(2016) ”A nearly endless number of procedures has been tried and in particular sold for the treatment of tinnitus, unfortunately they have not been evaluated appropriately in an evidence-based way. A causal therapy, omitting the tinnitus still does not exist, actually it cannot exist because of the various mechanisms of its origin. However or perhaps because of that, medical interventions appear and reappear like fashion trends that can never be proven by stable and reliable treatment success. This contribution will discuss and acknowledge all current therapeutic procedures and the existing or non-existing evidence will be assessed. Beside external evidence, the term of evidence also encompasses the internal evidence, i.e. the experience of the treating physician and the patient’s needs shall be included.
While there is no evidence for nearly all direct procedures that intend modulating or stimulating either the cochlea or specific cervical regions such as the auditory cortex, there are therapeutic procedures that are acknowledged in clinical practice and have achieved at least a certain degree of evidence and generate measurable effect sizes. Those are in particular habituation therapy and psychotherapeutic measures, especially if they are combined with concrete measures for improved audio perception (hearing aids, CI, hearing therapies).” https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5169077/
Year 2023 (BvS after 4 very hard years): Not much (at least in Sweden) is/are being done in health care to thoroughly try to understand how severe tinnitus can be, often not proper investigations and consequently no sensible interventions – although there are many more areas that also do not receive any serious investigations and interventions … Many are ”not seen” because many dysfunctions are complex and multifaceted-multidisciplinary – something that has not yet developed in traditional reductionist medicine! Below need not be a deterrent if one has a method to attack complex multidisciplinary dysfunctional suffering!
My own contribution a few years ago (worked with it while the alarm permanently perhaps influenced my approach to overview of complexity: https://carism.se/projekt-carism/a-multidisciplinary-overview-of-the-tinnitus-syndrome-fields/overview-of-some-of-the-tinnitus-syndrome-approaches/ also see https://carism.se/projekt-carism/urgent-needed-knowledge-and-practice-development-different-kinds-of-tinnitus/
Svensk text:
2016 ”Ett nästan oändligt antal procedurer har prövats och i synnerhet sålts för behandling av tinnitus, tyvärr har de inte utvärderats på lämpligt sätt på ett evidensbaserat sätt. En kausal terapi, utelämnande tinnitus existerar fortfarande inte, det kan faktiskt inte existera på grund av de olika mekanismerna i dess ursprung. Men eller kanske på grund av det verkar medicinska ingrepp och återkommer som modetrender som aldrig kan bevisas av stabil och pålitlig behandlingsframgång. Detta bidrag kommer att diskutera och erkänna alla nuvarande terapeutiska förfaranden och befintliga eller icke-existerande bevis kommer att bedömas. Förutom extern bevisning omfattar bevismaterialet även den interna bevisningen, dvs. den behandlande läkarens erfarenhet och patientens behov ska ingå.
Även om det inte finns några bevis för nästan alla direkta förfaranden som avser att modulera eller stimulera antingen cochlea eller specifika livmoderhalsområden som hörselbarken, finns det terapeutiska förfaranden som erkänns i klinisk praxis och har uppnått åtminstone en viss grad av bevis och genererar mätbara effektstorlekar. Dessa är särskilt tillvänjningsterapi och psykoterapeutiska åtgärder, särskilt om de kombineras med konkreta åtgärder för förbättrad ljuduppfattning (hörapparater, CI, hörselterapier)”. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5169077/
Inte mycket görs inom hälso- och sjukvården för att grundligt försöka förstå hur svårt tinnitus kan vara, ofta inte ordentliga utredningar och följaktligen inga vettiga interventioner – även om det är många flera områden som inte heller får några seriösa utredningar och interventioner … många ”syns ej” eftersom många dysfunktioner är komplexa och multifaceterade-multidisciplinära – något som ännu inte utvecklats inom traditionell reduktionistisk medicin! Nedan behöver inte avskräcka om man har en metod att angripa komplexa multidisciplinära dysfunktionellt lidande!
Mitt eget bidra för några år sedan (jobbade med det medan larmet permanent kanske påverkade min ansats till överblick över komplexiteten: https://carism.se/projekt-carism/a-multidisciplinary-overview-of-the-tinnitus-syndrome-fields/overview-of-some-of-the-tinnitus-syndrome-approaches/ se också https://carism.se/projekt-carism/urgent-needed-knowledge-and-practice-development-different-kinds-of-tinnitus/
Nedan länkar:
Tinnitus, Differential Diagnosis https://www.timeofcare.com/tinnitus-differential-diagnosis/
Most Common causes:
-Idiopathic tinnitus (cause not found),
-Sensorineural hearing loss (the most common identified cause)
Tinnitus originating from within the auditory system
Vascular
Stroke
Vascular malformations
Small vessel disease
Hypercoagulable states
Hypercholesterolemia
Diabetic vasculopathy
Hypertension
Pseudotumor cerebri
Sickle cell anemia
Other anemia
Vascular: arterial bruit, venous hum, arteriovenous malformation, vascular tumors, carotid atherosclerosis, dissection, or tortuosity
Infections (peripheral & central)
Viral, bacterial, fungal
Rubella
Neurosyphilis
Lyme disease
Meningitis
Measles
Cytomegalovirus
Chronic otitis media
Neoplasm
Tumor
Vestibular schwannoma (Acoustic neuroma)
Glomus tumor
Drugs
Drugs that injure the cochlear: Salicylates; Antibiotics; Loop diuretics; chemotherapy
Substance use.
Idiopathic/Iatrogenic
Idiopathic tinnitus
Congenital: Congenital hearing loss
Autoimmune:
Autoimmune inner ear disease (not always associated with systemic autoimmune disease)
Systemic lupus erythematosus
Sarcoidosis
Rheumatoid arthritis
Trauma:
Cochlear trauma, barotrauma
Cerumen removal
Endocrine / Metabolic disorders
Thyroid disease
Diabetes mellitus
Hyperparathyroidism
hyperlipidemia,
Chronic renal failure
Deficiencies:
Vitamin B12 deficiency
Musculoskeletal
Paget’s disease
Osteogenesis imperfecta
Otosclerosis
Fibrous dysplasia
TMJ dysfunction (see below)
Head or neck injury
Environmental: Noise-induced hearing loss
Neuropsychiatric:
Multiple sclerosis
Meniere syndrome (caused by injury to the cochlear)
Vestibular migraine
Idiopathic intracranial hypertension
Spontaneous intracranial hypotension
Type I Chiari malformation
Sensorineural hearing loss
Idiopathic
Presbycusis
Late-onset congenital hearing loss
Noise-induced hearing loss
Ototoxicity
Neurologic: palatal myoclonus, idiopathic stapedial or tensor tympani muscle spasm
Tinnitus originating from outside the auditory system
Vascular disorders (Pulsatile tinnitus)
Arterial bruits from arteries narrowed by atherosclerosis)
Congenital AVMs may be associated with hearing loss or tinnitus. This type of tinnitus generally occurs in only one ear.
Head and neck paragangliomas are highly vascular tumors that can cause a loud pulsing tinnitus.
Head and neck tumors compressing blood vessels causing tinnitus and other symptoms.
Hypertension (systemic or intracranial) produces venous hums.
Turbulent blood flow from narrowings or kinks in the carotid artery or jugular vein can cause tinnitus.
Neurologic disorders: pulsatile tinnitus caused by a muscle spasm one or both of the muscles within the middle ear (the tensor tympani and the stapedius muscle). They are supplied by CN V and VII respectively.
Eustachian tube dysfunction (A patulous eustachian tube)
Temporomandibular joint (TMJ) dysfunction
Whiplash injuries and other cervical-spinal disorders
Thinking through the differential diagnosis
Note: Tinnitus is a symptom, not a disease. It’s a symptom of an underlying problem.
See, classification of tinnitus. (Tinnitus originating from within the auditory system vs. Tinnitus originating outside the auditory system). Tinnitus originating from within the auditory system is the most common cause of tinnitus.
To come up with a differential diagnosis, the anatomic divisions we will use are 1) The auditory system, and 2) Outside of the auditory system (The rest of the head and body). The auditory system is further divided into the peripheral auditory system and central auditory system. Applying the mechanisms of disease (VINDICATED MEN) to these anatomic divisions at once gives following differential diagnosis.
Classification of Tinnitus https://www.timeofcare.com/classification-of-tinnitus/
“The etiology of tinnitus can be divided into tinnitus originating from within the auditory system (also called subjective tinnitus) and tinnitus originating from outside the auditory system (objective tinnitus). Some authors divide it into two kinds as follows:
- A) Tinnitus originating from within the auditory system
Subjective tinnitus is tinnitus only the patient can hear. This is the most common type of tinnitus. It is due to a sensorineural hearing loss which results from a dysfunction within the auditory system. It can be caused by a problem within the peripheral auditory system (the outer, middle or inner ear) or within the central auditory system (the auditory nerves or the part of your brain that interprets nerve signals as sound i.e. auditory pathways).
The causes of tinnitus originating from within the auditory system are many and are listed in the differential diagnosis of tinnitus.
- B) Tinnitus originating from outside the auditory system
Objective tinnitus is tinnitus the provider can hear when he or she does an examination. This rare type of tinnitus may be caused by a blood vessel problem, a middle ear bone condition or muscle contractions.”
Causes of tinnitus originating from outside the auditory system
Vascular disorders (Pulsatile tinnitus)
Arterial bruits (from atherosclerosis): With age, atherosclerosis leads to narrowing and loss of some elasticity–the ability to flex or expand slightly with each heartbeat. That causes blood flow to become more forceful (turbulent), making it easier for your ear to detect the beats. A patient can generally hear this type of tinnitus in both ears.
Arteriovenous Malformations. Congenital AVMs may be associated with hearing loss or tinnitus. This type of tinnitus generally occurs in only one ear.
Paraganglioma. Head and neck paragangliomas are highly vascular but usually benign neoplasms. They commonly cause a loud pulsing tinnitus that may interfere with hearing.
Head and neck tumors. A tumor that presses on blood vessels in your head or neck (vascular neoplasm) can cause tinnitus and other symptoms.
Hypertension (systemic or intracranial) produces venous hums. Systemic HTN, increased intracranial pressure (often due to pseudotumor cerebri, etc) can cause venous hums that can cause tinnitus and conductive hearing loss.
Turbulent blood flow. Narrowing or kinking in the carotid artery or jugular vein can cause turbulent, irregular blood flow, leading to tinnitus.
Neurologic disorders: pulsatile tinnitus caused by a muscle spasm one or both of the muscles within the middle ear (the tensor tympani and the stapedius muscle). They are supplied by CN V and VII respectively.
Eustachian tube dysfunction (A patulous eustachian tube)
Temporomandibular joint (TMJ) dysfunction
Whiplash injuries and other cervical-spinal disorders