Our Approach to Tinnitus and Our Treatment Principles
Unconscious approaches to the treatment of tinnitus and non-medical practices do not result in healing. Treatments should be carried out by physicians, who are conscious and experienced in tinnitus. Physicians engaged in this subject need to closely follow scientific developments and medical literature.
Negative discourses expressed to patients unconsciously by physicians with inadequate knowledge and background about tinnitus, when they apply for medical institution for the treatment of tinnitus, worsen their state and cause them to slip into a mood of pessimism. Such attitudes and behaviors discourage people from being in search of a suitable treatment, and drive them to despair, even if they have a curable tinnitus. Such attitudes also create confusion about tinnitus and causes information pollution. For this reason, people tend to look for also alternative ways besides medical practices. From a physician's point of view, it is very important to follow the latest information in the literature. In recent years, when everything has developed in this regard, many developments related to tinnitus have been experienced and such developments are still ongoing. Nowadays, studies carried out on tinnitus in recent years have gained momentum. The different perspectives and new theories in international tinnitus books published between 2011 and 2012 have caused the studies to gain speed. These acquirements have brought many innovations to the agenda. Despite today’s abundance of new information, the subject of tinnitus is drifting into a state of chaos, due to some physicians far from the subject, who are not interested in it, and still act based on their old classical knowledge. Unfortunately, this situation creates an exact chaos and information pollution in the social media and forums in our country. We often hear statements such as "it has been defined as incurable" or "they said I would get used to live with it". Today, when everything is developing, such unreasonable approaches reflect only ignorance. These approaches drive people to despair even if they can benefit from treatments, and lead them to different ways of searching.
We are strongly against such expressions and discourses. They are definitely unacceptable. With this counter-stance, we and our working group reach success in the treatment of our patients, by closely following scientific ideas, innovations, and literature.
Who are we and what we do regarding tinnitus? :
I and my working group carry out the innovative treatment procedures intended for tinnitus, in our country. We also contribute to scientific research and development about Tinnitus. We are the working group representing our country abroad for the subject of tinnitus. This working group is a scientific-based special institution with sub-working groups and assessment boards. We make investments and carry out scientific studies in the international arena.
Approach to the patient: Our patients who consult us are first subjected to detailed screening test of tinnitus. After examinations and anamnesisstages, we request the patients to fill out 3 different questionnaires, with intent to have preliminary information about their condition. Among questionnaires, we use THI (Tinnitus Handicap Inventory), VAS (Visual Analogue Scales), and Beck Depression Inventory questionnaires before and after treatment. Afterwards, we go through the examination, diagnosis and treatment stages, respectively. The newly developed diagnostic methods and routine tests are used in the examination stage.
Examination stage in Tinnitus:
Before treatment, we carry out highly advanced examination-based studies. We use Functional Magnetic Resonance Imaging devices specifically designed for tinnitus, in such a way as to serve for neurology. With these devices, we can identify all the activities and states of the neurons at the cellular level, in the inner ear including the auditory pathways extending up to the brain We can now identify the detailed neuronal analysis and pathologies of all auditory regions including the structures in the ear, pons, cerebellum, brain, and Heschl's gyrus (auditory center in the brain). The focus of tinnitus can be identified with an accuracy rate close to 100%. The possible causes of tinnitus in other structures are also investigated meticulously. In addition, we can include advanced computed tomographic and FMRI ( Functional Magnetic Resonance) Imagings in studies. We also detail many other possible parameter examinations, and carry out scans without skipping even the finest points. Besides these examinations, high frequency auditory tests and laboratory studies can be included in the examination stage, as well. In the general sense, the treatment stage is initiated after the causes listed under the headings of objective or subjective tinnitus are clarified, i.e. after the focus of tinnitus is clearly identified.
What do we perform in the stage of tinnitus treatment?
There are many causes of tinnitus. What is important is the treatment intended for the cause. Among these treatments, many different forms of treatment are carried out, depending on the findings. The r-TMS procedure that we often perform in our treatments is included in this stage, as well. A group of patients with tinnitus respond well to the R-TMS therapy. For patients in this group, who come to us with this complaint, we initiate the treatment by considering the findings of the patient, after exactly identifying his/her tinnitus pathologies. We carry out the r-TMS (repetitive transcranial magnetic stimulation) therapy, which is considered to be one of the new treatment procedures that we choose from the variety of treatments. We assess the causes both outside of the ear and inside the ear, as well as the causes in auditory pathways, and then implement the appropriate treatment protocols accordingly. We initiate treatments and practices depending on the determined pathologies such as the disorganizations, activity deficiencies, and defects caused by the cellular degeneration in the inner ear, disruption of electro-pathological activities, or impairment of neuron fibers, in the extension of the nerve or in the inner sections of the brain. Dosages and protocols are determined by us, in accordance with the condition of the patient. The treatment carried out in 10 sessions is adjusted in such a way as not to take longer than 2 weeks, as a total period including the examination stage.
In the treatment, the plan is made in accordance with the findings of the patient. When initiating the treatment of tinnitus, it should be kept in mind that tinnitus is specific to the person. Sometimes r-TMS therapy may not be the first aim. The findings of the patient determine the shape of the treatment in this regard. % 25 of patients who consult us are subjected to different treatments or medications, while the remaining 75% of the patients are treated with r-TMS that can be carried out in conjunction with certain drug therapies. Half of the group constituting the 25%, whose treatment is initiated with different treatment procedures and medications, get into the healing process without receiving r-TMS treatment. The remaining 12% of the 25% of patients are subjected to r-TMS treatment later on, depending on the findings obtained during their follow-up. The treatment lasts 12-14 days for 75% of patients with tinnitus, whose findings have been found to be suitable and whose R-TMS treatment has been initiated immediately after their examinations. At the end of this treatment, further planning of the patient is made. The patient needs to be followed-up for a period of one year. The plan for other additional treatments depends on the state of the patient after the r-TMS treatment. Even if 10-session of r-TMS is carried out, the positive effect of r-TMS waves last for a period of 1-1.5 months. At the end of this process, the patient is reevaluated. The control examinations should be performed on a monthly basis for the first three month, and then in the 6th, 9th and 12th months. During these control periods, we determine additional treatment periods, based on the findings of the patient. This is necessary because sometimes 6-12 months are needed for the recovery of the disrupted activities of neurons. Moreover, if we consider the fact that the structures of auditory cells are weaker than that of other neurons, we can say that follow-up with patience is very important.
When the medical scientific studies and the information in the literature are investigated, it is seen that treatments with the first version of TMS devices provide a success rate of 40%, while treatments with new r-TMS devices provide success rates up to 75%. Sometimes we encounter some expressions as follows: “I have been treated with TMS device but it has not resulted in success”. Devices used before 2008, which have low therapeutic value, give unsatisfactory results when treating tinnitus. TMS treatment is a procedure carried out in also neurology and psychiatry, besides the treatment of tinnitus. It should be kept in mind that classic TMS devices, which are the lower version devices, give inadequate performance and results in the treatment of tinnitus. The real TMS device required to be used in the treatment of tinnitus is should be repetitive (r-TMS). The way of carrying out the r-TMS procedures including the dosages, duration, and frequencies are very important. It plays a role in the success of the treatment. In other words, the treatment should not be carried out unconsciously. In our country, we witness applications performed casually and unconsciously. As in all other diseases, treatments carried out blindly cannot be expected to result in success. A conscious disciplinary approach is required to be successful in the treatment of tinnitus, and this is very important in r-TMS treatment. It would not be wrong to say that we are the only unit working consciously with a disciplinary approach in our country.
How is the therapeutic value of r-TMS in the treatment of tinnitus?
R-TMS treatment has a success rate of up to 65% -70%. This means that 6.5 or 7 of every ten patients with tinnitus will recover from it, while 3.5 or 3 patients will not be able to recover from it. It should not be noted that there is also a possibility of failure in the treatment. However, it is a fact that it is considerably superior to classical treatments in terms of therapeutic value. The therapeutic value is extremely lower in classical treatments. A maximum result of 1-5% was obtained with classical treatments, while in 65-70% of patients treated with r-TMS, from whom successful results have been obtained; the initial results were as follows: The tinnitus either completely disappeared or significantly diminished. 100% success can be obtained with the treatment; and on the other hand, the reduction rate can be between 50-90%. The reduction does not mean that it will never disappear completely. 100% cure can be achieved in the course of time. New treatment plans can be made and additional treatments can be carried out accordingly during the follow-up periods. Almost complete results are usually obtained within 3 months. Sometimes full treatment periods may last up to 8 months. This can be caused by the slowness of the response of the deterioration of the neurons to the healing, and the state of the damage in the patient. For this reason, patience is very important in the treatment of tinnitus. If even a minimum treatment value could not be obtained despite all the effortsat the end of the six-month, the treatment is considered to be unsuccessful and is terminated.
How are the results of treatment followed-up in tinnitus?
If tinnitus is considered to be a subjective finding, certain scales and surveys are needed for evaluation. Sometimes the patient forgets how his/her condition was at the beginning of treatment, and easily adapts to his/her improved condition. Such things are known facts observed in tinnitus studies across the world. In other words, the patient sometimes has difficulty in showing a clear rate when the healing is questioned. Therefore, the tinnitus status of the patient is objectively evaluated with multifaceted international valuation forms. The evaluation forms we use are the forms taken as a basis for medical studies on tinnitus. A multifaceted evaluation allows for understand the patient better. We use THI (Tinnitus Handicap Inventory), VAS (Visual Analogue Scales), and Beck Depression Inventory questionnaires before and after treatment. We obtain information about the healing their condition.
The control examinations should be performed on a monthly basis for the first three month, and then in the 6th, 9th and 12th months. During these control periods, we determine additional treatment periods, based on the findings of the patient. This is necessary because sometimes 6-12 months are needed for the recovery of the disrupted activities of neurons. Moreover, if we consider the fact that the structures of auditory cells are weaker than that of other neurons, we can say that follow-up with patience is very important. For some patients with tinnitus, who have a very severe pathology, the follow-up period can last up to 2-3 years. After 1 or 1.5 years, patients who have recovered from tinnitus are requested to take a FMRI test again for comparison. Thus, the findings of change can be observed objectively. Of course, this is limited to the possibilities of the person. Our patients usually do not take a second test after recovering from their diseases.