Tanit Ganz Sanchez

Transient tinnitus suppression induced by repetitive transcranial magnetic stimulation and transcranial direct current stimulation

Modulation of activity in the left temporoparietal area (LTA) by 10 Hz repetitive transcranial magnetic stimulation (rTMS) results in a transient reduction of tinnitus. We aimed to replicate these results and test whether transcranial direct current stimulation (tDCS) of LTA could yield similar effect. Patients with tinnitus underwent six different types of stimulation in a random order: 10‐Hz rTMS of LTA, 10‐Hz rTMS of mesial parietal cortex, sham rTMS, anodal tDCS of LTA, cathodal tDCS of LTA and sham tDCS. A non‐parametric analysis of variance showed a significant main effect of type of stimulation (P = 0.002) and post hoc tests showed that 10‐Hz rTMS and anodal tDCS of LTA resulted in a significant reduction of tinnitus. These effects were short lasting. These results replicate the findings of the previous study and, in addition, show preliminary evidence that anodal tDCS of LTA induces a similar transient tinnitus reduction as high‐frequency rTMS.

Repetitive transcranial magnetic stimulation improve tinnitus in normal hearing patients: a double‐blind controlled, clinical and neuroimaging outcome study

Background and purpose:  Tinnitus is a frequent disorder which is very difficult to treat and there is compelling evidence that tinnitus is associated with functional alterations in the central nervous system. Targeted modulation of tinnitus‐related cortical activity has been proposed as a promising new treatment approach. We aimed to investigate both immediate and long‐term effects of low frequency (1 Hz) repetitive transcranial magnetic stimulation (rTMS) in patients with tinnitus and normal hearing.

Ear and nose foreign body removal in children

The removal of foreign bodies in children is very common in the otolaryngologists daily routine. We present a prospective series of 187 cases of ear and nose foreign bodies removed from children aged 0-12 years old in a 6-month period--95 females (50.8%) and 92 males (49.2%); 78 children (41.71%) aged from 1 to 2 years, 66 (35.29%) from 3 to 5 years. There were 93 cases (49.73%) of ear foreign bodies, in which a bean was the most common (24.73%), and 94 cases (50.27%) of nose foreign bodies, in which sponge fragments predominated (36.17%). In 82 cases (45.85%), the removal was performed within the first 24 h after the foreign body insertion, and 86 (45.98%) of the patients had previous attempts to remove it. Thirteen cases with complications (external ear canal lacerations, tympanic membrane perforation) were observed in patients in whom these previous attempts had been made, but there were no sequelae. This corresponds to one of the largest reports of ear and nose foreign body removal in children in the literature; we conclude that younger children are more prone to insert foreign bodies, which are objects usually found at home. Complications may occur as a result of attempts to remove the foreign body without the help of specialised personnel or proper conditions.

The impact of gender, age and hearing loss on tinnitus severity

O zumbido e um sintoma que afeta aproximadamente 15% da populacao mundial. Acomete qualquer idade, mas predomina entre 40 e 80 anos e sua prevalencia alcanca 33% entre os idosos. Aproximadamente 20% dos pacientes incomodam-se com o sintoma, mas ainda nao se conhecem todos os fatores determinantes deste incomodo. OBJETIVO: Avaliar a influencia do sexo, idade e grau de perda auditiva no incomodo do zumbido. MATERIAIS E METODOS: Foram avaliados 68 pacientes do ambulatorio de zumbido da nossa instituicao, no periodo de marco de 2007 a marco de 2008, em estudo com corte transversal. Os procedimentos realizados foram: anamnese com protocolo sistematizado, exame otorrinolaringologico completo, versao brasileira do Tinnitus Handicap Inventory (THI) e audiometria tonal liminar. RESULTADOS: A idade variou de 24 a 83 anos e a media do THI foi de 39 pontos (36 no sexo feminino e 44 no masculino). Os graus de incomodo pelo THI foram: discreto: 32,3%; leve: 19,1%; moderado: 20,6%; severo: 13,2% e catastrofico: 14,7%. Nao houve correlacao significativa do incomodo pelo zumbido com as variaveis sexo (p=0,30), idade (p=0,77) e grau de perda auditiva (p>0,05 em todas as medias avaliadas). CONCLUSAO: Sexo, idade e perda auditiva nao influenciaram no incomodo gerado pelo zumbido.

Controversy: Does repetitive transcranial magnetic stimulation/ transcranial direct current stimulation show efficacy in treating tinnitus patients?

BACKGROUND Tinnitus affects 10% of the population, its pathophysiology remains incompletely understood, and treatment is elusive. Functional imaging has demonstrated a relationship between the intensity of tinnitus and the degree of reorganization in the auditory cortex. Experimental studies have further shown that tinnitus is associated with synchronized hyperactivity in the auditory cortex. Therefore, targeted modulation of auditory cortex has been proposed as a new therapeutic approach for chronic tinnitus. METHODS Repetitive transcranial magnetic stimulation (rTMS) and transcranial direct current stimulation (tDCS) are noninvasive methods that can modulate cortical activity. These techniques have been applied in different ways in patients with chronic tinnitus. Single sessions of high-frequency rTMS over the temporal cortex have been successful in reducing the intensity of tinnitus during the time of stimulation and could be predictive for treatment outcome of chronic epidural stimulation using implanted electrodes. RESULTS Another approach that uses rTMS as a treatment for tinnitus is application of low-frequency rTMS in repeated sessions, to induce a lasting change of neuronal activity in the auditory cortex beyond the duration of stimulation. Beneficial effects of this treatment have been consistently demonstrated in several small controlled studies. However, results are characterized by high interindividual variability and only a moderate decrease of the tinnitus. The role of patient-related (for example, hearing loss, tinnitus duration, age) and stimulation-related (for example, stimulation site, stimulation protocols) factors still remains to be elucidated. CONCLUSIONS Even in this early stage of investigation, there is a convincing body of evidence that rTMS represents a promising tool for pathophysiological assessment and therapeutic management of tinnitus. Further development of this technique will depend on a more detailed understanding of the neurobiological effects mediating the benefit of TMS on tinnitus perception. Moreover clinical studies with larger sample sizes and longer follow-up periods are needed.

The Influence of Voluntary Muscle Contractions upon the Onset and Modulation of Tinnitus

Objective: To evaluate the frequency of tinnitus onset (in normal subjects) and modulation (in tinnitus patients) during muscle contractions, estimating possible risk factors. Material and Method: This case-control study enrolled 121 tinnitus patients and 100 healthy volunteers who underwent medical history, ENT examination and 16 maneuvers of muscular contraction (head, neck and limbs). Modulation data were compared between patients with and without normal audiometry, well-defined diagnosis and symptoms of craniomandibular disorders. Results: The ability to modulate tinnitus (65.3%) was significantly higher than that to originate tinnitus (14.0%). The head and neck musculature was significantly more efficient than that of the limbs. Audiometric pattern, well-defined etiology and symptoms of craniomandibular disorders showed no relation to tinnitus modulation. Conclusions: Somatic modulation is a characteristic aspect of tinnitus.

Zumbido em pacientes com audiometria normal: caracterização clínica e repercussões

Pacientes com zumbido e audiometria normal constituem um grupo importante, pois seus achados nao sofrem influencia da perda auditiva. Apesar disso, este grupo e pouco estudado e nao sabemos se suas caracteristicas clinicas e repercussoes sao semelhantes as dos individuos com perda auditiva. OBJETIVOS: Comparar as caracteristicas clinicas do zumbido e sua interferencia nas atividades diarias em pacientes com e sem perda auditiva. FORMA DE ESTUDO: coorte historica. MATERIAL E METODO: Entre 744 pacientes atendidos no Grupo de Pesquisa em Zumbido do HCFMUSP, avaliou-se retrospectivamente com um corte transversal os 55 individuos com audiometria tonal normal. O grupo controle correspondeu a 198 pacientes com zumbido e perda auditiva atendidos sob o mesmo protocolo. Analisou-se os dados dos pacientes, as caracteristicas clinicas do zumbido e sua repercussao na vida do paciente. RESULTADOS: A idade media no grupo de estudo (43,1 ± 13,4 anos) foi significantemente menor do que a do grupo controle (49,9 ± 14,5 anos). Em ambos os grupos houve predominio do sexo feminino e o zumbido foi predominantemente bilateral, unico e constante, porem sem diferenca entre os grupos. A interferencia na concentracao e no equilibrio emocional foi significantemente menor no grupo de estudo (25,5% e 36,4%) do que no controle (46% e 61,6%), porem sem diferenca quanto a interferencia no sono e na atividade social. CONCLUSOES: O grupo de pacientes com zumbido e audicao normal apresentou caracteristicas clinicas semelhantes em relacao ao grupo com perda auditiva. Entretanto, a faixa etaria acometida e a interferencia sobre a concentracao e o equilibrio emocional foram significantemente menores nestes.

Treatment options for subjective tinnitus: Self reports from a sample of general practitioners and ENT physicians within Europe and the USA

BackgroundTinnitus affects about 10-15% of the general population and risks for developing tinnitus are rising through increased exposure to leisure noise through listening to personal music players at high volume. The disorder has a considerable heterogeneity and so no single mechanism is likely to explain the presence of tinnitus in all those affected. As such there is no standardized management pathway nor singly effective treatment for the condition. Choice of clinical intervention is a multi-factorial decision based on many factors, including assessment of patient needs and the healthcare context. The present research surveyed clinicians working in six Westernized countries with the aims: a) to establish the range of referral pathways, b) to evaluate the typical treatment options for categories of subjective tinnitus defined as acute or chronic, and c) to seek clinical opinion about levels of satisfaction with current standards of practice.MethodsA structured online questionnaire was conducted with 712 physicians who reported seeing at least one tinnitus patients in the previous three months. They were 370 general practitioners (GPs) and 365 ear-nose-throat specialists (ENTs) from the US, Germany, UK, France, Italy and Spain.ResultsOur international comparison of health systems for tinnitus revealed that although the characteristics of tinnitus appeared broadly similar across countries, the patients experience of clinical services differed widely. GPs and ENTs were always involved in referral and management to some degree, but multi-disciplinary teams engaged either neurology (Germany, Italy and Spain) or audiology (UK and US) professionals. For acute subjective tinnitus, pharmacological prescriptions were common, while audiological and psychological approaches were more typical for chronic subjective tinnitus; with several specific treatment options being highly country specific. All therapy options were associated with low levels of satisfaction.ConclusionsDespite a large variety of treatment options, the low success rates of tinnitus therapy lead to frustration of physicians and patients alike. For subjective tinnitus in particular, effective therapeutic options with guidelines about key diagnostic criteria are urgently needed.

Diagnosis and management of somatosensory tinnitus: review article

Tinnitus is the perception of sound in the absence of an acoustic external stimulus. It affects 10–17% of the worlds population and it a complex symptom with multiple causes, which is influenced by pathways other than the auditory one. Recently, it has been observed that tinnitus may be provoked or modulated by stimulation arising from the somatosensorial system, as well as from the somatomotor and visual–motor systems. This specific subgroup – somatosensory tinnitus – is present in 65% of cases, even though it tends to be underdiagnosed. As a consequence, it is necessary to establish evaluation protocols and specific treatments focusing on both the auditory pathway and the musculoskeletal system.

Myofascial trigger points: another way of modulating tinnitus

Tinnitus is a multifaceted symptom that may have many causes (otologic, neurological, metabolic, pharmacological, vascular, musculoskeletal and psychological) several of which often occur in the same patient. Tinnitus can often be modulated by different kinds of stimuli. In this chapter we describe the results of a study of modulation of tinnitus from stimulation of myofascial trigger points (MTPs). MTPs are small hypersensitive areas in palpable taut bands of skeletal muscles found in patients with the myofascial pain syndrome where stimulation of MTPs causes local and referred pain. We found a strong correlation between tinnitus and the presence of MTPs in head, neck and shoulder girdle (p<0.001). In 56% of patients with tinnitus and MTPs, the tinnitus could be modulated by applying digital compression of such points, mainly those of the masseter muscle. The worst tinnitus was referred to the side that had the most MTPs (p<0.001); Compression of the trigger point on the same side as the tinnitus was significantly more effective than the opposite side in six out of nine of the studied muscles. Compression of MTPs was most effective in patients who have had chronic pain earlier in the examined areas.