How to examine and treat a tinnitus patient
I use some time to discuss about the beginning of tinnitus to find out the cause of it. Sometimes there is no direct cause, but the patient can give some hints of it. Sudden hearing loss in an acoustic trauma or chronic noise trauma during work are quite common. Other traumas, like fallings, whip-lash injuries, shoulder injuries, commotions sometimes cause tinnitus after a while. Also ear inflammations and long lasting respiratory infections can cause tinnitus and so can dental problems and bruxism.
I am interested to the cause of tinnitus because there seem to be several subtypes of tinnitus and all of them might need a different treatment. Inflammation needs to be resolved, if it is the cause of tinnitus, and after that we can start to treat tinnitus itself. If there is mechanical trauma before the onset of tinnitus, the balance must be restored as good as possible. If hearing is worse in the ear with tinnitus, I start to think about tumors and want to have MRI. Patients, who have vertigo with tinnitus, should be searched for Meniere’s disease and benign positional vertigo and sometimes by treating the vertigo also the tinnitus is treated.
Also the length of tinnitus history has an effect to the treatment plan. If tinnitus has lasted 20 years drugs usually do not help much to diminish the tinnitus. But if tinnitus has lasted some days and is fluctuating there are several drugs that might work. I have not found a superior treatment, that could fit everybody. Sometimes drug can work to someone whose tinnitus has lasted years, they can help to cope with it and to live your life in spite of tinnitus. With every patient I have to make a treatment plan, but if it does not work, I have to change my plan and try something else.
I examine the ears of every tinnitus patient to make sure, that there is no wax or inflammation. Some people have tinnitus if they have wax in their ears and the removal of wax removes the tinnitus also. Hearing is also an important issue to examine. I also palpate the muscular tension in facial, neck and shoulder areas and compare the sides of the body. Then I do the benign positional vertigo tests (Rahko WRW test, Rahko test and Dix-Hallpike).
In some people tinnitus and benign positional vertigo are linked and treating vertigo helps tinnitus as well. For instance my own tinnitus is not audible if I do the maneuvers regularly.
If tinnitus is acute and comes with a hearing loss, I use corticosteroid and sometimes send my patients to oxygen therapy in the pressure chamber. If the patient has Meniere disease, I use betahistin. But even with those patients, I often add the some parts of following treatment (maneuvers and trigger point injections with other muscular treatment).
I do first the benign positional vertigo treatment (maneuvers) if I can find any positive results in the vertigo tests. If nothing happens to the tinnitus after them, I start working with muscles. Usually the muscles in the tinnitus side are harder and more painful than those of the other side. The most common points to treat are in the sternocleidomastoid muscle, in the masseter, in the temporalis and the trapezius muscle. I try to palpate the upper body to find the most important places to treat. The points are unique, they tend to be in certain places, but every patient seems to have a different pattern. I usually use my fingers and elbows to massage the points and then I do cold spray and stretch the muscles (I have learned the method from Travell and Simons: The Trigger Point Manual) and after that I use Lidocain injections to the most prominent points. I spray and stretch the muscles usually 2 to 5 times, I like to use my hands for the stretching. Usually I use 1-3 milliliters Lidocain in one session and divide it to 2-5 points. I retreat the patient after 1-2 weeks. If nothing happens after that and if during the post-treatment season(one week) no difference in the tinnitus has occurred, I have to change the treatment plan. The muscular treatment helps little more than one third of my patients. For the rest, there must be a plan B. If the treatment helps but the tinnitus keeps coming back, we have to find the patient some way how to prevent the worsening. The dentists can work with the bite, bruxism and temporomandibular joint problems can cause tinnitus. We have to think about the occupation of the patient, does it create tension by forcing the patient in bad posture. Has the patient some habits of sitting more in one side, using more the other hand or leaning most of the time forward for instance in computer work. I often teach the family members to do the muscular work at home. They can do all the other stuff except the needling. Acupuncture is useful too and some physiotherapists are allowed to do it. Sometimes the electrical acupuncture devices can do the job. Kinesiotaping is one possibility to relieve the tension in the neck area, and it works to some of my patients. The family members can be taught to do the taping at home. I have learned some manual work from Alef Gotis (who visited in Imatra 2013) and Iem Bakker (whom I have met in tinnitus congresses) and also 2014 I have studied fascial manipulation, which seems to give more opportunities in the future. It seems, that the muscles may be treated in several ways and the more you know about the methods, the more you can customize your treatment for the individual patient.
If there are hearing problems, I send my patients to the central hospital to have a hearing aid. Hearing aids help many patients by making the natural sounds louder and forcing the tinnitus to the background. However, not everybody seems to benefit from them. There are various kinds of maskers and noisers to help the patient to get accustomed to the tinnitus. They are machines, that make some noise, maybe musical type, maybe wind or rain-type noise. They are used to treat the brain: “Do not listen to the tinnitus, listen just the noise made by the masker, just ignore the tinnitus”. We have just one masker, I borrow it to my patients and if they like it, they may by themselves a masker to use.
Sometimes we have to think about medicine to help the patient. I am not good in sleeping pills and tranquilizers, but we have a psychiatry department in our hospital and I ask then to help my patients. If a person has insomnia because of tinnitus, it often makes the tinnitus worse. We have to consider the occupation and the conditions in the work to help the patients to cope with the situation. Especially if there are hyperacusia or severe hearing loss and the patient is working in a noisy environment (restaurant, open office etc), the tinnitus and hyperacusia may grow bigger and more bothersome than if the same person can stay in a quiet room. I also have studied hypnosis to help my patients to cope with their tinnitus. Hypnosis gives some new ways for the patients to react with their tinnitus.