Tinnitus is perception of sound where there is none

Just a few days ago, British newspapers reported that a rock fan committed suicide to relieve tinnitus that he had for 3 months after a supergroup's gig. Tinnitus is characterized as perception of sound where there is none. Read more about tinnitus in this blog post. The Cleveland Clinic Journal of Medicine recently published a review on Tinnitus: Patients do not have to ‘just live with it’ and Tinnitus relief: Suggestions for patients.



From NHS Choices YouTube channel: Tinnitus causes people to hear constant sounds in one ear, both ears or in their head. An audiologist explains the possible causes and effects it often has, such as stress and anxiety, plus how to deal with them. Ashleigh, who was diagnosed with tinnitus in 2005, describes how she copes with it.

Lars Ulrich, the drummer for the heavy metal band Metallica, also struggles with tinnitus and warns his fans that "once your hearing is gone, it's gone. I've been playing loud rock music for the better part of 35 years," said Ulrich, 46. "I never used to play with any kind of protection."

Early in his career, without protection for his ears, the loud noise began to follow Ulrich off-stage. "It's this constant ringing in the ears," Ulrich said. "It never sort of goes away. It never just stops." This is a classic description of tinnitus, a perception of sound where there is none (phantom ear sounds).

The military is generating a tremendous number of tinnitus patients, according to a recent CNN report on the problem.

Tinnitus differential diagnosis: Q SALAMI mnemonic

Quinidine

Salicylates (aspirin)
Aminoglycoside antibiotics (ABx)

Labyrinthitis
Acoustic neuroma, CN VIII
Meniere’s disease
Increased blood pressure (BP) (HTN)

References:

Metallica drummer struggles with tinnitus: "Once your hearing is gone, it's gone"
Metallica drummer struggles with ringing in ears. CNN.

Tinnitus: Patients do not have to ‘just live with it’. CCJM, 2011.

Tinnitus relief: Suggestions for patients. CCJM, 2011.
Rock Fan Commits Suicide to Relieve Tinnitus From Supergroup's Gig: Daily Mail and Fox News.
Noise Chart as It Relates to Hearing Damage and Hearing Loss http://goo.gl/tjZh1

There are patients with "gluten sensitivity" in whom neither allergic nor autoimmune mechanisms can be identified

There are 3 main forms of gluten reactions:

- allergic (wheat allergy)
- autoimmune (celiac disease, dermatitis herpetiformis and gluten ataxia)
- possibly immune-mediated (gluten sensitivity) ("non-celiac gluten sensitivity" or NCGS). We need to be extremely cautious in calling somebody gluten sensitive. It may be sensitivity to FODMAPs instead. It could have nothing to do with gluten at all. http://buff.ly/1k2UjNW

Celiac disease is the most common genetically based food intolerance (1% prevalence among general population) (JAMA 2014, http://buff.ly/1cJWgFy).

From BMJ:

It is now becoming clear that, besides those with celiac disease or wheat allergy, there are patients with gluten sensitivity in whom neither allergic nor autoimmune mechanisms can be identified. It has been estimated that, for every person with celiac disease, there should be at least six or seven people with non-celiac gluten sensitivity. Gluten sensitivity may therefore affect 6-10% of the general population.

Patients with gluten sensitivity have negative immuno-allergy tests to wheat and negative celiac disease serology; normal endoscopy and biopsy; clinical symptoms that can overlap with those of celiac disease, irritable bowel syndrome, and wheat allergy; and they show a resolution of symptoms when started on a gluten-free diet.

Currently there are no laboratory biomarkers specific for gluten sensitivity, and the diagnosis is based on exclusion criteria; elimination of gluten-containing foods from the diet followed by an open challenge is most often used to establish whether health improves with the elimination or reduction of gluten from the patient’s diet.

New nomenclature and classifications are proposed (see the figures below).



"Fibromyalgia of the gut"

Some physician have labeled "gluten sensitivity" "fibromyalgia of the gut" to reflect the presence of symptoms in the absence of pathological findings. The BMJ editor-in-chief reflected on these doubts in an editorial: Gluten sensitivity: real or not?.

Since there are no biomarkers, gluten sensitivity is the ultimate diagnosis of exclusion. The worldwide shift to the Mediterranean diet may explain the rising prevalence of gluten sensitivity. The has been an “explosion of requests” for serological testing for celiac disease since 2007.

3 million Americans are living with celiac disease

Celiac disease, an immune system reaction to gluten in the diet, is four times as common today as it was 50 years ago. Lack of awareness of celiac could be contributing to a delay of up to 11 years in diagnosis of adults in North America (http://goo.gl/sy778).

This is an informative and beautifully designed video by the University of Chicago Celiac Disease Center. It looks like an infographic made into video - have a look:



New classification is being proposed for gluten-related disorders: celiac disease; dermatitis herpetiformis; gluten ataxia; wheat allergy; gluten sensitivity. WSJ, 2012.

Recent studies support the existence of the new condition nonceliac gluten sensitivity which is defined as symptoms with negative celiac antibodies and biopsy (http://goo.gl/57IlB).

References:

Non-coeliac gluten sensitivity | BMJ, 2012.

Gluten sensitivity: real or not? | BMJ http://buff.ly/ZgKgK1

Does gluten sensitivity in the absence of coeliac disease exist? | BMJ http://buff.ly/RvC7zg

New nomenclature and classification of gluten-related disorders - http://www.biomedcentral.com/1741-7015/10/13/figure/F1

Algorithm for the differential diagnosis of gluten-related disorders, including celiac disease, gluten sensitivity and wheat allergy - http://www.biomedcentral.com/1741-7015/10/13/figure/F4

Spectrum of gluten-related disorders: consensus on new nomenclature and classification. Anna Sapone et al. BMC Medicine 2012, 10:13 doi:10.1186/1741-7015-10-13.

Image source: Colon (anatomy), Wikipedia, public domain.

Disclaimer: I am an Assistant Professor of Medicine and Pediatrics at University of Chicago.

Comments from Google Plus:

Neil Mehta: thanks for sharing this. Besides the content itself, Really like this type of articles where a patient can write about medical lessons learned. 


Howard Luks: That's me :-) thanks for sharing this! My GI guy will see it in the AM 

Tinnitus is perception of sound where there is none: what to do?

Tinnitus is perception of sound where there is none

Tinnitus, a common symptom, is defined as the perception of noise in the absence of an acoustic stimulus outside of the body.

In 2011, British newspapers reported that a rock fan committed suicide to relieve tinnitus that he had for 3 months after a supergroup's gig. Tinnitus is characterized as perception of sound where there is none.

The Cleveland Clinic Journal of Medicine published a review on Tinnitus: Patients do not have to ‘just live with it’ and Tinnitus relief: Suggestions for patients.

From NHS YouTube channel:



Causes of tinnitus

- idiopathic
- sensorineural hearing loss is the most common identified cause
- otologic, vascular, neoplastic, neurologic, pharmacologic, dental, and psychological factors

More serious causes, such as Meniere disease or vestibular schwannoma, can be excluded during the evaluation.

Tinnitus is a common medical symptom that can be debilitating.

Risk factors include:

- hearing loss
- ototoxic medication
- head injury
- depression

At presentation, the possibilities of otological disease, anxiety, and depression should be considered.

Diagnosis

Almost all patients with tinnitus should undergo audiometry with tympanometry, and some patients require neuroimaging or assessment of vestibular function with electronystagmography.

No effective drug treatments are available. Surgical intervention for any otological pathology associated with tinnitus might be effective for that condition, but the tinnitus can persist.

Available treatments include:

- hearing aids when hearing loss is identified (even mild or unilateral)
- wide-band sound therapy
- counselling

Cognitive behavioural therapy (CBT) is indicated for some patients. The evidence base is strongest for a combination of sound therapy and CBT-based counselling.

Metallica drummer struggles with tinnitus: "Once your hearing is gone, it's gone"

From CNN: "I've been playing loud rock music for the better part of 35 years," said Ulrich, 46, drummer for the heavy metal band Metallica. "I never used to play with any kind of protection." Early in his career, without protection for his ears, the loud noise began to follow Ulrich off-stage. "It's this constant ringing in the ears," Ulrich said. "It never sort of goes away. It never just stops." It is a condition called tinnitus, a perception of sound where there is none. "I try to point out to younger kids ... once your hearing is gone, it's gone, and there's no real remedy." The military is generating a tremendous number of tinnitus patients."

References:

Tinnitus : The Lancet http://bit.ly/1aAsa9E Diagnostic approach to patients with tinnitus. [Am Fam Physician. 2014] http://buff.ly/1ggzRox

There are 25,400 scientific journals and their number is increasing by 3.5% a year

More scientific and medical papers are being published now than ever before. Is it possible to be an expert nowadays, asks BMJ.

Every doctor has an ethical duty to keep up to date. Is this just getting more difficult or has it already become impossible? Since Alvin Toffler coined the phrase “information overload” in 1970, the growth of scientific and medical information has been inexorable.

There are now 25 400 journals in science, technology, and medicine, and their number is increasing by 3.5% a year; in 2009, they published 1.5 million articles. PubMed now cites more than 20 million papers.

One response of the medical profession to the increasing scientific basis and clinical capacity of medicine has been to increase subspecialisation. This may restrict the breadth of knowledge of the ultraspecialist, but can such subspecialists still maintain their depth of expertise?

I described my approach in 5 Tips to Stay Up-to-Date with Medical Literature:

1. RSS Feeds for Medical Journals.

2. Podcasts.

3. Persistent Searches on PubMed, Google News and Google.

4. Text-to-speech (TTS) for journal articles.
5. Blogs and Twitter accounts.

If you have a blog or Twitter account, you can try to deal with the information overload from blogs, RSS and Twitter more efficiently by using this:

The circle of online information (click to enlarge).

References:

On the impossibility of being expert. BMJ 2010; 341:c6815 doi: 10.1136/bmj.c6815.

How to deal with the information overload from blogs, RSS and Twitter?

5 Tips to Stay Up-to-Date with Medical Literature
The scientific journal through the centuries - a little bit of history from Health Librarian (HL) Wiki http://buff.ly/WZqP2S

Comments from Twitter:

MediaMed @MediTwitt: Isn't it too much? @DrVes: 25,400 scientific journals and their number is increasing by 3.5% a year buff.ly/OxDvev

Anand Segar @drsegar_nz: that is crazy. Totally unnecessary.