From Boars Semen To MDMA

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Tinnitus Past, Present And Future

• From boars semen to NMDA
• John Irwin Audiological Physician
• Tayside

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THE PAST
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• NB in all that follows please remember that
  approximately 80 85 of people will report some
  habituation to their symptom with time.
• This is probably independent of the management
  option as long as reassurance and explanation
  are included.

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Egyptians

• For the bewitched ear and humming in the ears,
  they would infuse oil, frankincense, tree sap,
  herbs, and soil.
• Administered via a reed stalk placed in the
  external ear.
• From Elizabeth Willingham,Baylor College of
  Medicine

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The Mesopotamians

• Documented on clay tiles their rituals and
  chants.
• They used two chants to get rid of the whispering
  or singing in the ears.

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• "Whoever thou may be, may E restrain me." (E was
  the god of water.)
• "It hath flown against me. It hath attacked me. O
  seven heavens, seven earths, seven winds, seven
  fires, by heaven be ye exorcised."

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Early Greco-Roman medicine

• Defined the treatment of tinnitus based on the
  cause of the disease.
• If it stemmed from a cold, then the ear should be
  cleaned and the breath held until some humor
  froths out from it.
• If the tinnitus stems from the head, then
  exercise, rubbing, and gargling should be carried
  out, as well as dieting and placing radish,
  cucumber juice, honey, and vinegar in the ear.
  (and Boars semen)

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• In the Middle Ages, they continued pouring things
  into the ear.
• A Welsh treatment recommended you take a loaf of
  hot bread, divide it in two, and put it in each
  ear as hot as you could take it and thus perspire
  and by the help of God you would be cured.

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• Hippocrates and Aristotle were the first to
  introduce the idea of masking.
• They wrote "Why is it that buzzing in the ear
  ceases if one makes a sound. Is it because a
  greater sound drives out the less?"

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Masking

• White noise to drown out tinnitus
• In a good RCT all other elements of management
  were used correctly in both groups
• Including amplification, counselling, anxiety
  management, CBT etc
• masking group no benefits v non-masking group.
• Stephens et al 1980s

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Hopi Ear Candle
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• The candles are made from the natural ingredients
  of beeswax, honey extracts, sage, St Johns Wort,
  chamomile, beta-carotene and organically grown
  flax.
• The candles work on a chimney principle, drawing
  any impurities to the surface where they can be
  gently removed.

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• They equalise the pressure in the head and ears,
  making them suitable for most conditions.
• Secretion flow is gently stimulated and the
  vapour collects and removes impurities or
  deposits. Most of these are carried away through
  the candle "chimney", although some of them can
  be found in the condensed candle wax residue
  after removal from the ear.
• Impurities can even work their way up to the
  surface 24-48 hours after candling.

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Uses

• Excessive or compacted wax in the ears
• Irritation in ears and sinuses
• Pressure regulation in cases of sinusitis /
  rhinitis / glue ear / colds / flu / headaches /
  migraine
• Stimulation of local and reflex energy flow
• Energetic revitalisation in cases of hearing
  impairment
• Relaxing and calming effect in cases of stress
• Noises in the ears, ringing, tinnitus

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• No contraindications are known to date but as a
  precaution, it is advisable not to use Hopi
  candles
• If grommets are in place
• If there is inflammation or infection
• In the event of an allergic reaction to the
  contents.
• However, most clients find the treatment relaxing
  and regularly describe a "slight relieved
  feeling" in the ears and head but also a relaxing
  and calming effect on the whole system.
• Where long-term conditions are being treated, the
  client sometimes experiences slight headaches and
  occasional popping shortly after the treatment.

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• The Renaissance saw the introduction of surgery
  into the treatment of tinnitus.
• The thought was that wind was trapped in the ear
  and circled around and around inside it.
• They would trephine the mastoid to allow the wind
  to escape.

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• In the 19th century, Frenchman, Jean Marie
  Gaspard Itard advanced the study of tinnitus with
  some progressive ideas that we still adhere to
  today.
• Most tinnitus is associated with hearing loss.
• Objective versus subjective tinnitus.
• Recognized that treatment often failed but,
  meanwhile, the physician was to make the tinnitus
  less unbearable.
• Usually he did this with masking.

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• 19th century also saw advances in technology,
  antisepsis and anaesthesia.
• Electrical stimulation
• Surgical therapy, including ligation of blood
  vessels as well as incudectomy.

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Drugs

• All may help some people
• None better than placebo in controlled trials

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• Lignocaine, tocainamide and other local
  anaesthetics
• Anxiolytics
• Anticonvulsants
• Antidepressants
• Antihistamines

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THE PRESENT
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Mystery object
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Ginkgo Biloba

• Large RCM showed no significant difference
  between Ginkgo and control.
• Has been known to make tinnitus worse in a
  minority of patients.

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See handouts for

• Other herbalist and homeopathic suggestions
• The spiritualist view

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Other treatments

• Amplification
• Cochlear Implants/Electrical stimulation
• Biofeedback
• TMJ Treatment
• Environmental sound therapy
• Relaxation therapy

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Counselling

• helping to understand that tinnitus is not a
  threat in any way.
• correcting any false or unhelpful ideas about
  tinnitus.
• providing information about tinnitus.
• helping develop a positive attitude.

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TRT

• NB Hazell and Jastreboff stress that you are not
  carrying out TRT unless you explain the tinnitus
  on the basis of the neurophysiological model
• See handout www.tinnitus .org

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• TRT has 2 arms
• White noise generator
• Counselling

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Cognitive Behavioural therapy

• CBT aims to help patients identify links between
• emotionally distressing feelings such as fear,
  anxiety, hopelessness and worry, associated
  thoughts, behaviours
• and
• their physical response to their tinnitus. 

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• By encouraging patients to adapt their responses
  and reduce the impact of distressing feelings,
  CBT aims to limit the attention they give to
  tinnitus rather than completely get rid of it.

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• Cognitive Behavioural Therapy has been shown to
  have proven benefits in RCTs.

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THE FUTURE
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NMDA(N-methyl d-aspartate)

• Acts on the NMDA receptor
• Activation of NMDA receptors results in the
  opening of an ion channel
• This allows flow of Na and K ions, and small
  amounts of Ca2

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• Calcium flux through NMDARs is thought to play a
  critical role in synaptic plasticity, a cellular
  mechanism for learning and memory.
• This also happens in the ear - video

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• Possibility of NMDA blocking therapy.
• Problem with widespread distribution of NMDARs
  learning, memory etc
• Local delivery via Cochlear Implant?

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Memantine

• Recently, it has been discovered that the
  spasmolytic drug memantine has anti NMDA
  properties.
• German researchers are interested in the action
  of memantine on the neurotransmission of inner
  hair cells.

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Repetitive Transcranial Magnetic Stimulation
(rTMS)

• (rTMS) involves the application of repeated
  magnetic field applications to induce electrical
  activity in the underlying cortical areas of the
  brain.
• When the magnetic device is placed on the skull,
  the resultant magnetic field passes through the
  skull and induces a small secondary current in
  the cortex.
• This probably leads to depolarization of cortical
  neurons.

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• At low frequency stimulation, it is believed that
  rTMS leads to an increase in the inhibitory
  activity of glutaminergic fibres in the CNS.
• rTMS could be a novel and promising treatment
  modality for tinnitus.

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• There are three Specific Aims to a project in St
  Louis
• To explore the effectiveness of rTMS therapy for
  patients with severe tinnitus.
• To assess the safety of rTMS for tinnitus.
• To generate preliminary data to be used in the
  design of a methodologically sound
  placebo-controlled clinical trial for rTMS for
  tinnitus.
• Jannie Serna (sernaj_at_ent.wustl.edu)

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Stem cells

• Have been introduced into the organ of Corti in
  animals
• They do grow into hair cells to replace those
  damaged by noise, ototoxics etc
• But they dont connect to nerve fibres

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YET!
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