of tinnitus including the role of 耳鸣包括作用概述课件

Overview of tinnitus including the role of hearing aids in tinnitus management A presentation for ENT specialists PIP_Tinnitus_Presentation V1.00/2014-03/XPl Phonak AG / uncontrolled copy*Slide 1 Objectives To describe the key features of tinnitus To show how tinnitus is a substantial health burden To reveal the role of hearing loss in tinnitus To present the options for management, including the central role of hearing aids *Slide 2 What is tinnitus? Perception of sound but no external source Usually experienced as buzzing, hissing or ringing Not fully-formed sounds e.g. speech or music Not sound hallucinations experienced during bouts of mental illness Occurs in one or both ears, or arising within the head It can have a profound effect on the sufferer “ perceived severity of tinnitus correlates closer to psychological and general health factors, such as pain or insomnia, than to audiometrical parameters ” (Zoger et al, 2006) Langguth B, et al. (2013) Lancet Neurol.12:920-930; Zger S et al. (2006) Psychosomatics. 47:282-288.*Slide 3 Sound features of tinnitus NOISE CRITERIAPOSSIBLE FEATURES OnsetSudden, gradual PatternPulsatile, intermittent, constant, fluctuating SiteRight or left ear, both ears, within head LoudnessWide range, varying over time QualityPure tone, noise, polyphonic PitchVery high, high, medium, low Sounds experienced in tinnitus can vary according to several criteria: Langguth B, et al. (2013) Lancet Neurol.12:920-930.*Slide 4 Evaluating tinnitus severity At the other extreme, some patients suffer so much that daily living is difficult and they are unable to work. Others suffer a level of impairment between these two levels. Tinnitus is highly variable. Some patients are able to cope with the noise and their lives continue as normal. Langguth B, et al. (2013) Lancet Neurol.12:920-930.*Slide 5 The burden of tinnitus SCALE OF PROBLEM IMPACT TINNITUS RISK FACTORS A GROWING PROBLEM Tinnitus affects 10%15% of the general population worldwide This is an estimated 280 million people Tinnitus limits daily living in 1% 2% of people with tinnitus Hearing impairment Increasing age Gender (male) Exposure to noise Increasing size of the elderly population Frequency of noise exposure in work and leisure environments Geocze L, et al. (2013) Braz J Otorhinolaryngol.79:106-111; Langguth B, et al. (2013) Lancet Neurol.12:920- 930; Roberts LE, et al. (2010) J Neurosci. 30:14972-14979. *Slide 6 Peripheral events lead to central neurological changes A range of peripheral events can lead to central neuronal changes that manifest as tinnitus Other factors can be involved in either the development or the persistence of tinnitus HEARING LOSS NOISE TRAUMA OTOTOXIC DRUGS AUDITORY NERVE ABNORMALITIES CENTRAL AUDITORY PATHWAY NEURONAL ABNORMALITIES TINNITUS ONSET TINNITUS PERSISTENCE Langguth B, et al. (2013) Lancet Neurol.12:920-930.*Slide 7 Brain response to auditory deprivation Patients with tinnitus exhibit enhanced auditory sensitivity This is caused by hyperactivity of the auditory central nervous system Homeostatic pathways cause increased central gain (i.e. sensitivity) in response to auditory deprivation to: 1.Maintain central nervous system activity during low sensory input 2.Ensure nerve activity is modulated to respond to changes in sensory input In patients with tinnitus and hearing loss, the tinnitus pitch and the hearing loss frequency spectrum are usually matched DECREASED SOUND INPUT INCREASED SOUND SENSITIVITY Hebert S, et al. (2013) J Neurosci 33:2356-2364; Langguth B, et al. (2013) Lancet Neurol.12:920-930; Norena AJ, Farley BJ. (2013) Hearing Res 295:161-171. *Slide 8 Tinnitus is a balance of sensory input and spontaneous activity The decreased input from the cochlea, due to outer hair cell damage, results in readjustments in the central auditory system resulting in abnormal neural activity including hyperactivity, bursting discharges and increases in neural synchrony. TINNITUS AUDITORY DEPRIVATION AND CENTRAL GAIN ALTERED SPONTANEOUS NEURONAL ACTIVITY Norena AJ, Farley BJ. (2013) Hearing Res 295:161-171. Kaltenbach JA. (2011) Tinnitus: models and mechanisms“. Hear Res. June; 276 (1-2) : 52 60. *Slide 9 Tinnitus and hearing loss Most patients with tinnitus have some degree of hearing loss 75%90% OF PATIENTS WITH OTOSCLEROSIS HAVE TINNITUS ABOUT 80% OF PATIENTS WITH IDIOPATHIC SENSORINEURAL HEARING LOSS HAVE TINNITUS “Hearing loss is a hidden disability and to have tinnitus is sort of like a double whammy” Family physician with moderate tinnitus, Canada Axelsson A, Ringdahl A (1989) Br J Audiol 23:53-62; Ayache D, et al (2003) Otol Neurotol 24:48-51; Nosrati- Zarenoe R et al (2007) Acta Otolaryngol 127:1168-1175; Sobrinho PG et al. (2004) Int Tinnitus J 10:197-201; Schaette R et al. (2012) PLoS One 10.1371/journal. pone.0035238. *Slide 10 Tinnitus and distress: a vicious cycle Experiencing sound in the absence of an external stimulus can be emotionally upsetting This reaction can make the sounds appear worse This results in a vicious cycle of worsening tinnitus and increasing distress TINNITUS EMOTIONAL DISTRESS Schaette R. (2012) Phonak Focus 42.*Slide 11 Other psychological associations with tinnitus Tinnitus is associated with increased levels of psychological problems 24/90 (26.7%) versus 5/90 (5.6%) for age-matched controls without tinnitus HYPOCHONDRIA HYPERACUSIS COGNITIVE IMPAIRMENT TINNITUS ANXIETY DEPRESSION SLEEP PROBLEMS Andersson G, McKenna L. (2006) Acta Otolaryngol Suppl. 556:39-43; Belli H, et al. (2012) Gen Hosp Psychiatry. 34:282-9; Jackson J, et al. (2013) Int J Audiol. E-pub ahead of print; Langguth B, et al. (2013) Lancet Neurol.12:920-930. *Slide 12 r = correlation coefficient between severity of tinnitus and prevalence of depression and anxiety (higher r = stronger correlation) HADS: Hospital Anxiety and Depression Scale; NS: non statistically significant; SCID: Structured Clinical Interview for DSM-III-R Anxiety and depression correlate with severity of tinnitus TINNITUS (ALL SEVERITIES), N=80 HIGH-RISK OF CHRONIC, DISABLING TINNITUS, N=144 rPrP Current minor depression (SCID)0.4210% THI: Tinnitus Handicap Inventory; THQ: Tinnitus Handicap Questionnaire; TRQ: Tinnitus Reaction Questionnaire; TSI: Tinnitus Severity Index; TQ: Tinnitus Questionnaire; VAS visual analogue scale (various) Tinnitus measurement tool Shekhawat GS, et al. (2013) J Am Acad Audiol. 24:747-762*Slide 17 Patient and hearing-care professional surveys of the benefits of hearing aids STUDY 1STUDY 2STUDY 3STUDY 4 Binaural hearing aids provided benefit in 66% (47/71) of tinnitus patients 65.5% of patients with frequent tinnitus reported improvements with hearing aids 41.4% reported disappearance of symptoms Fitting a hearing aid was the most frequently reported benefit of visiting a specialised tinnitus clinic Reported by 34.9% of patients Audiologist- reported tinnitus relief after fitting a hearing aid Minor to major relief in 60% of cases Major relief in 22% of cases Scoping review identified 4 survey studies Shekhawat GS, et al. (2013).J Am Acad Audiol. 24:747-762*Slide 18 Masking level and tinnitus reduction Retrospective study of 70 patients with tinnitus in Australia Tinnitus severity measured using the tinnitus reaction questionnaire (TRQ) Overall, 51% of patients experienced “clinically significant” change (40% change in TRQ score) McNeill C, et al. (2012) Int J Audiol. 51:914-919.*Slide 19 Psychological and behavioural support INTERVENTIONDESCRIPTION Counselling and education Delivered in person, to groups and via the internet Variable results may depend on personal characteristics Cognitive behavioural therapy Designed to modify maladaptive behavioural and emotional responses One-to-one and group settings, delivered by psychologists or psychiatrists, or via internet Statistically significant reductions in severity of tinnitus symptoms (P0.05) Relaxation therapyMay help reduce tinnitus symptoms and depressive symptoms Hoare DJ, et al. (2011) Laryngoscope 121:1555-1564; Langguth B, et al. (2013). Lancet Neurol.12:920-930*Slide 20 Drug options for tinnitus management No approved drugs (European Medicines Agency EMA or US Food and Drug Administration FDA) Some psychopharmacological agents may help reduce the severity of psychological