Management of Tinnitus: Literatur Reading Audiologi

LITERATUR READING
AUDIOLOGI
MANAGEMENT OF
TINNITUS
By : Dina Riana
Supervised : dr. Sally Mahdiani, Mkes, Sp.
THT. KL ,
DEPARTEMEN ILMU KESEHATAN TELINGA HIDUNG TENGGOROK
BEDAH KEPALA DAN LEHER RSHS / FK UNPAD BANDUNG
Sataloff, TR. Sataloff,J. Hawkshaw,
M. Tinnitus.2015
In Sataloff, TR.
Sataloff,J. Hearing Loss. 3th ed.
Marcel Dekker Inc, New York. 1993.
INTRODUCTIO
N
Non pulsatile /
pulsatile tinnitus
& subjective /
objective tinnitus
are critical in the
appropriate
diagnosis and
management
Tinnitus, or the
perception of
sound in the
absence of an
external auditory
source
up to 50 million
adults in the US,
with 16 million
experiencing
frequent or
chronic tinnitus
in the prior 12
months
A common
patient
complaint in
otolaryngologic
practices.
Sataloff, TR. Sataloff,J. Hawkshaw, M. Tinnitus. In Sataloff, TR. Sataloff,J. Hearing Loss. 3th ed. Marcel Dekker Inc,
New York. 1993. p433-44.

M. Tinnitus. In Sataloff, TR.
Caracteristics
pulsatil
tinnitus
nonpulsat
ile
4
New York. 1993. p433-44.
Following
heartbeat
Modified by
external
movements,or
change in
position
Tinnit
us
pulsat
if
Venous with
whoosingsoun
d
Rhytmic
with the
patients
pulse
5
New York. 1993. p433-44.
tinnitus
objektif
Able to be
heard by
patient and
examiner
Vascuar
bruits,vascular
tumor,palatal
tensor timpani
myoclonus
subjektif
Hard only
by the
patients
How to diagnosed?
7
New York. 1993. p433-44.
History

PHYSICAL
EXAMINATION

DIAGNOSTIC EVALUATION
10
New York. 1993. p433-44.
SUBJECTIVE NONPULSATILE
TINNITUS
Noise-induced hearing loss, presbyacusis,
ototoxic medications, labyrinthitis, herpes zoster
oticus, Meniere's disease, and genetic hearing losses cause
inner ear hair cell damage resulting in hearing loss, which
can lead to nonpulsatile tinnitus. Chronic otitis media.
cholesteatoma, canal occlusion, and otosclerosis can cause
a conductive hearing loss that ultimately may result in tinnitus.
Lesions that affect the cochlear nerve and central
nervous system (CNS) such as acoustic neuroma, meningioma,
multiple sclerosis, and Charcot-Marie-Tooth disease
can also induce tinnitus, typically along with a coincident
hearing loss (Fig. 161.1,
Table
161.1).
Sataloff,
TR. Sataloff,J.
Hawkshaw,
11
Risk factor
The most prevalent risk factor for
subjective, nonpulsatile tinnitus is
hearing loss.
Frequently this hearing loss includes
significant sensorineural losses at
higher frequencies
27% of patients with profound
sensorineural hearing loss (SNHL) will
not have tinnitus.
New York. 1993. p433-44.
12
Subjective Nonpusatile
tinnitus
Theories of generation of nonpulsatile
tinnitus: specifically the role of certain
cochlear structures such as outer hair cells.
observations that subjective nonpulsatile tinnitus
is frequently seen in individuals with measurable
hearing loss or following known ototoxic injuries.
(such as ototoxic medication exposure. noise
exposure,head injury).
13
New York. 1993. p433-44.
Etiologi cochleogenic ; Persistence of

tinnitus following truncation of the auditory
nerve or ablation of the cochlea
Many studies have noted a decrease in inhibitory neural
input at multiple sites along the central auditory
pathways,including the dorsal cochlear nucleus .
This leads to a net increase in excitatory signaling in
the auditory pathway and has been proposed as the
neurophysiologic basis for subjective tinnitus.
14
Meniere disease
Conductive or mixed hearing loss can
also be associated with tinnitus,
including that caused by otosclerosis,
ossicular discontinuities, or
obstruction of the external auditory
canal by cerumen or other factor.
caffeine, aspirin, ibuprofen, and nicotine can
cause tinnitus and head injury.
Sataloff, TR. Sataloff,J. Hawkshaw, M. Tinnitus. In Sataloff, TR. Sataloff,J. Hearing Loss. 3th ed. Marcel Dekker Inc, New
York. 1993. p433-44.
15

16

17
Etiologic factors in subjective tinnitus

Otologic factors
Presbycusis
Noise-induced hearing loss
Menieres disease
Otosclerosis
Neurologic abnormalities
Skull fracture or closed head
trauma
Whiplash injury
Multiple sclerosis
Meningitic effects
Metabolic function
Hypothyroidism
Hyperthyroidism
Hyperlipidemia
Zinc deficiency
Vitamin deficiency
Pharmacologic factors
Aspirin compounds
NSAID
Aminoglycosides
Heavy metals
Dental factors
TMJ syndrome
1.
Psychologic factors
Depression
Anxiety
Sataloff, TR. Sataloff,J. Hawkshaw, M. Tinnitus. In Sataloff, TR. Sataloff,J. Hearing Loss. 3th ed. Marcel Dekker
18
Inc, New York. 1993. p433-44.
Diagnostic Evaluation
New York. 1993. p433-44.
19
patients with unilateral tinnitus may have a

vestibular schwannoma or other intracranial
anomaly requiring further treatment (Fig.
161.1 ).

20
TREATMENT
AMPLIFICATIO
N
Use of a well-fitted hearing aid, that include a wide,

high-frequency amplification band and open ear mold.
Open mould decrease oclusion effect and extend
amplification at higer frekwencies.
Ideal hearing aid setting for patients with hearing loss
and tinnitus
Hearing aid increse the ambient noise perceived by the
patients,thus masking the tinnitus.
Nonpulsatile and pulsatile tinnitus sounds can

sometimes be covered (or masked) by external sounds,
thus blocking the tinnitus percept and the unpleasant
sensations associated with these sounds.
For many patients, use of environmental sounds such
as a noise generator or radio can effectively and
inexpensively mask their tinnitus.
The addition of masking tones to amplifications from a
hearing aid can mask tinnitus sounds more effectivdy
than a hearing aid alone.
Residual inhibition is hypothesized to result from
inhibition of synchronous activity within the auditoty
pathway &om masking sounds that lie within the
frequencies
affected
hearing
lossLoss.
being
21 Inc,
M. Tinnitus.
In Sataloff,by
TR. Sataloff,J.
Hearing
3th ed.presented
Marcel Dekker
New York.masking
1993. p433-44.
above the minimal
threshold
TINITUS
MASKING
TINITUS
RETRAINING TRT is based on the concept
THERAPHYpat meminimalisir
that habituation to the
unpleasant stimulus can
minimize the reactions that
these patients experience.
TRT does not seek to
reduce production of the
tinnitus sound but instead
attempts to change the
linkage
between
the
tinnitus perception and
autonomic and limbic systems
using extensive counseling
and sound therapi.

22
NEUROMONICS
Uses sound therapy. extensive

tinnitus education, and cognitive
therapy to treat patients with
tinnitus.
Patients
begin
their
therapy
by
listening
to
preprocessed
mixed
"calming
music (a combination of baroque
and new age) combined with noise
mixed by proprietary algorithm for
2 to 4 hours daily.
COCHLEAR IMPLANTATION
moderate to severe tinnitus cochlear

implant
PHARMACOTHERAPHY
including
anesthetic
agents
(IV
lidocaine),
anticonvulsants,
antidepressants,
antihistamines,
benzodiazepines,
diuretic,
GABA
agonists
(Baclofen),
Ginko
biloba,
extracts, histamine,. steroids, and
vitamins.
MICROVASCULAR
DECOMPRSION
microvascular decompression of the

Sataloff,vestibulocochlear
TR. Sataloff,J. Hawkshaw, nerve suggest surgical
treatment
loop syndrome 23
Sataloff,J.
Hearing Loss.of
3thvascular
ed.
24 Inc,
New York. 1993. p433-44.
PULSATILE TINNITUS
25
New York. 1993. p433-44.
26
27 Inc,
New York. 1993. p433-44.
Vascular anomalies
Anomales of the
jugularbulb
Sigmoid Sinus
Diverticulum
the jugular bulb

represents the junction
between the proximal
internal jugular vein and
the sigmoid
sinus at the skull base.
obsemmon to swgical
or endovascular
intervention. Published
reports desaibe
succefull improvement
or elimination of
pulsatile tinnitus with
middle ear floor
reconstruction, jugular
vein ligation, and
endOYasOJiar ooil
Embolization
20%
Successful elimination of
of cases of pulsatile
pulsatile
tinniws originating from symptoms has been
a venous
reported with
Source. hypothesized
transmastoid
that tu:rbulent
reconstruction
blood within the sigmoid of the sigmoid wall and
sinus may lead to
with endovascular coil
erosion of the
embolization and
overlying mastoid bone
stenting.
28 Inc,
withNew
development
of
a
York. 1993. p433-44.
Dural Arteriovenous
Malformation/F'IStula
Atherosderotic Carotid
Artel)' Disease
AVM/F may be
congenital or acquired,
with
symptoms precipitated
by trauma, infection,
puberty,
or pregnancy , pulsatile
tinnitus, headache,
neurologic
compromise, or
intracranial hemorrhage
Treatment modalities
include endovascular
embolization, swgical
ex.cision of the :fistula .
Tinniws may result from carotid stenoses

impairment of the inner typically resolve
ear
following carotid
microcircullation due to
endarterectomy
atherosclerotic disease
or intravascular stenting
or from the
referred sound of
turbulent flow through
sclerotic carotid
arteries.
Intravascular
tu:rbulence
due
to a
M. Tinnitus. In
Sataloff,
TR.
Maura K, Pamela C.. Tinnitus. In Bailey, JB.
Johnson,
TJ. Head
and
Neck
Sataloff,J.
Hearing
Loss.
3th
ed. Otolaryngology. 5th ed. Vol 2. Lippincott
29
torturous
carotid
artfery
Williams
&
Wilkins.
2014..
Congenital Carotid
Anomalies
intrapetrous carotid
ligation, either via
arteiy is replaced by
direct swgical
an enlatged
obliteration or
inferior tympanic
embolization, must be
artery (a branch of
preceded
the ascending
by angiography to
pharyngeal).
delineate any
Rather than entering
intracranial territory
the skull base through supplied by the
the
persistent stapedial
inferior tympanic
artery and ensure
canaliculus, the
there is redundant
inferior tympanic
blood supply to that
artery
region.
anastomoses with the
caroticotympanic
Sataloff, TR. Sataloff,J. Hawkshaw, M. Tinnitus.
In Sataloff,
Sataloff,J. Hearing Loss. 3th ed. Marcel Dekker
artery
in theTR.
middle
30 Inc,
New York. 1993. p433-44.
ear where it is visible
Vascular Neoplasms
Paragangliomas
glomus tumors, are the

observation, radiation
most common
therapy, and surgery.
vasallar tumor of the
temporal bone. Believed
to arise
from paraganglia on the
cochlear promontory
Surrounding
Jacobson's nerve
(glomus tympanicum) or
from the
adventitia of the jugular
bulb within the jugular
foramen
(glomus jugulare), these
highly vasallarized
tumors typically
present with pulsatile
tinnitus
31 Inc,
New York. 1993. p433-44.
Hemangiomas
Temporal bone
hemangiomas,
including facial nerve
and
cavernous
hemangiomas, are
rare vascular tumors
of the
temporal bone that
can occasionally be
associated with
pulsatile tinnitus.
Cavernous
hemangiomas are
located
predominately in the
middle ear and can
resemble a glomus
tympanicum on
both physical exam
and radiologic
imaging.
32
New York. 1993. p433-44.
Nonvascular
Etiologies
Idiopathic Intracranial
Hypertension
The pathophysiology
Treatment options for
of
IIH include lifestyle
pulsatile tinnitus in
modifications,
IIH is currently
particularly weight
unknown. Potentially, loss,Acetazolamide,
increased ICP
corticosteroids, and
compresses the
diuretics ,Surgical
intracranial venous
intervention.
sinuses,
creating turbulence in
normally laminar
blood flow that
may lead to unilateral
or bilateral pulsatile
tinnitus (
New York. 1993. p433-44.
33
Semicircular Canal
Dehiscence
SCD syndrome results

from a deficiency
in the bony covering
overlying one of the
semicircular
Canals. patients with
posterior canal
dehiscence resulting
in contact between
contents of the
posterior canal and
the jugular bulb or
sigmoid sinus may
also lead to pulsatile
tinnitus
Management options
include observation
or surgical correction
of the dehiscence by
plugging or
resurfacing the
dehiscence (116).
34 Inc,
New York. 1993. p433-44.
Palatal and Middle Ear Muscle spasm of the

Myodonus
levator
veli palatini or tensor
veli palatini cause ET
opening
leading to tinnitus,
which can be
subjective or
objective.
reatment options
include observation,
masking
techniques, lysis of
the stapedial or
tensor tympani
tendon,
and use of Botox on
pledgets placed into
the middle
ear
35 Inc,
New York. 1993. p433-44.
Patulous Eustachian
Tube
Pulsatile tinnitus
arising from a
patulous ET originates
outside the auditory
pathway. Normally
dosed in the
resting position, a
patulous ET leads to
symptoms of
autophony, aural
fullness and, in some
cases, pulsatile
tinnitus.
A variety of medical
treatment options
have been proposed,
including weight gain,
discontinuation
of decongestants and
steroid nasal sprays,
mucous
thickening agents,
and nasal estrogen
drops. Surgical
interventions
include myringotomy
and tube insertion,
endoscopic
peritubal
augmentation of ET
valve. and surgical
closure of the ET
lumen
36 Inc,
New York. 1993. p433-44.
37 Inc,
New York. 1993. p433-44.

38

Johnson,
TJ. Head
and
Neck
Sataloff,J.
Hearing
Loss.
3th
39
Williams
&
Wilkins.
2014..

40

41
Tinnitus Handicap Inventory scores:

I. Slight THI 016
II. Mild THI 1836
III. Moderate THI 3856
IV. Severe THI 5876
V. Catastrophic THI 78 100

Johnson,
TJ. Head
and
Neck
Sataloff,J.
Hearing
Loss.
3th
ed. Otolaryngology.
42 5th ed. Vol 2. Lippincott
Williams
Wilkins.
2014..
Marcel
Dekker&Inc,
New York.
1993.
Treatment
Avoidance : Aspirin-containing compounds, NSAID
Avoid disturbing noise
Noise protection
Home-masking techniques
Bedside masker
Psychologic testing

Johnson,
TJ. Head
and
Neck
Sataloff,J.
Hearing
Loss.
3th
ed. Otolaryngology.
Williams
Wilkins.
2014..
Marcel
Dekker&Inc,
New York.
1993.
Tinnitus Program
In attempting to treat patients disabled by their
symptoms, measurement of the tinnitus is
important. Four aspects of tinnitus are measured in
the standard tinnitus program:
- Pitch
- Loudness
- Minimum masking level
- Residual inhibition

Johnson,
TJ. Head
and
Neck
Sataloff,J.
Hearing
Loss.
3th
ed. Otolaryngology.
Williams
Wilkins.
2014..
Marcel
Dekker&Inc,
New York.
1993.
Pitch Masking
Tinnitus synthesizer
tonal, hissing, whistling and cricket-like
Loudness Matching
Tinnitus is not usually loud
57 % less than a 7-dB sensation level
Tinnitus is matched and the matching sound is
increased from threshold to the level at which the
sound is perceived to be equal to the tinnitus
Johnson,
TJ. Head
and
Neck
Sataloff,J.
Hearing
Loss.
3th
45
Williams
Wilkins.
2014..
Marcel
Dekker&Inc,
New York.
1993.
Minimal Masking Level

The number of decibels of sound required
to cover the tinnitus
Residual Inhibition
Phenomenon of patients experiencing
periods of decreased or no tinnitus after
having been exposed to masking
Some patients actually have long tinnitusfree intervals after various masking
exposures.

Johnson,
TJ. Head
and
Neck
Sataloff,J.
Hearing
Loss.
3th
ed. Otolaryngology.
Williams
Wilkins.
2014..
Marcel
Dekker&Inc,
New York.
1993.

Johnson,
TJ. Head
and
Neck
Sataloff,J.
Hearing
Loss.
3th
47
Williams
&
Wilkins.
2014..

Maura K, Pamela C.. Tinnitus. In Bailey,Sataloff,J.
JB. Johnson,
TJ. Head
Hearing
Loss.and
3th Neck
ed. Otolaryngology.
Williams
Wilkins.
2014..
Marcel
Dekker&Inc,
New York.
1993.

Maura K, Pamela C.. Tinnitus. In Bailey,Sataloff,J.
JB. Johnson,
TJ. Head
Hearing
Loss.and
3th Neck
ed. Otolaryngology.
Williams
Wilkins.
2014..
Marcel
Dekker&Inc,
New York.
1993.

Johnson,
TJ. Head
and
Neck
Sataloff,J.
Hearing
Loss.
3th
50
Williams
&
Wilkins.
2014..
HIGHLIGHT
Complaints of tinnitus should be divided
into subjective versus objective and
nonpulsatile versus pulsatile categories
to facilitate diagnosis and management.
All patients with tinnitus should have
a complete audiogram as part of their
evaluation. Imaging and other studies
may be indicated based on findings on
history and physical examination.
Johnson,
TJ. Head
and
Neck
Sataloff,J.
Hearing
Loss.
3th
51
Williams
&
Wilkins.
2014..
HIGHLIGHT
Nonpulsatile tinnitus can result from a
variety of causes, including SNHL, CHL.
ingestion of stimulants, head trauma, and
psychiatric disease. When possible,
treatment of the underlying cause can
alleviate tinnitus.
When etiology-specific management of
nonpulsatile tinnitus fails or is not
possible. nonspecific management of
tinnitus should be attempted.
Johnson,
TJ. Head
and
Neck
Sataloff,J.
Hearing
Loss.
3th
52
Williams
&
Wilkins.
2014..
HIGHLIGHT
Pulsatile tinnitus can be generated by
a variety of arterial and venous causes,
vascular tumors, fluid within the middle
ear, otosclerosis, and tumors of the lAC.
In up to one-third of these cases, no
etiologic agent will be identified.
Treatment of the underlying cause of
pulsatile tinnitus, when possible. can
resolve this complaint.
Johnson,
TJ. Head
and
Neck
Sataloff,J.
Hearing
Loss.
3th
53
Williams
&
Wilkins.
2014..

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LITERATUR READING

Sataloff, TR. Sataloff,J. Hawkshaw,

Sataloff, TR. Sataloff,J. Hawkshaw,

Sataloff, TR. Sataloff,J. Hawkshaw,

Etiologi cochleogenic ; Persistence of

Sataloff, TR. Sataloff,J. Hawkshaw,

Sataloff, TR. Sataloff,J. Hawkshaw,

Etiologic factors in subjective tinnitus

patients with unilateral tinnitus may have a

Sataloff, TR. Sataloff,J. Hawkshaw,

Use of a well-fitted hearing aid, that include a wide,

Nonpulsatile and pulsatile tinnitus sounds can

Sataloff, TR. Sataloff,J. Hawkshaw,

Uses sound therapy. extensive

moderate to severe tinnitus cochlear

microvascular decompression of the

the jugular bulb

Tinniws may result from carotid stenoses

glomus tumors, are the

SCD syndrome results

Palatal and Middle Ear Muscle spasm of the

Sataloff, TR. Sataloff,J. Hawkshaw,

Sataloff, TR. Sataloff,J. Hawkshaw,

Sataloff, TR. Sataloff,J. Hawkshaw,

Sataloff, TR. Sataloff,J. Hawkshaw,

Tinnitus Handicap Inventory scores:

Sataloff, TR. Sataloff,J. Hawkshaw,

Sataloff, TR. Sataloff,J. Hawkshaw,

Sataloff, TR. Sataloff,J. Hawkshaw,

Minimal Masking Level

Sataloff, TR. Sataloff,J. Hawkshaw,

Sataloff, TR. Sataloff,J. Hawkshaw,

Sataloff, TR. Sataloff,J. Hawkshaw,

Sataloff, TR. Sataloff,J. Hawkshaw,

Sataloff, TR. Sataloff,J. Hawkshaw,

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