Tinnitus Facts, Theories, and Treatments (1982) / Chapter Skim
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4 Treatments
4 Treatments
Pages 55-116
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From page 55... ...
, and this statistic presumably ignores those patients satisfied by the explanations of general practitioners or others prior to referral to specialists. When they are being precise, medical specialists often reserve the use of the word treatment for actions taken to actually cure a disorder or disease, as opposed to actions taken only to relieve the pain or distress of the disorder or disease.
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From page 56... ...
The possibility of interplay between psychological and physiological factors is obvious when stress is considered. (Many tinnitus sufferers report exacerbation of their problem during times of stress.)
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From page 57... ...
Results have been unpredictable at best, and success rates have been low. House and Brackmann (1981)
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From page 58... ...
As Hazell (CIBA Foundation, 1981:213) has pointed out, cutting the eighth nerve may obviate the later use of other, possibly more effective treatments yet to be developed.
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From page 59... ...
Drugs Causing Tinnitus It is not uncommon for patients with various maladies to report tinnitus for the first time soon after beginning a new drug regimen. For any particular drug, the fraction of patients reporting new or enhanced tinnitus is typically small, but this should not lead us to disbelieve the reality of the reports.
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From page 60... ...
. Upon termination of the drug, the hearing loss invariably recovers within 24-72 hours, depending upon the serum salicylate level achieved (Myers and Bernstein, 1965; McFadden and Plattsmier, 1982c)
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From page 61... ...
No mention could be found in the literature of two features of aspirin-induced tinnitus that the author has personally observed. Attempts to match the pitch of an aspirin-induced tinnitus were frustrated by residual inhibition; a brief, relatively weak matching tone presented to either ear had the ability to eliminate the tinnitus for periods of 30-60 seconds as soon as its frequency approximated that of the tinnitus.
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From page 62... ...
Some reports indicate that in sensitive individuals the quinine contained in a single gin-and-tonic highball can be adequate to produce tinnitus. The occurrence of tinnitus following administration of quinine sulfate is mentioned by Markham et al.
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From page 63... ...
However, no information was found on the dose levels needed, the time course of onset and decline, etc. Marijuana It has been asserted that marijuana can markedly increase a preexisting tinnitus (CIBA Foundation, 1981:168)
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From page 64... ...
Further, the actual proportion of the sample of patients reporting relief in a particular study will depend heavily upon the makeup of that sample. If, for some reason, an investigator ended up with a sample heavily dominated by patients whose tinnitus arose from the same problem -- (say)
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From page 65... ...
to the reported success rates. When some of the patients have been through months or years of frustration trying to get relief from their tinnitus, it may be that anyone's doing anything in an attempt to help them might be met with reports of success.
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From page 66... ...
Because it is possible to overdose on vitamin A, it is not advisable for tinnitus sufferers to experiment with heavy doses of this agent without medical supervision.
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From page 67... ...
(Exactly when following the injection this judgment was made is not specified, but presumably it was within a few minutes of injection.) Approximately 35 percent of these severely affected patients reported total abolition of the tinnitus, and an additional 28 percent reported the tinnitus to be 0.3 or less of its initial magnitude; about 26 percent reported no relief from their tinnitus.
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From page 68... ...
Of the 55 patients with "pure sensorineural hearing loss, n three subgroups -- constituting 41 patients -- stand out, as shown in the following breakdown of patients reporting either a total abolition of tinnitus (excellent relief) or a reduction in it to 0.3 or less of its preinjection magnitude (good relief)
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From page 69... ...
m e subjective results in the Martin and Colman study are even more impressive than the objective results. One would expect that the reductions in the matched intensity of the tinnitus would produce concomitant reductions in the perceptibility or the annoyance of the tinnitus, and, in fact, 72 percent of the subjects judged their relief from tinnitus to be 50 percent or greater following the lidocaine injection (versus 9 percent following saline)
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From page 70... ...
Intravenous lidocaine was administered to 592 patients having ~extremely bothersome tinnitus." One minute after injection, the patients were asked to indicate the magnitude of tinnitus relief in percentage units. Unlike other studies, the data are reported separately for the unilateral and the bilateral tinnitus sufferers.
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From page 71... ...
that an agent apparently quite effective against some forms of tinnitus binds to the melanin in the inner ear raises the two questions of whether tinnitus incidence is also correlated with melanin content, and whether dose levels of lidocaine (and some other tinnitus-ameliorating agents) might better be tied to
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From page 72... ...
. In a discussion at a recent conference (CIBA Foundation, 1981:27-28)
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From page 73... ...
Of the patients reporting total abolition of tinnitus following a single I.V. injection of lidocaine, about 60 percent reported either total abolition of tinnitus or reduction in its magnitude to 0.3 of its original magnitude or less by the carbamazepine regimen.
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From page 74... ...
This -- plus the fact that some patients receiving excellent relief from lidocaine received only minimal relief from carbamazepine -- seems to make screening on the basis of the lidocaine injection a questionable procedure. Given the current level of understanding about the actions of these drugs, future investigators may wish to consider eliminating such screening (but note that Goodey 11981]
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From page 75... ...
On the other hand, it is clear that clinicians and experimentalists do have an additional weapon in their arsenal against tinnitus. Finally, an intriguing possibility was raised by Hazell (CIBA Foundation, 1981:50)
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From page 76... ...
reported that none of 15 patients treated with this drug had any relief from tinnitus, even though all had some relief from the lidocaine injection. Primidone (Mysoline is a registered trademark)
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From page 77... ...
briefly mentions this drug, indicating that it reduces tinnitus in about the same proportion of subjects as does carbamazepine, but that, at the doses used to date, the amount of relief experienced is less than with carbamazepine. Apparently side effects are minor.
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From page 78... ...
This implies a reversal of the conditions initially responsible for the tinnitus -- an unlikely event -- which makes this an outcome requiring verification through further study. Alcohol Excess alcohol consumption is frequently mentioned in anecdotes as a cause of tinnitus, but curiously, some tinnitus sufferers apparently find that small amounts of alcohol assist in tinnitus control (Goodey, 1981)
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From page 79... ...
It has been asserted that barbiturates do not cause tinnitus (CIBA Foundation, 1981:169; see "Sodium Amylobarbitone~ in this chapter) , and it has been suggested that the aminoglycosides may produce only a temporary tinnitus (CIBA Foundation, 1981:34)
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From page 80... ...
Many patients report a marked subjective improvement in everyday hearing; to date these impressions have not been confirmed by objective test (Melding et al., 1978; Melding and Goodey, 1979; Shea and Harell, 1978; Emmett and Shea, 1980; CIBA Foundation, 1981:190-191) , but it is possible that audiometric measures other than pure-tone sensitivity would reveal improvements.
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From page 81... ...
Thus, it appears that allergy management may aid some tinnitus sufferers who also have Meniere's-like symptoms, but the published success rates indicate that unless But beyond comments of this
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From page 82... ...
and thus could not serve as the basis for a feedback signal, and (2) a line of reasoning that goes: tinnitus magnitude has been reported to co-vary with level of anxiety, anxiety is widely believed to be related to muscular tension, and therefore reduced muscular tension ought to reduce tinnitus (a view that surely oversimplifies the etiology of tinnitus)
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From page 83... ...
No breakdown of these proportions by type of auditory pathology is provided. Thus, biofeedback training does appear to offer hope to some tinnitus sufferers, but it is likely that whatever improvement results is due more to the patients' increased ability to cope with the symptom than to its having been reduced.
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From page 84... ...
. Given that such values are probably in the range of spontaneous remissions and given that higher success rates are achieved with other procedures, there appears to be little justification for resorting to acupuncture for the treatment of tinnitus.
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From page 85... ...
With the electrode polarity reversed, these patients reported an increase in tinnitus magnitude as the current was increased. (Residual inhibition was not tested for or spontaneously noted.)
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From page 86... ...
me electrical stimulation was only effective in suppressing tinnitus clearly localized in the ipsilateral ear -- never in the contralateral ear (compare Hatton et al., 1960)
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From page 87... ...
Apparently some patients did report periods of relief extending beyond the duration of the electrical stimulation (so-called residual inhibition) , but Aran and Cazals are clearly dubious about the reality of this effect.
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From page 88... ...
manipulated the relative air pressure in the middle and outer ears of patients with Meniere's Disease and found that an overpressure in the middle ear produced decreases in the tinnitus, vertigo, and low-frequency hearing loss that are characteristic of this disease, as well as decreases in the feelings of nausea and fullness. It is reported that attempts to incorporate such pressure changes into a treatment regimen for Meniere's Disease is being attempted in Tjernstrom's laboratory in Malmo, Sweden (J.
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From page 89... ...
are typically given credit for first implementing the idea. To a nonsufferer, there may seem to be something inconsistent in a sufferer's willingness to substitute one continuous sound for another -- a point to which we shall return -- but its effectiveness for some tinnitus sufferers is not to be denied.
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From page 90... ...
The idea apparently originated in part out of frustration in treating tinnitus sufferers having reasonably normal hearing over the standard audiometric frequencies. These patients often had tinnitus at such high frequencies that masking it by using hearing aids to amplify ambient sounds was either impossible -- due to the bandwidth limitations of the aids -- or impractical -- due to the consequent amplification-induced distortion in the low- and mid-frequency regions in which hearing was normal.
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From page 91... ...
While this ideal is nearly achievable with modern technology, to date it has not been vigorously pursued. Instead, the masking sounds generated by all tinnitus maskers/instruments are rather broadband, with limited energy in the region above about 6 kHz (see Vernon et al., 1977)
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From page 92... ...
Efficacy of Tinnitus Maskers/Instruments m e early reports on the efficacy of tinnitus maskers were very optimistic (Vernon et al., 1977; Vernon, 1978b; Vernon and Schleuning, 1978) , perhaps misleadingly so, and, as a consequence, maskers began to receive much attention from auditory specialists and the popular press (Gallon, 1979)
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From page 93... ...
The implication given in this report is that the average patient routinely experienced 35-40 minutes of residual inhibition following a day's use of the tinnitus masker; at the other extreme, one patient had once experienced 16 hours of relief, and another, 18 hours. By 1978, 158 patients had been seen at the Oregon tinnitus clinic (Vernon and Schleuning, 1978)
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From page 94... ...
Unfortunately, this 1978 report contains no update on the proportion of patients showing residual inhibition, but two cases are related in which the patients' residual inhibition gradually increased with continued use of the tinnitus masker, until the tinnitus eventually disappeared completely, causing the patients to return the masking units. Both of these "cures" involved tinnitus of several years' duration.
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From page 95... ...
Approximately 41 percent of the 493 patients had been recommended tinnitus maskers, and an additional 9 percent had been recommended the newly developed tinnitus instruments; this total of 50 percent is more than double the 24 percent cited by Vernon and Schleuning (1978)
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From page 96... ...
96 ~s oo a~ U
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From page 98... ...
noted that the interpretation of this outcome is unclear; it may have been that some patients had complete relief from tinnitus during the wearing of their devices (so-called active relief) but that they had acquired high expectations of pronounced residual inhibition that were not realized, causing them to regard their overall relief as only "partial." The percentages cited above were only for the 1976-1978 subset of respondents to the questionnaire; the data for the 105 patients in the 1979 subset are different in a number of ways (compare Tables 1 and 2)
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From page 99... ...
The patient took that initial recommendation to a hearing-aid dispenser and tried the recommended device for a month before deciding to purchase or return the unit. An unspecified number of patients returned to the clinic with complaints during this 1-month period, and some received new "tentative" recommendations.
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From page 100... ...
Even though the sample size is still quite small, note should be taken of the greater apparent success of tinnitus instruments than of tinnitus maskers (Table 2) , a trend that is worth watching.
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From page 101... ...
Other Reports The article by Roeser and Price (1980) is frequently cited as containing evidence on the efficacy of tinnitus maskers that is contrary to that of the Oregon group.
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From page 102... ...
. Roeser and Price report data on three items from their questionnaire, but unfortunately only for the 20 patients encouraged to try tinnitus maskers; no information is supplied on the 11 patients who tried hearing aids.
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From page 103... ...
Several hundred tinnitus sufferers have been seen, but to date only preliminary results have been published (CIBA Foundation, 1981:257-258)
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From page 104... ...
However, the reader is cautioned to draw only interim and conservative conclusions at this time, in recognition of the weaknesses in the currently available data. A conclusion that appears consonant with the available data, yet conservative, is that tinnitus maskers/instruments appear to offer hope of at least partial relief to a substantial fraction of tinnitus sufferers.
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From page 105... ...
A standard procedure to measure residual inhibition is obviously desirable, and the Oregon group claims to have developed one, although the details of its development are not clear from the published reports. First, masking of the tinnitus is attempted with tones and narrowband waveforms.
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From page 106... ...
has noted that following a period of complete residual inhibition, some patients report that their tinnitus does not return gradually and monotonically, but rather it "bounces back" in intermittent spurts; this fact obviously has important implications for the underlying mechanisms. Goodey (CIBA Foundation, 1981:288)
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From page 107... ...
In this select sample she finds that, following exposure to the masker, about one-third report no change, about one-third report decreased tinnitus (residual inhibition) , and about one-third report increased tinnitus.
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From page 108... ...
. The spectral characteristics of several available tinnitus maskers were shown by Agnew (1979b)
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From page 109... ...
With digital synthesis and manipulation of waveforms, such a possibility exists, but manufacturers of tinnitus maskers/instruments have yet to take advantage of this approach. A small, easily wearable device could be produced that is programmable by the manufacturer or the dispenser to generate a waveform with the specific spectral characteristics determined to be necessary to produce the most efficient masker of that patient's tinnitus -- that is, a "master" tinnitus masker/ instrument.
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From page 110... ...
, whose cumulative and long-term characteristics are unknown. It would be ironic indeed if a new generation of tinnitus maskers/instruments were themselves responsible for inducing additional tinnitus.
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From page 111... ...
.) Thus, it is not possible to reach a decision about the safety of tinnitus maskers/instruments by simply comparing their maximum overall intensities with the standard damage/risk criteria -- longer daily exposures and more successive days per week are involved.
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From page 112... ...
About all we presently have to go on when evaluating the safety of tinnitus maskers/instruments is the manufacturers' specifications of maximum level. The manufacturers' specifications sheets for many models of tinnitus masker state a minimum overall output level of 40-45 dB SPL (note, not "A-weightedn)
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From page 113... ...
People with bilateral hearing loss but monaural tinnitus would be particularly interesting, since the nontinnitus ear would serve as a within-subjects control for additional loss. It should be noted that, if manufacturers do begin producing tinnitus maskers/instruments capable of generating narrowband waveforms, it will raise a further complication to the use of existing DRC and other guidelines as standards for regulating maskers/instruments.
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From page 114... ...
Tinnitus maskers/instruments appear to be indistinguishable from common drugs and hearing aids in this regard. That is, it can be argued that, if tinnitus sufferers are made aware of the potential risks to hearing involved in using a tinnitus masker/ instrument at high intensities and/or for prolonged periods of time, and they still choose to wear the device, perhaps that decision should be theirs to make.
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From page 115... ...
It might be possible to capitalize on the residual inhibition effect to gain greater safety and reduced inconvenience in tinnitus maskers/instruments. A member of the Working Group (L.
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From page 116... ...
For our purposes here, it must be concluded that, while the safety aspects of tinnitus maskers/instruments would appear to have much in common with those of hearing aids, too little is known about the latter to help us reach a decision about the former.
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