THERAPEUTIC PROLONGED RESIDUAL INHIBITION OF TINNITUS Following An Acoustic Masking Signal: Preliminary Results And Possible Mechanisms.

This paper was first published at the IXth International Tinnitus Seminars in Goteborg, Sweden in June 2008 and at Frontiers in Otolaryngology in Australia. 

 INTRODUCTION.   A series of digitally synthesised low frequency complex acoustic waveforms (TIPA) has been engineered to specifically produce prolonged residual inhibition (RI) of tinnitus. The sounds were developed during a 5 year search using trial and error on patient volunteers in the authorís solo E.N.T. Specialist practice.

METHODS.    TIPA is a series of 3 complex sounds played in a sequence  lasting for 12 minutes. The patient listens to the sound using conventional high definition headphones. The sound is delivered to the patient at the minimum masking level and the same sound is used irrespective of tinnitus pitch. When the sound ceases the patient assesses the tinnitus loudness on a scale of 1 to 10 with 10 being the loudness of the tinnitus before the masking signal. The RI is recorded as the amount of reduction of tinnitus loudness. Thus RI of 100% means that the tinnitus is completely absent i.e. complete RI. This method is used as there is some confusion in the literature quantifying partial RI. The patient is then followed up to determine the duration of the RI. 20 patients with severe longstanding unremitting tinnitus, unresponsive to previous treatment were selected in order of presentation to the clinic for this trial.

RESULTS.    It was decided that a minimum therapeutically useful response is 50% RI lasting more than 3 hours after a 12 minute signal exposure. This would be sufficient to provide sleep without tinnitus disturbance. Of the 20 patients, 11 experienced RI better than this minimum therapeutic level. The results were: 2 patients had 100 % RI for 24 hours; 3 patients had 100% for 12 hours; 1 had 100% for 4 hours; 2 had 70% for 4 hours and 1 each had 80% for 7 hours, 50% for 12 hours and 50% for 7 hours (Fig1). One of these patients demonstrated continuation of RI by using TIPA a second time while still experiencing 100% RI. This produced continuous 100% RI for 5 consecutive days using a daily 12 minute signal. Patients subsequently treated with repeated exposures to TIPA have demonstrated cumulative responses. 

 DISCUSSION.   Although Residual Inhibition is a common phenomenon it has remained a clinical curiosity due to its short action. There is no real understanding of its mechanism. The patient responses to TIPA, particularly the consistency of duration and potentiation by a second masker make it very tempting to postulate that a neurotransmitter is involved. There is also evidence of a synergistic action between the different TIPA wave forms and frequencies. However the duration of RI after TIPA is so long that a chemical mediator might be of a neurotrophic type.  Neurotrophic factors have actions involving functional plasticity of the nervous system. Delayed onset of RI in the acoustic neuroma patient below suggest that inhibitory transmitters may may be involved.

A 50 year old male with unilateral tinnitus and normal hearing was treated with TIPA. He experienced initial 30% RI for 5 hours and then suddenly developed 100% RI 24 hours later which lasted 7 hours. He produced the same result on a second test. This is extremely unusual as RI is usually maximum immediately upon cessation of the masker. His routine MRI then found a 5mm ipsilateral intracanalicular acoustic neuroma which was treated expectantly. This delay of RI parallels the delay of ABR in acoustic neuroma and suggests the possibility of an inhibitory transmitter.

CONCLUSION.   The concept that RI can be successfully prolonged by modifying the waveforms and frequencies of the acoustic masking signal is novel. The TIPA signal is now being used to treat tinnitus patients and preliminary results of repeated use are showing cumulative effects and increased duration of the reduction in tinnitus loudness. 
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The following paper was published at the Third International Tinnitus Seminars in Stresa Italy in June 2009.


                                  EARLY EXPERIENCES WITH 
                                  TIPA TINNITUS TREATMENT.



                                          INTRODUCTION 

The TIPA signal was first published at the IXth International Tinnitus Seminars in Sweden in April 2008.

The TIPA signal is a series of complex, digitally engineered, non sinusoidal very low frequency sounds that have been found to produce prolonged residual inhibition in tinnitus patients. There are three different signals each lasting 3 minutes and are played in the sequence 1,2,1,3. Subjective clinical testing has shown that the sounds are synergistic in their ability to prolong residual inhibition (RI) if played in this order. This is an empirical observation and the underlying physiologic mechanisms are unknown.

                                            METHODS

The TIPA signal was developed over a 5-year period using trial and error subjective testing in the authorís solo ENT practice. Patients who experienced RI on initial testing were supplied with the TIPA Device as soon as it received Australian regulatory approval.

                                             RESULTS

Patient JL a 63-year-old farmer had constant unremitting, extremely disturbing tinnitus. His audiogram shows noise induced loss. Initially he experienced 12 hours of complete RI by using the signal morning and evening for 12 days. He continued to use the device and by March 2009 his complete RI would last 24 hours after a single 12-minute exposure at midday. As well as having his life vastly improved he also reported that his chronic headaches had disappeared.

Patient LM a 77-year-old female retiree with presbyacusis and unremitting tinnitus achieves 3 hours of complete RI every night after a single 12-minute exposure to the device. She previously had sleep disturbance from her tinnitus but is now able to get to sleep while her tinnitus is absent.

Patient MC a 45-year-old male health care worker has had constant unremitting bilateral tinnitus since he was a teenager and has a normal audiogram. He usually experiences complete RI from the TIPA Device lasting 48 hours, however using the device again before the tinnitus returned he was able to achieve a two-week tinnitus free period. He subsequently experienced 4 days of complete RI following a single TIPA signal.

 

                                              CONCLUSION 

The concept that digital manipulation of the spectrum of a masking signal can be of therapeutic benefit in tinnitus patients by prolonging residual inhibition is novel. The fact that a tinnitus patient can be improved by such a simple measure has changed patientsí lives.

---------------------------------------------------------------------------------------------------------   The following paper was presented at the 4th Tinnitus Research Initiative meeting in Dallas, Texas, USA in June 2010 and also at the following Australian meetings: 
Frontiers in Otolaryngology, The Australian Society of Otolaryngology Head and Neck Surgeons and The Australian Society of Audiologists.


EARLY INTERVENTION IN SUDDEN ONSET TINNITUS.

 

                                                           Dr Peter Winkler

Macquarie Street Tinnitus Clinic. Sydney, Australia

 

 

         BACKGROUND

It is  proposed that recent or sudden onset tinnitus is more susceptible to change if treated early. These are the principles that are applied to sudden sensorineural hearing loss. Two recent cases with good outcomes are presented.

OBJECTIVES

Tinnitus theory postulates that the failure of inhibitory neural pathways is instrumental in the persistence of tinnitus. Therefore if we can be proactive in enhancing these inhibitory pathways we may achieve a better therapeutic outcome. The concept of brain plasticity suggests that if we can switch tinnitus off even temporarily we may be able to prevent the establishment of long term tinnitus.

METHODS

In some patients tinnitus can be switched off for extended periods using a digitally synthesized low frequency series of non-sinusoidal sound signals  which play for twelve minutes (TIPA). This effect constitutes prolonged residual inhibition.

RESULTS

Case 1

A 56 year-old early childhood teacher with no other illnesses awoke at 4am with severe constant tinnitus in her right ear. She had no vertigo, her audiogram was normal and her CT of brain was normal. The tinnitus had been unremitting for 4 months.

 On her first 12 minute exposure to TIPA she experienced complete residual inhibition (i.e. no tinnitus). The patient continued to use the signal daily and for the next four days had no tinnitus. Over the next four days her tinnitus stopped completely and has remained in remission.

CASE 2

A healthy 36 year old female suddenly developed pain in both ears which was severe on the right and accompanied by right tinnitus. She had a normal audiogram and no vertigo. A month later the tinnitus was no better and she was becoming concerned. She had a single 12 minute exposure to TIPA and achieved complete residual inhibition. She was advised to have further treatment but reported the following week  that her tinnitus had gone. She remains in remission.

CONCLUSION

TIPA is a new therapeutic tool for the treatment of tinnitus. The fact that we can switch tinnitus off for an extended period in any patient is in itself a major advance.


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