Tinnitus and sound intolerance: evidence and experience of a Brazilian group / Zumbido e intolerância a sons: evidência e experiência de um grupo brasileiro

Abstract Introduction Tinnitus and sound intolerance are frequent and subjective complaints that may have an impact on a patient's quality of life. Objective To present a review of the salient points including concepts, pathophysiology, diagnosis and approach of the patient with tinnitus and sensitivity to sounds. Methods Literature review with bibliographic survey in LILACS, SciELO, Pubmed and MEDLINE database. Articles and book chapters on tinnitus and sound sensitivity were selected. The several topics were discussed by a group of Brazilian professionals and the conclusions were described. Results The prevalence of tinnitus has increased over the years, often associated with hearing loss, metabolic factors and inadequate diet. Medical evaluation should be performed carefully to guide the request of subsidiary exams. Currently available treatments range from medications to the use of sounds with specific characteristics and meditation techniques, with variable results. Conclusion A review on tinnitus and auditory sensitivity was presented, allowing the reader a broad view of the approach to these patients, based on scientific evidence and national experience.

Resumo Introdução Zumbido e intolerância a sons são queixas frequentes e subjetivas que podem ter impacto na qualidade de vida do paciente. Objetivo Apresentar uma revisão dos principais pontos, inclusive conceitos, fisiopatologia, diagnóstico e abordagem do paciente com zumbido e sensibilidade a sons. Método Revisão da literatura com levantamento bibliográfico na base de dados da LILACS, SciELO, Pubmed e MEDLINE. Foram selecionados artigos e capítulos de livros sobre zumbido e sensibilidade a sons. Os diversos tópicos foram discutidos por um grupo de profissionais brasileiros e as conclusões, descritas. Resultado A prevalência de zumbido tem aumentado ao longo dos anos, muitas vezes associado a perda auditiva, fatores metabólicos e erros alimentares. A avaliação médica deve ser feita minuciosamente no sentido de orientar a solicitação de exames subsidiários. Os tratamentos disponíveis atualmente variam de medicamentos ao uso de sons com características específicas e técnicas de meditação, com resultados variáveis. Conclusão Foi apresentada uma revisão sobre os temas que permitindo ao leitor uma visão ampla da abordagem dos pacientes com zumbido e sensibilidade auditiva baseada em evidências científicas e experiência nacional.

Tinnitus and sound intolerance: evidence and experience of a Brazilian group.

INTRODUCTION: Tinnitus and sound intolerance are frequent and subjective complaints that may have an impact on a patient's quality of life. OBJECTIVE: To present a review of the salient points including concepts, pathophysiology, diagnosis and approach of the patient with tinnitus and sensitivity to sounds. METHODS: Literature review with bibliographic survey in LILACS, SciELO, Pubmed and MEDLINE database. Articles and book chapters on tinnitus and sound sensitivity were selected. The several topics were discussed by a group of Brazilian professionals and the conclusions were described. RESULTS: The prevalence of tinnitus has increased over the years, often associated with hearing loss, metabolic factors and inadequate diet. Medical evaluation should be performed carefully to guide the request of subsidiary exams. Currently available treatments range from medications to the use of sounds with specific characteristics and meditation techniques, with variable results. CONCLUSION: A review on tinnitus and auditory sensitivity was presented, allowing the reader a broad view of the approach to these patients, based on scientific evidence and national experience.

Eficácia da estimulação magnética transcraniana em pacientes com zumbido e audiometria normal: avaliação clínica e por neuroimagem / Transcranial magnetic stimulation efficiency in patients with tinnitus and normal pure-tone audiometry: clinical and neuroimaging evaluation

INTRODUÇÃO: O zumbido é um sintoma muito frequente e de difícil tratamento. Atualmente, algumas evidências mostraram que o zumbido está associado a alterações funcionais do sistema nervoso central. Nos últimos anos, a modulação da atividade cortical relacionada ao zumbido por meio da estimulação magnética transcraniana repetitiva (EMT) tem sido proposta como um tratamento promissor. Entretanto, nenhum estudo avaliou sua eficácia no controle do zumbido em pacientes sem perda auditiva concomitante, nem seu efeito de longa duração. O objetivo do trabalho foi investigar os efeitos imediatos e a longo prazo da estimulação magnética transcraniana repetitiva de baixa frequência (1 Hz) em pacientes com zumbido e audiometria normal. MÉTODOS: Utilizando um ensaio clínico aleatorizado, duplo cego e paralelo, foram randomizados 20 pacientes para receber a EMT ativa ou placebo. A estimulação foi aplicada no córtex têmporo-parietal esquerdo por cinco dias consecutivos. A avaliação clínica foi feita por meio do Tinnitus Handicap Inventory e da escala análogo-visual. A avaliação por neuroimagem foi feita por meio do SPECT, o qual foi realizado antes e 14 dias após o período de estimulação. RESULTADOS: Clinicamente, o grupo submetido à estimulação magnética transcraniana ativa apresentou uma melhora significativa do zumbido, mantida por até seis meses, quando comparado ao grupo que recebeu a estimulação placebo. A avaliação por SPECT demonstrou redução do fluxo sanguíneo no lobo temporal esquerdo após o período de estimulação ativa. CONCLUSÃO: Os resultados revelam o potencial terapêutico da estimulação magnética transcraniana como nova ferramenta no tratamento do zumbido, proporcionando redução significativa do incômodo provocado pelo zumbido por até seis meses e reduzindo a atividade neuronal no córtex temporal.

INTRODUCTION: Tinnitus is a frequent disorder which is very difficult to treat. There is compelling evidence that tinnitus is associated with functional alterations in the central nervous system. Recently, the targeted modulation of tinnitus-related cortical activity through repetitive transcranial magnetic stimulation (rTMS) has been proposed as a promising new treatment approach. However, its efficacy in patients without hearing loss has never been studied, as well as the long-term duration of its effect. The objective of this study was to investigate both immediate and long-term effect of low frequency (1 Hz) rTMS in patients with tinnitus and normal hearing. METHODS: Using a randomized double-blind and parallel clinical trial, 20 patients were divided to receive either active or placebo transcranial magnetic stimulation over the left temporoparietal cortex for 5 consecutive days. The clinical evaluation was performed by using the Tinnitus Handicap Inventory and the visual analogue scale. The neuroimage evaluation included and ECD-SPECT imaging, which was performed before and 14 days after rTMS. RESULTS: From the clinical point of view, the group submitted to active rTMS presented significant improvement of the tinnitus score, which was sustained up to six months, when compared to the group that received the sham rTMS. SPECT measurements demonstrated a reduction of metabolic activity in the left temporal lobe after active rTMS. CONCLUSION: These results support the potential of rTMS as a new therapeutic tool for the treatment of chronic tinnitus, by demonstrating a significant reduction of tinnitus complaints over a period of at least six months and a significant reduction of neural activity in the temporal cortex.

Controversy: Does repetitive transcranial magnetic stimulation/ transcranial direct current stimulation show efficacy in treating tinnitus patients?

BACKGROUND: Tinnitus affects 10% of the population, its pathophysiology remains incompletely understood, and treatment is elusive. Functional imaging has demonstrated a relationship between the intensity of tinnitus and the degree of reorganization in the auditory cortex. Experimental studies have further shown that tinnitus is associated with synchronized hyperactivity in the auditory cortex. Therefore, targeted modulation of auditory cortex has been proposed as a new therapeutic approach for chronic tinnitus. METHODS: Repetitive transcranial magnetic stimulation (rTMS) and transcranial direct current stimulation (tDCS) are noninvasive methods that can modulate cortical activity. These techniques have been applied in different ways in patients with chronic tinnitus. Single sessions of high-frequency rTMS over the temporal cortex have been successful in reducing the intensity of tinnitus during the time of stimulation and could be predictive for treatment outcome of chronic epidural stimulation using implanted electrodes. RESULTS: Another approach that uses rTMS as a treatment for tinnitus is application of low-frequency rTMS in repeated sessions, to induce a lasting change of neuronal activity in the auditory cortex beyond the duration of stimulation. Beneficial effects of this treatment have been consistently demonstrated in several small controlled studies. However, results are characterized by high interindividual variability and only a moderate decrease of the tinnitus. The role of patient-related (for example, hearing loss, tinnitus duration, age) and stimulation-related (for example, stimulation site, stimulation protocols) factors still remains to be elucidated. CONCLUSIONS: Even in this early stage of investigation, there is a convincing body of evidence that rTMS represents a promising tool for pathophysiological assessment and therapeutic management of tinnitus. Further development of this technique will depend on a more detailed understanding of the neurobiological effects mediating the benefit of TMS on tinnitus perception. Moreover clinical studies with larger sample sizes and longer follow-up periods are needed.

Laparoscopic partial nephrectomy in rats

PURPOSE: To establish an experimental model of laparoscopic partial nephrectomy (LPN) in rats and to analyze morphological alterations in the renal parenchyma utilizing an electric cautery and harmonic scalpel. METHODS: Forty Wistar rats were used, divided in 2 experiments with 20 rats each: experiment I, LPN was performed with an electric cautery and the rats were subdivided into groups A and B; experiment II, LPN was performed with a harmonic scalpel and they were subdivided into groups C and D. The animals in groups A and C were sacrificed shortly after surgery and the remnant kidney was removed to study the following variables: necroses and degeneration. In groups B and D a laparatomy was performed for retrieval of the remnant kidney on the 14th day after surgery to analyze fibrous scarring. RESULTS: For the variables necroses and fibrous scarring, the electric cautery creates, on average, greater width than that produced by the harmonic scalpel (p=0.0002 and p=0.0068 respectively). Regarding the variable of degeneration, we found no significant difference between the two types of scalpels (p=0.1267). CONCLUSIONS: LPN in rats is an adequate and feasible experimental model. The electric cautery caused greater damage to remnant renal tissue when compared to harmonic scalpel.

OBJETIVO: Estabelecer um modelo experimental de nefrectomia parcial laparoscópica (NPL) em ratos e analisar as alterações morfológicas no parênquima renal utilizando-se bisturi elétrico e harmônico. MÉTODOS: Foram utilizados 40 ratos Wistar, distribuídos em dois experimentos com 20 ratos cada: experimento I, NPL utilizando-se de bisturi elétrico e subdividindo-se os ratos em grupos A e B; experimento II, NPL realizada com bisturi harmônico e subdividindo-se os ratos em grupos C e D. Os animais dos grupos A e C foram sacrificados após a cirurgia para a remoção do rim operado e estudo das seguintes variáveis: necrose e degeneração. Nos grupos B e D a laparotomia para a retirada do rim operado foi após o décimo quarto dia de pós-operatório para a análise da cicatriz fibrosa. RESULTADOS: O bisturi elétrico provocou uma necrose e cicatriz fibrosa mais extensas em relação ao bisturi harmônico (p=0.0002 e p=0.0068 respectivamente). Em relação a variável degeneração, não houve diferença entre os tipos de bisturis (p=0.1267). CONCLUSÕES: NPL em ratos é um modelo experimental adequado e factível. O bisturi elétrico causa danos teciduais mais intensos no rim operado quando comparado com o bisturi harmônico.

Laparoscopic partial nephrectomy in rats.

PURPOSE: To establish an experimental model of laparoscopic partial nephrectomy (LPN) in rats and to analyze morphological alterations in the renal parenchyma utilizing an electric cautery and harmonic scalpel. METHODS: Forty Wistar rats were used, divided in 2 experiments with 20 rats each: experiment I, LPN was performed with an electric cautery and the rats were subdivided into groups A and B; experiment II, LPN was performed with a harmonic scalpel and they were subdivided into groups C and D. The animals in groups A and C were sacrificed shortly after surgery and the remnant kidney was removed to study the following variables: necroses and degeneration. In groups B and D a laparatomy was performed for retrieval of the remnant kidney on the 14th day after surgery to analyze fibrous scarring. RESULTS: For the variables necroses and fibrous scarring, the electric cautery creates, on average, greater width than that produced by the harmonic scalpel (p=0.0002 and p=0.0068 respectively). Regarding the variable of degeneration, we found no significant difference between the two types of scalpels (p=0.1267). CONCLUSIONS: LPN in rats is an adequate and feasible experimental model. The electric cautery caused greater damage to remnant renal tissue when compared to harmonic scalpel.

Tinnitus and brain activation: insights from transcranial magnetic stimulation.

The mechanisms underlying tinnitus are still not completely elucidated, but advances in neuroimaging and brain stimulation have provided us with new insights. Evidence suggests that tinnitus might actually be generated by central rather than peripheral structures. To illustrate the importance of brain activity changes in the pathology of tinnitus, we report the cases of 2 patients who experienced a recurrence/worsening of their tinnitus after they had undergone treatment for major depression with repetitive transcranial magnetic stimulation. We suggest that the tinnitus in these 2 patients was induced by changes in brain activity resulting from transcranial magnetic stimulation of the prefrontal cortex. We also review the pathophysiology and other aspects of tinnitus, focusing on associated brain reorganization.

The effect of stapedotomy on tinnitus in patients with otospongiosis.

Stapedotomy is primarily performed to treat hearing loss secondary to otospongiosis, although some patients find that the accompanying tinnitus is more bothersome than the hearing loss. We prospectively studied 23 consecutive patients with tinnitus secondary to otospongiosis who had undergone stapedotomy, and we compared their pre- and postoperative medical and audiologic findings. Patients' annoyance with their tinnitus was quantified by means of a visual analog scale, and their air-conduction thresholds were determined by measurements of a 4-frequency pure-tone average (0.5, 1, 2, and 4 kHz). Statistical analysis was performed using the paired Student's t test and Fisher's exact test. In the group as a whole, the mean tinnitus annoyance visual analog scores were 8.34 preoperatively and 1.56 postoperatively, a highly significant difference. Clinically, 22 of the 23 patients (95.7%) achieved satisfactory control of their tinnitus (improvement or complete resolution) following stapedotomy. With respect to hearing loss, all patients clinically improved postoperatively, and audiometry confirmed improvement at all 4 frequencies between 0.5 and 4 kHz. An air-bone gap of less than 10 dB was noted in 17 patients (73.9%). We conclude that in addition to improving hearing, stapedotomy also provides good control of tinnitus.

Cirurgia endoscópica endonasal: experiência em 708 casos / Endoscopic endonasal surgery: experience in 706 cases

Introdução: A cirurgia endoscópica endonasal (CEE) é utilizada para diagnóstico, biópsia, tratamento e acompanhamento de diversas doenças. Apresenta taxa de sucesso que varia de 76 por cento a 98 por cento. É uma cirurgia conservadora, com acesso mais anatômico às estruturas do nariz, preservando a mucosa e restabelecendo a função nasal. Objetivo: O objetivo deste estudo é relatar a experiência com CEE em nosso serviço. Forma do estudo: C1ínico retrospectivo. Material e método: Os autores realizaram estudo retrospectivo de todas as cirurgias endoscópicas endonasais realizadas no período de dezembro de 1995 a março de 2000. Todas foram realizadas por médicos residentes do terceiro ano do programa de Residência Médica em Otorrinolaringologia do Hospital das C1ínicas da Universidade de São Paulo, sempre com a supervisão de um médico assistente do Serviço. Resultados: Foram analisados 706 pacientes, 386 (54,7 por cento) do sexo masculino e 320 (45,3 por cento) do sexo feminino. A média de idade foi de 35,8 anos. Em relação ao tipo de anestesia, 700 (99,2 por cento) procedimentos foram sob anestesia geral. O sangramento intra-operatório foi considerado escasso em 432 pacientes (61,2 por cento), não tendo sido necessária a realização de tamponamento nasal em 96,6 por cento dos pacientes. Entre todos os casos, ocorreram 16 (2,27 por cento) complicações. Conclusão: Em nossa experiência, a cirurgia endoscópica endonasal é método eficaz, pois além de permitir abordar uma grande diversidade de afecções, possibilita preservar ao máximo a anatomia e fisiologia nasal, apresentando baixos índices de complicações