Clm. OtokuryngoI. 1992, 17, 240-242
Intra-tympanic injections in the treatment of tinnitus ROSS R.A.COLES*, A D R I A N C.THOMPSONt & G E R A R D M . O . ' D O N O G H U E t * MRC Institute of Hearing Research, University Park, Noltingham. and TDepartmcnt
of Otolaryngology, Universiiy Hospital,
Nottiiigham, U K
Accepted for publication
18
October 1991
COLES R.R.A., THOMPSON A . C . & O'IIONOGHUE G . M .
(1992) Clin. Otolaryngol. 17, 240-242
Intra-tympanic injections in the treatment of tinnitus Prolonged reduction or abolition of tinnitus has been reported in about two-thirds of patients treated with a single or weekly-repeated injection through the tympanic membrane of either dexamethasone or lignocaine. In a small-scale trial of these treatments, dexamethasone gave 6 patients little benefit but few side-effects. Lignocaine gave 5 patients no lasting benefit but violent vertigo for several hours. A.Axelsson (personal communication) had similar experience with 6 patients treated with intratympanic lignocaine. It is concluded that this form of treatment does not seem sufficiently effective to offset its low acceptability. Kcywords
tinnitus treulmmt
lignocuine
dcrnmethasonr
Local anaesthetic agents have sometimes been used for the treatment of tinnitus and vertigo arising from disorders of the internal ear. Three decades ago intra-tympanic' or intravenous' lignocaine (lidocaine, Xylocaine) was first reported to reduce the severity of vertigo in MCniire's disorder. For tinnitus, the use of intravenous lignocaine became widely recognized after the work of Melding and colleagues in 1 (978,3although previously Sakata and Umeda' had used intra-tympanic lignocaine and reported reductions in severity of tinnitus in 42 out of 58 ears. Its actual site of action is uncertain, some believing it to be peripheral' and others centraL6 Fradis and colleagues' subsequently treated patients with Meniere's disorder with intra-tympanic lignocaine and reported improvements in both vertigo and tinnitus, while Sakata and colleagues' also tried intra-tympanic injections of a steroid, dexamethasone (Decadron), as an alternative form of intra-tympanic injection for tinnitus. The technique of iontophoresis has been used to dcliver lignocaine into the middle ear.9 but the highly promising results reported initially have not been replicated in subsequent studies.",' ' Our interest in the possibility of treating tinnitus by intratympanic injcctions of lignocaine, and also of dexamethasone, was stimulated by receipt of the translation of an unpublished monograph by E. Sakata describing extensive experience of such treatment. In this he discussed such Correspondence: Dr R.R.A.Coles,MRC Institute of Hearing Research. University Park, Nottingham NG7 2RD, UK.
240
intru-tympanic injections
treatment in one or both ears of a large number of patients seen at the Saitama Clinic in Japan between January 1987 and December 1988. In Sakata's practice 348 ears in 274 patients with vertigo and tinnitus were treated with intratympanic lignocaine carried out up to 5 times at weekly intervals, with a reported success rate in terms of improvement of the tinnitus of 81%. As he pointed out, the major disadvantage of such treatment is that the patients have to be dealt with in hospital, at least on the day of injection, because of the side-effects of dizziness, nausea and vomiting which continue for several hours. He later gave intratympanic injections of dexamethasone in order to avoid these side-effects. 1623 ears in 1142 patients were so injected on up to 5 occasions, and tinnitus was reported as much reduced in 34% and moderately reduced in a further 34%, with few side-effects apart from slight giddiness lasting for a minute or so afterwards. Thirty-four of the patients who did not benefit from the dexamethasone therapy went on to a course of lignocaine injections, with good results in 21 of them. The translation received did not give details on how long the benefit from dexamethasone lasted, but implied that it lasted quite a long time. The reports of Sakata led us to conduct an exploratory trial of this therapy on a small group of patients attending the Nottingham Tinnitus Clinic who had been particularly resistant to other forms of treatment such as hearing aids, tinnitus maskers, extensive counselling, relaxation therapy, and a variety of drugs such as clonazepam and carbamazepine.
Intra-tympanic injections in tinnitus
Table 1. Details of patients and of injections given
Intra-tympanic injection
Patien1 details ~
~~
~
Female. 63 ? Genetic (cochlear) Unilateral tinnitus
Dexamethasone Dexamethasone
Male. 44
Dexamethasone Lignocaine
Noise-induced HL Unilateral tinnitus
Effect on tinnitus
__ _ _ Much increased
Unilateral tinnitus
Caused
vertigo pain _ ~ _ _ -
Much increased
-
Much increased Much increased
-
Dexamet hasone Lignocaine Lignocaine
Male, 49 Noise-induced H L
Caused
241
Slight Slight
V. severe
Moderate Slight
V. severe V. severe
Slight
-
-
Modisevere Moderate Minimal
V. severe
-
Slight Severe
Severe Moderate
Dexamethasone Dexamethasone Dexamethasone Lignocaine
Slight increase
-
-
-
Female. 68 ? Otosclerosis Unilateral tinnitus
Dexamethasone Ligiiocaine
Slight increase Slight increase
Male. 50 Unknown (cochlear) Bilateral tinnitus (both cars injected)
Dexamethasone Dexamethasone Dexamethasone Dexamethasone Dexamcthasone
Moderate Severe Moderate Moderate Moderate Slight* Slight* (*Bonain’s cocaine solution on T.m. beforehand)
Female. 49 MCnkre’s disorder Unilateral tinnitus
Lignocaine Lignocaine Lignocaine
-
Male. 52 Noise-induced H L Unilateral tinnitus
Materials and methods Six patients were treated with intra-tympanic 4 % dexamethasone initially. the same strength as used by Sakata. If this proved completely ineffective or even caused a worsening of the tinnitus, then the patient was to be offered intratympanic lignocaine. Five patients were subsequently treated with lignocaine. Injections were to be repeated at weekly intervals for a maximum of 5 weeks, but discontinued earlier if the patient experienced increased tinnitus or severe sideeffects such as vertigo or pain. One hour prior to intratympanic lignocaine, patients were given 10 mg prochlorperazine orally in an attempt to reduce vertigo. U p to I ml of fluid was injected, although in most patients part of this leaked back around the puncture site, presumably where the middle ear volume was less than 1 ml. Sakata used 4% lignocaine, Fradis et al.’ 1%: in this study, we used 2% lignocaine. Careful attention was given to positioning the head following the injection, in order to pool the injected fluid onto the region of the round window.
Results The results obtained are summarized in Table I . In 6 patients, dexamethasone was used first, but this proved so
~
~
-
Slight reduction Slight reduction Slight reduction
Slight Abolished 10 days Slight Much red. 3 days V. severe
-
disappointing. often with pain at the time of injection and worse tinnitus subsequently, that it was not used at all for the seventh patient. The lignocaine injections caused severe vertigo in all 5 patients so treated, sometimes necessitating temporary admission of the patient to hospital. Tinnitus was reduced in only one patient, and then not for more than a few days. Patient number 7 reported a temporary improvement in her tinnitus following intra-tympanic lignocaine, but had such severe vertigo that the treatment could not be continued. However, she incidentally reported that her frequent and severe attacks of vertigo were reduced and that, at follow-up 6 months later, the improvement in this symptom had been maintained. In another patient, not in this series as she was treated primarily for recurrent vertigo, there has also been a marked reduction in such attacks following a course of four intra-tympanic injections of lignocaine.
Discussion It is curious that such poor results were achieved in compari-
son with previous reports. No explanation of this can be offered, although it is possible that by chance the small number of patients we treated with the dexamethasone injec-
242 R.R.A.Cnles et al.
tions comprised a group of non-responders. or that Sakata and collcagues had been less rigorous in trying all other forms of therapy first and had thereby had morc treatmentresponsive patients. However. all five patients treated with lignocaine experienced prolonged. severe vertigo. This confirnied that the injection fluid had diffused into the intcrnal ear in sufficient quantity to cause a paralytic effect on the vestibular receptors, which lasted for very much longer than would be expccted from a caloric cffect alone. There was however little or no corrcsponding cffect on the cochlear receptors, such as reduced tinnitus or hearing sensitivity. Wc believc that intra-tympanic injections of lignocaine arc, at best, likely to produce worthwhilc results for tinnitus in only a small proportion of thc patients who are resistant to other forms of treatment. and at the cost of extremely unpleasant vcrtigo. In fact, our experience was similar to that of A.Axclsson in Gothenburg, Sweden, who tried this treatment on 6 patients using 1 % lignocaine (personal communication). In nonc o f his paticnts was there any long-standing relief. and in most there was such violent vertigo. nausea and vomiting for several hours that hc also has discontinued this possible line of treatment for tinnitus. Given this combined cxperience we conclude. at any rate for our own practicc. that this line of therapy is not sufficiently useful to bc an acceptable option for tinnitus. Intra-tympanic injection with lignocaine may howcver have a place in management of vertiginous attacks in Menitrc’s disorder.’.’’
Conclusion Intra-tympanic injections of dexamcthasone or lignocaine did not give a useful improvcment in the tinnitus of any of our patients studied. Most patients found the treatment unpleasant, with side-effects of severe vertigo common. This
form of treatment for tinnitus would not appear to be sufficiently effective to offset its low acceptability.
References I KROATHF. (1960) Transtympanale lnjektion zur Behandlung des Meniire‘schen Syndroms. Z . Laryng. Rhin. Otol. 39, 190- I95 2 GERJOTT. (1963) Intravenous xylocaine in the treatment of attacks of Meniere’s disease. Acta O/olaryngol. 8qSuppl. 188), 190- 195 3 MELDINGP.S.. GOODEY R.J. & THOHNE P.R. (1978) The use of intravenous lidocaine in the diagnosis and treatment of tinnitus. J . Lurvng. Orol. 92, 115-121 4 SAKATA E. & UMEUA Y . (1976) Treatment of tinnitus by transtympanic infusion. Auris Nasus Larynx 3, 133-1 38 5 LYTTKENSL.. LARSSONB. & WASTERSTROM %-A. (1984) Local anaesthetics and tinnitus: proposed peripheral mechanism of action of lidocaine. J . Oto-Rhino-Laryng. Borderlands 46, 17-23 6 EMMETJ . R . & SHEAJ.J. (1980) Treatment of tinnitus with tocainide hydrochloride. Oiolaryngol. IIead Neck Surg. 88, 442-446 7 FKADISM.. PODOSHIN L., BEN-DAVID J. & REINERB. (1985) Treatment of MhuZre’s disease by mtra-tympanic injection with lidocaine. .4rch. Orolaryngol. 11 1. 491-493 8 SAKATA E.. ITOH A.. OKTSUK.. NAKAZAWA H. & IWASHITAN. (1982) Pathology and treatment of cochlear tinnitus by blocking with 4% lidocaine and with Decadron infusion. Pracr. Otol. Kyoto 7 5 , 2525--2515 9 BRUsis T. & LoEh’h’tcKEx I . (1985) Die behandlung von ohrgerauschen mit de iontophorese lokalanaesthesie. Laryng Rhinol. O l d . 64, 355-358 10 WILLATTD.J., OSULLIVAN (3.0..STONEY P.J.. JACKSOS S . R . . M.S. (1987) A sequential doublePRLTCIIARI) J. & MTCORMICK blind crossover trial of iontophoresis. In Proceedings u/’ 111 Infernational 7‘innitirs Seminar. Ed. H. Feldmann, pp. 316-319. 1Iarsch Verlag. Karlsruhe J.B.. VERME~J I I LAFFR~E P. & HIJLSHOFJ.H. (1989) Thc eRect of iontophoresis of lignocaine in the treatment of tinnitus. Clin. Otolaryngol. 14, 40 1-404 M.. 12 A i ~ oY . . MUKAIY.. ISHIKAWAT., ISHIYAMA E., HASEGAWA SHIGIHARA S., ABEH. & TOMITA, H . (1987) Treatment of severe Meniere’s disease by intra-tympanic injections with lidocaine. Equil. Res. JUPUII46, 207-21 3
Intra-tympanic injections in the treatment of tinnitus ROSS R.A.COLES*, A D R I A N C.THOMPSONt & G E R A R D M . O . ' D O N O G H U E t * MRC Institute of Hearing Research, University Park, Noltingham. and TDepartmcnt
of Otolaryngology, Universiiy Hospital,
Nottiiigham, U K
Accepted for publication
18
October 1991
COLES R.R.A., THOMPSON A . C . & O'IIONOGHUE G . M .
(1992) Clin. Otolaryngol. 17, 240-242
Intra-tympanic injections in the treatment of tinnitus Prolonged reduction or abolition of tinnitus has been reported in about two-thirds of patients treated with a single or weekly-repeated injection through the tympanic membrane of either dexamethasone or lignocaine. In a small-scale trial of these treatments, dexamethasone gave 6 patients little benefit but few side-effects. Lignocaine gave 5 patients no lasting benefit but violent vertigo for several hours. A.Axelsson (personal communication) had similar experience with 6 patients treated with intratympanic lignocaine. It is concluded that this form of treatment does not seem sufficiently effective to offset its low acceptability. Kcywords
tinnitus treulmmt
lignocuine
dcrnmethasonr
Local anaesthetic agents have sometimes been used for the treatment of tinnitus and vertigo arising from disorders of the internal ear. Three decades ago intra-tympanic' or intravenous' lignocaine (lidocaine, Xylocaine) was first reported to reduce the severity of vertigo in MCniire's disorder. For tinnitus, the use of intravenous lignocaine became widely recognized after the work of Melding and colleagues in 1 (978,3although previously Sakata and Umeda' had used intra-tympanic lignocaine and reported reductions in severity of tinnitus in 42 out of 58 ears. Its actual site of action is uncertain, some believing it to be peripheral' and others centraL6 Fradis and colleagues' subsequently treated patients with Meniere's disorder with intra-tympanic lignocaine and reported improvements in both vertigo and tinnitus, while Sakata and colleagues' also tried intra-tympanic injections of a steroid, dexamethasone (Decadron), as an alternative form of intra-tympanic injection for tinnitus. The technique of iontophoresis has been used to dcliver lignocaine into the middle ear.9 but the highly promising results reported initially have not been replicated in subsequent studies.",' ' Our interest in the possibility of treating tinnitus by intratympanic injcctions of lignocaine, and also of dexamethasone, was stimulated by receipt of the translation of an unpublished monograph by E. Sakata describing extensive experience of such treatment. In this he discussed such Correspondence: Dr R.R.A.Coles,MRC Institute of Hearing Research. University Park, Nottingham NG7 2RD, UK.
240
intru-tympanic injections
treatment in one or both ears of a large number of patients seen at the Saitama Clinic in Japan between January 1987 and December 1988. In Sakata's practice 348 ears in 274 patients with vertigo and tinnitus were treated with intratympanic lignocaine carried out up to 5 times at weekly intervals, with a reported success rate in terms of improvement of the tinnitus of 81%. As he pointed out, the major disadvantage of such treatment is that the patients have to be dealt with in hospital, at least on the day of injection, because of the side-effects of dizziness, nausea and vomiting which continue for several hours. He later gave intratympanic injections of dexamethasone in order to avoid these side-effects. 1623 ears in 1142 patients were so injected on up to 5 occasions, and tinnitus was reported as much reduced in 34% and moderately reduced in a further 34%, with few side-effects apart from slight giddiness lasting for a minute or so afterwards. Thirty-four of the patients who did not benefit from the dexamethasone therapy went on to a course of lignocaine injections, with good results in 21 of them. The translation received did not give details on how long the benefit from dexamethasone lasted, but implied that it lasted quite a long time. The reports of Sakata led us to conduct an exploratory trial of this therapy on a small group of patients attending the Nottingham Tinnitus Clinic who had been particularly resistant to other forms of treatment such as hearing aids, tinnitus maskers, extensive counselling, relaxation therapy, and a variety of drugs such as clonazepam and carbamazepine.
Intra-tympanic injections in tinnitus
Table 1. Details of patients and of injections given
Intra-tympanic injection
Patien1 details ~
~~
~
Female. 63 ? Genetic (cochlear) Unilateral tinnitus
Dexamethasone Dexamethasone
Male. 44
Dexamethasone Lignocaine
Noise-induced HL Unilateral tinnitus
Effect on tinnitus
__ _ _ Much increased
Unilateral tinnitus
Caused
vertigo pain _ ~ _ _ -
Much increased
-
Much increased Much increased
-
Dexamet hasone Lignocaine Lignocaine
Male, 49 Noise-induced H L
Caused
241
Slight Slight
V. severe
Moderate Slight
V. severe V. severe
Slight
-
-
Modisevere Moderate Minimal
V. severe
-
Slight Severe
Severe Moderate
Dexamethasone Dexamethasone Dexamethasone Lignocaine
Slight increase
-
-
-
Female. 68 ? Otosclerosis Unilateral tinnitus
Dexamethasone Ligiiocaine
Slight increase Slight increase
Male. 50 Unknown (cochlear) Bilateral tinnitus (both cars injected)
Dexamethasone Dexamethasone Dexamethasone Dexamethasone Dexamcthasone
Moderate Severe Moderate Moderate Moderate Slight* Slight* (*Bonain’s cocaine solution on T.m. beforehand)
Female. 49 MCnkre’s disorder Unilateral tinnitus
Lignocaine Lignocaine Lignocaine
-
Male. 52 Noise-induced H L Unilateral tinnitus
Materials and methods Six patients were treated with intra-tympanic 4 % dexamethasone initially. the same strength as used by Sakata. If this proved completely ineffective or even caused a worsening of the tinnitus, then the patient was to be offered intratympanic lignocaine. Five patients were subsequently treated with lignocaine. Injections were to be repeated at weekly intervals for a maximum of 5 weeks, but discontinued earlier if the patient experienced increased tinnitus or severe sideeffects such as vertigo or pain. One hour prior to intratympanic lignocaine, patients were given 10 mg prochlorperazine orally in an attempt to reduce vertigo. U p to I ml of fluid was injected, although in most patients part of this leaked back around the puncture site, presumably where the middle ear volume was less than 1 ml. Sakata used 4% lignocaine, Fradis et al.’ 1%: in this study, we used 2% lignocaine. Careful attention was given to positioning the head following the injection, in order to pool the injected fluid onto the region of the round window.
Results The results obtained are summarized in Table I . In 6 patients, dexamethasone was used first, but this proved so
~
~
-
Slight reduction Slight reduction Slight reduction
Slight Abolished 10 days Slight Much red. 3 days V. severe
-
disappointing. often with pain at the time of injection and worse tinnitus subsequently, that it was not used at all for the seventh patient. The lignocaine injections caused severe vertigo in all 5 patients so treated, sometimes necessitating temporary admission of the patient to hospital. Tinnitus was reduced in only one patient, and then not for more than a few days. Patient number 7 reported a temporary improvement in her tinnitus following intra-tympanic lignocaine, but had such severe vertigo that the treatment could not be continued. However, she incidentally reported that her frequent and severe attacks of vertigo were reduced and that, at follow-up 6 months later, the improvement in this symptom had been maintained. In another patient, not in this series as she was treated primarily for recurrent vertigo, there has also been a marked reduction in such attacks following a course of four intra-tympanic injections of lignocaine.
Discussion It is curious that such poor results were achieved in compari-
son with previous reports. No explanation of this can be offered, although it is possible that by chance the small number of patients we treated with the dexamethasone injec-
242 R.R.A.Cnles et al.
tions comprised a group of non-responders. or that Sakata and collcagues had been less rigorous in trying all other forms of therapy first and had thereby had morc treatmentresponsive patients. However. all five patients treated with lignocaine experienced prolonged. severe vertigo. This confirnied that the injection fluid had diffused into the intcrnal ear in sufficient quantity to cause a paralytic effect on the vestibular receptors, which lasted for very much longer than would be expccted from a caloric cffect alone. There was however little or no corrcsponding cffect on the cochlear receptors, such as reduced tinnitus or hearing sensitivity. Wc believc that intra-tympanic injections of lignocaine arc, at best, likely to produce worthwhilc results for tinnitus in only a small proportion of thc patients who are resistant to other forms of treatment. and at the cost of extremely unpleasant vcrtigo. In fact, our experience was similar to that of A.Axclsson in Gothenburg, Sweden, who tried this treatment on 6 patients using 1 % lignocaine (personal communication). In nonc o f his paticnts was there any long-standing relief. and in most there was such violent vertigo. nausea and vomiting for several hours that hc also has discontinued this possible line of treatment for tinnitus. Given this combined cxperience we conclude. at any rate for our own practicc. that this line of therapy is not sufficiently useful to bc an acceptable option for tinnitus. Intra-tympanic injection with lignocaine may howcver have a place in management of vertiginous attacks in Menitrc’s disorder.’.’’
Conclusion Intra-tympanic injections of dexamcthasone or lignocaine did not give a useful improvcment in the tinnitus of any of our patients studied. Most patients found the treatment unpleasant, with side-effects of severe vertigo common. This
form of treatment for tinnitus would not appear to be sufficiently effective to offset its low acceptability.
References I KROATHF. (1960) Transtympanale lnjektion zur Behandlung des Meniire‘schen Syndroms. Z . Laryng. Rhin. Otol. 39, 190- I95 2 GERJOTT. (1963) Intravenous xylocaine in the treatment of attacks of Meniere’s disease. Acta O/olaryngol. 8qSuppl. 188), 190- 195 3 MELDINGP.S.. GOODEY R.J. & THOHNE P.R. (1978) The use of intravenous lidocaine in the diagnosis and treatment of tinnitus. J . Lurvng. Orol. 92, 115-121 4 SAKATA E. & UMEUA Y . (1976) Treatment of tinnitus by transtympanic infusion. Auris Nasus Larynx 3, 133-1 38 5 LYTTKENSL.. LARSSONB. & WASTERSTROM %-A. (1984) Local anaesthetics and tinnitus: proposed peripheral mechanism of action of lidocaine. J . Oto-Rhino-Laryng. Borderlands 46, 17-23 6 EMMETJ . R . & SHEAJ.J. (1980) Treatment of tinnitus with tocainide hydrochloride. Oiolaryngol. IIead Neck Surg. 88, 442-446 7 FKADISM.. PODOSHIN L., BEN-DAVID J. & REINERB. (1985) Treatment of MhuZre’s disease by mtra-tympanic injection with lidocaine. .4rch. Orolaryngol. 11 1. 491-493 8 SAKATA E.. ITOH A.. OKTSUK.. NAKAZAWA H. & IWASHITAN. (1982) Pathology and treatment of cochlear tinnitus by blocking with 4% lidocaine and with Decadron infusion. Pracr. Otol. Kyoto 7 5 , 2525--2515 9 BRUsis T. & LoEh’h’tcKEx I . (1985) Die behandlung von ohrgerauschen mit de iontophorese lokalanaesthesie. Laryng Rhinol. O l d . 64, 355-358 10 WILLATTD.J., OSULLIVAN (3.0..STONEY P.J.. JACKSOS S . R . . M.S. (1987) A sequential doublePRLTCIIARI) J. & MTCORMICK blind crossover trial of iontophoresis. In Proceedings u/’ 111 Infernational 7‘innitirs Seminar. Ed. H. Feldmann, pp. 316-319. 1Iarsch Verlag. Karlsruhe J.B.. VERME~J I I LAFFR~E P. & HIJLSHOFJ.H. (1989) Thc eRect of iontophoresis of lignocaine in the treatment of tinnitus. Clin. Otolaryngol. 14, 40 1-404 M.. 12 A i ~ oY . . MUKAIY.. ISHIKAWAT., ISHIYAMA E., HASEGAWA SHIGIHARA S., ABEH. & TOMITA, H . (1987) Treatment of severe Meniere’s disease by intra-tympanic injections with lidocaine. Equil. Res. JUPUII46, 207-21 3
