Tinnitus Q & A 02/2016 Pt 2/4

right may I see that and here yes so which so we're looking on looking on page 15 here in the lower right section beginning with the highlighted word gabapentin and so it's it's a summary of the research paper numbered 8 so some doctors have reported the gabapentin has been at some benefit to that and it is patient but is known to patients but it gabapentin is known to have many side effects and it can only be used in very low doses there has already been research in which gabapentin given in tablet form has been combined with lidocaine a local anesthetic this is the same thing I've mentioned if injected can eliminate tinnitus but there's just no feasibility for sustained treatment with that lidocaine injected in directly into the middle ear so there's been research into tablets of gabapentin and lidocaine direct directly injected into the ear so pertaining to the present study Italian researchers combined gabapentin with lidocaine injections given just under the skin 72 patients were randomly allocated to receive gabapentin only gabapentin plus lidocaine or a placebo treatment this was six weeks the injections were given four times over that period the improvement in tinnitus tinnitus handicap inventory scores was significantly higher in the gabapentin group than in the control group and those in the gabapentin plus lidocaine group did significantly better than those receiving gabapentin alone but yes concludes with much more research is needed to it to put an initial and very and very small study that's another one for me – another one for me – that's a fairly recent one to add add to the list you know any such study is a very promising lead if we get replication of results in additional studies or larger studies that's particularly encouraging unfortunately there are always many there always many reasons any single study cannot always deliver on the benefits that's hoped for sometimes random chance there's a phenomenon called publication bias where studies are much more likely to be published if they deliver positive results than negative results so what we see in the literature is not always a fair reflection but the these are these are drugs with some track record of usage in tinnitus as a rationale for my they why they might work so this is another another space to watch alongside looking for harmful effects of gabapentin as well or whether there's even a split with benefits and some people and paradoxical triggering and others it's seems unclear at the moment but thank thank you for thank you that I've always been surprised that benzodiazepines have been used to help to this because it's my understanding that these drugs are highly addictive in insufficient doses for sufficiently long periods of time they are they are addictive so we wouldn't normally give high dose benzodiazepines for any indication if avoidable for more than say three weeks there are many conditions for which we use long term low dose benzodiazepines everything from epilepsy through to sleep disorders and and other conditions so that some movement disorders so that in in the lower doses we don't we don't in modern practice we don't tend to find much for a problem I know historically there have been terrible problems with benzodiazepine addiction when high doses were given out very readily for a wide variety of indications and actually one of the colleague who have worked with Heather Ashton at Newcastle University who's very big on benzodiazepines she she first found out of it you know came across tinnitus as a phenomenon that was being reported time and time again in people with this benzodiazepine withdrawal syndrome this is consistent of course that something might treat a symptom and withdrawal might actually from high doses might produce the symptom again these are gaba acting drugs as that's the prime primary action so they have a blanket inhibitory effect hence sedation and here the effects effects on muscle activity pain or a wide variety of things but I think I think the trialing of low doses is very reasonable as a rationale to think you think these drugs might work I gather as with many things the evidence has not been for as much benefit as one as one might hope for but as I say there is there is some evidence of benefit low doses of clonazepam etc so I suppose the conundrum facing many doctors looking after people with tinnitus and many patients making decisions about what treatment would like to receive is you know whether to try something that has a bit of evidence that it might work some potential side effects but a financial benefit and I think you know if approached cautiously in sensible doses with discussion of doctor and patient there there's I can't see any good reason not to try these things and tinnitus is in its effect a symptom and when treating symptoms some sometimes you just have to try as long as it's not something that's going to cause permanent harm sometimes try a thing and decide on balance after a period are you better on it or offense and if you're on it long term and you're not sure the other thing to do is sometimes try coming off it for a period see what happens and if and if things are worse back on it and if better I think all of this sometimes speaks to the surprising surprisingly unscientific nature of modern medicine at times that although they've been fantastic advances but you know much of from a doctor and patients point of view much of things is an art and a craft and a sort of you know a journey patient and doctor take together and feeling their way with something until until it's really solid evidence to you know to guide us more strongly than that I would just like to see you sometimes I go on diazepam when it starts to stress us out in our static good signs of panic attacks I go on it for a week at 15 milligrams a day and that seems to settle it down for a couple of month and I'm just on it a week and I don't get any other side Effects I get it and she gives us it with a sleeping tablets up lakorn for a week and it it seems to do wonders for me like I just wonder how long okay so I'm I mean as a neurologist gabapentin is one of the medications I prescribe most frequently of all for a number of indications it's it's not thought to have any sort cumulative or long-term harmful effects in in general so I don't think there's you know unless it's causing it unexpected idiosyncratic side effects or anything like that barring my previous discussions about causing tinnitus potentially but in general if it's not provided presenting intolerable side effects like sedation or weight gain difficulties concentrating or anything I I would say there's no particular time limit I'd there should be no harm to come from from prolonged use it it's a medication that's been around a long time so by this kind of stage we have a fair bit of long-term data and if if there were long long-term health risks we would we would probably know about them by now so it's not something I would worry about either you know a family member a patient or anything being on long term if it if it was tolerated okay and doing any good I would not have qualms about that personally yeah and so the point was there's a bit of a worry cuz the GP is obviously had to look after a great many things and yet he was just expressing that an amount of relief and just saying that no disrespect to GP is that you don't always have the greatest confidence that gp's have an in-depth knowledge of all of these things so I don't I'm not sure I absolutely do either but certainly it's not something in Neurology that we we worry about as a as a long term that actually we prescribe a lot of its actually I'm about to say before that I do have another meeting later and so I would if I do slip out at the end please don't think I've been rude sir William – thank you going back to your original point about the early intervention in tinnitus no that's the first time I've heard that really mentioned from the medical people and I think that yeah there's definitely something there I remember the last time I looked into this that NHS are very proud they'd introduced a new regime then the view of the fact that they would aim to see that his patients in audiology in 16 weeks and they were really proud of that but if you're just starting off 60 weeks is an awfully long time to get and that's not the tinnitus therapy that's just to get to audiology the the thought would be that if you if you accept that the the the problem is the conditioned response to the sound there's and a very negative reaction to what they're experiencing and fear and uncertainty very quickly this anxiety this negative reaction builds up and the thought would be that if as you say you could get in early where they say if it was possible within 24 hours and start very early Samba therapy I mean I don't know about medication but in terms of reducing this reaction if you can get in there before it becomes too severe the thought would be that this would be very beneficial to dually presenting clients I'll just respond to that and then I'll come on – on to you as well I'm really interested for your views there because I very much agree in and I think it it really is important to emphasize at least two strands to the benefit that might be achieved by early intervention and you know bit anything about an early drug effect is speculative worth looking up as speculative but yeah there is I'm sure as you know many of you will know and many people with tinnitus experience citizen – the pointers often the Nohr that there can be a huge huge snowballing of anxiety and additional attention to the tinnitus particularly when it first starts and we do see that the natural history of tinnitus is that it's at its most distressing generally early in the course and then there's a normal for the majority of people certainly not everybody a process of a degree of habituation which for many people is complete to the point where they're no longer bothered by it for many people signifies a reduction in a reduction in the distress associated with it and then a few unfortunate people who who don't have it you eight or who continue to build continue to continue to build this sort of escalation the additional anxiety attention much of Munim a great deal of which is outside of conscious control probably but processes going on subconsciously that we have very little influence over so I think it would be hugely beneficial and you know again this is something that one could could potentially produce evidence for see is is there a benefit to an even early counseling reassurance information early exercises such as some you know very simple forms of tinnitus therapy relaxation therapy sound therapies and anything to just gain a bit of control in the early in the early sense another thing I'm very very keen to keen to pursue is actually seeing how many of people who get about of tinnitus because a lot of people will get and probably many of you have experienced you may have had transient tinnitus for an hour and you know five minutes an hour a day at some point previously maybe after loud noise exposure or something so it's it really really critical to see actually what proportion of people who do get a bout of tinnitus severe enough and long enough to look online to get plugged into these kind of services that we're hypothetically talking about what proportion of them then go it does this turn into a chronic problem then if it's a high enough proportion and there's something that can be done to prevent this transition to chronic tinnitus then this is huge but the the weight of evidence needed to support such a thing will be considerable because we're talking about a big big shake-up of medical service organization for this now I think this you know it may be the case that in future this is where things go and for the time being I want to see actually is is there mileage in this and I was always struck by the fact that there doesn't seem to be a lot of interest in this so from my point of view my plan is to is to start start amassing this data one bit question is actually is that can we even get people within within this time frame into a setting where where we can see them are people are people looking online consulting their GPS getting some way into the system where they where they can be picked up like this and I I would hope a great many it's it's yes but it remains to be seen can we get people you know can we get people in can we get them in early and then what's the natural history and then is there an intervention that helps so that I think this is a fantastically interesting and useful question and I just don't know what the answer is and I'm you know keen to pursue this in tandem with trying to look at more at chronic tinnitus as as I have been doing doing previously made up place to work in the ENT the Fremen when I asked him about hey just poop wish near tape race near tape I totally get old him he never gives any sort of advice if we if we get people to the BTA that's the key because that's where they reliable and sensible information is the trouble is within the first 24 hours if they get this they will Google and we all know how many hundreds of thousands of false leads and very upsetting leads there are on Google before they hit the BTA website so that and the sort of reaction that you're describing alan obviously you can see that although it was inadvertent that type of reaction tends to add the anxiety and the early stages rather than what you're suggesting william is to get in some there would be fairly quick i agree i'm judith you had a point before that you I'm sure you were just gesturing for the mic before we got on to this topic do you still have a question I wish well if you read the quiet magazine quite often these pop stars say all you know they have the tinnitus as you see for a few hours and then sometimes it stays so I think doing it that way would obviously get a lot of people who got better but what I was gonna say was when I started with tinnitus I lost the hearing in my right ear as certainly over a few G's and I was a lip reading teacher so and you a little bit about things like tivities and then a few days later the tinnitus started and I couldn't decide whether the hearing loss was more of a problem other challenges because the hearing loss was only a problem when I wanted to hear people where the tinnitus that side was the problem 24 hours a day and then and now I just forget it mostly I'm glad I'm glad to hear that and is do you come here as a source of social social exercise and out of interest and and that sort of thing now to help other people and you know and that and that's really not to be underestimated actually because it is easy for support groups to be a concentrating effect on on people who are particularly struggling or in a bad place with with any particular condition and I think well I can't I can't speak for anyone else I imagine it's probably really helpful for people who are struggling to see meet someone who said well I was really struggling and actually well you know overt I you know over time whether it be cuts water under a bridge or some part of your brain just gives up you know so that holders hands up and says I can't be bothered to be bothered about this anymore or something yes there's been a lot of interest in this and I think the short answer is no one has ever demonstrated tinnitus with truly normal hearing so when if you a standard hearing test well I'll backtrack there are in the air at any given frequency there are low threshold fibers so they fire very easily it only takes a little bit of noise to make them fire and high threshold fibers that are only activated by very loud sounds and you you might you might think that the low threshold very sensitive fibers are very easily damaged because they're so sensitive but actually we are evolved that in such a way that those fibers are going to be active for very long periods very large parts of the day and they're quite resilient to noise overexposure to long periods of moderately loud noise the high threshold fibers in you know in a caveman hunter-gatherer type of society will only ever be activated for very short periods of time because loud sounds general generally are not enduring like that and these fibers are actually quite sensitive and if you stimulate them for long periods loud noise occupational exposure etc then they just start to die of exhaustion and you know the two waves of hearing loss and tinnitus we've seen we're seeing so that we're on the down slope of the occupational hearing damage and we're on the upslope of the recreational noise iPods concerts and everything all of these types of things will selectively damage the high threshold fibers more than the low threshold fibers and it's the low threshold sensitive fibers that are what's picked up on the hearing test measuring the quietest sound you can possibly hear and now there are there are tests that look at your the integrity of the high threshold less sensitive fibers and they measure things like your ability to hear one sound in the presence of another background sound etc and when those tests are done on people with tinnitus actually there are abnormalities so probably what we're seeing is a in milder cases a selective loss of a certain fiber type that the standard hearing tests aren't picking up and then in case there's a more extreme hearing loss damage to all the fiber types including the low threshold ones and that's when you have there you know abnormal audiogram so the short answer is we think everyone with tinnitus probably has some amount of hearing loss but then there's the massive question of why do some people are great many people with hearing loss not get tinnitus why do only some people get it and I think this is a really interesting question I have some theories which I think I talked a little bit about last time I which I don't know if people are interested to hear reiterated or I'm getting some nods okay so I my personal theory is that if you're hearing is damaged there is it gives rise to spontaneous noise as in random firing within the auditory pathway whether that's the damaged hair cells themselves firing randomly or the next relay station or the next relay station due to the hearing loss and that that's normal when you damage a system if the hearing if the hearing is damaged the brain will turn up the gain or the dial to amplify things to compensate and that amplifies the random firing so there's this noise random signal coming coming from low down in the auditory pathway or the ear in anybody with hearing loss in fact in anybody at all but much more so in anybody with any hearing loss and the brain is brilliant at tuning irrelevant things out we are any any of us at any time is being bombarded with sensations from all our organs every point of our skin is sending signals every part of our retinas every fiber in our ear everything's sending some signals every all our internal organs everything and we we are not aware of most of these because our brain before anything reaches our radar it's it picks up on what's important and amplifies it and it picks up on what's irrelevant and it filters it out and I think what's happening is in the most cases and the normal case is the sound that becomes tinnitus should be filtered out because it is it is irrelevant it doesn't contain any information it doesn't relate to anything else in our surroundings it doesn't it shouldn't it has no beneficial effect on our behavior or survival but there's something happens to allow the brain to pick up on this to amplify this at the is that the brains idea of the importance of this signal it the strength of representations and many people describe many people describe tinnitus coming on at the time of the damage to their hearing but often it's much later at the time of a particular stress either a physiological stress psychological stress worrying time something that puts you on high alert mode where the brain is in the mode of detecting threats because it's worried whether or not that's inside or outside of our control and once we're worried and once we're looking for threats we start to notice a lot of things we wouldn't normally pick up on and I think this sort of pre tinnitus signal is one of those things and that once you pick up on it once you notice it's there as soon as it starts to take on any importance once you react to it oh it's there what's this sound is this a worry it's my hearing damaged have I got a brain tumor as soon as you start to think about it that's it it's got important so it's it's changed from being something with no relevance to something with relevance once it's got the relevance you know you can't just tell your brain to forget something and I used the analogy of a picture with a lot of black and white splotches last time and when you look at it you know two black-and-whites lods bludgers but after a while it clicks and you got oh it's a Dalmatian dog standing under a tree with like like going through the tree and everything and yes I can see the dog once you've seen the doc you can't unsee the dog and you can see that pit you can never see it you could see that picture ten years later and instantly it's right there you can't you know once you make sense of the chaos and the the noise and everything your brain won't learn it and I think that's the problem here once you've registered the tinnitus once you've seen the dog that's it you can't unlearn it or maybe you can maybe there's a minimum amount of time it has to happen for going back to the theories of early intervention maybe there is a window in which it can be reversed when it hasn't really set in stone but beyond which it sets in so maybe now this is theory and you know it love to produce more evidence on the subject you

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