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30.03.2015

Treatment for tinnitus 2014, acupuncture against tinnitus - Try Out

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Researchers at the University of Texas at Dallas are hopeful a new device that stimulates the vagus nerve in the neck could help bring silence to tinnitus sufferers. Electric nerve stimulation to treat tinnitus is delivered using an electrical pulse generator connected to the vagus nerve inside the neck.
Vagus nerve stimulation, or VNS, is an approved therapy for treatment of epilepsy and treatment-resistant depression.
This pacemaker-like device that will be used in a clinical trial on Vagal Nerve stimulation for the treatment of tinnitus.
Good informative article, but if anyone else trying to find a good tinnitus treatment try Bodhi Tinnitus Ender (do a google search). Henry et al (2005) reported that noise was an associated factor for 22% of cases, followed by head and neck injury (17%), infections and neck illness (10%), and drugs or other medical conditions (13%). Thus it can see that there are numerous factors that are weakly correlated with tinnitus, and that hearing impairment is the most strongly associated. Most tinnitus comes from damage to the inner ear, specifically the cochlea (the snail like thing on the right of figure 1, labeled '9').
Patients with Meniere's disease often describe a low pitched tinnitus resembling a hiss or a roar. Tinnitus can also arise from damage to the nerve between the ear and brain (8th nerve, labeled 6, auditory nerve). Tinnitus arises more rarely from injury to the brainstem (Lanska et al, 1987), and extremely rarely, to the brain itself (e.g.
Tinnitus can be associated with Basilar Artery Migraine (BAM), and also tinnitus can be more bothersome when one is having a migraine (Volcy et al, 2005), like sound and light and smells. In our opinion, people are very quick to blame drugs for their tinnitus, but it is rare that this is borne out. Often people bring in very long lists of medications that have been reported, once or twice, to be associated with tinnitus.
As tinnitus is essentially subjective, malingering of tinnitus as well as psychological causes of tinnitus is certainly possible. In malingering, a person claims to have tinnitus (or more tinnitus), in an attempt to gain some benefit (such as more money in a legal case). Schecklmann et al (2014) suggested that tinnitus is associated with alterations in motor cortex excitability, by pooling several studies, and reported that there are differences in intracortical inhibition, intra-cortical facilitation, and cortical silent period. ABR (ABR) testing may show some subtle abnormalities in otherwise normal persons with tinnitus (Kehrle et al, 2008). We occasionally recommend neuropsychological testing using a simple screening questionnaire -- depression, anxiety, and OCD (obsessive compulsive disorder) are common in persons with tinnitus. Microvascular compression of the 8th nerve is not a significant cause of tinnitus (Gultekin et al. Other entities that can sometimes be seen on radiological testing and that can cause pulsatile tinnitus, include AVM's, aneurysms, carotid artery dissection, fibromuscular dysplasia, venous hums from the jugular vein (found in half the normal population), vascular tumors such as glomus, ossifying hemangiomas of the facial nerve, osseous dysplasias such as otosclerosis and Paget's, elevated intracranial pressure. Disrupted sleep is the most significant complaint, and affects between 25-50% of tinnitus patients. The algorithm that we use in our practice to diagnose and treat tinnitus is here (a PDF graphic). The bottom line is that it is unusual (although not impossible) for people to get substantial relief from medication, devices, or surgery. There is a small literature concerning use of intravenous and local anesthesia for tinnitus.
Liu et al (2011) reported use of botox for tinnitus due to tensor tympani myoclonus, by inserting gelfoam with botox through a perforation in the tympanic membrane.
Pramipexole was recently reported effective for tinnitus in a study of 40 patients with age related hearing loss in Hungary. Most of the discussion of devices for tinnitus are discussed, as is proper, under the placebo page. Cochlear implants, which are used for severe bilateral unaidable hearing loss, usually improve tinnitus (Amoodi et al, 2011). These are devices based on the idea that tinnitus is usually worst when things are very quiet. Occasionally persons with Meniere's disease have relief or reduction of tinnitus from transtympanic gentamicin. Microvascular compression syndrome, in theory, may cause tinnitus, but we have had very little success when the few patients we have seen with this syndrome have undergone surgery. Tinnitus usually improves in profoundly deaf individuals who undergo cochlear implantion (Olze, 2015). Avoid exposure to loud noises and sounds, avoid environments that are very quiet (as this makes tinnitus more noticeable). Tinnitus Retraining Therapy (TRT) is a method of treating tinnitus helpful for some (Wang et al, 2003). We sometimes refer patients for TRT, but the time required and general lack of health insurance support for long term psychotherapy are significant barriers. Dawes P, Fortnum H, Moore DR, Emsley R, Norman P, Cruickshanks K, Davis A, Edmondson-Jones M, McCormack A, Lutman M, Munro K. Hoare DJ, Kowalkowski VL, Kang S, Hall DA.Systematic review and meta-analyses of randomized controlled trials examining tinnitus management.
Mahboubi H, Ziai K, Brunworth J, Djalilian HR.Accuracy of tinnitus pitch matching using a web-based protocol. Piccirillo JF, Garcia KS, Nicklaus J, Pierce K, Burton H, Vlassenko AG, Mintun M, Duddy D, Kallogjeri D, Spitznagel EL Jr.Low-frequency repetitive transcranial magnetic stimulation to the temporoparietal junction for tinnitus Arch Otolaryngol Head Neck Surg.
Wineland AM, Burton H, Piccirillo J.Functional Connectivity Networks in Nonbothersome Tinnitus.
Newman, Sandridge, and Jacobson1 estimated 50 million people in the United States experience tinnitus. Clearly, the majority of hearing care professionals (HCPs, audiologists, otolaryngologists, and hearing aid dispensers) manage patients with tinnitus every day.
It almost goes without saying that step one is a differential diagnosis for the patient perceiving tinnitus, and step two is treatment.
Zagolski and Strek7 report tinnitus pitch and minimum masking level (MML) depend on the etiology of the tinnitus. Henry5 reports the primary tinnitus management tool (based on peer-reviewed literature) is cognitive behavioral therapy (CBT), and he reports acoustic therapies (ie, sound-based) have the next largest evidence base (after CBT). Further, Fagelson reports hearing aid amplification provides a method through which sound can be delivered therapeutically, because hearing aids amplify environmental sounds (which reduces the contrast between the perceived tinnitus and the acoustic environment), potentially allowing the patient to feel more secure and to relax.
Folmer et al6 explored the peer-reviewed literature from the last 70 years related to tinnitus and determined there are effective noninvasive tinnitus treatments that are useful and often help manage the problem. CBT management of tinnitus has been occasionally criticized due to the need for focused attention on the tinnitus, and focused attention may indeed prevent habituation. Progressive Tinnitus Management (PTM) is an evidence-based and clinically tested approach developed by Department of Veterans Affairs research audiologists.
Patients generally enter PTM at the triage level and progress through each stage as necessary and appropriate for their unique needs. The goal of these individualized appointments is to learn skills and techniques that empower patients to self-manage their tinnitus across multiple environments.


Tinnitus Retraining Therapy (TRT) is based on a neurophysiological model of tinnitus first introduced by Jastreboff.21 This model is guided by the hypothesis that bothersome tinnitus has origins within the limbic (emotional) and autonomic (involuntary) nervous system. Counseling sessions incorporate demystifying tinnitus, educating patients about the underlying causes of tinnitus and its effects, and introducing methods that can lead to tinnitus habituation. For permanent habituation, sounds should be used 24 hours a day.22 In addition to structured sound therapy, patients engaged in TRT are encouraged to avoid silence while enhancing ambient background sounds using nature sounds or music. As we assess, manage, and treat tinnitus patients, we should keep in mind the vast majority of tinnitus patients have almost certainly searched dozens of websites looking for a cure. And for more than 10 million of them, the experience of hearing that sound is severe enough to seek medical attention. He’s been conducting choirs for decades – and he first noticed a ringing in his right ear in 1983 after a recording session. To change tinnitus, he says, you have to change the activity in the brain and stop the overcompensation. For those with a lesser degree of tinnitus, we have two iPhone apps that help manage the tinnitus annoyance.
For example, Tandon (1987) reported that 1% of those taking imiprimine complained of tinnitus. This unfortunate behavior makes it very hard to care for these patients -- as it puts one into an impossible situation where the patient is in great distress but is also unwilling to attempt any treatment. We doubt that this means that motor cortex excitability causes tinnitus, but rather we suspect that these findings reflect features of brain organization that may predispose certain persons to develop tinnitus over someone else. Because papilloedema is so rare, and tinnitus is so common, it is very unusual to find this dangerous condition. A brain MRI is used for the same general purpose and covers far more territory, but is roughly 3 times more expensive.
This is not surprising considering how disturbing tinnitus may be to ones life (Holmes and Padgham, 2009).
This is because of the very high correlation between anxiety and depression with tinnitus-related annoyance and severity (Pinto et al, 2014). At that date there were 4 double-blind placebo controlled trials of antidepressants for tinnitus.
A recent trial in older people showed that atorvastatin had no effect on the rate of hearing deterioration but there was a trend toward improvement in tinnitus scores over several years. This is a drug designed for heart disease, that is marketed in Europe for vertigo and tinnitus. If you have tinnitus associated with a hearing loss, a hearing aid is a reasonable thing to try. For venous tinnitus, possibilities include jugular vein ligation, occlusion of the sigmoid sinus, or closure of a dural fistula. The effects of unilateral cochlear implantation on the tinnitus handicap inventory and the influence on quality of life.
Medium-term results of combined treatment with transcranial magnetic stimulation and antidepressant drug for chronic tinnitus. Comparison of auditory brainstem response results in normal-hearing patients with and without tinnitus.
Maintenance repetitive transcranial magnetic stimulation can inhibit the return of tinnitus. Fortunately, 95% to 97% of all people who perceive tinnitus are not disabled by their tinnitus.2 That is, for 95% to 97% of the people who perceive tinnitus, they may notice it now and then, but their tinnitus does not cause stress, anxiety, or depression, or cause them to lose sleep.
For them, tinnitus is a major problem that may significantly attenuate quality of life and may significantly facilitate and exacerbate behavioral and physiological problems. Therefore, the goal of this article is to review contemporary thoughts and findings, as well as the status quo, with regard to managing the patient with subjective tinnitus.
Subjective tinnitus is a phantom sound or noise perceived in the ear(s) most often described as buzzing, ringing, crickets, whistling, humming, static, hissing, or a tone (most often high-pitched) which occurs in the absence of a known external stimulus. That is, objective tinnitus occurs secondary to a physical anomaly such as a foreign object in the ear canal, a perforated tympanic membrane, a patent eustachian tube and more. Objective tinnitus can often be managed medically or surgically, and therefore a differential diagnosis is extremely important. Unfortunately, in their haste to discover and implement treatment, many consumers skip step one (diagnosis), placing themselves at substantial risk. Moller reasoned curing cancer, tinnitus, or pain (with a single solution) remains a noble cause and honorable goal, but is not likely to happen.
MML was defined as the level at which tinnitus was rendered inaudible and defined in dB SL. Cima et al10 report cognitive behavioral therapy is the most evidence-based treatment option with regard to managing the tinnitus patient. CBT often fosters an improved patient response to their tinnitus in tandem with their perception of tinnitus becoming less handicapping and more manageable.
Goal setting can be used to help the patient move forward as they address irrational thoughts and fears. Further, to ensure therapy is effective, a supportive and collaborative partnership is formed between therapist and patient. However, the evidence base does show attending to tinnitus via CBT allows the individual to reconstruct their perception of it.19 The meta-analysis by Hesser et al17 indicates long-term benefits.
Key to PTM is the inclusion of multiple treatment options to address individual audiologic and psychological needs.
Of course, for some audiologists in certain clinical settings, it may not be logistically feasible to include mental health professionals on the clinical team assessing and treating patients with tinnitus. By reclassifying tinnitus into a neutral signal, adverse reactions to the presence of tinnitus are reduced or eliminated.
According to TRT, the ideal loudness setting for a sound generator is when the perception of tinnitus and external sounds begin to blend together and the tinnitus is still audible. For individuals with hearing loss, background sounds can be increased by the use of hearing aids. Indeed, when counseling is combined with sound (or acoustic) therapies, we provide the most successful and reasonable approach to managing the tinnitus patient. According to the Department of Defense, in the past four years, the number of veterans on disability compensation for tinnitus has nearly doubled to an estimated 1.5 million.
Sven Vanneste, an associate professor who works at UT-Dallas’ Callier Center for Communication Disorders, explains some people are helped with hearing aids, others with sound therapy, some with anti-depressants – even meditation. For a period of a few hours, every 15 to 30 seconds, the device sends tiny jolts of electricity at the same time as a tone – reinforcing the tones you want the brain to respond to, and not the others. Serene Ears provides masking therapy, which helps hide the tinnitus by playing soothing sounds. According to Park and Moon (2004), hearing impairment roughly doubles the odds of having tinnitus, and triples the odds of having annoying tinnitus. Somatic tinnitus means that the tinnitus is coming from something other than the inner ear. In a double-blind trial of paroxetine for tinnitus, 3% discontinued due to a perceived worsening of tinnitus (Robinson, 2007). Specialists who care for patients with ear disease, usually know very well which drugs are problems (such as those noted above), and which ones are nearly always safe.


Of course, tumors are a very rare cause of tinnitus, as tinnitus is at least 100 times more common than tumors of the inner ear area. On the other hand, Hoekstrat et al (2011) suggested that in general these drugs do not work for tinnitus.
This study suggested that Botox might improve tinnitus to a small extent (7 improved with active, 2 improved with placebo). Be sure that you try the hearing aid before buying one, as tinnitus is not always helped by an aid.
Given that smartphone apps do the same thing as tinnitus maskers, and that most newer hearing aids are blu-tooth capable, we see little reason to pay for a masker-hearing aid when one already owns a cell phone. Surgery seems worth considering only in extreme situations - -the tinnitus is extremely loud, very distressing, and there is a methodology to decide whether or not the tinnitus can be improved with surgery.
On the other hand, very few individuals with tinnitus are deaf enough to qualify for cochlear implants. Instead, they relegate tinnitus to the background, and they habituate to it without very much effort and without discomfort. Subjective tinnitus can only be perceived by the patient, and this type of tinnitus represents 95% to 98% of all tinnitus presentations. Therefore, we recommend all tinnitus patients be evaluated and diagnosed by a physician or a hearing care professional who has intimate knowledge of the topic area.
Nonetheless, we can often successfully manage these problems, and therefore the successful management of the tinnitus patient is our goal. Henry5 reports the tinnitus patient searching the web may fall prey to the millions of websites that promise to silence, quiet, or cure tinnitus. Specifically, acoustic therapy may be delivered via hearing aid amplification and other products that make background sounds louder, thus reducing the loudness difference between the background noise and the perceived tinnitus. With regard to the cost-effectiveness of CBT, Maes et al11 report the cost-effectiveness (ie, economic evaluation) of multidisciplinary tinnitus treatment based on cognitive behavioral therapy is more cost-effective than usual care. Cima and colleagues10 note that improvements in tinnitus management via CBT have been reported to last up to 15 years.
Using information provided to them, they provide the appropriate referral for further clinical services to assess and potentially treat the disorder. Treatment options for hyperacusis (oversensitivity to sounds), misophonia (negative reaction to sounds), and phonophobia (fear of sound) are included in the TRT protocol via exposure, desensitization, and reassociation with more pleasant sound images. Nonetheless, many factors are important as we develop a solution for the individual tinnitus patient. Of note, when providing sound therapies, we recommend flexible sound options (as patient preferences clearly change over time) and, of note, while providing acoustic therapy, the HCP must avail sounds that are not aversive and do not create negative associations or feelings for the patient. Cost-effectiveness of specialized treatment based on Cognitive Behavioral Therapy versus usual care for tinnitus.
A meta-analysis of cognitive-behavioural therapy for adult depression, alone and in comparison with other treatments.
Effectiveness of a cognitive behavioural group therapy (CBGT) for social anxiety disorder: immediate and long-term benefits. Standardized tinnitus-specific individual cognitive-behavioral therapy: a controlled outcome study with 286 tinnitus patients.
A randomized controlled trial of mindfulness-based cognitive therapy for treating tinnitus. The other app, Nix TInnitus Amp, is like a low cost hearing aid that can help with tinnitus in two ways.
Similar statistics are found in England (Dawes et al, 2014) and Korea (Park and Moon, 2014). Practically, as there is only a tiny proportion of the population with objective tinnitus, this method of categorizing tinnitus is rarely of any help.
In other words, the changes in the brain associated with tinnitus seem to be associated with emotional reaction (e.g. In a large study of tinnitus, avoidance of occupational noise was one of two factors most important in preventing tinnitus (Sindhusake et al. Tinnitus from a clear cut inner ear disorder frequently changes loudness or pitch when one simply touches the area around the ear. There are case reports concerning tinnitus as a withdrawal symptom from Venlafaxine and sertraline (Robinson, 2007).
Nevertheless, this quality of tinnitus probably justifies a trial of oxcarbamazine (a less toxic version of carbamazepine). TMS seems to be somewhat helpful for depression and migraine, and one would think that a modality that worked for these, would also work to some extent for tinnitus.
If tinnitus is reduced by intratympanic lidocaine injection, it seems reasonable to us that surgical treatment may also be effective (for unilateral tinnitus).
Just over half the participants reported bilateral tinnitus for a total of 625 ears with tinnitus. They identified specific counseling techniques shown to help the patient better manage their tinnitus, including cognitive behavioral therapy, psychological counseling and hypnosis, biofeedback, and relaxation training.
They say researchers and clinicians more or less agree the larger part of tinnitus suffering is associated with negative psychological reactions to tinnitus, and these negative psychological reactions need to be addressed properly to effectively manage tinnitus.
For example, someone afraid of being in noise because it will make their tinnitus worse may find the idea of attending a large social gathering impossible. It has a white noise generator for masking therapy, and it can provide notch therapy by eliminating the frequencies at which tinnitus seems to occur. It seems to us that it should be possible to separate out tinnitus into inner ear vs everything else using some of the large array of audiologic testing available today. The exact prevalence of TMJ associated tinnitus is not established, but presumably it is rather high too. In our clinical practice, we have occasionally encountered patients reporting worsening of tinnitus with an antidepressant, generally in the SSRI family. When this doesn't happen, the treatments that work the best for tinnitus are those that alter ones emotional state -- antidepressants and antianxiety drugs, and ones that allow you to get a full night's sleep.
Robinson reported that tinnitus in depressed patients appears more responsive to antidepressants than in non-depressed patients.
Because it is easily available in the US, and has a rather benign side effect profile, we think that it is a good candidate for medication trials. We have encountered patients who have excellent responses to cervical epidural steroids, and in persons who have both severe tinnitus and significant cervical nerve root compression, we think this is worth trying as treatment. Having TMJ increases the odds that you have tinnitus too, by about a factor of 1.6 (Park and Moon, 2014). Mechanisms for impovement were suggested to be direct effects of increased serotonin on auditory pathways, or indirect effects of tinnitus on depression or anxiety. For approximately half the group, tinnitus was sudden onset, and for the other half, a gradual onset was reported. The authors categorized their patients into groups according to probable tinnitus etiology.



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Comments to “Treatment for tinnitus 2014”

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