Romanian Neurosurgery | Volume XXXII | Number 3 | 2018 | July - September  DOI: 10.2478/romneu-2018-0062 Article Tinnitus after traumatic brain injury: an overview B. Ushasree Reddy, Ranabir Pal, Amrita Ghosh, Luis Rafael Moscote-Salazar, Vishnu Vardhan Reddy, Amit Agrawal INDIA, COLOMBIA      Romanian Neurosurgery (2018) XXXII 3: 487 - 490 | 487             DOI: 10.2478/romneu-2018-0062 Tinnitus after traumatic brain injury: an overview B. Ushasree Reddy1, Ranabir Pal2, Amrita Ghosh3, Luis Rafael Moscote-Salazar4, Vishnu Vardhan Reddy1, Amit Agrawal1 1Department of Neurosurgery, Narayana Medical College Hospital, Chinthareddypalem, Nellore, Andhra Pradesh, INDIA 2Department of Community Medicine, MGM Medical College and LSK Hospital, Kishanganj, Bihar, INDIA 3Department of Biochemistry, Calcutta Medical College, INDIA 4Neurosurgery-Critical Care, RED LATINO, Organización Latinoamericana de Trauma y cuidado Neurointensivo, Bogota, COLOMBIA Abstract: Tinnitus is a frequent clinical feature encountered during follow up of Traumatic brain injury (TBI) that can be incapacitating in the long run. Literature suggests that post-TBI carries a higher psychological burden than tinnitus patients presenting with other non-traumatic or unknown etiologic. Posttraumatic tinnitus is of longer duration, frequently associated with hyperacousis and occurs in younger age group. If the symptoms are severe post-traumatic tinnitus can affect quality of life of the patients. The management of these patients needs detail evaluation and comprehensive rehabilitation plan. Key words: Tinnitus, traumatic brain injury, auditory dysfunction Introduction Traumatic brain injury can lead to the damage to auditory nerve and cochlear structures resulting in hearing loss and labyrinthine dysfunction.1,2 Injury to cochlear hair cells can result in tinnitus which can persist a long time after TBI as a part of post- concussive symptoms.3,4 Many advancements have been made in the management of TBI, however little has been understood regarding the pathophysiology of post-traumatic tinnitus. Traumatic Brain Injury (TBI) has been reported to be associated with a spectrum of sequel and the post-TBI tinnitus has been reported as a frequent yet difficult to treat symptom.5,6 It has been suggested that forces generated during trauma leads to neuronal dysfunction7 including injury to the otic capsule.8,9 or damage to the medullary somatosensory nuclei can cause tinnitus.10 Clinical spectrum Tinnitus is a subjective feel and there is no specific test to confirm, all the details e.g. location, character, presence of hyperacusis, any rhythmicity or pulsatile component needs 488 | Reddy et al - Tinnitus after traumatic brain injury             to be obtained from the patient.11,12 Obviously these patients have history suggestive of traumatic brain injury and shall need standardized assessment to rule out other non- traumatic causes of tinnitus.13 Details needs to obtained include is the tinnitus affecting quality of life, whether it is disturbing sleep or concentration and increasing the psychological stress.14-16 Post-traumatic tinnitus needs to be differentiated from other non-traumatic causes of tinnitus. Usually post-traumatic tinnitus occur in younger patients, more severe in nature and accompanied by many other co-symptoms including frequent headache, impaired memory and concentration and transient episodes of depression. 4,17 Diagnosis Selected audiological investigations will help to rule out treatable pathologies i.e. disruption of the ossicular chain disruption or any perilymphatic fistulas.18 Pure-tone audiometry shall help to assess any hearing impairment.19 In a patient who present with pulsatile tinnitus, we need to rule out trauma induced carotid-cavernous fistulas, arteriovenous malformations, and carotid artery dissections where the treatment approach will be entirely different. 18 Appropriate imaging will help to rule out cervical spine injuries and any intracranial lesions as an underlying cause of tinnitus.11,18 Management The management of post-traumatic tinnitus is to control underlying pathology, management of any treatable cause and to suppress the tinnitus perception and thus to improve the quality of life of the patient.20,21 Several categories of drugs have been used to manage post-traumatic tinnitus including drugs acting on vestibular system as well drugs to help to reduce concomitant psychological stress.22-24 Drugs which improve microcirculation in auditory systems have also not shown to be much effective.25-27 Betahistine, has been used to increase cochlear blood flow with variable success.28 The management of post-traumatic tinnitus is largely conservative and surgery is reserved for the cases where there are underlying structural lesions as the cause of tinnitus (i.e. carotid- cavernous fistulas, arteriovenous malformations, and carotid artery dissections etc.)18 or there are any other underlying pathologies (i.e. Otosclerosis or Meniere’s disease etc.).29-34 Brain stimulation techniques including repetitive transcranial magnetic stimulation are under investigation as non- invasive tool to manage tinnitus.34-39 Role of laser therapy has been explored in the management of tinnitus however how it works and much it is effective both are controversial.40 Conclusion Findings from this review hopefully going to help the health care providers and stakeholders working in this area of rehabilitation of TBI cases. Patients with tinnitus need extensive investigations regarding etiology and functional assessments to devise tailor-made plan of interventions to treat not only the auditory problems but also to address the associated deficits in patients recovering from TBI. Presently the treatment of post-traumatic tinnitus is directed towards Romanian Neurosurgery (2018) XXXII 3: 487 - 490 | 489             improving the quality of life as still there is not advancements to achieve definitive cure. In the clinical practice guidelines of the office practice of clinicians we need standard operative procedures (SOP) to help patients with tinnitus in an empathetic manner. Correspondence Dr. Amit Agrawal Professor of Neurosurgery Department of Neurosurgery Narayana Medical College Hospital Chinthareddypalem Nellore-524003 Andhra Pradesh (India) Email- dramitagrawal@gmail.com dramitagrawal@hotmail.com Mobile- +91-8096410032 References 1.Henry JA, Dennis KC, Schechter MA. General review of tinnitus: prevalence, mechanisms, effects, and management. Journal of speech, language, and hearing research 2005;48:1204-1235. 2.Schuknecht HF. Mechanism of Inner Ear Injury from Blows to the Head. Annals of Otology, Rhinology & Laryngology 1969;78:253-262. 3.Fitzgerald DC. Persistent dizziness following head trauma and perilymphatic fistula. Archives of physical medicine and rehabilitation 1995;76:1017-1020. 4.Ferber‐Viart C, Postec F, Duclaux R, Dubreuil C. Perilymphatic fistula following airbag trauma. The Laryngoscope 1998;108:1255-1257. 5.Kreuzer PM, Landgrebe M, Frank E, Langguth B. Repetitive transcranial magnetic stimulation for the treatment of chronic tinnitus after traumatic brain injury: a case study. The Journal of head trauma rehabilitation 2013;28:386-389. 6.Jury MA, Flynn MC. Auditory and vestibular sequelae to traumatic brain injury: a pilot study. N Z Med J 2001;114:286-288. 7.Ommaya AK, Hirsch AE. Tolerances for cerebral concussion from head impact and whiplash in primates. Journal of biomechanics 1971;4:13-21. 8.Grimm RJ, Hemenway WG, Lebray PR, Black FO. The perilymph fistula syndrome defined in mild head trauma. Acta Oto-Laryngologica 1989;108:1-40. 9.Claussen C, Constantinescu L. Tinnitus in Whiplash Injury. The international tinnitus journal 1995;1:105. 10.Levine RA. Somatic (craniocervical) tinnitus and the dorsal cochlear nucleus hypothesis. American journal of otolaryngology 1999;20:351-362. 11.Baguley D, McFerran D, Hall D. Tinnitus. The Lancet 2013;382:1600-1607. 12.Khalfa S, Dubal S, Veuillet E, Perez-Diaz F, Jouvent R, Collet L. Psychometric normalization of a hyperacusis questionnaire. Orl 2002;64:436-442. 13.Kreuzer PM, Landgrebe M, Schecklmann M, Staudinger S, Langguth B. Trauma-associated tinnitus: audiological, demographic and clinical characteristics. PLoS One 2012;7:e45599. 14.Newman CW, Jacobson GP, Spitzer JB. Development of the tinnitus handicap inventory. Archives of Otolaryngology–Head & Neck Surgery 1996;122:143-148. 15.Hoare DJ, Gander PE, Collins L, Smith S, Hall DA. Management of tinnitus in English NHS Audiology Departments: an evaluation of current practice. Journal of evaluation in clinical practice 2012;18:326-334. 16.Meikle MB, Henry JA, Griest SE, et al. The tinnitus functional index: development of a new clinical measure for chronic, intrusive tinnitus. Ear and hearing 2012;33:153-176. 17.Folmer RL, Griest SE. Chronic tinnitus resulting from head or neck injuries. The Laryngoscope 2003;113:821- 827. 18.Møller AR, Langguth B, DeRidder D, Kleinjung T. Textbook of tinnitus: Springer Science & Business Media, 2010. 19.Fowler EP. The “illusion of loudness” of tinnitus—its etiology and treatment. The Laryngoscope 1942;52:275- 285. 20.Dobie RA. A review of randomized clinical trials in tinnitus. The Laryngoscope 1999;109:1202-1211. 21.Jastreboff PJ, Gray WC, Gold SL. Neurophysiological approach to tinnitus patients. Otology & Neurotology 1996;17:236-240. 490 | Reddy et al - Tinnitus after traumatic brain injury             22.Baldo P, Doree C, Lazzarini R, Molin P, McFerran DJ. Antidepressants for patients with tinnitus. Cochrane Database Syst Rev 2006;4. 23.Johnson RM, Brummett R, Schleuning A. Use of alprazolam for relief of tinnitus: a double-blind study. Archives of Otolaryngology–Head & Neck Surgery 1993;119:842-845. 24.Jalali MM, Kousha A, Naghavi SE, Soleimani R, Banan R. The effects of alprazolam on tinnitus: a cross-over randomized clinical trial. Medical Science Monitor 2009;15:PI55-PI60. 25.Jayarajan V, Coles R. Treatment of tinnitus with frusemide. J Audiol Med 1993;2:114-119. 26.Mora R, Salami A, Barbieri M, et al. The use of sodium enoxaparin in the treatment of tinnitus. International Tinnitus Journal 2003;9:109-111. 27.Davies E, Knox E, Donaldson I. The usefulness of nimodipine, an L-calcium channel antagonist, in the treatment of tinnitus. British journal of audiology 1994;28:125-129. 28.James A, Burton MJ. Betahistine for Meniere's disease or syndrome. The Cochrane Library 2001. 29.De Ridder D, Elgoyhen AB, Romo R, Langguth B. Phantom percepts: tinnitus and pain as persisting aversive memory networks. Proceedings of the National Academy of Sciences 2011;108:8075-8080. 30.Atik A. Pathophysiology and treatment of tinnitus: an elusive disease. Indian Journal of Otolaryngology and Head & Neck Surgery 2014;66:1-5. 31.Foyt D, Wazen JJ, Sisti M. Selective cochlear neurectomy for debilitating tinnitus. Annals of Otology, Rhinology & Laryngology 1997;106:568-570. 32.Pulec JL. Cochlear nerve section for intractable tinnitus. Ear, nose, & throat journal 1995;74:468,-470- 466. 33.Baguley DM, Atlas MD. Cochlear implants and tinnitus. Progress in brain research 2007;166:347-355. 34.Shi Y, Burchiel KJ, Anderson VC, Martin WH. Deep brain stimulation effects in patients with tinnitus. Otolaryngology—Head and Neck Surgery 2009;141:285- 287. 35.Eggermont JJ, Roberts LE. The neuroscience of tinnitus. Trends in neurosciences 2004;27:676-682. 36.Noreña AJ. An integrative model of tinnitus based on a central gain controlling neural sensitivity. Neuroscience & Biobehavioral Reviews 2011;35:1089-1109. 37.Norena AJ, Eggermont JJ. Changes in spontaneous neural activity immediately after an acoustic trauma: implications for neural correlates of tinnitus. Hear Res 2003;183:137-153. 38.Meng Z, Liu S, Zheng Y, Phillips JS. Repetitive transcranial magnetic stimulation for tinnitus. The Cochrane Library 2011. 39.Cheung SW, Larson PS. Tinnitus modulation by deep brain stimulation in locus of caudate neurons (area LC). Neuroscience 2010;169:1768-1778. 40.Kleinjung T. Low-level laser therapy. Textbook of tinnitus: Springer, 2011: 749-752.