Tinnitus management using intra tympanic
Dr. T. Balasubramanian M.S. D.L.O.
Tinnitus is defined as abnormal sound heard in the ear.
It can be divided into two types:
Subjective tinnitus: where the sound is heard only by the
patient and not by the physician.
Objective tinnitus: Is heard both by the patient as well
as the examining physician. One common example of objective tinnitus
is palatal myoclonus.
The term tinnitus is derived from the Latin word
tinnire which translated means ringing
sound. Tinnitus can occur alone or in combination with sensorineural
hearing loss. People affected belong to the 5th and 6th decade age
groups. It is a very difficult condition to manage because of its
Management of tinnitus an overview:
Tinnitus could be managed by:
1. Hearing amplification (use of hearing
2. Use of tinnitus maskers
3. Use of oral drugs
4. Tinnitus retraining therapy
To this list recently intra tympanic medications have
also been added. This should infact be considered in selected cases.
Schuknecht first used intra tympanic
aminoglycosides (Streptomycin) for treatment of Meniere's disease.
Because of its ototoxic effects this therapy had immediate effect on
tinnitus. Beck later used gentamycin in tinnitus management. This
drug gained in popularity because of its ability to preserve
hearing. Lignocaine and steroids were also used
with success in the management of tinnitus.
Use of intratympanic lignocaine in the management of
Lignocaine belongs to a drug group called amides. Its
mechanism of action is through sodium channel blockade at the level
of neurons. It also has a profound analgesic, antiarrythmic and
anticonvulsant properties. It has this unique ability to silence the
hyperactive neurons responsible for the production of tinnitus.
Eventhough it was highly effective in the management of
tinnitus, it had certain unpleasant side effects like vertigo,
nausea and vomiting which necessitated hospitalisation of the
Use of intratympanic corticosteriods in the management of
Corticosteriods are well known for its anti inflammatory
property. Steriod receptors have been demonstrated in the inner ear.
It also increases the blood supply to the cochlea. It is this
property which has been attributed as the cause for its effect on
tinnitus. The advantages of intra tympanic adminsitration of
steriods is as follows:
1. When administered intra tympanically, it is devoid of
its systemic toxic effects.
2. There is an immediate increase in concentration
of this drug in the inner ear. There is virtually
no latent period.
Methylpredinsolone has been found to have the best effect
in the reduction of tinnitus because of its ability to penetrate
into the inner ear fluids though the round window
Factors influencing the passage of drugs through the
1. Normal round window membrane
2. Presence of inflammation around round window membrane
increases its permeability to the drug.
3. Obstruction due to eustachean tube block: This allows
the drug to stay a long time within the middle ear cavity
facilitating inner ear penetration via the round window
4. Molecular weight of the drug administered: Lesser the
molecular weight of the drug better is the penetration.
5. Liposolubility: The more liposoluble the drug the
better is its penetration through the round window
Studies have shown that steriods have better effects in
controlling the tinnitus caused by Meniere's disease, while
lignocaine has better effect in controlling tinnitus associated with
Dexamethasone can be perfused through the middle ear in a
dose of 4mg/ml. This drug can be instilled into the middle ear
through a tympanotomy incision. Injections can be repeated once a
week till the patient is symptom free. Grommets can be introduced to
facilitate repeated injections of this drug.
Gentamycin can be administered intra tympanically in
doses of 40mg/ml. It can be repeated at weekly intervals till the
patient is symptom free.
Modern middle ear drug delivery systems:
The aim of this delivery system is to predictably deliver
drug directly over the round window membrane to facilitate easy
absorption. The Silverstein micro wick has been specifically
designed for this purpose. The main advantage of this system is that
after the initial administration of the drug by the physician the
patient himself can administer the drugs at home at specified
intervals. The microwick absorbs the medication and transports it
directly to the round window membrane.
The microwick is made up of polyvinyl acetate. It
measures 1mm in diameter and about 9mm long. It can be easily
inserted through a grommet. As a first step grommet must be inserted
into the round window area under local anesthesia. Round window
niche is identified as a dark area just posterior and inferior to
the umbo. Microwick can easily be inserted through this ventilation
tube in such a way that it lies in contact with the round window
membrane. After the first administration of the drug patient himself
can administer the drug as ear drops two or three times a day as
advised. The only precaution is that the patient must lie with the
drug adminstered ear facing up for at least 5 minutes to enable
adequate drug perfusion into the middle
showing the round window area
inserted through a grommet
After treatment the microwick can easily be removed
without anesthesia using a micro cup forceps.
Indications for intratympanic medications:
1. Meniere's disease
2. Sudden sensori neural deafness (steriod is
Complications of intratympanic medications:
1. Intense giddiness
3. Middle ear infection
4. Residual perforation
Pitfalls of microwick therapy:
1. Accurate placement of the microwick over the round
window area is a must.
2. Laser tympanotomy is preferred to conventional one
because of the blood less field. This is a must for accurate
placement of the wick. When the area is moist insertion of the wick
becomes difficult because it swells up on exposure to moisture.
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