Case study: Rational assessment of tinnitus sufferer ends up with remission

Taking on the suggestion to present a clinical case, Dr. Tanit Ganz Sanchez from Brazil (see below) chose the gratifying story of a patient who got cured from tinnitus. This is an interesting example of how a set of information collected during the diagnosis process helps to figure out different personalized treatment strategies. In this perspective, ENT doctor’s role is essential.

On August 12, 2013 we first saw Mrs R. R., a 38-year-old, Caucasian, married woman from São Paulo, architect by profession. She had been referred by a psychiatrist who treated her for "depression", which was also present in her father and mother.

R. R. reported that 40 days earlier, she had suddenly developed tinnitus in the right ear (RE), similar to the sound of an engine, that had become constant. As worsening factors, she cited quiet times, especially before bedtime. Interestingly, she also worsened under the influence of the sound of the shower, which is not usually reported by other patients. As temporary improvement factors, she mentioned a previous steroid injection and the natural masking obtained with environmental sounds.

Concomitant with the onset of tinnitus, R. R. also perceived: a) sudden hearing loss in the RE, which remained stable over that time period (40 days); b) aural fullness, apparently bilateral; c) sound intolerance (hypersensitivity to sound), such as touching the ear with - or talking - on cell phones, in addition to voices, which seemed to be a bit distorted or metalized. She did not complain of balance disorders or other ear-nose-throat symptoms.

Sporadic bilateral otalgia and neck pain radiating to both shoulders

The annoyance scores, considering the visual analogue scale of 0 to 10 were: 7 for tinnitus, 6 for sound intolerance, 4 for hearing loss, and 3 for aural fullness. In the TBF 12 questionnaire (maximum 24 points), she scored 16 for tinnitus.

Regarding the pain of neighboring regions, R. R. mentioned: 1. recent and sporadic bilateral otalgia; 2. migraine with aura, which had improved in the last 6 months with medication; and 3. neck pain radiating to both shoulders, already improving after beginning pilates. She did not complain of specific symptoms related to the temporomandibular joint (TMJ), such as pain, clicking or crepitation during movement, clenching or bruxism during daytime or nighttime.

Regarding her eating habits, R. R. is adequately dividing meals, without caffeine abuse, but consumes candy almost daily. Verifying other habits, we found no harmful exposure to noise, ototoxic drugs or electromagnetic waves.

Current medications were levothyroxine (hypothyroidism) and escitalopram (depression). Her previous attempts for treating tinnitus with other colleagues included antibiotics (did not remember the name) and intramuscular steroids (with which she partially improved for a few days). She reported no family history of hearing loss or tinnitus, but her maternal grandmother had diabetes mellitus. The ENT physical examination was normal. However, she felt pain on palpation of the right TMJ and on both sternocleidomastoid muscles (tender points).

Narrow band noise tinnitus

R. R. already had several blood tests and a normal CT scan of the paranasal sinuses and temporal bones at the first visit.

Her audiometric test battery showed:

  • Normal pure tone thresholds in both ears from 250 to 16,000 Hz, but with asymmetry at 6,000 Hz and all higher frequencies (worse on the right), with normal bilateral SDT.
  • Tinnitus pitch/loudness matching: 125 Hz, narrow band, 27 dBNA/17 dBNS (threshold = 10 dBNA for narrow band).
  • Discomfort thresholds to sounds between 80 and 100 dBNA in both ears.

Considering all the reported information obtained by history, physical examination and additional tests, the following diagnostic hypotheses for tinnitus were considered according to our experience:

  • Metabolic disorders (frequent intake of candy, bilateral ear fullness and family history of diabetes).
  • Somatosensory (presence and pattern of ear, neck and head pain, beyond the palpation of TMJ and sternocleidomastoid).
  • Emotional (depression, although under treatment).

Thus, logically, I suggested the following approaches after the first visit: restriction of candy for 30 days, dental evaluation and, if necessary, the use of a centrally-acting muscle relaxant for 30 days.

Resolution of tinnitus

On September 13, 2013, R. R. returned for the first follow-up, stating that her dentist had found no changes. As a result, together with the restriction of candy that she had started shortly after the consultation, she also initiated the use of medication. She reported significant improvement in the first 10 days of medication associated with diet. However, she interrupted treatment to make a trip and had worsening tinnitus. She then decided to reinstate use and noted gradual improvement up to disappearance. She finished the medication one week before this visit, with no recurrence of tinnitus. In order to verify if tinnitus was really absent or just momentarily masked by environmental sounds, she was tested inside the audiometric booth. After two minutes, R. R. had not perceived any sound compatible with tinnitus. We chose not to perform audiometry that day and to maintain medication for 2 more weeks, then discontinuing it to observe possible recurrence.

On November 4, 2013, R. R. returned for the second follow-up, reporting resolution of tinnitus for the last 2 months! By her own decision, she had stopped medication one month before. Throughout this period, there had been only two episodes of recurrence of tinnitus, for less than 5 minutes (“physiological tinnitus”?). She also noted improvement in sound intolerance to her usual level ("I had always been sensitive to sounds") and in the distortion of voices, with no recurrence after withdrawing the medication. Audiometry performed that day showed normal thresholds in both ears up to 16,000 Hz, with recovery of the asymmetry that was present at the first examination from 6,000 Hz on. No tinnitus was identified in the silence of the booth.

Comments:

1. We prefer to build more than one diagnostic hypothesis (DH) in each patient, because this increases the possibility of therapeutic strategies. Such DH depends on a set of detailed information obtained by history, physical examination and laboratory tests. In 100 % of cases we ask for audiological evaluation and blood tests. Whenever needed, we perform electrophysiological tests or imaging, or ask for multidisciplinary evaluations.

2. Despite all normal audiometric thresholds in the first audiometry, a more careful interpretation highlights the asymmetry between ears, worse on the right, consistent with the history of tinnitus and sensation of distorted sounds in the RE. This view was facilitated by the extension of 6 higher frequencies (9, 10, 11.2, 12.5, 14 and 16 kHz), but it could already be seen in the conventional audiometry at 6 and 8 kHz. Thus, the presence of tinnitus should prompt ENT specialists and audiologists to give greater attention to minimum audiometric changes.

3. The dental evaluation was requested to confirm or rule out the presence of TMJ and/or cervical changes. The patient chose to consult her own dentist, who did not credit the otologic symptoms to his area, or found it relevant to forward R. R. to a physical therapist. If his opinion had been different, I would have agreed to first observe the effect of his treatment without using medication.

4. A hypothesis of metabolic tinnitus was made based on facts which were already highlighted. However, R. R. did not have a compulsion for candy, despite the daily habit of eating candies after meals. As she seemed willing to make a temporary restriction of this intake, I chose not to ask for a glucose-insulin tolerance test, but this could have been done.

5. Believing that patients with good prognosis do exist, it is essential for us to create customized treatment strategies that have at least some chance of reaching total or significant improvement. The role of ENT specialists at this stage is vital. If such a high degree of improvement does not occur, then we should indicate other treatment options aimed at "only" improving the quality of life of patients.

R. R. was considered as a case of cure and agreed to be interviewed for the largest Brazilian TV channel (Rede Globo), an interview aired on November 20, 2013, so as to motivate others to seek early treatment. According to the broadcaster, the live program reached approximately 58 million houses that day. Hopefully, this example can motivate and trigger other rewarding stories in Brazil or abroad.

Dr Ganz Sanchez is Associate Professor of Otolaryngology at the University of São Paulo School of Medicine, Director of the Institute Ganz Sanchez and President of the Association for Interdisciplinary Research and Divulgation of Tinnitus – APIDIZ (Brazil).

Tanit Ganz Sanchez, MD, PhD


Photo: Divulgação