Management of sudden sensorineural Hearing Loss

Previous Post:- Causes and evaluation of sudden sensorineural hearing loss

Sudden sensorineural hearing loss is an otologic emergency and challenge to otolaryngologist.

Thorough history, physical examination, appropriate laboratory and radiologic investigations including gadolinium enhanced MRI, and Audiometry tests should be carried out to find out known cause such as: – Infection (bacterial-meningitis/viral-mumps, herpes), Tumor, Trauma, Acoustic trauma, Ototoxic drugs (amino glycoside antibiotics), and Systemic diseases (hypothyroidism, Diabetes mellitus).

If an etiology is apparent, appropriate treatment may be initiated such as antibiotics for infection, withdrawal of ototoxic drugs.

In most cases cause remains unknown (idiopathic) thus existent treatment aims at improving blood flow.

Optimal treatment is still under research and controversies exist but treatment versus non-treatment and early initiation of treatment is proved to give better result.

1. Antivirals- Because of common association with viral infection antiviral medication is prescribed by some clinicians.

2. Steroids- Most widely accepted treatment option studies shows improved recovery rate with use of steroid. It can be given orally, or by injection, or Trans tympanic by means of middle ear instillation or round window micro catheter which is more effective than oral administration.

3. Vasodilator to improve blood flow or oxygenation to inner ear. Clinical studies shows mixed results. Carbogen inhalation, Papaverin, Histamine, Nicotin and Niacin have been used.

4. Immunosuppressant- Wang et al etanercept in experimental animal study improves hearing result.

5. Ginkgo Biloba-

6. General measures-

• Low salt diet,
• Avoid caffeine, nicotine and alcohol,
• Avoid noise exposure,
• Avoid heavy physical activity,
• Well balanced diet,
• Alpha-lipoic Acid, Antioxidants, Co-enzyme Q10.
• Zinc, Magnesium, Calcium,
• Vitamin D, B -Complex, Vitamin C

Prognosis of sudden sensorineural hearing loss-

50-65% spontaneous recovery within first 4-6 weeks.

Symptoms of ear blockage or deceased hearing is often considered as wax or middle ear infection and person delays visit to an otolaryngologist. A delay in initiating treatment may decrease the chances of recovery.

Negative factors in prognosis-

• Age more than 65 years or less than 15 years
• Severe hearing loss specially affecting high frequency
• Hearing loss in opposite ear
• Associated vertigo
• Elevated ESR

Treatment protocol should be carefully applied and potentially harmful treatment should be avoided. A thorough evaluation to be done on emergency basis and all efforts should be taken to find out known causes. Steroids are most widely accepted treatment options.

Sudden Sensorineural hearing loss-

• It should be regarded as an otologic emergency.
• Patient should be evaluated by otolaryngologist.
• A thorough history, physical examination, appropriate laboratory and radiologic investigations including gadolinium enhanced MRI, and Audiometry tests should be carried out to find out known cause.
• A tapering course of prednisolone/methyle prednisone is prescribed.
• Antiviral medication may be considered.

Sudden Sensorineural Hearing Loss: Causes and Evaluation

Sudden Sensorineural Hearing Loss (SSNHL) is defined as a hearing reduction greater than 30 db, over at least 3 consecutive frequencies (on pure tone audiogram), occurring over or less than 3 days. It usually affects one ear, there may be mild to sever reduction of hearing, and there may be tinnitus and dizziness.

Most People (30-65%) may have a spontaneous recovery; others may have permanent hearing difficulties.

Causes of sudden sensorineural hearing loss-

There is no conclusive evidence as why it happens but some theories are suggested-

1. Generally 90% cases are idiopathic where cause is not known. Viral diseases appears to be most common cause (about 60% cases) as shown by association with herpes.

2. There may be partial or complete blockage of circulation or vascular spasm to inner ear and nerves of hearing.

3. There may be rupture of delicate inner ear membrane after strong physical activity or sudden change in barometric pressure (flying/scuba diving).

4. Immune theory may ply a role, because of its association with Cogan syndrome, SLE, Lupus and AIDS.

In most cases reason remains unclear.

Diagnosis of SSNHL requires thorough investigation to determine any known causes of sudden hearing loss. Some of the causes are following-

* CONGENITAL -

• Rubella Syndrome
• Atresia of the External ear canal
• Congenital Cytomegalovirus
• Congenital Perilymphatic Fistula
• Fetal Methyl Mercury Effects
• Fetal Iodine Deficiency Effects

* MEDICATIONS (Ototoxic Drugs)-

• Aminoglycoside Antibiotics-streptomycin, kanamyin, neomycin, amikacin, gentamicin, tobramicin and netilmicin
• Loop diuretics, ethacrynic acid
• Antimalarial (quinine, chloroquine),
• Salicylates

• NSAIDS
• Vancomycin
• Erythromycin
• Cisplatinum

* INFECTIOUS DISEASES-

Bacterial infection:

• Otitis media

• Labyrinthitis
• Encephalitis
• Meningitis

Viral infections:

Evidence is circumstantial, with the possible exception of mumps parortitis and herpes zoster, the clinical diagnosis of viral infection is unreliable.

• Common Colds

• Adenovirus
• Cytomegalovirus (Cmv)
• Infectious Mononucleosis
• Influenza

• Parainfluenza
• Ear Infection (Otitis Media)
• Mumps
• Measles
• Rubella
• Herpes Simplex Virus Type 1

Others:

Rocky Mountain spotted fever-tick borne infection

Lyme disease- tickborne especially in endemic areas (mostly causes facial palsy)

Syphilis and AIDS

* IMMUNOLOGIC DISEASES-

Immunologic activity within the cochlea may be the cause as suggested by finding of antibodies and response to steroid therapy in many patients. Hearing loss in certain autoimmune diseases is documented.

• Cogan’s Syndrome
• Systemic Lupus erythomatosus
• Fibromyalgia
• Temporal arteritis

* TRAUMATIC-

Direct trauma (temporal bone fracture) or blunt head injury (concussion to labyrinth) can cause SSNHL.

• Traumatic ear drum Perforation
• Head Injuries

• Skull Fracture (Temporal Bone)

* ACOUSTIC TRAUMA

• Explosions
• Fireworks,
• Gunfire
• Rock Concerts/Mp3 Players
• Jets
• Occupational Work Noise

* BAROTRAUMA and perilymphatic fistula

Barotraumas is caused by unequalized pressure differentials in middle ear and external ear such as in scuba diving, air travellingor blow to ear. If the pressure is severe, eardrum can rupture.

Barotrauma can cause acquired perilymphatic fistula (communication between inner ear and middle ear) leading to SSNHL and vertigo. Other causes of acquired perilymphatic fistula are direct or indirect trauma to temporal bone, heavy lifting or straining and complication of stapes surgery.

* TUMORS-

• Acoustic Neuroma or Vestibular Schwannoma – SSNHL may be initial manifestation
• Temporal Bone Metastases

• Neoplasm of CPA or IAC

* OTHER SYSTEMIC DISEASES-

• Leukemia
• Diabetes
• Hypothyroidism
• Multiple Sclerosis
• Ménière’s Disease
• Syphilis

Evaluation  of sudden sensorineural Hearing loss (searching for cause)-

A thorough and detailed history of associated symptoms, noise exposure, any trauma, fever, medication and family history of hearing loss is necessary to determine the diagnosis.

Ear examination by otoscopy and pneumotoscopy is critical step.

Hearing assessment by Tunning fork test, pure tone audiometry (PTA) and speech audiometry should be done. Tympanometry, Auditory Brainstem Response and Otoacoustic emission may be useful.

Electronystagmogram (ENG)

Radiologic study should be done especially for patients with unilateral sensorineural hearing loss, such as MRI with gadolinium/CT temporal bone to investigate IAC/CPA tumors.

Laboratory investigations-

FTA-antibodies for syphilis

ANA, RA Factor, ESR for autoimmune disease

Coagulation profile

CBC for infection

TH for thyroid function

RBS/PPBS for Diabetes

Cholesterol/triglycerides for hyperlipidemia

Sudden Sensorineural hearing loss-

• It should be regarded as an otologic emergency.

• Patient should be evaluated by otolaryngologist.
• A thorough history, physical examination, appropriate laboratory and radiologic investigations including gadolinium enhanced MRI, and Audiometry tests should be carried out to find out known cause.

Next Post- Management of sudden sensorineural hearing loss

Protective Measures to avoid workplace allergen/irritants

Previous post- workplace allergy; where is the risk?

Best treatment is avoidance of allergen but one can not just stop going to work…So certain measures should be taken to reduce the risk.

Sensitized workers should be removed from the offending environmental agent and the workplace modified or they can be relocated to another work area. People with irritant reactions may work with protective measures which should address worker and work environment.

Personal control-

• Nutritional support of body defenses especially Vitamin C, zinc, selenium and magnesium.

• Keep good hygienic measures by frequent hand washing but avoid excessive washing as resulting dryness may actually predispose to allergic/contact dermatitis.

• Use masks, gloves, and protective clothing. Air hoods are better than simple filter-type face masks to adequately protect from exposure to allergens. A helmet with a respirator that protects against dusts can also be used. Gloves may sometimes actually cause contact dermatitis or certain irritants may penetrate through it and trapped inside.

• Health Education and awareness regarding occupational allergy Posters and newsletter articles) is very important.

• Workers in high risk areas should have routine checks for work related allergic sensitization by means of Skin Tests and Lung Function Tests.

Environmental control-

• Keep your work area uncluttered as dust and molds gets collected over piles of papers, books, and files.

• Dust your workplace regularly using a damp cloth. Tiles, plumbing fixtures, Leather goods should be regularly inspected and wiped down with Milton or Lysol.

• Reduce moisture, as relative humidity greater than 40 percent increases mold growth. Don’t use carpets in areas with dampness. Remove anything damaged by water including carpet pad to prevent establishment of a mold colony.

• Clean humidifier regularly of the mold in the water container. Try lowering the thermostat.

• Improve the air quality and circulation by periodic checking of work place air exchange system.

• Use an air purifier which can help keep the air around your workstation clean. Environmental Control measures include the use of ventilated spray-paint booths, extractor fans, respirators and visors.

• Ask coworkers not to smoke around you as Cigarette, pipe, and cigar smoke can aggravate allergies.

Allergic diseases in the workplace is a cause of growing concern for work related morbidity and absence from work. Every effort should be taken at all possible levels to protect from allergen. Further research is needed to answer questions concerning threshold levels for initial sensitization and post-sensitization reaction-producing levels.

Workplace Allergy…Where is the risk?

We like cleaned carpets but do we ever bother about chemical residues sneaking around after cleaning?  We can not work without air-conditioner on but do we ever realize mold spores taking rounds in the room? We may not realize the importance … but for a person sensitive to allergy its real terror… Especially with closed spaces of tall office buildings and several cubicles which are filled with allergens and irritants workplace are now a significant source of illness.

The Occupational Safety and Health Administration (OSHA) have estimated there are 575,000 potentially hazardous chemicals in the work place. Substances with high molecular weight are more likely to sensitize workers than low molecular weight, especially in atopic individuals.

Occupational allergen and irritants may cause skin disease in from of urticaria/contact dermatitis or involve nose and respiratory passages causing allergic rhinitis/sinusitis/occupational asthma in susceptible individual.

Prompt intervention for suspected occupational allergies is most important as early detection may lead to reversibility of symptoms. Although medication and symptom control is important, the offending allergen must be identified early and removed from the environment to prevent chronic ill health.  Best treatment is avoidance of allergen but one can not just stop going to work…So certain measures should be taken to reduce the risk.

Who are at risk and what are the high risk jobs?

* High risk person: -

• History of atopy

• Genetic factors

• Certain pre existing condition lowering immunity

• Cigarette smoking (by increasing IgE level and injury to airway)

• Poor hygiene or over washing of hands

* High risk jobs: -

• Bakers and flour mill workers: exposed to flour, mites, and molds.

• Food processing: exposure to Soya beans, fish, shellfish and egg.

• Farmers, dock workers and cotton workers: mold spores, poultry and plant dusts.

• Carpenters and wood workers: exotic hardwoods.

• Metal refining, plating and grinding workers: nickel. Chrome, cobalt , mineral oil

• Plastic, rubber and adhesives: Isocynates, anhydrides, acrylate, epoxy resins

• Construction worker: solvent and cement.

• Detergent and pharmaceutical factory workers: enzymes, medication and biological dusts.

• Foundries: resins, isocynates

• Hospital workers: powdered latex gloves and formaldehyde

• Laboratory workers:  airborne animal allergens.

• Beauty-Parlors and hair dressing workers: chemicals from hair dye and shampoo (formaldehyde).

Types and symptoms of occupational allergy:

• Occupational contact dermatitis: Skin rashes and eczema are most common cause of work related disease.
• Occupational Rhinitis: sneezing, runny nose or teary, red and itchy eyes after prolong exposure to workplace allergen may precede asthma. Early diagnosis by nasal challenge test to find out the offending agent may prevent further exposure and development of asthma.
• Occupational asthma is caused by sensitization to an agent inhaled in the workplace and usually presents with cough, wheezing and shortness of breath. It may occur after years of repeated exposure to chemicals and allergens. Non-allergic Reactive Airways Disease Syndrome (RADS) may develop more rapidly due to irritants such as chlorine, ammonia fumes or dust.
• Nausea, vomiting or upset stomach.
• Headaches or migraines.
• Anaphylaxis.

What to Do?

Person should be routinely inspected by occupational health physicians to monitor preventative measures and assessing air samples. Sensitized workers should be removed from the offending environmental agent and the workplace modified or they can be relocated to another work area. People with irritant reactions may work with protective measures. Severe allergic reactions, or anaphylaxis, (such as breathing problems, rapidly spreading urticaria, and swelling of the lips, face, tongue or loss of consciousness) can be life threatening and need urgent medical attention.

Next Post: - Preventive measures to avoid workplace allergy/irritants

Management of tinnitus (ringing in the ears)

There is no cure and no specific treatment is efficacious for noise/ringing in the ears/head; however person can opt from many options available. In some cases it can be quieted with treatment of underlying cause, thus thorough otologic evaluation and investigation is to be done. In majority of sufferers there is no serious pathology and reassurance is all what is needed.

Most important aspect is patient education regarding nature and prognosis of condition, and general preventive measures.

Medicines-

There is no specific drug designed specifically for tinnitus. There is no active research going on because of high cost and high rate of failure involved in creating a new drug.

Anxiolytics, Carbamazepine, Lidocaine, and intravenous Barbiturates show encouraging results but potentially serious side effects limit usefulness. Relatively low doses may bee effective in tinnitus management.

Patient and clinician together determine right drug considering side effects if it is worth.

Tinnitus Retraining Therapy-

Person can be habituated to sound in the environment, so aim is to train the brain to adapt to sound.

TRT has 2 elements- Direct counseling and sound therapy

Sound therapy: -

Sound therapy is to be combined with other therapies like counseling to improve effectiveness.

Tinnitus is more noticeable and disturbing when environment is quiet. Person with tinnitus thinks that sound is because of or can cause some serious damage to brain or inner ear. This negative emotional response from our subconscious brain (limbic system) travels to conscious brain-cortex, so person reacts.

In sound therapy instead of treating patient surrounding sound is manipulated so that it becomes less noticeable, here are many ways to achieve the goal such as: -

1. Table top devices-environmental sound machine, water fountain, clocks, fan, radio
2. CD based system
3. Hearing aids
4. Masker
5. Combination of hearing aid and masker

6.  Cochlear implant/electric stimulation-

Table top devices;

Devices kept on side of bed such as ticking clock, adjusting radio in between two stations, or fan, may divert attention and make tinnitus less noticeable.

Hearing aids;

If a patient has a hearing loss in the frequency range of the tinnitus, hearing aids may be helpful in covering the tinnitus.

Masker;

The use of masking in the treatment of the tinnitus has mixed success, Patient’s perception of the pitch and loudness and the overall intensity of the masking signal should be well understood.

Tinnitus maskers introduce an external pleasant masking sound into affected ear , thereby minimizing or eliminating the perception of the tinnitus.

Cochlear implant;

Cochlear implant may mask tinnitus by ambient sound or may suppress tinnitus by the electrical stimulation sent through the auditory nerve. Some forms of electrical stimulation to the ear can stop tinnitus briefly.
Counseling: -

Effective counseling is most critical aspect of tinnitus management. Tinnitus sufferers are anxious and frightened by the presence of tinnitus and need a careful and clear explanation of the nature of the disorder.

It can be quite disturbing leading to sleep deprivation, depression & decreased work efficiency. Most important aspect of tinnitus is distress, irritation and distraction caused by the noise. Person often feels that such noise is a symptom of brain tumor or stroke. Reassurance should be given by E.N.T. specialist, neurologist and audiologist.

Biofeedback:–

Distress caused by tinnitus is in correlation to degree of attention paid to tinnitus and shifting attention of person to a different signal is bio feedback. It is relaxation technique that teaches to improve coping ability and has 70-90% success rate.

Tinnitus patients have high levels of anxiety, tension, or other symptoms of chronic stress. Biofeedback is quite effective relaxation technique; it teaches person to control certain autonomic body functions such as pulse, muscle tension and skin temperature. Goal is to help person manage stress not by reducing stress but by changing the body reaction to it.

Controversies exist about role of alternate therapies: –

Research results have not conclusively identified these treatments as helpful for tinnitus.

Hypnotherapy

Control of inhalational and food allergy

Bio feedback

Zinc, magnesium and vit-B12

Herbal ginkgo biloba have mixed result

Homeopathic remedies

Acupuncture

Hyperbaric O2

Music- music is soothing to soul, relieves pain and anxiety, and promotes relaxation and positive impulse to limbic system.

But it emphasizes the low frequencies and has little power in high frequency.

Tinnitus patient mostly has less hearing in high frequency and hear better at lower frequency. To correct this mismatch neuromonics are created (creator Dr Paul Davis and Peter Hankey, Australia). Modified music is delivered through high fidelity ear phones that match hearing and tinnitus level.

Research: –

*Research is going on for drugs Acamprosate, Vestipitant+Piroxitine, Neramaxane

*Trans Cranial Magnetic Stimulation-  SHAM stimulation-safe and effective.

*Chronic electrical stimulation of auditory cortex- Rehabilitation by specially trained clinician -daily acoustic neural stimulus customized to audiometric profile is presented to desensitize. Approximately 90% success rate is observed in selected patients with improved life

*Transtympanic perfusion inner ear:

Genta- in menieres disease with intractable vertigo.  Successful and less invasive than surgical procedures such as vestibular nerve section or labirynthectomy.

Dexa- in cochlear meneires may improve hearing, tinnitus, pressure feeling.

General measures and prevention of tinnitus

Previous post- Treatment of underlying cause

Prevention is the best way to ensure no worsening of disease. Certain life style changes are required for tinnitus -

• Take care of the body by giving it enough rest, sleep and water.
• Dietary supplements Vitamins A, C, E, and B group and Zinc
• Micro nutrients to prevent noise induced hearing loss
• Support and stress management; taking a positive step in controlling the condition and changing response to it
• Regular exercise
• Decrease intake of salt
• Avoid food with high sugar
• Limit exposure to loud noise, occupational and recreational
• Avoid aspirin, and NSAIDS
• Avoid ototoxic medicine
• Avoid nicotine, alcohol, caffeine
• Take steps to lower blood pressure and cholesterol
• Ginkgo Biloba extract is an effective, well tolerated whilst not effective in every single patient, the proven benefits far outweigh any risks.

Next post- management of tinnitus

Treatment of conditions causing tinnitus

( Previous post: – Treatment options for tinnitus)

Person should be assessed and investigated properly by otolaryngologist, audiologist and neurologist if required, to find any treatable condition; management of cause usually take care of tinnitus.

• Stop medicines causing tinnitus.
• Wax, foreign bodies can be removed.
• Treatment of middle ear infections and fluid should be done.

• Otosclerosis and tinnitus- Surgery and/or hearing aids; surgery may not cure tinnitus and a failed surgery can cause severe tinnitus but correcting conductive deafness (even with poor speech discrimination) allows masking effective.

• Menieres disease- Tinnitus is difficult to treat in non functioning (dead) ear, so decision for destructive surgery should be taken with care.

• Abnormal patency of ET- Mostly seen after weight loss, can be corrected by minor surgical correction (25% silver nitrate or diathermy)

• Surgery for tumor
• Hearing aids for hearing loss

• Treatment of blood pressure/thyroid disorder/other medical conditions causing tinnitus.

Next post: -

General measures and prevention of tinnitus

Management of tinnitus

Tinnitus treatment options

There is no cure and no specific treatment is efficacious for noise/ringing in the ears/head; however you can opt from many options available. In some cases it can be quieted with treatment of cause. In majority of sufferers there is no serious pathology and reassurance is all what is needed.

‘Nothing can be done and you have to live with it’ is to be avoided and patient should be assessed and investigated properly by otolaryngologist, audiologist and neurologist if required, to find any treatable condition.

Most important and essential aspect is educating person with respect to causes and nature of tinnitus, keep in mind treat the patient not the tinnitus…

Treatment protocol should be reviewed, explained to the patient and rational behind the treatment should be clearly understood by the person.

Various treatment options

• Treat the treatable cause
• Prevention and General Measures for tinnitus
• Medicines
• Tinnitus retraining Therapy- includes sound therapy and counseling.

• I. Sound Therapy-

1. External sound source
2. Hearing Aids
3. Masker
4. Cochlear electric stimulation/implant

• II. Counseling

• Biofeedback (relaxation technique)
• Alternative therapy (and ginkgo biloba)
• Music
• Research

Next post: – treatment of  conditions causing tinnitus

Previous post: finding cause for tinnitus

Finding Cause for Tinnitus

Some Latest Research news:-

Hyperactivity of Touch-sensing Nerves in Head, Neck Causes Tinnitus

Scientists Exploring Brain Area Responsible for Tinnitus

Tinnitus is not a disease rather an annoying symptom of myriad of conditions, caused by minor changes in the sensitive hearing system (Cochlea and auditory nerve).

Patient with tinnitus should undergo thorough otologic evaluation and if required neurological examination. In most cases tinnitus is not harmful but patient should be investigated properly to find any treatable condition.

Most common cause for tinnitus is hearing loss because of aging, noise, drugs or chemicals.

Possible theory: -

1. Because cochlea is no longer sending normal signals to brain, confused brain create own noise.
2. Made worse by anything that makes hearing worse like infection/wax.

Causes: -

I. Related to ear (otologic)-

** Cause may be in the external, middle or inner ear

Subjective causes-

• Impacted wax
• Fluid in the middle ear
• Acute and chronic otitis media
• Otosclerosis
• Menieres disease
• Presbiacusis (age related hearing loss)
• Head trauma
• Noise-trauma
• Ototoxic drugs (such as ACE inhibitors, Antibiotics-ciprofloxacin, erythromycin, streptomycin, and vancomycin, Anti depressant-alprazolam, Anti-malarials-chloroquine and quinine, B-blockers, Diuretics-acetazolamide and amiloride, NSAIDs and Aspirin)
• Tumor (acoustic neuroma)

Objective causes are less frequent-

• Aneurism of carotid artery (it is synchronous with pulse)
• Vascular tumor of middle ear
• Palatal myoclonus
• Temporomandibular joint syndrome (misaligned jaw)
• Tinnitus synchronous with respiration may occur with abnormally patent Eustachian tube (mostly seen after weight loss).

II. Not related to ear-

Disease of CNS, anemia, arteriosclerosis, hypertension, hypotension, hypoglycemia, epilepsy, migraine,

III.  Psychological-

Assessment of tinnitus-

Most important is History and Identification of hearing loss and Clinical Examination of ear by otoscope/operating microscope with detail head and neck examination by specialist.

Investigations:-

• PT Audiometry
• Brain-stem Evoked Response Audiometry
• CT scan (especially if tinnitus is asymmetrical, 10% of cases it may be a tumor (Acoustic Neuroma).
• Blood Investigations to test Anaemia- CBC, Hypothyroidism- TSH, Diabetes-sugar, Syphilis- FTABS and lipid profile.
• Tinnitus pitch matching and masking.

Most important aspect is educating person with respect to nature of tinnitus,  keep in mind treat the patient not the tinnitus…

Some Latest Research news:-

Hyperactivity of Touch-sensing Nerves in Head, Neck Causes Tinnitus

Scientists Exploring Brain Area Responsible for Tinnitus

Tinnitus-overview

Tinnitus is not a disease rather an annoying symptom of myriad of conditions, caused by minor changes in the sensitive hearing system (Cochlea and auditory nerve).

Tinnitus (means ringing in Latin) is sound sensation in the ear or head, in the absence of any external source of sound.  Commonest types are hissing, roaring, swishing, rustling, buzzing, humming, or chirping.

(Photo by nathaniel)

Tinnitus varies in pitch and loudness and is more annoying in quiet surroundings, particularly at night.  It can be quite disturbing leading to sleep deprivation, depression & decreased work efficiency. Most important aspect of tinnitus is distress, irritation and distraction caused by the noise. Person often feels that such noise is a symptom of brain tumor or stroke. In most cases tinnitus is not harmful.

Patient with tinnitus should undergo thorough ENT evaluation and if required neurological examination. ‘Nothing can be done and you have to live with it’ is to be avoided and patient should be investigated properly to find any treatable condition.

Treatment of the cause should take care of tinnitus but tinnitus may persist even after the disease causing tinnitus has been cured, When a lesion or disease process is not identifiable, then tinnitus management is more difficult.

There is at present no effective surgery or medical therapy for the treatment of tinnitus.

In majority of cases our system adapts to noise over a period of time and is accepted as a part of normal environment. This process can be helped by proper reassurance and counseling. Relaxation and biofeedback help to improve coping with the condition.

Tinnitus maskers are sometimes recommended. These are similar to hearing aids and generate continuous noise. Their use is based on the fact that the patient is more comfortable in a noisy environment than in a quiet surrounding.

Research shows encouraging result on the effectiveness of pharmacological therapy for tinnitus, such as carbamazepine, lidocaine, and intravenous barbiturates, but potentially serious side effects limit their use.