treatment varies depending on the individual needs of each patient
(on average 8 one-hour sessions for a complete protocol).

 

Key points:
- It is a short-term mind-body therapy
- The therapy is based on a protocol
- The therapy is educational: relaxation and breathing exercises
- The patient looks into the future with a better quality of life.

 

Hearing aids

Hearing devices serve to:


1. mask tinnitus and
2. reduce the asymmetry in hearing, the cause of plastic changes in the auditory centres (inferior colliculus, auditory cortex), which fundamental studies have demonstrated are reversible.
It is therefore possible that in the future, a hearing device that selectively amplifies the hearing loss frequency zone could be used to treat the tinnitus without the patient having to wear the hearing aid all the time.

 

Surgery

Inner or middle ear cochlear implants, and magnetic and electrical stimulation of the primary or secondary auditory areas are being assessed after fMRI characterisation of the abnormally activated cortical areas.

7. Conclusion

ENT specialists are no longer at a loss when treating tinnitus patients: gone are the times when patients were told that they would have tinnitus their whole lives and that they would simply have to get used to it. The doctor should reassure the patient and offer different treatments ranging from less aggressive solutions (drugs, cognitive behavioural therapy or a hearing aid) to more invasive ones (surgery). Multidisciplinary management is often useful. Lastly, progress in fundamental research has helped to better understand the causes and develop new treatments. This area is still seeing major breakthroughs.