Alexandra D. Costlow, B.S.

 From Latin, tinnire, to ring

 Of imitative origin
 First Known
Use: 1843

http://www.merriam-webster.com/dictionary/tinnitus
 Ringing
 Hissing
 Roaring
 Whistling
 Swishing
 Buzzing
 Chirping, crickets
 Clicking
 “It goes along with my heartbeat.”*
 http://www.neuromonics.com/patient/treatm
ent/index.aspx?id=50
 Hearing loss
 Cerumen accumulation/occlusion
 Eustachian tube blockage
 Otitis media
 Exposure to loud noise
 Ototoxic chemicals*
 Otosclerosis - frequently
 Meniere’s Disease (episodic tinnitus along with hearing
loss, dizziness, and aural fullness)
 Acoustic neuroma – Even when the tumor is
removed, 50% of pts continue to experience tinnitus
(Benson et al., 2009)

http://www.emedicinehealth.com/tinnitus/page2_em.htm
SUBJECTIVE TINNITUS OBJECTIVE TINNITUS

 Only the patient perceives  Head noise is audible to the

head noise patient and to the
 This is the more common professional
 Relatively rare
form
 Originates in the
ear, head, or neck
 Muscular or vascular
etiology
 Myoclonus is found in pts
with degenerative
diseases*
Benson, A.G., McGuire, J.F., Djalilian, H.R., Hanks, K.M., Robbi
ns, W.K. (2009)
 The neuromuscular control over ear muscles
deteriorates in an individual with good very
good sensory perception.
 The stapedius and/ or tensor tympani muscles
repeatedly contract and relax.
 This results in audible click noises arising from
the ear.
 Can be unilateral or bilateral.
 Treatment is lysis of the muscle/s through
tympanotomy incision.
Benson, A.G., McGuire, J.F., Djalilian, H.R., Hanks, K.M.,
Robbins, W.K. (2009)
 Jaw joint misalignment
 i.e. the tempero-
mandibular
joint (TMJ)

http://www.emedicinehealth.com/tinnitus/page2_em.ht
m
CAROTID ARTERY JUGULAR VEIN AND BULB

 Injury due to aging or  More common than the 2

surgery other objective etiologies
 Ectasia:  Produces a “Venous hum”
Dilation, expansion, distent  Pt describes a vibratory or
sion, bulging low-pitched sound
 Blood flow through the
artery is tumultuous
 Follows the pt’s heartbeat
 Can be ausculated by the
examiner
Benson, A.G., McGuire, J.F., Djalilian, H.R., Hanks, K.M., Robbins,
W.K. (2009)
http://www.frca.co.uk/article.aspx?articleid=100030
http://www.nlm.nih.gov/medlineplus/ency/presentatio
ns/100124_1.htm
 Suggests involvement of blood flow through
vessels near the ear
 May be normal or pathological
 Space-occupying lesions
 Anemia* (Contributing cause)
 Overactive thyroid
 Hypertension
 Benign intracranial pressure
http://www.emedicinehealth.com/tinnitus/page2_e
m.htm
 Sudden onset tinnitus (with or without
hearing loss)
 Sudden onset hearing loss and tinnitus
 Unilateral tinnitus
 Pulsatile tinnitus
 Report of tinnitus + symptoms of a stroke
 Sudden difficulty communicating, movement
disorders, personality changes
http://www.emedicinehealth.com/tinnitus/page4_em
.htm
 Tinnitus is a symptom, NOT a disease.
 The pathology causing tinnitus may be outside
of the scope of audiologists.
 The actual “cause” of tinnitus depends on
pathophysiology.
 Understanding the pathophysiology will help us
(AuDs, PhDs, MDs, DOs, neurologists,
neurosurgeons, etc…) to better treat people who
experience tinnitus.
 Patient: I’ve had this ringing in my ears for
years. My doctor told me that there’s no cure
for it. Is that true?

 Audiologist:
 Nuerophysiologically, “ … Tinnitus is the
consequence of the brain’s response to
input deprivation from the auditory
periphery” (Benson et al., 2009).
 Leaver et al. (2011) suggest that tinnitus
occurs due to abnormal function of the limbic
system, which controls emotion.
 Suggests link to depression, anxiety?
 In a healthy cochlea, there is a tonotopic
organization (peripheral).
 Signal travels from the cochlea to the
midbrain to the auditory cortex.


 In a damaged cochlea, cortical and subcortical
pathways adapt to lack of stimulation (plasticity) and
the tonotopic organization (not just of the cochlea,
but rather of the projections from the cochlea 
mesencephalon  cortex) is altered (Benson et al.,
2009).
 Neuroplasticity may take the form of:
 Creation or elimination of synapses, including their axons
and dendrites, causing changes in how effectively the
electrical signal is transmitted (Moller).
http://hshgp.genome.washington.edu/teacher_resources/modules-
view.htm
 In the auditory cortex, the area that no longer
receives stimulation due to cochlear injury is
called the lesion projection zone (LPZ).
 Following cochlear injury, neurons in the LPZ
change in two ways:
 Increase in spontaneous firing rate
 Neurons that are adjacent to the LPZ represent
a larger frequency range

(Benson et al., 2009)

 This mechanism is believed to be the
neurophysiological correlate of tinnitus
(Benson et al., 2009).
 A key understanding in tinnitus research
over the years was that although tinnitus
presents in the ear, it is a neurological
phenomenon.
 As evidenced by the fact that if the auditory nerve
was severed, tinnitus was yet able to persist
(Moller).
 May use pitch and loudness mapping
 90% of pts report tinnitus at an intensity level of
<20 dB
 84% of pts report tinnitus at an intensity level of
<9 dB
 These measures are useful for masking devices
 Do these measures match subjective reports of
tinnitus severity?
(Benson et al., 2009)
 The Tinnitus Handicap Inventory
 Self-report measure
 Validated in 1996
 Measures how tinnitus affects daily life
▪ Functional, Emotional, and Catastrophic subscales

(Newman, Jacobson, & Spitzer, 1996)

 If the patient has tinnitus:
 Sound may be distorted.
 Patient may also have hyperacusis and/or
phonphobia (Moller).
 The patient may have anxiety, isolation, and/or
depression.
 May depend on etiology
 Glomus tumor: Surgical removal
 Meniere’s Disease: Endolymphatic shunt,
labyrinthectomy, antibiotic injection

Courtesy of Hood Labs www.earassociates.com

 Let’s hear from Roger Miller, PhD, Director
for Hearing and Balance at NIDCD
 http://ocplmedia.od.nih.gov/nihradio/20110113NI
DCDtinnitus.mp3?utm_source=twitterfeed&utm_
medium=twitter
▪ Behavioral: Tinnitus Feedback Retraining, Support
Groups, Counseling (informational and affective)
▪ Masking
▪ Vagal Nerve Stimulation: Like pressing “Reset” button in
the brain
 Pharmacologic: Treat symptoms related to
tinnitus, such as depression and anxiety.
 Nortriptyline (50 mg): Most effective drug, although it
causes dry mouth and takes 3-4 weeks to build up
summative effect for benefit.
 SSRIs
 Paroxetine (10 mg) AKA Paxil
 Sertraline (50 mg/d) AKA Zoloft: Reduced tinnitus
severity, as well as symptoms of depression and anxiety
 Benzodiazepines: Treats tinnitus as an anxiety disorder
BUT should not use these if depression is present (and
often it is).
(Benson et al., 2009)
 Electrical Stimulation
 Overall, mixed success
▪ Stimulation may only be effective during stimulus
presentation
 First attempted by Volta in the 1800s
 Types:
 Cutaneous, brain stimulation, promontory
stimulation
 New: Repetitive transcranial magnetic stimulation
(rTMS)
(Benson et al., 2009)
The Society for
Neuroscience
www.sfn.org
 Biofeedback
 Commonly used for the management of pain
 Pt monitors involuntary bodily processes such as
heart rate, blood pressure, and muscle tension
through electromyography (EMG) and
electroencephalography (EEG) (UMMC, 2011).
 Goal is to reduce anxiety and/or stress that may
aggravate tinnitus
 Conducted by a psychologist
 <80% of pts report reduction in tinnitus symptoms
(Benson et al., 2009).
Homeopathic Therapy
 Ginko Biloba: Antioxidant that inhibits platelet
aggregation  promotes circulation to small
blood vessels such as those that supply the
cochlea.
 Niacin: May provide smooth muscle relaxation
and promote circulation to small blood vessels.
▪ Pts may report that Niacin reduces severity of tinnitus
(Benson et al., 2009).
 Prevalence varies
 Shetye and Kennedy (2010) noted it occurs in
12 - 36% of children with normal hearing and
in <66% of children with hearing loss.
 Shetye and Kennedy (2010) noted that 3 –
10% of children are significantly affected by
it.
 May be more difficult to identify in children
 Might pediatric tinnitus become more
prevalent due to environment?
(Shetye & Kennedy, 2010).
 Caffeine: Anecdotal evidence tells us that
caffeine consumption exacerbates tinnitus.
 St. Claire et al. (2010) found that caffeine
consumption had no effect on tinnitus severity
but that caffeine withdrawal symptoms were
observed.
 Heritability: Anecdotally, tinnitus may “Run in
families.”
 Kvestad et al. (2010) found low heritability of
tinnitus.
 American Tinnitus Association (ATA). What you should know about tinnitus. Retrieved from
http://www.ata.org/sites/ata.org/files/pdf/ATA%20Facts% 20About%20Tinnitus.pdf
 AnaesthesiaUK. (2010). Cannulation of the internal jugular vein. [Graphic].
 Benson, A.G., McGuire, J.F., Djalilian, H.R., Hanks, K.M., Robbins, W.K. (2009). Inner Ear, tinnitus.
MedScape online encyclopedia. Retrieved from http://emedicine. medscape.com/article/856916-
overview
 Gurr, P., Owen, G. Reid, A. & Canter, R. (1993). Tinnitus in pregnancy. Clinical
Otolaryngology, 18(4), 294-297.
 Kvestad, E., Czajkowski, N., Engdahl, B., Hoffman, H., & Tambs, K. (2010). Low heritability of
tinnitus: Results from the second Nord-Trandelag study. Archives of Otolaryngology, Head and
Neck Suergery, 136(2), 178-182.
 Leaver, A.M., Renier, L., Chevillet, M.A., Morgan, S., Kim, H.J., Rauschecker, J.P.
(2011). 

Dysregulation of limbic and auditory networks in tinnitus. Neuron, 69(1), 33-43.
 Moller, A. R. Pathophysiology of tinnitus. [Powerpoint slides] presented at the University of Texas
at Dallas, School of Behavioral and Brain Sciences. Retrieved from
http://www.slideworld.org/slideshow.aspx/Pathophysiology-of-tinnitus-ppt-4329
 Neuromonics Inc. (2011). What tinnitus sounds like. Retrieved from
http://www.neuromonics.com/patient/treatment/index.aspx?id=50
 Newman, C.W., Jacobson, G.P., & Spitzer, J.B. (1996). Development of the tinnitus handicap
inventory. Archives of Otolaryngology, Head and Neck Surgery, 122(2), 143-8.
 Shetye, A., & Kennedy, V. (2010). Tinnitus in children: An uncommon symptom? Archives in
disease in childhood, 95(8), 645-648.
 St. Claire, L., Stothart, G., McKenna, L., & Rogers, P.J. (2010) Caffeine abstinence: An ineffective
and potentially distressing tinnitus therapy. International Journal of Audiology, 49(1), 24–29.
 The Society for Neuroscience. (2011). Obsessive-compulsive disorder. Retrieved from
http://www.sfn.org/index.aspx?pagename=brainbriefings_ obsessivecompulsivedisorder
 University of Maryland Medical Center. (2011). Biofeedback. Retrieved from
http://www.umm.edu/altmed/articles/biofeedback-000349.htm
 U.S. Department of Health and Human Services National Institutes of Health. (2011). Carotid
artery surgery – series. In MedLine Plus. Retrieved from http://
www.nlm.nih.gov/medlineplus/ency/presentations/100124_1.htm