The Best Advice I’ve Ever Received From An ENT Doctor About Tinnitus

The Best Advice I've Ever Received From An ENT Doctor About Tinnitus

Ben Thompson, AuD.

Hello everyone. My name is Dr. Ben Thompson, audiologist based out of California. This is a special episode of my podcast, where we have Dr. Michael Golenhofen, who is coming to us from Europe. Dr. Golenhofen, please introduce yourself.

Michael Golenhofen, ENT Specialist

Thank you. My name is Michael Golenhofen, I’m an ENT specialized physician working in Germany and treating tinnitus patients for the last 25 years, approximately. And I did describe a way of treating tinnitus patients by doing a very accurate differential diagnosis before we start treating.

Ben Thompson, AuD.

And you have some research published on the differential diagnosis and how to treat tinnitus patients effectively, correct?

Dr. Ben Thompson talks about the researches that were published by Dr. Michael Golenhofen on the differential diagnosis and treating tinnitus patients effectively. 

Michael Golenhofen, ENT Specialist

That’s accurate. That’s actually the center of my work. ENT physicians do not really care very much about tinnitus patients all over Europe, and I try to improve this situation a little bit.

Ben Thompson, AuD.

Yeah, thank you so much. And I have some questions to ask during this podcast about medications, about TMJ, about neck contribution to tinnitus, about what your perspective is on treatment, on the audiology intervention and the psychology intervention. But let’s start by having you explain what were the major findings of this research, how to effectively diagnose and treat tinnitus patients?

Michael Golenhofen, ENT Specialist

Well, I think the center is that we read how to investigate, to assess a tinnitus patient and then some recommendations for treatment. However, the daily practice is that we somehow stop thinking very much and do a step very quickly forward into the direction of cognitive behavior therapies. So we do not really assess our patients in an accurate way. We forget about the different disorders that are causing the tinnitus, we consider tinnitus to be the disorder itself, which it is not, and we forget about doing our job in diagnosing our patients.

Ben Thompson, AuD.

In your perspective, what are some common mistakes or errors that doctors make with tinnitus patients that you have tried with your research to improve?

Michael Golenhofen, ENT Specialist

Well, the main misunderstandings and faults that are made are that a patient approaches a doctor and hears, “I can’t do anything about it, you’ve got to live with it and so on.” And this causes a lot of fear and disorientation, and we need to improve this because this is a major problem in the management of tinnitus patients in general.

Ben Thompson, AuD.

How about other misunderstandings of the different types of tinnitus or the subgroups, and how to effectively manage the condition based on the subgroup.

Michael Golenhofen, ENT Specialist

Well, the major misunderstanding is that we do know that you can ask the question, which subtype does the patient come from, okay? And this is important. I try to show that in my research that it is not that difficult, whereas the treatment always is difficult with tinnitus patients, tinnitus is a symptom that occurs very late in the disorder when the disorder has gotten severe. So the treatment always is difficult, but the diagnosis actually is not so difficult. There is a very large number of disorders that are causing the tinnitus in general, but in practice, there are not so many different disorders. In my research, I’ve found that only three disorders cause 80% of the tinnitus conditions. So to learn about those three is not so difficult. And when we make this distinction, then we can already be so much more specific and the patient is so much more helped.

Ben Thompson, AuD.

And what are those three subcategories? What are the three most common representations of tinnitus from your research?

Michael Golenhofen, ENT Specialist

There is one type that is very generally understood already, that’s the subtype that is located in the auditory cortex, which is some kind of a hearing attention disorder where I focus very much on auditory phenomenon. And I start to hear a sound that is actually intrinsic in the human auditory pathways. And that is usually filtered out, but from subconscious mechanisms, this sound is consciously heard, okay? And this is most often a condition that needs to be treated psychotherapeutically, or at least with a good positive counseling from an expert helping this patient. And the second one, the second condition is the sensory motor disorder that happens in the TMJ, in the neck muscles, in the head bones, and so on, coming from a craniomandibular or craniovertebral disorders, causing most likely a monolateral high pitch sound and that needs to be treated accordingly with a dentist, with an orthodontic dentist or with orthopedic osteopaths and so on. And the third, of course, for an ENT doctor, very obvious is the cochlear disorders, the hearing loss acute or chronic, which can cause or which causes very often a tinnitus perception, especially when it occurs very acutely, by sudden hearing loss, for example, that causes usually a monolateral tinnitus sound. These are the major three.

Ben Thompson, AuD.

Thank you, and what comes to mind, I work with a lot of tinnitus patients as well, what comes to mind is that it’s sometimes a combination of the three. The first group that you described, I think right now a lot of professionals would describe that as stress-induced tinnitus. Do you find that people are using that language to describe that first group?

Michael Golenhofen, ENT Specialist

Oh, that’s as a matter of fact, the case, this is some kind of distress, I tried to explain my patients that we have the hearing function to protect ourselves, and the moment we are distressed and we seek from our evolution, we try to find the predator, okay? And that’s why we listen very strongly. And this is the way this type of tinnitus occurs. And what we need to do is to defocus, to help to defocus our patients, by explaining how this subtype actually works and its pathology. But as a matter of fact, this is stress-induced and I wouldn’t mind, what then as the next step is very important to help those patients not to focus on the tinnitus perception itself, but to focus on the distress, the cause of the distress. In this subtype, the tinnitus perception is the symptom of the distress situation, not the other way around, in other subtypes it’s different. But this subtype has the tinnitus because of the distress.

Ben Thompson, AuD.

A lot of patients ask, “Can stress cause tinnitus?” My answer is the stress is like the heat, and if I’m making hot water to make tea with a tea kettle over the stove, if there’s enough heat underneath the tea kettle, it will create enough pressure inside of the tea kettle to create allowed auditory sound, a whistle of the tea being ready. And similar effects can happen with the nervous system and stress on the system. In your medical perspective, how do you define stress in this relationship with tinnitus?

Michael Golenhofen, ENT Specialist

That’s a very good question, difficult one. I just try to find when I do the medical history with these patients, and investigate them from the neck muscles situation and so on, I try to find this tension, okay? And then I try to explain that the tinnitus sound itself is intrinsic, okay? But we usually filter it out and do not perceive it consciously. But the stress kind of deactivates the filter mechanism, okay? And this is what I try to communicate that let’s forget about the sound itself, but let’s care about the filter, which acts accordingly to the distress level. And then we need to focus on what is the distress for the individual? And then we’re on the right track.

Ben Thompson, AuD.

Thank you. And what is your opinion on anxiety and tinnitus? A common question is did my anxiety make my tinnitus worse or did my tinnitus make my anxiety worse? What came first?

Michael Golenhofen, ENT Specialist

Yeah, that’s a very good question. As a matter of fact, anxiety increases the tinnitus perception. Every single time when I start to focus on the tinnitus, for example, because you mentioned medication when I take this pill, my subconscious asks, “Why are you taking this pill?” And I answer, “Because I have the tinnitus, I want to get rid of it.” And this whole process increases the tinnitus phenomenon in my subconscious. So that’s not what I want. And defocusing means to clarify a situation and to communicate very clearly the management, how this perception can be lowered or made disappear. And this is what is most important.

Ben Thompson, AuD.

Absolutely, what are the common situations you see, the common circumstance in someone’s life, what is happening at the time of developing this type one? Of course these categorizations are from your research, but the terms we’re using now are not widely used amongst all doctors, but from what you laid out, this stress-induced or this type one tinnitus, what are the common life situations in someone’s life? Is it work stress? Is it family stress? From your experience, what do you see in the case history that comes up over and over?

Michael Golenhofen, ENT Specialist

Yeah, that’s a very good question. I once tried to define this subtype by saying it is a lack of order structured in a life. And my question to these patients when they describe, “I have this tinnitus sound since two years.” Is usually what actually happened in the 12 months before the onset of your tinnitus perception? What went wrong? And very often people describe something that creates a deep distress in terms of an existential question, depending a work situation, a family, a partnership situation where I develop a deep fear of a loss, and in this fear I get into a disorientation. So what needs to be provided most is to restructure a life in terms of what is the order structure in my life, and what is my exit strategy for the distress I feel inside?

Ben Thompson, AuD.

Thank you. I know that was also studied in 1995, I believe, and they looked at what are the factors associated with the emergence of bothersome tinnitus? I believe from the Hazel group in 1995. And it was something like retirement or work stressors, emotional distress, other types of fear, and then some anxiety illness, things like that. And yes, on the list was an acoustic trauma or an auditory trauma, but it was not number one, number two, nor number three, it was number four on the list. So it makes us realize that this is much more than just an ear condition. Can you please tell us about the second category you found in your research with the jaw and the neck, and what should someone do? Is there a quick way for them to test it or should they go to a doctor who can test it for them?

Michael Golenhofen, ENT Specialist

Well, I think generally tinnitus situation should be seen by a doctor. I think ENT physicians have the duty to make a proper assessment. That helps so much, creates so much clarity. But of course, the somatosensory subtype is not something ENT doctors are trained well in. Okay, that’s why I communicate that we need interdisciplinary teams in the assessment and in the treatment. And I try to learn a little bit more about those sensory motor disorders, our training in work, and on educational semantics. So to understand what actually happens in somatosensory subtype, tinnitus patients is very complex. Sometimes it’s a dental treatment, sometimes it’s an orthopedic treatment, a chiropractor treatment, sometimes it’s just an orthodontic treatment or for example, and this subtype is very complex, but you can hear from the medical history actually very clearly that patients describe this monolateral symptom of tinnitus usually a high pitch, but sometimes also a hissing sound, usually without a hearing loss situation and very often combined with the somatosensory modulations phenomenon that occurs also in other subtypes, but very often is found in the type that is caused by a sensory motor disorder.

Ben Thompson, AuD.

And what should I be asking my patients when I’m an audiologist performing a consultation forwards in this patient? What should be my case history question so that I can refer these patients to the appropriate doctor.

Michael Golenhofen, ENT Specialist

I think that this table is helpful that I put in my publication that the symptom itself, when we ask accurately, perhaps it’s very much to find out about the subtype even if we’re not physicians, if we’re not specialized in the ENT, we simply listen to the way a patient describes the symptom, and from that, if we know the subtypes, we realize and we recognize what we know, okay? As long as we do not care about, it will be difficult, but the moment we know those subtypes, we recognize them very quickly when a patient tells a story. And so for the somatosensory subtypes, it’s the monolateral perception, the lack of a hearing loss situation, and the very typical sudden onset. You know, I fell asleep on the sofa and I woke up and had this tinnitus perception, very typical. Or I woke up at night and I all of a sudden had this tinnitus perception and I had no hearing loss, okay? And this is the main distinction to the cochlear subtype, no hearing loss, monolateral high-pitch sound, most often a subtype from the sensory motor disorder.

Ben Thompson, AuD.

I think that professionals are good at referring when there is pulsatile tinnitus in the history, tinnitus that seems to have the rhythm of a heartbeat. But what you described is taking it another step of no, we’re saying that if the hearing test does not suggest unilateral or asymmetrical hearing loss, if they have a sudden onset of tinnitus on one side, and especially if there’s some modulation that can happen, correct me if I’m wrong, through neck movement or jaw movements, and we’ll talk about that in a little bit, then you’re saying this patient may fall into this subcategory, subtype of somatic tinnitus. So I have two questions here, it’s common, it happens to me when I clench my jaw, the little muscles behind the eardrum will change the auditory perception. And to a lesser degree, moving my neck can change my tinnitus slightly. So tell me, I don’t want to over refer every single patient who can do that, so where’s the threshold? How much of those changes from the jaw and the neck are significant enough to warrant a referral?