Debilitating Tinnitus. Tinnitus Who Gets it?

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Gavin Gibbs
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Recorded March 28, 214 Phantom Sound Tinnitus: Human Brain Imaging, Neural Plasticity, Animal Models and Therapy Richard Salvi, Ph.D. Center for Hearing & Deafness & Dept.

~12-14% of Adult have experienced tinnitus 1% experience significant tinnitus and seek medical treatment Patients In Tinnitus Clinic (Nicholas-Puel 26) Age 55 years (+/- 15); 55% males; 45% females

1 Recorded March 28, 214 Phantom Sound Tinnitus: Human Brain Imaging, Neural Plasticity, Animal Models and Therapy Richard Salvi, Ph.D. Center for Hearing & Deafness & Dept. Communicative Disorders & Sci., University at Buffalo, Buffalo, NY AAA Orlando Mar 214 Tinnitus Who Gets it? ~12-14% of Adult have experienced tinnitus 1% experience significant tinnitus and seek medical treatment Patients In Tinnitus Clinic (Nicholas-Puel 26) Age 55 years (+/- 15); 55% males; 45% females Age Tinnitus Onset: ~48 years Presbycusis: 42% Noise Trauma: 22% Meniere s & Meniere s like: ~1% Sudden Hearing Loss: 2% Ototoxicity: 4% No Hearing Loss: 5.6%???? Debilitating Tinnitus "I remember waking up on the morning of April 12, 1994, with a high-pitched squealing in my ears, I thought it was the microwave going off downstairs, but I wasn't able to find the sound anywhere. Ultimately, I went into a state of depression and couldn't even work. I have spent the last four years looking for help, but I have been told to learn to live with it." 1

Recorded March 28, 214 Noise-Induced Tinnitus (9 patients) Patients In Tinnitus Clinic (Nicholas Puel 26) Amplified Music:

Hyperacusis-Loudness Intolerance Point Prevalence: ~9% (Andersson 21) Patient with primary complaint of tinnitus- 4% have

clinically normal hearing had sound tolerance problems Audiogram: does not detect damage to inner hair cells or spiral

2 Recorded March 28, 214 Noise-Induced Tinnitus (9 patients) Patients In Tinnitus Clinic (Nicholas Puel 26) Amplified Music: 4% Firearms/Exlosions: 25% Alarms: 14% Medical treatment 9% Explosion 9% ~5% US combat soldiers develop tinnitus Hyperacusis-Loudness Intolerance Point Prevalence: ~9% (Andersson 21) Patient with primary complaint of tinnitus- 4% have hyperacusis (Baguley 23) Patients with hyperacusis-86% have tinnitus Gu, Melcher 21-Most patients with tinnitus and clinically normal hearing had sound tolerance problems Audiogram: does not detect damage to inner hair cells or spiral ganglion neurons Insensitivity of the Audiogram to Carboplatin Induced Inner hair cell loss in Chinchillas, Lobarinas et al. 213, Hearing Res 2

Recorded March 28, 214 What Does Tinnitus Cost? VA Disability Costs Skyrocketing!

Generator in Ear Spontaneous Hyperactivity Tumor-Cut Auditory Nerve No spontaneous

Tinnitus Spontaneous activity reduced Maybe Tinnitus Generated in Brain Test

3 Recorded March 28, 214 What Does Tinnitus Cost? VA Disability Costs Skyrocketing! $2 Billion 211 Traditional Hypothesis Tinnitus Perceived in Damage Ear Tinnitus Generator in Ear Spontaneous Hyperactivity Tumor-Cut Auditory Nerve No spontaneous activity-tinnitus persists Ototoxic drugs damage inner & outer hair cells Induces Tinnitus Spontaneous activity reduced Maybe Tinnitus Generated in Brain Test Hypothesis that Tinnitus Generated in Central Nervous System 1994 Positron Emission Tomography (PET) 3

4 Recorded March 28, 214 Positron Emission Tomography Utilizes radioisotope-isotope is unstable and breaks down into a more stable element when this occurs positrons (positively charged electrons) are given off which are annihilated. Annihilation-occurs when positron (+) collides with electrons (-). Disintegration of positron gives off 2 gamma rays that move in opposite directions. Gamma rays are detected by PET scanner + -e gamma ray Annihilation 1-4 mm gamma ray Positron Emission Tomography (PET) Functional Imaging-Sound Evoked 15 O labeled water-estimate local blood flow a marker of neural activity Conditions Rest-Quiet scanner Tone bursts SPM-Statistics High Level Background Noise Can Mask Tinnitus PET Scanner Noise ~7 db SPL, Steady, Low Frequency Ear Plug+Active Noise Reduction-Little Effect on Threshold PET THRESHOLD- BOOTH THRESHOLD 2 CHANGE IN THRESHOLD (db) FREQUENCY (Hz) 4

Recorded March 28, 214 Normal Hearing Listeners-4 Hz Tone Right Ear versus Quiet L & R Auditory Cortex L Medial

activates both left & right auditory cortex Right Ear 4 Hz Somatic Tinnitus -Modulate Tinnitus with Oral Facial

(n=45) 65% modulate tinnitus with jaw movement = Trigeminal Nerve (V) 6% modulate tinnitus with neck movement =

5 Recorded March 28, 214 Normal Hearing Listeners-4 Hz Tone Right Ear versus Quiet L & R Auditory Cortex L Medial Geniculate R L R L R L L Lateral Lemniscus L Brainstem Tegmentum L Parafloccular Lobe Note: Sound to right ear activates both left & right auditory cortex Right Ear 4 Hz Somatic Tinnitus -Modulate Tinnitus with Oral Facial Maneuver Conditions Resting Brain Activity 2 Hz tone, 8 db OFM-Jaw Clench Somatic Tinnitus-Modulate Tinnitus Percept (n=45) 65% modulate tinnitus with jaw movement = Trigeminal Nerve (V) 6% modulate tinnitus with neck movement = Cervical spinal nerve 1-2 5% modulate tinnitus with hear rotation = Accessory Nerve (XI) Jaw Clench/Thrust Neck Extension/Flexion Head Rotation/Shrug 5

Recorded March 28, 214 Oral-Facial Maneuver & Right Ear Tinnitus 1 patient loudness increases, 2 patients loudness decreases Loudness

region Right medial geniculate R L R L R L Normal Subjects 2 Hz, 8 db SPL Right Ear Monaural stimulation activates left & right

BA41 Auditory cortex L R R Tone Activation Tinnitus Patients 2 khz tone burst, 8 db SPL Tinnitus patients greater than normal

6 Recorded March 28, 214 Oral-Facial Maneuver & Right Ear Tinnitus 1 patient loudness increases, 2 patients loudness decreases Loudness decrease (Rest-OFM) + Loudness increase (OFM-Rest) CBF Significant Change Left auditory cortex (BA21, BA41) Left hippocampus-limbic region Right medial geniculate R L R L R L Normal Subjects 2 Hz, 8 db SPL Right Ear Monaural stimulation activates left & right auditory cortex L transverse temporal gyrus BA41 R L L L hippocampus2 Hz R superior temporal gyrus BA22 R transverse temporal gyrus BA41 Auditory cortex L R R Tone Activation Tinnitus Patients 2 khz tone burst, 8 db SPL Tinnitus patients greater than normal activation in left auditory cortex (BA38 and BA41)-Hyperactive Patients normal hearing 2 khz Patients hearing loss 4 khz R L R L BA38 BA41 Right 4 Hz 6

Recorded March 28, 214 Allman et al., (29) Proc. Nat. Acad.

Auditory Cortex Gaze-Evoked Tinnitus Unusual complication-vestibular Schwannoma surgery

7 Recorded March 28, 214 Allman et al., (29) Proc. Nat. Acad. Somatosensory Invasion of Deaf Auditory Cortex Activation by touch to face, neck, shoulder Auditory Cortex Gaze-Evoked Tinnitus Unusual complication-vestibular Schwannoma surgery Tinnitus-loudness and pitch change in lateral eye gaze Found 125 patients-gaze-evoked Tinnitus-Acoustic Neuroma Newsletters Gaze-evoked tinnitus is common! Patient with Acoustic/Vestibular Schwannoma Contrast-enhanced CT scan 44 year old woman, operated on 2/8 for 3.6 cm right acoustic schwannoma GET on right lateral gaze (Whittaker, 1982, 1983) 7

8 Recorded March 28, 214 Single subject SPM analysis Left Acoustic neuroma Gaze to left alters tinnitus loudness Activation-Angular Gyrus Next to Auditory Cortex 3 Subject SPM, R Acoustic Neuroma Activation vestibular nuclei & cochlear nuclei Lidocaine & Tinnitus! Otology-Suppresses Tinnitus! Cardiology-Induces Tinnitus! 8

Recorded March 28, 214 Lidocaine-Increases & Deceases Tinnitus Loudness Reduction in

region that shows a change in rcbr with change in tinnitus loudness Model/Hypotheses

Plasticity Analogous to Phantom Limb Pain Gain Control: Brain Turns Up Volume Control to

9 Recorded March 28, 214 Lidocaine-Increases & Deceases Tinnitus Loudness Reduction in tinnitus decrease in rcbf Increases in tinnitus increase in rcbf Right Auditory Cortex-Only region that shows a change in rcbr with change in tinnitus loudness Model/Hypotheses Tinnitus-Loss of Cochlear Input Cochlear Damage Alters Central Auditory System Abnormal Plasticity Analogous to Phantom Limb Pain Gain Control: Brain Turns Up Volume Control to Compensate for Hearing Loss Tinnitus & Hyperacusis Mechanisms Animal Models Physiology Biochemical Molecular Behavior 9

Behavioral Model of Tinnitus Schedule Induced Polydipsia-Avoidance Conditioning Quiet = Lick-for-Water Food Pellet 1/minute 8 7 6 5

10 Recorded March 28, 214 Animal Model of Tinnitus (SIPAC) Schedule Induced Polydipsia (SIP) Deliver food pellet 1/min-drives drinking in food deprived rats Avoidance Conditioning (AC) Drinking (Licks) is put under stimulus control (pairing sound with foot shock) Behavioral Model of Tinnitus Schedule Induced Polydipsia-Avoidance Conditioning Quiet = Lick-for-Water Food Pellet 1/minute Tinnitus Rat 1 Licks-in-Quiet Licks-in-Sound Licks baseline Fig 13 saline 35mg Recovery 15mg Recovery Treatment 5 mg Aspirin Recovery 1 mg/kg 1

11 Recorded March 28, 214 Salicylate-Dose-Response Study Licks-in-quiet decrease with increase in salicylate Average Lick Data (n=5) 7 6 Lick Count Tinnitus Licks in Quiet Licks in Noise 2 1 Baseline Saline 5mg/kg 1mg/kg 15mg/kg 35mg/kg Treatment Memantine (NMDA) Antagonist-Tinnitus Treatment Memantine Causes Slight Increase Licks in Quiet Not Significant; Not Dose Dependent Sodium Salicylate (15 mg/kg/d, 2 d) 7 (n=6) 6 Tinnitus 5 Control #Licks CNT SA M-1.5 M-3. SS SS+M-1.5 SS+M-3. Scopolamine, Anti-Cholinergic-Tinnitus Treatment 1 mg/kg-slight Increase Licks in Quiet, Not Significant SS (15 mg/kg ) + SC (1mg/kg ) 3 #Licks in Quiet Baseline Saline Tinnitus SS Tinnitus SC SS+SC 11

12 Saline Baseline SS 1 mg Maxi 5 mg Maxi SS + 1 mg Maxi SS + 5 mg Maxi Phantom Sound Tinnitus: Human Brain Recorded March 28, 214 Potassium Channels Greatest Ion Channel Diversity Important targets for therapy Kv in cochlea Drug Kv Kv7.1 BK (K Ca ) Maxipost (BMS 24342) Positive modulator (activation) Negative Modulator (inhibition) Positive modulator (activation) R-Maxipost Negative modulator (inhibition) Negative Modulator (inhibition) Positive modulator (activation) 7 6 BK (K Ca ) positive modulator (activation) Kv7.1: Negative Modulator (inhibition) Effects of M axipost (n=6) Average Licks-in-Quiet tinnitus * * ** Treatm ent BK (K Ca ) positive modulator (activation) Kv7.1: Negative Modulator (inhibition) Effects of R-Maxipost (n=6) 7 Average Licks-in-Quiet Baseline Saline 5 mg R-Maxi SS 1 mg R-Maxi * tinnitus SS + 1 mg R-Maxi SS + 3 mg R-Maxi SS +1 mg R-Maxi SS + 5 mg R-Maxi * * Treatment 12

Recorded March 28, 214 What are the Neural Correlates of Tinnitus? Identify Neural Changes in Auditory Cortex During Salicylate Induced Tinnitus?

Distortion Product Otoacoustic Emission (DPOAE) Frequency Dependent Loss in Cochlear Amplifier Large Loss above and below 16 khz Small loss near 16 khz Salicylate Suppresses CAP from Inner Ear A B C

13 Recorded March 28, 214 What are the Neural Correlates of Tinnitus? Identify Neural Changes in Auditory Cortex During Salicylate Induced Tinnitus? Use 16 Channel Microwire Electrodes to Record from Neurons in Auditory Cortex of Awake Rats 16 Channel Microwire Electrode A B Connector Glue Glue Bridge 16 Electrode tips 16 Electrode tips Distortion Product Otoacoustic Emission (DPOAE) Frequency Dependent Loss in Cochlear Amplifier Large Loss above and below 16 khz Small loss near 16 khz Salicylate Suppresses CAP from Inner Ear A B C CAP Amp ( V) Pre Post-SS Pre SS-1h 2 V 1ms CAP: Salicylate-Round Window CAP Amp ( V) D AC Amp ( V) CAP: Salicylate-Systemic Injection 4 Pre 3 SS-1h Sound Intensity (db SPL) AC: Salicylate-Round Window Pre SS-1h Sound Intensity (db SPL) Sound Intensity (db SPL) 13

Recorded March 28, 214 Recording From Awake Rat Single Unit and Evoked Potential Recorded

Effect of Salicylate on Evoked Response & Spike Awake Rat Treated with 3 mg/kg Salicylate

12 16 2 msec 2ms Spikes 4 3 2 1 2 4 6 8 1 12 14 16 18 2 msec -1 Spikes 4 8 12 16 2 msec S/N

14 Recorded March 28, 214 Recording From Awake Rat Single Unit and Evoked Potential Recorded from Same Electrode in Awake Rat 1 µv 1kHz Evoked Potential -1 µv ms Spikes 5µV 2ms Effect of Salicylate on Evoked Response & Spike Awake Rat Treated with 3 mg/kg Salicylate 8kHz 1 2ms Pre-Salicylate 1 8kHz 2ms Post-Salicylate EVP Increases microv MicroV -1 8kHz msec 2ms Spikes msec -1 Spikes msec S/N Ratio Improves-Spontaneous Rate Decreases-Driven Rate Unchanged msec 14

15 Recorded March 28, 214 Driven Spike Rate Increases after Salicylate- Decreases 2 days Post-Treatment 12 1 Pre Post 6' Time Post-Salicylate (25 mg/kg) Spikes/sec Post 18' Post 24' Post 2 day Frequency (khz) 4 Auditory Cortex Salicylate Reduces Spontaneous Discharge Rate (n=1 units) 3 Spikes/second 2 1 pre 2 h 1 d 2 d 3 d Salicylate Increases Cortical Field Potential Greatest A Effect 16-2 khz Pre 3 µv Post SS (1 hr) 25 ms Normalized AC Amp 2.5 Pre 2. Post-1h db SPL 1 15

16 Recorded March 28, 214 Systemic Salicylate CAP reduced but little Effect on Inferior Colliculus Some Neural Amplification Between Auditory Nerve & Inferior Colliculus Salicylate on Round Window-CAP Reduced CAP and Auditory Cortex Response Reduced A B C CAP Amp ( V) Pre Post-SS Pre SS-1h 2 V 1ms CAP: Salicylate-Round Window CAP Amp ( V) D AC Amp ( V) CAP: Salicylate-Systemic Injection 4 Pre 3 SS-1h Sound Intensity (db SPL) AC: Salicylate-Round Window Pre SS-1h Sound Intensity (db SPL) Sound Intensity (db SPL) Use Startle Reflex-Behavioral Test of Hyperactivity Speaker Electrode 16

17 Recorded March 28, 214 Startle Reflex Amplitude TDT Recording System Piezo Sensor Salicylate-Enhance Startle Reflex Amplitude Salicylate-Induced Shifts in Tuning Curve CFs Low CFs shift up to 16 khz High CFs shift down to 16 khz Tinnitus pitch:1-2 khz 17

Salicylate-Induces c-fos expression AI, AAF, P: auditory cortex Perception

18 Recorded March 28, 214 Jastreboff Neurophysiological Model Wallhauser-Frank 23, Exp. Brain Res. Salicylate-Induces c-fos expression AI, AAF, P: auditory cortex Perception CeA, LA: amygdala Emotion, Attention Record from Lateral Amygdala -Systemic Salicylate Salicylate Enhances Local Field Potentials 18

CF increased Tinnitus-Total Discharge in Quiet Spontaneous rate x # 16 khz neurons Does Amygdala Influence Response of

19 Recorded March 28, 214 Salicylate Alters Tuning of Auditory Neurons in Amygdala Low CFs shift up to 16 khz High CFs shift down to 16 khz One Multiunit Cluster Tuning Curve Tinnitus Model Spontaneous rate-little change # Neurons tagged with 16 khz CF increased Tinnitus-Total Discharge in Quiet Spontaneous rate x # 16 khz neurons Does Amygdala Influence Response of Auditory Cortex? Infuse Salicylate into Amygdala; Record from Auditory Cortex No Change in Threshold Auditory Becomes Hyperactive 19

Recorded March 28, 214 Peripheral Effects of Salicylate Frequency Dependent Loss Greatest Loss at Very Low and Very High

Increases Gain (Hyperactive) Symptoms Associated with Tinnitus Stressed Linked to Tinnitus (Niger et al.

Salicylate Increases Corticosterone Stress Hormone Salicylate Levels Increases in dose dependent manner =>15 mg/kg

20 Recorded March 28, 214 Peripheral Effects of Salicylate Frequency Dependent Loss Greatest Loss at Very Low and Very High Frequencies Central Effects of Salicylate CFs Shifts to Mid-Frequencies (Peripheral + Central Effect) Amygdala Further Increases Gain (Hyperactive) Symptoms Associated with Tinnitus Stressed Linked to Tinnitus (Niger et al., 28) High Depression & Anxiety Scores (Andersson et al., 2) Is a High Dose of Salicylate Stressful? Salicylate Increases Corticosterone Stress Hormone Salicylate Levels Increases in dose dependent manner =>15 mg/kg Salicylate induces tinnitus/hyperactivity 1 Salicylate Corticosterone * 1 Corticosterone (ng/mlserum) * * Salicylate ( g/mlserum) 5 15 Salicylate Dose (mg/kg) 25 2

Recorded March 28, 214 Corticosterone Levels Normal 24 h Post-Salicylate Corticosterone Stress Hormone

2 Salicylate Corticosterone * * 14 12 1 8 6 4 2 Salicylate ( g/mlserum) Saline 2 2 24 48 Time following

Expose Left Ear 126 db, 12 khz Narrow Band Noise, 2 hr OHC Lesion IHC Lesion Noise-Induced Tinnitus

21 Recorded March 28, 214 Corticosterone Levels Normal 24 h Post-Salicylate Corticosterone Stress Hormone High 2 h Post-Salicylate Corticosterone levels decline to baseline ~24 h Corticosterone (ng/mlserum) Salicylate Corticosterone * * Salicylate ( g/mlserum) Saline Time following Salicylate Dose (hr) Noise Induced Hearing Loss in Left Ear Retain Normal Hearing in Right Ear Noise Expose Left Ear 126 db, 12 khz Narrow Band Noise, 2 hr OHC Lesion IHC Lesion Noise-Induced Tinnitus Assessed with SIPIC Unilateral Exposure 12 db, 2 h, OBN Centered at 11 khz Noise Induced Tinnitus Persistent Transient A B 21

Recorded March 28, 214 2 Alternative Forced Choice Tinnitus Paradigm Normal Behavior AM Tinnitus Behavior AM QUIET In Quiet the rat is trained to respond to the right feeder If rat has tinnitus on

22 Recorded March 28, Alternative Forced Choice Tinnitus Paradigm Normal Behavior AM Tinnitus Behavior AM QUIET In Quiet the rat is trained to respond to the right feeder If rat has tinnitus on Quiet trials, it shifts its response to the left feeder Expose: 16 khz, 11 db, 4 min tinnitus tinnitus tinnitus tinnitus Expose: 16-2 khz noise, 96 db, 96 h Noise tinnitus Noise tinnitus tinnitus Noise Noise tinnitus 22

Recorded March 28, 214 Current Treatments for Tinnitus Hearing Aids Sound Generator Cochlear

Electrical Stimulation Frequent Comments of Tinnitus Patients Why Haven t You Found a Cure Yet?

23 Recorded March 28, 214 Current Treatments for Tinnitus Hearing Aids Sound Generator Cochlear Implants (75-8% suppress) Future New Pharmaceuticals Transcranial Magnetic Stimulation Brain Electrical Stimulation Frequent Comments of Tinnitus Patients Why Haven t You Found a Cure Yet? How much funding goes to Tinnitus Research? Research Dollars for Tinnitus 26 $4.3 M Abrams Tank Billion Millions NCI NIAID DE NIDDK NINDS NIMH NICHD NIA NIDA NIEHS NIDCD NCCAM NIDCD Tin TRC ATA Funding Agency All Tinnitus NIDCD Tin TRC ATA Funding Agency 23

24 Recorded March 28, 214 Thanks to my collaborators: A. Lockwood, W. Sun, E. Lobarinas, D. Ding, D. Stolzberg, S. Monohar, G. Chen, S. Hayes, W. Sun Funding: UB, NIH, American Tinnitus Association, Tinnitus Research Initiative, Tinnitus Research Consortium, Office of Naval Research 24

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Physicians Hearing Services Welcomes You! Signia GmbH 2015/RESTRICTED USE Signia GmbH is a trademark licensee of Siemens AG Tinnitus Definition (Tinnitus is the) perception of a sound in the ears or in