Miroslav Prochazka, M.D. Private Rehab Clinic Jarov, Prague, CZ

tusita@mbox.vol.cz

 

Abstract

Our paper on therapy of tinnitus through comprehensive rehab treatment including application of therapeutic laser (LLLT) has become in a certain way "a classical stuff". It was for the first time published in Laser Paertner Clinixperience No. 4/2000, and its conclusions have been quoted in numerous other studies. It has been presented on domestic as well as on international congress platforms. Let us present some interesting cases in order to enrich rather dry language of figures, for case histories have always been more pleasant to read, leaving in the minds of many of us a better memory trace than statistics and diagrams can do...

 

A Typical Case

Patient V. S. , born 1966. First examined in April 2000 when visiting our clinic due to several-months lasting tinnitus in his right ear. He had not been able to determine the incitory stimulus explicitly, indicating possible connection to a dental surgery (surgical op extraction of left molar tooth) followed by rather a long abuse of antibiotics. A possible ototoxic effect of this therapy cannot be excluded. The operation must have been performed under local anesthesia, and local or total anesthesia often appear as a possible trigger momentus of tinnitus. Frequent mesotitis in his childhood, with no significant lateralization, may also be worth mentioning in the patient`s anamnesis. An acoustic trauma was rejected by the patient. Other anamnesic data revealed no remarkable details. The sound was described by the patient as a continuous rustle, non pulsing, changing its intensity or its pitch sometimes. ENT examination revealed no extraordinary pathology within the specialty, medication with Betaserc, dosage 0-1-0 at the time of the introductory examination with no major effect.

Objective finding revealed no major pathology in neurological as well in general otoneurological examinations. Frequent functional blockages of C - Th passage and proximal Th spine. An interesting finding was a minor hypertonus of masticatory muscles (anamnesis!), slightly blocking even mouth opening.

We have added a Gingko Biloba preparation to the medication - Tanakan 1 - 0 - 1. Simultaneously, a comprehensive rehab therapy with mobilization of acute blockages, DD currents aimed at C - Th, therapeutic exercises focused on training of ease of distal neck area were performed. We have also added activities aimed at masticatory muscles (training of poptizometric relaxation activities). Simultaneously with this rather "classical" rehab therapy, LLLT was applied on the right ear, on procesus mastoideus - directing the beam to the contralateral orbit - 90 J/cm² with continuous beam and 45 J/cm² pulsed in 5 Hz. Furthermore, during one session, LLLT was applied on meatus acousticus externus - in the direction of the axis of the duct - 50 J/cm² with continuous beam and 25 J/cm² pulsed in 5 Hz frequency. Above mentioned irradiated dosages we consider minimum and we never apply lower values! These dosages can only be applied, with regard to bearable time parameters for both the patient and therapeutic staff, with a probe with a higher output - we ourselves use probes with 300 mW output power. Obviously, it is necessary to work with an IR wavelength probe (830 nm). Patient`s visits were twice a week.

Even after the first series of 10 procedures the patient was practically without tinnitus, starting from August 2000 he was left with only a "maintenance" dosage of Tanakan, 1 - 0 - 1. After a longer abuse of Tanakan temporary upper dispeptic complaints appeared and therefore the dosage was reduced to 1 - 0 - 0. Further checkups were agreed as necessary.

The patient visited our clinic in January 2001 when tinnitus in the right ear appeared again, probably with the trigger momentum in endured virosis. At this time numerous functional blockages of distal C vertebra dominated and after their mobilization, and practically immediately after the mobilization, tinnitus was reduced to minimum intensity.

The patient was kept on Tanakan medication with dosages "titrated" by himself according to his needs (1 - 0 - 0 every other day, up to 1 - 1 - 1when complaints increased).

Patient`s last check up was realized on November 8, 2001. He was without tinnitus for a long term, being very satisfied with the effect of the therapy and having no medication for long.

 

The Case of a Miraculous Healing

Patient B. R., born 1914. He sought our clinic due to several-months lasting tinnitus in July 2001 for the first time. He had not been aware of the incitory stimulus. However, there was rather an interesting detail in his anamnesis on a noise burden - the patient was an active participant of the Second World War in the UK, serving his duty as an aircraft mechanician. He had been followed for several years with a chronic obstructive broncho-pulmonary disease, medicated with Bromhexin and Ventoline, no other serious illness, no other medication. ENT examination revealed no organic pathology in terms of the specialty. Medicated with Betaserc in order to mitigate the intensity of tinnitus from high intensity, when he could not even sleep, to lower intensities, more bearable although mutilating his daily activities and quality of life. Tinnitus not found lateral, being described as a hissy phenomenon, sometimes with the feeling of pulses in the rhythm of heart activity.

Objective finding shown a neurologic condition in accordance with the age of the patient, no grave pathology, no pathology in the sense of an otoneurologic examination. The anamnesis might suggest a possible partial ethiology in terms of affection of arterias vertebrales, however directed examinations with no pathology (Hautant`s test modified by Lewit, de Kleijn`s test). Blockages of distal C vertebra and C-Th passage mobilized with a gentle maneouvre.

Our therapy: Due to the age and the anamnesis of a chronic obstructive broncho-pulmonary disease we rather excluded medicamentous therapy, and dealt with physiotherapy only. It consisted of gentle soft and mobilization techniques aimed at distal neck and instructions of therapeutic exercise in proportion to the age. LLLT applied in parameters identical with the above mentioned case history (i.e. IR 300 mW probe, application on processus mastoideus and meatus acousticus externus, CW and frequency modulated in 5 Hz, total dosage of 120 J/cm² irradiated on each ear).

Practically after the third procedure the patient was free of tinnitus, this condition found during a check up in September 2001 when the treatment was finished.

 

The Case of a Therapeutic Failure  

Patient J. K., born 1985. First examined in April 2000 after being forwarded by an ENT specialist due to several days lasting tinnitus in the right ear, with hypacusis verified by an audiogram. The incitory stimulus was unequivocally an acoustic trauma, complaints had appeared directly after a visit to a noisy discotheque. Medicated by an ENT specialist with Betaserc, with no remarkable effect. Other anamnesic data not interesting, never before having being seriously ill.

Objective finding without a neurologic pathology, minor blockages of distal C vertebra and C - Th passage mobilized.

We have started the whole of the comprehensive therapy - Tanakan 1 - 0 - 1 added to medication, DD currents on C - Th passage applied as physiotherapy, instructed in therapeutic exercise aimed at ease of the distal C vertebra and C - Th passage. LLLT applied on his right ear identically as in the cases of the above mentioned patients.

After a series of 10 procedures with practically no effect, another series of procedures repeated after 8 weeks with no effect either. Subjective complaints of the patient lasting despite of continuing therapies provided by us as well as by an ENT specialist, practically with no dynamics.

 

Subjects for Discussion

1. There is an interesting "age paradox" of tinnitus patients. On the basis of our years-lasting clinical experience we dare to say that higher prospects of success can be reached with older patients rather than with patients in younger age categories. Identical clinical experience have been also confirmed by foreign colleagues (Wilden, Ohshiro). In older patients the ethiology of tinnitus is often based on multilayered interspersion of different factors with significant roles of vascular (positive effect of vasoactive medication, in case of gingko preparations also with a good nootropic potential) and vertebrogenous pathologies, as well as with the pathology of the initial auditory apparatus. Each of these layers can be reliably therapeutically affected, thus diminishing at least a respective part of subjective complaints. On the other hand, in younger patients suffering from tinnitus organic defects of the initial structures of the inner ear must be obviously expected, very often even as a result of an acoustic trauma (hobbies!).
2. We must not be affraid of therapy of patients in higher age groups. We reject the sentence: "Your tinnitus is connected with your age, and you should get used to it."
3. The significance of acoustic trauma as of a prognostically disadvantageous factor in patients with tinnitus must lead to acceleration of importance of prevention. Nowadays we live in the age of noise, noise creating in urban areas practically a steady background. Numerous hobbies and free time activities of our patients are, from the point of view of noise burden, particularly unfortunate.
4. It is necessary to stress the significance of a serious gathering of anamnesic data as well as of a proper clinical examination. Even now, when potentials of diagnostic devices have been improved very much, standard techniques has lost none of their importance. Should there appear a discrepancy between examination by devices and clinical picture, let us believe in the clinics and better use diagnostic devices once more.
5. Interdisciplinary co-operation of physicians of different specialties appears to be a big benefit for the patients. Recently a group of specialists with an intensive interest in the issue of otoneurological (or neurootolocical) diseases, especially vertigo and tinnitus, has shaped up. There is growing interest in congresses devoted to this issue among physicians and GP`s. No wonder. In no case it is only a marginal issue for tinnitus, if only as an episode, is experienced by more than 80 per cent of population over the sixth decade of age. Vertigo, if only in a form of balancing/positioning complaints can be a problem of the majority of this population. Interdisciplinary co-operation appears to be for patients really very beneficiary.

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This paper is dedicated to our patients - no one of us, healthy ones, can never conjecture what a suffering the life with tinnitus can be. Perhaps these few interesting case histories can make us contemplate.

Tinnitus treatment - application of LLLT on procesus mastoideus