(Formerly International Tinnitus Forum)
By Barry Keate
The meeting previously known as the International Tinnitus Forum convened on September 11th in San Francisco at the American Academy of Otolaryngology’s annual meeting. Aswith last year’s gathering the forum morphed from a 4½-hour conference, occurring the day before the annual meeting, to a one-hour meeting during the ENT convention. No longer referred to as the International Tinnitus Forum but as the Tinnitus Mini-Seminar, this new format has led to both positive and negative changes.
On the positive side, the Tinnitus Mini-Seminar now attracts many more physicians interested in learning about tinnitus. Meetings have swollen from 50-100 members to about 600 participants per meeting. The mini-seminar also qualifies for Continuing Medical Education (CME) credits. These credits allow physicians to increase their knowledge in emerging fields and are required in most states to maintain their medical license. This format is a big incentive for attendance by physicians, and helps to improve treatment for their tinnitus patients.
On the negative side, the shortened duration of the meetings leads to fewer and shorter presentations due to obvious time constraints.
The primary focus of the mini-seminar provided information presented at past forums, helping to bring the majority of attending physicians up to date with current treatments.
Prior to the tinnitus mini-seminar there was a discussion on alternative treatments for common otolaryngology (ORL) problems including tinnitus. This presentation dovetailed nicely with the tinnitus seminar and so is presented here first.
Alternative Treatments for Common ORL Problems Mini-Seminar
1 – Ear Candling uses a hollow cone embedded with paraffin or beeswax. The cone is inserted in the external auditory canal while the patient is laying on their side. The candle is ignited at the opposite end and burns for 10-15 minutes. The candle is allegedly drawing out earwax (cerumen), toxins and impurities. After it is extinguished, the ear candler will often slice up the remaining part of the candle to show how it has absorbed impurities.
Ear candling allegedly dates back to ancient civilizations. Reports of Hopi Indians, Aztecs and ancient Egyptians using ear candling are very common. Yet there is no historical evidence that any of this is true.
Ear candling materials are sold in health stores today, many salons and alternative health centers. They are also being marketed on the web for ear infections and even for use in children with otitis media (infection of the middle ear). There are many claims of purification of the blood, opening up of chakras (energy centers) and even as a cure for cancer.
In one survey of otolaryngologists, published in The Laryngoscope, a highly regarded otolaryngology publication, 122 ENT physicians were questioned about their knowledge of serious side effects of ear candling. In this very small sample of physicians, there were 21 reports of ear damage, including burns, occlusion of the ear canal by candle wax, causing temporary hearing loss, and one tympanic membrane operation that was required.
Testing was conducted on ear candling which showed by lighting the candle no negative pressure was generated, refuting the hypothesis that negative pressure was the method of draining the wax, toxins and impurities.
Researchers also did analysis of the deposits, which showed they were actually residue from the candle wax and not earwax.
The Academy of Otolaryngology published in its Clinical Practice Guideline in 2008 its findings that there are no observed positive effects of ear candling and there are considerable risks involved. It is opposed to the use of ear candling for any condition.
The FDA considers ear candles to be medical devices used in the diagnosis, prevention and treatment of disease. It has pursued action against companies that market materials for ear candles.
2 - Nutritional Treatments for Tinnitus. Michael Seidman, MD presented on various nutritional treatments for tinnitus. I was honored to help provide some of the materials that were used.
A study was conducted on treating tinnitus with Vitamin B-12. Treating patients with tinnitus who were also Vitamin B-12 deficient took 4-6 months to obtain good results. Nutritional deficiencies typically take up to 6 months to rectify. Vitamin and nutritional therapies don’t work like taking insulin to immediately drop blood sugar. They take months to have good effect. In the Vitamin B-12 study, they eventually reached 56% having a good effect.
Zinc is another nutrient that positively affects tinnitus. A number of studies show that zinc is helpful for tinnitus. The highest concentrations in the body are in the retina and the cochlea. Some studies show there is no improvement over placebo. It doesn’t hurt anyone, as long as they don’t take over 90 mg per day. Some multivitamins contain up to 15 mg of zinc so this has to be taken into consideration. A landmark study on zinc and tinnitus is in our Tinnitus Library.
Ginkgo biloba extract has been extensively studied for its effect on tinnitus. There was a compilation of 19 controlled clinical trials on ginkgo for tinnitus, five placebo-controlled and the rest controlled by another medication. Ten of eleven open trials showed improvement with ginkgo. The rest showed significant improvement of ginkgo over placebo and reference medications.
Another study known as the Birmingham Study examined 1,000 patients using ginkgo and found no benefit. The biggest problem with the study is while citing the German Commission E report on Ginkgo biloba for tinnitus, the authors ignored the Commission's recommended dosage of 120 to 240 mg two to three times daily. The average dosage being 480 mg daily. The Birmingham Study used only 150 mg of ginkgo daily.
Editor's Note: Arches Tinnitus Formula™ uses the German Commission E recommended dosage of 240 mg of Ginkgo biloba extract, twice daily.
Dr. Seidman states he uses ginkgo with many of his patients. There is very little risk of harm and it helps many of them. The greatest risk is that ginkgo also reduces the action of PAF (Platelet Aggregating Factor), the same method of action of prescription blood thinners such as Coumadin and Plavix. It can enhance the function of these drugs and should not be combined with them without the knowledge of their prescribing physician. The physician can turn down the dosage of the medication to account for the action of ginkgo and there is no problem. However, if this is not done, there can be bleeding problems.
Valerian Root is called “Nature’s Valium.” There are some potential side-effects. This does help some patients. It helps them to sleep and relax.
St. John’s Wort is used for minor depression. A recent study showed it was not effective for major depression. Dr. Seidman says it was never meant for major depression. It is also helpful for some tinnitus patients.
St. John’s Wort is contraindicated when major anesthesia is to occur. It combines with many anesthetics and the danger is the patient may not wake up.
Bioflavonoid complex is used for Meniere’s disease and tinnitus. The retail product using this is Lipoflavonoid. The most recent studies were in 1963 and 1966. Most discussed its use on Meniere’s disease. Some studies showed an effect on tinnitus but a major study from Walter Reed Hospital showed it does not affect tinnitus that is not caused by Meniere’s.
Antioxidants have been studied for a long time. N-Acetyl Cysteine (NAC) has been shown to reduce hearing loss from noise exposure provided it is taken before or very shortly after exposure. The number one issue facing our returning veterans from Iraq and Afghanistan is tinnitus. The second major issue is hearing loss. Some of hearing loss can be prevented with the use of antioxidants.
Phosphatidyl choline and phosphatidyl serene are derived from lecithin. An animal study showed that, over a lifetime, animals that took lecithin had a 10 – 15 dB hearing loss compared to 40 dB with placebo control.
3 – Alternative treatments for Meniere’s disease. Meniere’s is characterized by episodic vertigo lasting 20 minutes to 24 hours, fluctuating and unilateral hearing loss, and generally unilateral tinnitus.
The three alternative treatments discussed here are diuretic therapy, betahistine and acupuncture. Betahistine and acupuncture have the most clinical support.
Diuretic therapy is commonly used by ENT physicians but there has not been a single clinical study to prove or disprove efficacy. It is therefore considered that there is insufficient evidence to support the therapy.
Betahistine has been studied in seven clinical trials, all in Europe, which compared betahistine to placebo. In Europe the product has been marketed for 40 years as SERC. There is strong clinical evidence that it is helpful for vertigo but less so for hearing loss. The conclusion was that more research is needed but there is a strong suggestion that it is beneficial.
One of the problems is it has a short half-life so it has to be taken much more frequently, typically three times daily. For many years it was not available in the US but is now available through compounding pharmacies.
Acupuncture/Traditional Chinese Medicine (TCM) is used for Meniere’s. There is strong scientific evidence acupuncture is helpful for nausea, osteoarthritis and chronic pain.
Three randomized, placebo-controlled clinical studies in China show acupuncture is beneficial for vertigo episodes. It is also helpful in controlling hearing loss.
Acupuncture is not without risks. Complications are usually mild but serious complications can occur. There have been 86 deaths attributable to acupuncture as well as seven cases of hepatitis B. It is imperative to seek therapy from a practitioner who is licensed.
1 – Cochlear implant technology. Attempts to treat tinnitus with electrical stimulation began in the early 1800’s. Electrodes were placed in the ears and current applied. There were many claims of great success using electrical stimulation throughout the 19th century, however no clinical studies were conducted.
In about 1960, some studies were able to reconstruct earlier experiments and produced somewhat positive results. Through the 1990’s there were many studies on electrical stimulation and cochlear implants. The majority of patients who had cochlear implants had significant improvement in their tinnitus. In some, the tinnitus was completely resolved.
It is nearly impossible to conduct a placebo-controlled trial for electrical stimulation because they cannot implant a bogus cochlear implant. Eligible patients for a cochlear implant are profoundly deaf or close to it. If it is a placebo implant, the patient can’t hear and knows it was a placebo.
When hair cells in the cochlea are damaged there is a loss of spontaneous activity in the neurons of the central auditory pathways. It is possible to recreate the spontaneous activity in a deaf or mostly deaf ear by use of cochlear implants.
The rest of the discussion was composed of various electrical stimulation technicalities such as current, pulse rate, pulse width, etc., and their effect on tinnitus. There is still much work to be done before the exact parameters for tinnitus suppression will be known.
2 – Brain Implants for Tinnitus. Michael Seidman, MD gave his second presentation of the day on middle ear implants and brain implants for the control of hearing loss and tinnitus.
A recent survey of 230 hearing care professionals showed that 40% of tinnitus patients received between minor up to moderate relief of tinnitus when they wear hearing aids. 20% reported major relief and about 40% received no benefit.
There followed a discussion of different kinds of implantable devices. There is a new type of hearing aid that is surgically implanted in the mastoid bone behind the ear. Responses are quite favorable with 40% of patients having a significant reduction in tinnitus and another 35% of patients having varying degrees of reduction. This is not a cochlear implant where the cochlea is destroyed and replaced with an electronic one. It is a hearing aid but one that is more effective and hidden from sight. This will be the focus of a future article in this publication.
A brief discussion of auditory cortex brain implants followed. Dr. Seidman has conducted 6 of these brain surgeries. The first patient was essentially cured. Two others had a good outcome and one had moderate improvement. Two patients did not change at all. Dr. Seidman stated his is no longer going to engage in these experiments. They are extremely time-consuming and he believes others will be able to build on the knowledge he has developed.
Next year's meeting will take place in Washington D.C. Arches will be there and once again I'll keep you abreast on all the latest information on tinnitus treatments and research.