Abstract
Tinnitus has become one of the most challenging tasks faced by the medical field. It has a moderately negative impact on patient’s quality of life. Different methods had been developed in medical science for managing tinnitus but none of these offered a permanent cure. In our study we used a simple procedure of intratympanic injection of dexamethasone in managing our tinnitus patients. Total number of patients involved in this study were 40, 26 females and 14 males with age spanned from 15 to 65 years. Out of 40 patients, 22 of them complained of tinnitus only while the other 18 of them complained of tinnitus with impaired hearing which was confirmed further by pure tone audiometry. Injection was given under otologic microscopic vision through posteroinferior quadrant of tympanic membrane in weekly interval. After receiving several number of injections, 24 patients (60%) reported complete disappearance of tinnitus, 10 of them (25%) still had residual tinnitus but comparatively less severe and 6 (15%) of them reported no improvement.
Keywords: Inner-ear drug delivery system, Steroid targeting therapy, Tinnitus, Trans tympanic perfusion technique
Introduction
Tinnitus may be defined variously, as ‘a sound perceived for more than five minutes at a time, in the absence of any external acoustical or electrical stimulation of the ear and not occurring immediately after exposure to loud noise’. It is derived from the Latin tinnire, to ring. The condition is usually subjective and audible only to patients. When tinnitus is mild, patient may not noticed it. However, when it is continuous and loud, it can interfere with person’s quality of life. Treatment of tinnitus has been done by various methods since ancient time but till recently there is no promising method that can provide permanent cure of it. These methods ranges from pharmacological agents to transcranial stimulation of brain to surgical destruction of vestibular system. Historically intratympanic delivery of various medication for the control of idiopathic tinnitus or tinnitus associated with other diseases had been done by many. Some of these Pioneers who had popularised this intratympanic technique for treatment of various inner diseases include Sakata, Barany, Lempert, Fowler, Schuknecht etc. Medication frequently used by these pioneers are lidocaine [1], gentamycin, streptomycin, steroids [2–4].
Materials and Methods
The study was conducted in a durations of 20 months from February 2014 to September 2015. Fourty patients were involved, 26 females and 14 males with age spanned from 15 to 65 years. Out of 40 patients, 22 of them complained of tinnitus only while the other 18 complained of tinnitus with impaired hearing which was confirmed by pure tone audiometry on which 11 of them had mild and 7 of them had moderate sensorineural hearing loss.
Materials used during the procedure were otoscope, microscope, 1 ml syringe, spinal needle number 26G, 4% xylocaine in cotton wick, aural speculum. The patients were made to lie supine with the head turned 45° to other side and the ear to be treated facing upward. Thorough microscopic examination of the ear to be injected was done. Any debris in external auditory canal was removed. A cotton wick soaked in 4% xylocaine was inserted in external auditory canal and left for 5 min. The procedure was also performed without local anaesthesia in some patients. One milliliter of dexamethasone was loaded in 1 ml syringe and attached to a 26G spinal needle. Cotton wick removed, any remains of xylocaine solution was sucked out. The posteroinferior quadrant [5] of tympanic membrane was focussed in microscope, aural speculum was used in 7 patients. The spinal needle was then slightly bend by fingers and introduce in the external auditory canal. In all the patients 1 ml of dexamethasone was introduce into the middle ear through posteroinferior part of tympanic membrane. The patient’s head was then maintained as such for 30 min to allow concentration of drug in round window. The patients were instructed not to swallow their saliva to prevent escape of drug from Eustachian tube.
Results
After the procedure, the patients were sent home on the same day and adviced them to review after 7 days. Patient were then subjected to further doses of dexamethasone injection depending on their report. Maximum number of doses given was 4 injections. The effectiveness of this therapy for tinnitus was recorded as: 1. Tinnitus disappear, 2. Residual tinnitus present (intensity of tinnitus decreased as compare to before receiving the therapy), 3. No improvement. Table 1 summarise the total number of patients participated in the study with their corresponding result. Patients experiencing other symptoms other than tinnitus is shown in Table 2. The overall response of the patients is shown in Table 3.
Table 1.
Age and effectiveness
| S. No. | Ages (years) | No. of patients | Result |
|---|---|---|---|
| 1 | 0–20 | 11 | All = tinnitus disappear |
| 2 | 21–40 | 20 | 13 = tinnitus disappear |
| 7 – residual tinnitus | |||
| 3 | 41–60 | 5 | 2 – residual tinnitus |
| 3 – no improvement | |||
| 4 | > 60 | 4 | 1 – residual tinnitus |
| 3 – no improvement | |||
| Total | 40 | 24 – tinnitus disappear | |
| 10 – residual tinnitus | |||
| 6 – no improvement |
Table 2.
Associated factors of tinnitus and effectiveness
| S. No. | Associated factors | No. of patients | Effectiveness |
|---|---|---|---|
| 1 | Tinnitus only | 22 | 13 – tinnitus disappear |
| 5 – residual tinnitus present | |||
| 4 – no improvement | |||
| 2 | Tinnitus + impaired hearing | 18 | 11 – tinnitus disappear with improvement of hearing |
| 5 – residual tinnitus | |||
| 2 – no improvement | |||
| Total | 40 | 24 – tinnitus disappear | |
| 10 – residual tinnitus present | |||
| 6 – no improvement |
Table 3.
Overall effectiveness of the therapy
| S. No. | Effectiveness | No. of patients |
|---|---|---|
| 1 | Tinnitus disappear | 24 |
| 2 | Residual tinnitus | 10 |
| 3 | No improvement | 6 |
| Total | 40 |
Among the 40 patients who were subjected to this study, 24 patients (60%) reported complete disappearance of tinnitus, 10 of them (25%) reported residual tinnitus present and 6 (15%) of them reported no improvement.
Discussion
Treatment of tinnitus had been a frustrating situation since the ancient times. Till date there is no single modality for treatment of tinnitus which can provide complete cure of tinnitus universally. Different methods have been developed by different physician in attempting to provide a good quality of life to tinnitus patients. Pharmacological, psychotherapy, masking device, electrical and magnetic stimulation, herbal medicine etc., had been tried to various extend but none of these technique provide promising result for the control of tinnitus.
The practise of administering steroid systematically for inner earn diseases had been practised since long, but due to the potential systemic side effect, this methods of administering steroid is not an encouraging method, more so when treatment is required for long duration. The discovery of steroid receptors in inner ear and the recognition of side effects of steroid when administered systematically had led to an encouraging method of direct delivery of steroid to inner ear through middle ear by absorption via round window membrane. Drugs can be deliver to inner ear by various methods, by transtympanic injection, instilling drops through pressure equalising tube, or by raising as posterior tympanomeatal flap and placing a catheter pump near the round window with controlled releasing of drugs. Transtympanic injection is the easiest and non invasive technique of delivery of drugs to inner ear.
When the drug is infused into the middle ear it is absorb through the round window to the inner ear. The mechanism of action of this therapeutic modality is multifactorial, including anti-inflammatory effect, a metabolic improving effect, and an edema-relieving effect, which may eliminate abnormal excitation of auditory hair cells, which are believed to cause tinnitus.
Conclusion
Intratympanic injection of steroid is an easy procedure which can be performed in an outdoor procedure for delivery of drug to inner ear for treatment of tinnitus. In this series we observed that 60% of patients received complete disappearance of tinnitus. Some of those patients with associated impaired hearing along with their tinnitus problem were found to receive improvement in their hearing also. Patients who received the therapy in their early onset of tinnitus received maximum improvement from the therapy. In 15% of cases no improvement in tinnitus was observed and most of these patients who received no benefit had experienced tinnitus for long duration. Whereas in 25% of cases experience residual tinnitus even after receiving the full four dose of injection.
Compliance with Ethical Standards
Conflict of interest
The authors declare that they have no conflict of interest.
Ethical Approval
All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.
Informed Consent
Informed consent was obtained from all individual participants included in the study.
Contributor Information
Chanmiki Sayoo, Email: csayoo@gmail.com.
Satish Kumar, Email: satish.kumar07@gamil.com.
References
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