Exploring Diagnosis and Treatment Options for Tinnitus

A 55-year-old man reports hearing a high-pitched, staticky sound in both ears. He doesn’t remember when it started, but he does feel it for several months and it’s annoying. How should this case be handled?

Tinnitus (tinnitus) is the perception of a sound whose origin is not external. The sensation is described as a continuous ringing in the ear, but the sound may be perceived inside or outside the head, or predominate in one or both ears. This sound has been described as humming, tonal buzzing, hissing, static, roaring, or the screeching of a cicada.

Tinnitus can be categorized as objective or subjective .

Objective tinnitus , rare, is a sound generated in the body by blood flow. muscle contractions or spontaneous cochlear emissions that can be detected and measured by an external observer. In this review, the author addresses subjective tinnitus.

Population surveys estimate that the prevalence of tinnitus is between 10% and 25% in those over 18 years of age, of various nationalities. In population surveys, only a small percentage of people find the sensation of tinnitus severely bothersome (1 to 7%).

The prevalence of persistent tinnitus increases with age, reaching a peak in people in their seventh decade of life, but, in the last 10 years, the prevalence has increased in younger groups, presumably due to greater exposure to tinnitus. harmful recreational noise.

A large cross-sectional study involving children and adults referred to a regional otolaryngology hospital showed that 97% of those reporting tinnitus had concomitant hearing loss detected by routine audiometry.

Two-thirds of people with tinnitus who participated in a population-based study had baseline hearing impairment in frequencies between 500 and 4,000 Hz, compared with 44% of people without tinnitus.

In another study, the strongest risk factor for mild or sleep-disturbed tinnitus was hearing loss; history of occupational noise exposure was also strongly correlated with tinnitus.

Clinical experience indicates that sudden hearing loss is associated with the sudden onset of tinnitus, but when hearing loss is gradual, tinnitus tends to develop over months or years.

Often; The severity of tinnitus resolves or significantly decreases with resolution of hearing loss, such as after treatment of conductive earwax impaction hearing loss or middle ear effusion.

Tinnitus can affect daily life in multiple domains. People with bothersome tinnitus report sleep disturbance, interference with concentration, decreased social enjoyment, and difficulty hearing conversations.

In cross-sectional studies, tinnitus has been associated with increased odds of anxiety disorder and depression. In a prospective study from Japan among older community-dwelling adults, tinnitus was associated with increased risk of later development of depressive symptoms in men, even after adjustment for age and hearing impairment; In women, no significant association was observed.

The psychophysical characteristics of tinnitus, such as loudness and pitch, are not very predictive of its psychological effect. In one report, some patients who had tinnitus loudness similar to a sensitivity level <5 dB (as assessed by the patient by identifying an external sound most consistent with subjective tinnitus) were very disturbed by their condition, not thus, patients who had a tinnitus volume that coincided with higher sensation levels.

This discrepancy may be explained by the attention a person pays to tinnitus. Whereas most people with tinnitus get used to it and don’t pay attention to it, people who are very disturbed by tinnitus report that they are constantly aware of it.

The volume, severity and effect of tinnitus are dynamic and change over time. In some people, the severity of tinnitus may progress, but in others it may decrease or even disappear.

For example, in a longitudinal study, almost 40% of people who had reported mild tinnitus, and almost 20% who had reported severe tinnitus at baseline reported its resolution at 5 years.

Familiarity with the natural changes in tinnitus that occur over time is important for counseling patients about expectations for improvement. On the other hand, given the possibility of spontaneous reduction in the severity of tinnitus, it is necessary that trials of interventions for this condition have a control group.

> Diagnosis

People with tinnitus should be asked about the nature of the sound (location, gradual or sudden onset), duration, effect on daily life (sleep, work, concentration, mood, and social activities), and associated symptoms. even hearing difficulties.

• A history of ear drainage, otalgia, or both would indicate a possible infectious, inflammatory, or allergic ear disease.
   
• A history of vertigo and imbalance would suggest a possible cochlear or retrocochlear disorder such as Menière’s disease, acoustic neuroma, or migraine-associated vertigo.

The qualitative characteristics of tinnitus, as described by patients, may also suggest causes, for example, a roar may indicate Manière’s disease, and a rhythmic clicking sound may indicate muscle spasms of the stapedial or tensor tympani muscles.

Acute tinnitus must be distinguished from persistent tinnitus, although there is no well-accepted definition of chronicity. In clinical trials, the definition varies from a minimum duration of 3 months to a minimum duration of 12 months.

It is reasonable to perform audiological evaluation of patients with recent onset tinnitus (<6 months), given its frequent association with hearing loss.

In patients with tinnitus who have hearing difficulties, persistent tinnitus of more than 6 months duration, or unilateral tinnitus, a complete audiological evaluation should be performed in order to determine the presence, type, severity, and symmetry of the hearing loss.

It is also reasonable to perform audiological evaluation of patients with recent-onset tinnitus (<6 months), given its frequent association with hearing loss. The results of these evaluations will determine whether additional audiometric testing (e.g., otacoustic emissions testing, high-frequency audiometry, or auditory brainstem response testing) or diagnostic imaging (e.g., MRI) should be performed. or computed tomography of the temporal bone).

Additional audiologic studies for qualitative features of tinnitus (e.g., pitch matching, loudness matching, or tinnitus suppression with acoustic stimulation [residual inhibition]) are not diagnostic and are not used to decide tinnitus management.

Standardized questionnaires exist for use in clinical and research settings, intended to assess the severity of tinnitus and its effect on specific domains of daily life (communication, cognition, emotion, quality of life and sleep). These instruments are useful for the initial evaluation of tinnitus and monitoring treatment changes.

The Inventory Handicap of Tinnitus is a widely used assessment tool that is sensitive to changes in tinnitus severity after treatment.

Population surveys show that most people with tinnitus have a minimally bothersome sensation. Those who seek medical help often report fears that tinnitus is due to a much worse condition, such as progressive hearing loss and deafness. An important component of treatment includes educating patients about the causes of tinnitus and its natural history, including possible spontaneous reduction over time.

Some patients find educational materials, information about support groups, and other self-help materials helpful in facilitating tolerance of tinnitus. Discussions about treatment and management goals should emphasize modulation of the patient’s attention and perception, as well as emotional responses to the sensation.

> Medications and supplements

A wide range of drugs have been approved for the treatment of tinnitus, including antidepressants, anxiolytics, antiepileptics, and anesthetics. Large systematic reviews have concluded that the evidence to support these agents is weak.

For example, a Cochrane review on the use of antidepressants for the treatment of tinnitus identified only 6 trials of sufficient quality, of which 5 were rated as "low quality", and concluded that there is no evidence for the effectiveness of tinnitus treatment. tinnitus with antidepressants.

While some studies have reported subjective acoustic reduction in tinnitus and improved tinnitus-specific quality of life outcomes, these modest improvements may reflect modulation of depression and anxiety and not direct effects on tinnitus. Current clinical practice guidelines do not recommend medication for the management of tinnitus.

Over-the-counter treatments, such as herbal extracts, dietary supplements, and vitamins, are commonly advertised as tinnitus cures, but their effectiveness is unproven. While Ginkgo biloba is the most commonly used supplement, a systematic review also showed no evidence of benefit in relieving tinnitus.

> Acoustic Stimulation

For centuries, sound has been used in various forms and intensities as an empirical treatment for tinnitus. Currently, treatment with acoustic stimulation is based on the concept that hearing loss induces compensatory homeostatic changes within central structures (known as central auditory gain) to maintain auditory nerve activity. Tinnitus may be a maladaptive consequence of this process.

The proposal of this mechanism has been supported by findings from basic science research in animals, computational models, and functional imaging studies. It has been hypothesized that acoustic stimulation may reverse maladaptive changes by increasing neuronal activity in central auditory structures.

The types of sound used for acoustic stimulation include broadband noise, amplification of speech and environmental sounds with hearing aids alone, and amplification with hearing aids in combination with broadband noise or music.

Acoustic stimulation can be provided at sound levels sufficient to make the tinnitus inaudible (masking) or at lower intensity levels, at which the tinnitus remains audible.

A review of 4 trials of acoustic stimulation showed a benefit with respect to specific tinnitus and overall quality of life outcomes from interventions with hearing aids or sound generators, but did not show superiority of any specific form of acoustic stimulation over another. although it was noted that the studies had methodological limitations.

More recently, a randomized trial involving adults with chronic bothersome tinnitus and hearing loss showed significantly greater benefit with the use of combined devices (hearing aids with sound generators) and directive counseling to reduce attention and emotional response to tinnitus. , than with the use of hearing aids (without sound generators) and counseling with information on strategies to deal with hearing loss and improve communication.

In this trial, intention-to-treat analysis showed that clinically significant improvement rates (defined as =50% decrease in Tinnitus Disability Inventory score, from baseline to 18-month follow-up) were greater in the group who received the combination of devices and directive counseling than the group that received hearing aid alone (without sound generators) and audiological counseling (74% vs. 37%).

In another trial involving people with tinnitus and minimal hearing loss there was no significant difference in the rate of the same outcome (clinically significant improvement) in people who received treatment with sound generators and directive counseling and those who received audiological counseling alone (50% and 25%, respectively), although at 12 months and 18 months, the decrease from baseline in subjective measures of tinnitus loudness was significantly greater in the group treated with sound generators than in the group treated with received counseling alone.

Because coaching in these trials was different in the experimental and control groups, the effect of directive coaching versus the sound generator on the study results is unknown.

> Psychological therapy

Interventions address anxiety and depression because these are the most common psychological responses to tinnitus

The objective of psychological intervention is to reduce the negative effect of tinnitus on the patient’s life and thus improve their well-being. Generally, interventions address anxiety and depression because these are the most common psychological responses to tinnitus; Interventions include biofeedback training, hypnosis, and cognitive behavioral therapy.

Cognitive behavioral therapy is currently the most common psychological approach used and studied worldwide for the treatment of tinnitus. It is a collaborative therapy that includes attention refocusing techniques, relaxation technique training, mindfulness training, cognitive restructuring, and behavior modification to change a person’s reaction to tinnitus.

It can be provided as individual, group, or remote therapy (Internet therapy). Therapy is provided by a trained medical professional and usually in once-weekly sessions, 1 to 2 hours long, for 8 to 24 weeks.

Results from large systematic reviews of trials comparing cognitive behavioral therapy with either a treatment control (involving participants on a waiting list for treatment) or an active control with various combinations of yoga, education, biofeedback, relaxation and distraction, are discrepant .

The evaluation showed no reduction in tinnitus intensity from baseline in those who received cognitive behavioral therapy, had active monitoring, or were assigned to a waiting list for treatment.

However, the effect of specific tinnitus on quality of life was significantly better with cognitive behavioral therapy than with active control or no treatment; effect sizes were small to moderate.

Depression scores were significantly better with cognitive behavioral therapy than with no-treatment control, but results of comparisons between cognitive behavioral therapy and active controls (yoga or counseling) were inconsistent. Overall, the strength of evidence to support cognitive behavioral therapy was considered low, given the high risk of bias and small sample sizes of most studies.

> Other therapy

Repetitive transcranial magnetic stimulation is an investigational treatment for tinnitus that involves applying a strong pulsed magnetic field to the scalp, to induce an electrical current that alters neuronal activity directly in the underlying superficial cortex and indirectly in remote areas. of the brain.

Systematic reviews of randomized trials have found conflicting results regarding a benefit, as well as a lack of information on long-term effects. Determining effectiveness is complicated by methodological limitations of the available studies, including small sample size, variability in design, and outcome measures.

Research suggests that abnormal attentional engagement may be a fundamental mechanism that perpetuates tinnitus and increases its severity. In small, short-term trials, attention training programs designed to modulate tinnitus awareness through multisensory games, or repetitive training to identify and localize other sounds, have resulted in reductions in tinnitus severity and better quality of life scores.

A better understanding of attention mechanisms could lead to greater treatment effectiveness. Further studies of the relationship between mood disorders and tinnitus, and of therapeutic strategies for patients with comorbidities, are also needed. Cognitive behavioral therapy requires active engagement and a better understanding of predictors of response to this approach, as well as other interventions.

The subjective nature of tinnitus, its variety of causes and the variability of its effects on patients, as well as the possible spontaneous reduction in severity over time make it a difficult condition to study.

Limitations of many randomized studies of tinnitus treatments include lack of blinding, differences in definitions of bothersome tinnitus used in trials, small sample sizes, lack of attention to many variables that affect tinnitus (e.g., associated mood disorder, hearing loss, duration and severity of tinnitus, and stability of subjective severity scores), lack of comparisons with placebo and, take into account some results that, although significant, are not clinically significant.

To measure the primary outcome of the tinnitus effect, only a standardized instrument was used in 20 to 36% of clinical trials. Identifying participants who wish to enroll in tinnitus research studies with a follow-up of 12 to 18 months is problematic.

The American Academy of Otolaryngology–Head and Neck Surgery (AAOHNS) published a practice guideline for the evaluation and management of chronic bothersome tinnitus in adults.

This guideline applies to adults who have had tinnitus for at least 6 months, without identification of the cause beyond sensorineural hearing loss. The recommendations in this article are largely consistent with AAOHNS guidance; An exception is the strongest recommendation made here for hearing aids: sound generators and directive advice since, at the time of its preparation, the guide did not provide supporting data.

The patient described in the vignette has new-onset tinnitus in both ears, and the hearing loss is not asymmetric. The author recommends taking additional history regarding vertigo or fluctuating hearing loss and would look for an ear disease in the patient that would indicate an underlying disorder such as otosclerosis or Menière’s disease, although symmetrical tinnitus would make these conditions unlikely.

Furthermore, you would obtain an initial assessment of tinnitus severity using the Tinnitus Disability Inventory and audiometry , to determine the presence and level of hearing loss. If the hearing shows notable asymmetry, I would obtain diagnostic imaging.

I would review the audiometry with the patient and discuss the relationship between hearing loss and tinnitus, and what is known about the natural history of new-onset tinnitus with respect to resolution or reduction in severity over time.

If hearing thresholds were not normal, the author would recommend the use of hearing aids. He would also discuss with the patient the potential benefit of educational counseling and acoustic stimulation with hearing aids or devices that combine hearing aids with sound generators, to reduce awareness of tinnitus and the negative effects on their quality of life.

If there is evidence of a co-occurring mood disorder , moderate to severe distress, I would discuss the options of consulting with a mental health professional and cognitive behavioral therapy.