Dr. Alok Banka

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Jastreboffdefined tinnitus as “the perception of a sound which results exclusively from activity within the nervous system without any corresponding mechanical, vibratory activity within the cochlea. For 1 percent to 2 percent of the general population, this condition causes a considerable amount of distress and seriously interferes with the ability to lead a normal life.It is very difficult to treat and undoubtedly represents one of the most difficult therapeutic problems for the otolaryngologist. Furthermore, the mechanisms for its generation and maintenance are not yet fully understood.

Since the well-known Heller and Bergman experiment,it is widely believed that tinnitus is a common subaudible physiological phenomenon of the normal auditory system. In their study, 94% of apparently normally hearing individuals experienced tinnitus when placed in a soundproof room for 5 minutes.

Tuckeralso investigated the effect of silence on the perception of tinnitus in 120 normal hearing young adults. Each person was seated in the sound booth and given instructions for the “listening experiment” for a period of 20 minutes. No acoustic signal was presented, but auditory attention was strongly activated again, and tinnitus-like sounds were perceived in 64% of listeners.

It is theorized that Vincent Van Gogh may have cut off his ear during a particularly severe episode of tinnitus (associated with Ménières disease) in an effort to assuage the symptoms. Affected individuals often report difficulties with concentration, sleep, and activities of daily living because of tinnitus, impacting not only the individual experiencing the tinnitus, but those around him as well.Tinnitus has been found to impact attention, working memory, and ability to complete complex tasks.Varied and constantly evolving speculations as to etiology and treatment of tinnitus have continued to the present day. Despite difficulties with defining and treating tinnitus, the disability that patients experience due to tinnitus is real and this continues to prompt further research into viable treatment options.

Tinnitus sounds perceived by normal hearing listeners after sitting in a relatively silent environment vary. Ring (57%), buzz (21%), pulse (22%), heartbeat (21%), and hum (14%) are the most common sounds heard, with “ring” being the most common overall tinnitus sound.. Females most commonly hear ring and pulse whereas males most commonly hear ring and buzz.

Clinically, there is a distinction between subjective and objective tinnitus. Objective tinnitus has also been described as “vibratory” tinnitus, is relatively uncommon, its cause is apparent, and specific treatment can be directed to its cause. Subjective idiopathic tinnitus (SIT) is the most common and can be a component of many diseases.The medical evaluation of SIT comprises the following: a complete clinical history, a general medical examination, general otolaryngology examination, cochleovestibular evaluation, and tinnitus evaluation.

Etiology vary from hearing loss, otosclerosis, ear infection, acoustic neuroma, Meinère’s disease, and presbycusis. The vast majority of tinnitus is idiopathic in origin. Tinnitus imparts a substantial burden upon many patients, thereby negatively impacting quality of life.

To date, there is no medical cure for tinnitus. However, patients suffering with severe tinnitus can find relief and comfort from their symptoms through tinnitus management protocols.

Treatments currently employed throughout the world include tinnitus retraining therapy (TRT), masking, magnetic stimulation, biofeedback, behavioral therapy, trans-tympanic medications, and herbal/mineral supplementation.

Tinnitus retraining therapy (TRT) is based on the fact that the remodeling of tinnitus-related connections could minimize its perception (habituation to perception) and eliminates its reaction (habituation to reaction). The goal is to reduce the impact of tinnitus in the patient’s quality of life and to be aware of it most of the time. It employs a combination of audiologic testing, directive counseling, and the use of sound therapy to treat tinnitus patients. A core principle of the TRT program is the recommendation to avoid silence. This recommendation is given to tinnitus patients for two reasons. First, the presence of sustained silence may have a direct effect on the functioning and neuronal organization of the central auditory nervous system. This phenomenon may be evidenced in the significant and sometimes rapid and reversible changes observed in the auditory system resulting from sensory deprivation due to conductive and/or sensory hearing loss.Secondly, the perception of tinnitus is increased in silence as a result of the lack of any other environmental masking sound.

Because patients with severe tinnitus often have negative affectivity (characterized by tendencies to be distressed, worried, anxious, and self-critical), their counseling should be as positive and productive as possible. Jakes et al19 admonished clinicians: “instead of advising patients that they must ‘learn to live with it’ with no advice as to how this is to be achieved, one could rather advise them that distress about tinnitus is not determined by having tinnitus, and that an intrusive, subjectively loud tinnitus will not necessarily produce a strong effect on the patient’s social, domestic, or economic functioning.” After appropriate tests have ruled out acoustic neuroma or other retrocochlear causes for a patient’s tinnitus, clinicians should reassure the patient that tinnitus is usually related to hearing loss and that it is a harmless perception of sound generated by the auditory system. Tinnitus will not necessarily become worse with time, and it does not portend additional hearing loss or the manifestation or exacerbation of any other medical condition. Because each tinnitus patient has a unique medical, psychological, and social history, therapeutic interventions should be individualized. In fact, the most successful treatment programs use multimodal strategies that are designed to address the specific needs of each patient.

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