More on tinnitus

Tinnitus accounts for billions of dollars in Veterans Administration disability claims each year.
In 2014 it was the number one cause for such disability claims according to the VA annual benefits report of 2013.
Because nobody dies from tinnitus it has received little attention until now.
Functional magnetic resonance imaging testing has allowed researchers to evaluate new regions of the brain that may become active when stimulated with tinnitus.
These areas include the amygdala, the reticular formation, and the hippocampus.
Targeted therapy according to Dr. Salvi appears promising. Drugs need to be selected very carefully for the multiple etiologies that have been implicated in tinnitus. With new research modalities the future appears promising.


Tinnitus is the perception of sound when there is no external stimulus. Research to treat and control tinnitus has been very difficult. It is due to many etiologies which has made research and treatment challenging. The disease can be due to pathology involving the outer middle or inner ear as well as the brain. A recent study by an international team of researchers has focused on the issue of how patients can hear sounds after the nerve connection between the ear and brain has been severed because of disease. How can a person hear phantom sounds in this situation. It would be impossible ? The researchers have noted that in fact there are several interconnected brain structures which upto now are not felt to be involved with tinnitus. The neural areas include the amygdala and the reticular formation. These are arousal centers of the brain. This may well explain why so many patients with tinnitus feel depressed anxious or under stress during active periods of disease.

There are several investigational drugs targeting neurotransmitters in these regions. In phase 2 and phase 3 studies they seem to be promising for the long anticipated treatments for tinnitus.

Obstructive sleep apnea

The primary treatment for obstructive sleep apnea is CPAP. Despite efforts to improve compliance only 40 to 60% continue to use CPAP on a long-term basis. Hypoglossal nerve stimulation is now being pursued as an alternative therapy in the treatment of obstructive sleep apnea according to a recent review in a 2015 issue of Laryngoscope magazine. Sleep endoscopy can indicate that specific subset of patients who may benefit from hypoglossal nerve surgery and potentially avoid the use of CPAP. The studies are in their infancy but the results are looking very promising in this subset of patients where the obstruction is at the tongue area.

Endoscopic sinus surgeries

The last 30 years has seen a dramatic change in the type of medical and surgical intervention for chronic rhinosinusitis. With the introduction of endoscopic sinus surgery in the 1980s there has been a marked decrease in the classical Open procedures.since the 1980s to approximately 2010 open procedures had decreased by one third while endoscopic procedures increased nearly threefold to approximately 19,262 procedures per year with the greatest increase occurring from 2007 to 2011.

Chronic rhinosinusitis

Chronic rhinosinusitis is an inflammatory disorder of the paranasal sinuses. It is defined as having symptoms lasting 12 or more weeks including two major symptoms specifically nasal obstruction, nasal discharge, facial pain or pressure, and reduction of sense of smell. A study in the International Forum of Allergy and Rhinology indicates that surgery is generally more successful than ongoing medical therapy alone. In a multi-hospital study, 20% of people elected medical therapy alone while approximately 80% decided to proceed with surgery. Overall those undergoing surgery experience significantly better improvement in discharge, facial pain or pressure.
This recent study indicates that endoscopic sinus surgery results in much greater improvement in the major symptoms of chronic rhinosinusitis then ongoing medical therapy alone

Minimizing Post-surgical Scars

Patients commonly ask what is the best product to minimize a scar after surgery. There are many conflicting reports by different manufacturers of these products. Since they are over-the-counter there is no regulation by the US FDA. Vitamin E,  “surgical glue”, and onion extracts are commonly used topical products for post surgical scar healing.
A recent article in Laryngoscope in 2015 stated the  most important initial standard of care to minimize scarring after surgery during epithelialization is to keep the incision moist, clean, and protected from tension and mobility. The Laryngoscope article further stated that after the incision is closed, silicon gel surgical glue products and paper taping have shown progress in reducing dermal scaring. The article also stated that topical use of vitamin E and onion extracts have not been shown to reduce scaring. Further clinical studies are indicated.

Coblation Tonsillectomy

Approaches and procedures are constantly in flux as medicine involves a new technology interfaceing with clinical experience. Hearing from colleagues and attending the national meetings can also lead to a change in perspective and approach. Dr. Choi at Children’s Hospital of Pittsburgh recently reviewed numerous approaches to tonsillectomy.
The cold tonsillectomy which is the most conventional approach is still commonly used. The downside is blood loss and postoperative pain.
A new approach to tonsillectomy using “Coblation” has the advantage of utilizing relatively low heat during the procedure. Additionally suctioning throughout the procedure improves visibility. I have been utilizing this approach for the past  several years and I’ve noticed that there are far less complaints by patients of postoperative pain and bleeding.