Complementary and Integrative Medical Options
for Tinnitus
-a speech-
by Michael Seidman, M.D., F.A.C.S.

Thank you all for coming. I see a lot of familiar faces. I was asked to talk tonight about complementary and integrative medical options for tinnitus. Part of the reason that we need to is, as you've heard over and over again, there's no cure for tinnitus. That doesn't mean that there isn't help, and that doesn't mean we can't improve upon the symptoms you experience.

I just wrote a very nasty editorial (co-authored by Arches President Barry Keate) in response to an article that was in the premier otolaryngology journal. A physician wrote about myths, smoke and mirrors, and the treatment of tinnitus. Basically, he just shot holes in everything and said nothing works, just tell that to the patients and have them get out of your office. And I'm pretty sure that's what most of you have experienced. Most patients tell me, "My doctor said I have a high frequency hearing loss, that's why I have tinnitus, and I need learn to live with it." And the doctor might have spent two or three minutes with you.

At the Henry Ford Health System, we see people from around the country with this problem. We can't spend 5 minutes with a patient, and that's why it takes three to four months to get in to see us-because we need to work in a 30-40-60 minute appointment with you, if that's what you choose to do.

There are many medicines that have been tried that have helped some tinnitus patients. You always hear of somebody who tried "x" and it worked for them, so you try "x" and it doesn't work for you. What I tell my patients is what works for you may not work for the next person. So with that in mind, complementary alternative medicine-I'll abbreviate it as CAM-is basically alternative therapy: it's chiropractic, it's acupuncture, herbs and nutritional supplements. It's anything that's not standard in the current medical curriculum.

There's a huge increase in public use: roughly 40 percent of Americans use some form of CAM. About 70 percent of those people using CAM don't tell their physicians. And that's a problem. In part, people say, "Why bother telling my physician? He/she doesn't know anything about it and will just laugh at it anyway," which is possibly true. But there are certainly many herbs and medicines that people take that are considered alternative that can interfere with anesthesia, they can make you bleed, they can fry your liver, they can cause lots of problems, so you need to be able to address this with your doctor. And if your doctor doesn't know, then you need to find sources and look it up.

About 27 billion dollars was spent on CAM in 1998 and 32 billion dollars was spent in 2000. There are more visits today to alternative practitioners than there are to primary care physicians. That means people are paying out of their pocket for these types of things. It's not a covered benefit by most insurance companies.

What we have to realize is that though physicians think I'm crazy when I talk about this stuff, what's alternative in the United States is likely mainstream someplace else. So, for instance, if you have high cholesterol here, your doctor might briefly tell you, "Avoid eggs, avoid meat, avoid dairy," and most doctors won't even go that far. They'll tell you, "Here's Zocar, here's Prevacor, here's something." So they will give you a drug to lower your overall cholesterol. Well, the first line of therapy in Asia is either gugulipid or Chinese red yeast rice, both of which can significantly lower cholesterol with a much lower risk of liver toxicity. So you can still have liver problems with those types of things, but it's much less than your standard medications prescribed for you.

We also have to realize that conventional medicine started some 200 years ago. Your M.D.'s and D.O.'s really started thinking about this sort of stuff a couple of hundred years ago and alternative therapies have been present since civilization began. There are references in the Bible talking about the use of specific herbs as medicines, and it dates back, obviously, thousands of years.

In the mid 20th Century there was the rapid elimination of alternative practices because they were considered quackery, and physicians tend to disregard practices that are not double-blinded and placebo-controlled, and most things in medicine are not. There are many things that we do in medicine that have never undergone randomized, controlled trials, yet we still do them. We give somebody a drug. It works. We give it to 20 people. It helps. So we then start incorporating that into our practice.

I went to the University of Michigan for my degrees in nutrition and medicine, and I was fairly well trained in that whatever wasn't double-blinded, placebo-controlled doesn't mean anything. And that's ridiculous. Now, having said that, skepticism is healthy. It's important. You have to be critical. You have to look at the studies. But a closed mind will negate consideration of potentially beneficial therapies.

In 1992, there was a congressional mandate because of people like you who lobbied their representatives and said we need to look into this alternative medicine. Congress gave two million dollars to the National Center for Complementary and Alternative Medicine (NCCAM) under the auspices of the NIH, and this year the Center has about 120 million dollars. It's still the most poorly funded institute, but it's increased significantly. I have a grant now from the California Table Grape Association to study red wine and extracts of red wine because we've shown in preliminary studies that they may slow some of the progress of hearing loss. We're investigating that, and we have a larger grant sent in to NCCAM.

In Western medicine, what we offer is pretty good, but it's not the best-it's not the only thing. More and more patients are realizing that it's probably important to have a physician who is at least open minded to considering some alternatives. We don't have the answers for everything. You think about the major problems. If you have appendicitis, we're darn good at fixing that. We open up your belly, we take out your appendix, we keep you in the hospital for a day, send you home, and you heal and you're better. But what about low back pain, what about chronic headaches, obscure forms of dizziness? What about tinnitus? We don't do a great job with that and it's because we don't have all the answers. We need to keep an open mind, we need to fund research, we need to look at what our colleagues are doing in Europe, in Asia, in other places in the world. So with that in mind, most medical schools are now offering some forms of alternative medicine. I really think that collaboration between physicians and people who practice CAM is still frontier territory, but it might be the best-case scenario for all of you in the audience and me as well.

There are other things to keep in mind. This is where a lot of doctors or nutritionists say, "You've got to be really careful," and I would agree-you have to be very careful. The Dietary Supplement Education Act of 1994 places the responsibility for safety of the product being made on the manufacturer, and the Act specifies the use of literature in connection with sales. So you can't say that something will "cure tinnitus." The Act tells you what claims you can and can't use and it talks about good manufacturing processes. You're in the hands of whoever manufactures the different products. Sixty Minutes and 20/20 have done programs on, say, SAM-e, which is used for depression, arthritis, and for liver. And they said that they took 20 bottles off the shelf and 10 of them didn't have any Same in it, five of them had more than what they said, five of them had less than what they said, one or two might have been right on. So you definitely don't know precisely what you're getting,

I just spoke to a physician who said he took a drug, and two hours later he was passed out on the floor. The drug was supposed to be for a headache that he had. Turned out it was Glucophage, which is a diabetes medicine, so it dropped his blood sugar down to about 30. If his friend hadn't called earlier, he would have been dead. That drug came right from the manufacturer. One hundred thousand deaths per year are caused by pharmaceutical errors, so you do have to be careful. You do have to look at labels somewhat cross-eyed and scrutinize them

So, just by a show of hands, how many of you have tried supplements to help the ringing in your ears? How many of you have tried Ginkgo biloba for your ringing? A lot of you. How many of you have tried other herbs, kava kava, St. John's Wort? Okay. So you've tried some of these things to help. There is some evidence that supports their use, and I'll give you some specific dosages because there have been some studies. For example, studies were done on Israeli soldiers that were exposed to noise; they found that they were able to protect against hearing loss if they gave the soldiers magnesium before they fired their rounds of ammunition during practice. There have been studies looking at potassium, calcium, lipoflavinoids.

There have been some very good studies on B vitamins, particularly B-12; a study looked at over a thousand individuals and found that roughly 10 to 12 percent of people over 60 have a deficiency of B-12 and don't even know it. When patients with tinnitus took B-12 supplements, about 40 percent of those patients improved with regard to their tinnitus-it made them better. So there is scientific evidence out there for some of these things. Here's a different study looking at 385 people; they received 1000 micrograms of B-12 per day, and they had a 56 overall percentage points average as far as improvement is concerned.

Beta-carotene hasn't shown any specific ability to help tinnitus, but it is an anti-oxidant supplement that may have some benefit. Copper, selenium, vitamin C, vitamin E, zinc-these kinds of things, and manganese, you can see improve the symptoms, in some cases, of patients with tinnitus. Typically, you would think this would be someone who has a deficiency in these nutrients, but not necessarily. There are some people, for example, athletes who eat 6,000 to 8,000 calories per day, who take additional supplements because they're working harder than, perhaps, you and I are. They're doing more exercise activities and they need more in the way of supplements than what a recommended dietary type of allowance might call for. And so patients with tinnitus, for one reason or another, perhaps with some hearing loss might have some benefit.

People will talk about 20 different nutrients and 20 different herbs, and you say, "Now what? Which one do I take?" And the answer is that we don't know. I can tell you what I do for my patients and what helps a lot of patients, but it doesn't help everybody. There's no standardization there. What I've found is that some patients come in and say "It bothered my stomach," the next person says, "It gave me a headache," the next person says, "It made me sleepy." You name it, I've heard it.

With Ginkgo biloba, I got tired of that. I'm putting out this disclaimer: I was asked by the company if I would endorse their ginkgo. I said show me your certificate of analysis, so they showed me their certificate of analysis. They've done a lot of the due diligence with that. I checked with the Henry Ford system: Am I allowed to endorse a product if I think it's okay? And they said, yes, you can do whatever you want, as long as it's Michael D. Seidman, M. D., not Michael D. Seidman, M. D. of Henry Ford Health Systems. So I scrutinized the company, I looked at the people, and basically it's where I send people now to get their ginkgo. It's called Arches Tinnitus Relief Formula®, and they asked if they could use a quote from me, and I said that they could. A lot of companies with supplements and stuff like that are these multi-level marketing companies, and this is not a multilevel marketing company. I do recommend their ginkgo; I think it's a very good ginkgo and I've had good results with it.

The major claims of ginkgo are that it improves circulation. It can be helpful for some cognitive or mental problems with reduced mental capacity with aging, perhaps Alzheimer's, and tinnitus and vertigo. This is straight out of the German Commission E, probably the leading resource for the medicinal use of herbs. And the actions are that ginkgo vasodilates, which means that it opens up blood flow to different organs throughout the body. It has antioxidant properties. "CI" stands for contra-indications. With every herb I talk about, I'll talk about the claims, the actions, the contraindications, the side effects, the interactions, and dosages where known. You have to be careful with patients on anti-coagulants. So if you're taking coumadin for one reason, you're supposed to not take ginkgo. Most doctors would say just don't take it, but the answer would be that you would just need to lower coumadin levels. It would be a little bit more difficult for your doctor to manage your PT and your PTT, which are things which they follow to determine how thick or thin your blood is. The side effects are rare-- GI upset -- and I find that particularly with the off-brands. For example, how many here shop at Costco? Costco has a ginkgo where they grind up the entire tree or leaf or something, and they say it's standardized. I don't really buy it. On the flip side, they have a really nice glucosamine-chondroitin. For arthritis or joints, I recommend that brand very much. You've got to be really careful what you buy. The interactions, we've already alluded that coumadin, heparin, and other anticoagulants There is no concern with aspirin in my opinion, but there have been people who have talked about that, because both aspirin and ginkgo inhibit a property of platelets and therefore they both make them somewhat less sticky. The dosage of ginkgo that I recommend now is 240 milligrams twice a day, which is a pretty high dose. I used to recommend 40 to 60 milligrams but most of the studies show that really now 240 milligrams twice a day is probably most appropriate in that regard.

Black Cohosh is an herb that women have used to reduce symptoms of PMS, but it's also good for bronchitis. It's been used for vertigo and tinnitus, and it basically has no interactions. The only contra-indication is you should be careful if you're pregnant.

I've had a few people try Ligustrum. It's hard to find, but a good herbalist would be able to get it for you. It protects and supports the liver and kidney and is listed in most of the pharmacopeias. And many of the Asian doctors feel that tinnitus is caused by what they call poor kidney chi. Chi is energy, so they want to give you things that help energy chi. Medical doctors, osteopaths, and allopaths sort of roll their eyes when they hear that term. But there is no doubt that these things exist. It's the basis of acupuncture. They can actually stick needles in you in different places then crack open your chest while you're awake. They can do open-heart surgery and you can be talking to them because they're delivering the anesthesia by putting needles on you. It's unheard of here, but about 25 percent of major operations done in Asia are done with local anesthetic using acupuncture. And they do major abdominal, chest, and brain operations and you can still be talking to the doctor while you're having it done.

Mullein is another herb that can alleviate central nervous system irritation. There are no contraindications that have been noted. There are no specific side effects. There are no interactions with other drugs. This is the beauty of some of the herbs we use: Many of them are very safe or safer than many of the medicines that you get.

Pulsatilla is another herb that has been shown to be helpful for mild dizziness and some tinnitus. And it increases circulation. Really no significant contraindications except to avoid during pregnancy.

There are many other alternatives for tinnitus out there. Acupuncture has been shown in studies to be effective for about 40 percent of patients. How many of you here, by a show of hands, have tried acupuncture for tinnitus? Okay. Osteopathic adjustments, chiropractic manipulations: anybody try that for the tinnitus? Did it help? A lot of people with trauma, whiplash, or neck injuries will say that it helped them. A lot of my patients will say, "If I open my jaw, or push my jaw, or bite down hard I can increase or decrease my tinnitus, or if I turn my head to the right or to the left I can do it." And those people I will often send to a St. John's neuromuscular therapist. They work to realign the spine, and they have to do it over and over again. St. John's neuromuscular therapists say that what's pulling the spine out of alignment and what's attached to the spine are muscles. So they do a form of deep muscle, deep tissue massage to put the muscles back where they belong and the spine goes back where it belongs. And they work from your head all the way down to your toes. St. John's neuromuscular therapy is helpful for a small number of my patients.

Meditation and relaxation therapy is critical, defusing, demystifying-it's trying to put things into context to the best of our ability. Hypnotherapy works from the same standpoint. Clear Tinnitus and Wobenzyme-N are two products that are out there on the Internet that say they help. The Clear Tinnitus Company sent me 12 bottles; I think I've been through all but two of them where I've given them to patients to try for two months to see if it helps. It's helped a small number.

Again, what helps some people might not help you. Unfortunately, you have to do a bit of trial and error and you have to be your own little bit of test tube-within reason. There are no guarantees, and if anybody promises you one, walk in the opposite direction as quickly as possible.

Valerian root, an herb, is a sedative; it promotes sleep. It works on the GABA release, and inhibits its breakdown. Many of these herbs are felt to work on neural or brain responses. But the effect is similar to benzodiazepines, drugs like valium or Xanax. So it makes sense that these might be effective for some patients. They've had some warnings about kava kava recently, that it caused liver problems. Again, it's also an anxiolytic, which means that it helps anxiety. St. John's Wort has been used for mild to moderate depression. Two papers came out back to back in the Journal of the American Medical Association saying that it is ineffective for major depression. I wrote an editorial to that, but it didn't get published. I was disappointed because the bottom line is that the authors missed the point. St. John's Wort is not used, touted, recommended for major depression. It is recommended for mild depression. There is a big difference. You have to be careful with St. John's Wort. There are some side effects. It can increase your risk to sun exposure. So, overall my advice to doctors and their patients about herbs is to ask your patients if you're a doctor, and tell your doctor if you're a patient, about what you're using. And proven therapeutic options should be discussed prior to or in addition to considering alternatives. If a viable alternative exists, consider it.

Natural does not mean safe. Quality control and standardization may be an issue. Herbal pharmaceutical interactions occur. You have to be careful about using herbal remedies in higher than recommended doses, and you've got to be careful during pregnancy or lactation. You always want to know what disease or condition is being treated, or perhaps in this case, a symptom. What's the therapy? Are there conventional options? What's the benefit to the patient? Are there risks? What's the cost? And does it work?