وصف
Over 40% of the population may experience tinnitus at some point in their lives; older individuals are the most common victims. The perception of sound in the absence of outside stimuli is known as tinnitus. A patient's quality of life, both physically and psychologically, may be significantly impacted. The goal of gathering information from the clinical history is to determine whether the symptoms are unilateral or bilateral, pulsatile or nonpulsatile, and if there is any concomitant hearing loss. Referral to an otolaryngologist is advised for tinnitus that is unilateral or pulsatile, as these characteristics may be linked to more significant underlying disorders.
ملخص
- Tinnitus is a challenging condition to manage, causing frustration for patients and often resulting in healthcare providers suggesting patients learn to ignore it. However, a duty to care necessitates offering relief and comfort, even when a cure is not possible. The focus should be on alleviating suffering, particularly in cases of idiopathic tinnitus where no apparent cause can be identified.
- Idiopathic tinnitus is defined as tinnitus in which neither the patient nor the provider can identify a treatable cause. While routine causes like loud sound exposure or ear infections are easily addressed, idiopathic tinnitus requires a more nuanced approach.
- Tinnitus affects 10-15% of adults worldwide and becomes debilitating in 2-4% of the population. This can lead to sleep deprivation, social isolation, anxiety, depression, and a decline in work performance and quality of life.
- Tinnitus is primarily a failure of adaptation and a central, rather than purely auditory, phenomenon. A lesion in the auditory periphery, such as hair cell loss, causes overrepresentation of lesion edge frequencies, leading to hyperactivity and an initial tinnitus signal.
- The tinnitus signal is normally canceled out at the level of the thalamus via inhibitory feedback. However, compromised paralymbic regions can lead to a loss of inhibition, resulting in the signal being relayed to the auditory cortex, causing permanent reorganization and chronic tinnitus.
- A patient progresses from abnormal neural activity to perceiving it as tinnitus. The brain interprets this as a threatening stimulus, activating the limbic and sympathetic systems. This leads to a failure of adaptation and a self-reinforcing condition reflecting the tinnitus.
- Most tinnitus sufferers have some hearing loss, though 20-30% have normal hearing. Tinnitus is commonly associated with decreased sound tolerance, involving hyperacusis (abnormally strong amplification) and misophonia (dislike of sounds). Tinnitus retraining therapy (TRT) aims at habituating to intrusive tinnitus and external sounds.
- Further investigation is needed for asymmetrical tinnitus or hearing loss, potentially indicating a vestibular schwannoma. Pulsatile tinnitus requires investigation for vascular or neoplastic causes. Possible conductive hearing loss necessitates assessment for early otosclerosis. Miscellaneous causes like temporal arteritis, hypertension, anemia, and hyperthyroidism should also be considered.
- The management protocol includes a thorough ENT examination and audiometry, with specialized testing such as tinnitus matching, masking, and the Tinnitus Handicap Index (THI). The THI assesses the impact of tinnitus on the patient's life, focusing on sleep disturbance, annoyance from natural sounds (phonophobia), and aggravation by noise.
- Medical management may include tricyclic antidepressants to reduce tinnitus and depression. Anxiolytics can help with anxiety and sleep disturbance. Beta-blockers are useful for pulsatile tinnitus.
- TRT combines low-level broadband noise and counseling to habituate to tinnitus, diverting the mind away from it. The goal is not to eliminate tinnitus but to weaken the connections between auditory pathways and the limbic autonomic nervous system, leading to habituation of perception.
- Masking involves creating sound in the ear to cover up the tinnitus. There are three types of responders: complete masking, partial masking, or no effect. Variable tinnitus maskers include hearing aids, tinnitus maskers, and combined tinnitus instruments.
- Sound enrichment involves providing relaxing neutral sounds, like ocean waves or white noise, as background noise. The goal is not to completely mask the tinnitus but to retrain the brain to listen to both the enrichment sound and the tinnitus, potentially leading to habituation.
- Trans-tinnitus, involving intratympanic injections of gentamicin or steroids, can be considered in certain cases. Cochlear implantation can benefit patients with pre-operative tinnitus, improving tinnitus perception. CBT can identify and modify maladaptive behaviors and negative thoughts about tinnitus.
- Complementary and alternative medicines, such as acupuncture and homeopathy, may be explored when mainstream medicine provides insufficient relief. Jinko Biloba has also been used, but only in adequate doses.
- In children with tinnitus, TRT, enriched environment sounds, and avoidance of silence can be helpful. The escalation matrix for tinnitus management includes patient education and reassurance, medical management, TRT, sound enrichment, tinnitus masking, intratympanic injections, cochlear implantation, CBT, and CAM.
- Randomized control trials conclude that patient education, relaxation therapy, CBT, and TRT are effective in making patients feel better. It's crucial to understand the basis of tinnitus and offer patients some kind of relief to improve their quality of life.
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