Tinnitus: past, present, and future

okay welcome everybody to the lakeside art center of the University of Nottingham my name is Michael Aykroyd and under director of the Medical Research Council Institute of hearing the search it is an honor to introduce tonight's inaugural lecture given by David Bagley the new professor of hearing sciences here at University David had a very distinguished career starting in Manchester with undergraduate degree and then Open University palatal approximant the last 15 years at Cambridge he is possibly unique in UK audiology for having degrees in audiology psychology and MBA and a diploma in pastoral therapy for the last five years he has been head of the Auden school services added books hospital in Cambridge which is very much one of the best in the entire country and he's won national and international awards and recognition is been editor of primary journals and he's been instrumental in many of the UK professional and patient societies including being president of the British society of audiology and current president of the British tinnitus Association it really is wonderful for him to join our fiber in healing and tinnitus community here in Massena so here we are they tell us about the tip that past the present and most excitingly the future of tinnitus thank you very much everybody welcome and thank you indeed for joining us this evening it's a pleasure to be with you and a pleasure to be here in Natyam amongst what Michael has said is an absolutely thriving community of scientists clinicians audiologists and researchers looking at tinnitus amongst many other exciting things but I've come to join them and one of the reasons I have come to join them is that in Nottingham they occupy we occupy this translational space taking ideas from the basic science laboratories feeding them through pushing them into the clinic but importantly feeding them back also so the questions that clinicians ask that patients ask set the agenda and the mindset of the basic scientists so essentially a good two-way flow of conversation there that I'm delighted to have become part of but my core discipline is as an audiologist this is a real t-shirt you can buy on the internet and you know what to buy your audiologist friends for Christmas our audiologists intelligence are they funny are they attractive all of the above but there are a couple of other things as well they're fortunate and very often they get to help people and very often the very best audiologists a compassionate sometimes people think audiology is a technology profession taking hearing aids prescribing them cochlear implants and giving them actually what audiologists do is intervene in people's lives so that they live their lives to their full potential so a profession fueled and powered by compassion I am delighted here to see so many people I think I've got a personal interest in tinnitus and some people have got a professional in and tinnitus so it might be nice for you to see who each of you are so without putting anybody on the spot if you have a personal interest in tinnitus could you just raise your hand thank you lots of people and a big component if you have a professional interest in tinnitus and if you have both raised both hands yes ok so you now know who you all are now now I was determined that this that there would be a lay audience here so thank you very much people for coming it means my job is a little bit harder and that I need to provide things for you and for the science community but let's work on that and when I do your thing let's be kind and tolerant Amanda Jesus I think let's be kind and tolerant to and start that dialogue because that's the translational dialogue too so what we're going to do is to talk about definitions about some past instances of thinking about tinnitus to talk about tinnitus in the present day to glimpse some of the future maybe perhaps and then at the end I'm gonna close by talking about the particular research theme that I've chosen that's going full steam ahead very excitingly for me at least and to share some of those new horizons with you so what of definitions this is the first definition of tinnitus in the English language especially the first time tinnitus has ever used recorded in the English language and it comes from a physician's dictionary in the late sixteen hundreds at the time tinnitus was either buzzing or a sensation and was thought to be an obstruction and all sorts of trepanation or opening up operations were performed to try and release the traps air from within the head or the ear of the person that was struggling here's the actual book itself it's in the university library in Cambridge and one of the librarians as tinnitus was kind enough to get that for those of you who have got very good eyesight will see one of my favorite things which is tinnitus is right next to tickling it's probably the only instance where tinnitus and tickling have been linked together maybe somebody in the world is looking at the link between the two but I'm not sure I've heard of that anywhere else but a more usual definition is from an American ENT doctor called McFadden who suggested tinnitus is conscious so you know that you're hearing it it feels like a sound it's involuntary so you hear it whether you want to or not it appears in the head well maybe I'd question that as good numbers of people start to hear their tinnitus in the environment or around the head or elsewhere in their body or perhaps it just appears to do such that it's a reasonably helpful definition some of you are busily writing things down taking photos if you want me to send you the slides send me an email and I'll send you a PDF of the slides to save you a nice tres now what is the impact of tinnitus and the impact of severe tinnitus well it's very particular and unfortunately as we'll see in a minute more common that it ought to be it's an impact of agitation arousal an irritation of reduced concentration the ability to hold different pieces of information in your mind at any one time sleep can become fragile and collapse and over time a person can become anxious and depressed Scandinavian term for that is emotional exhaustion I think it fits really well with the experiences some tinnitus people having we're going to hear more from you tart homes that French otologist in the late seventeen hundreds but I love his quotes here an extremely extreme discomfort which leads to profound sadness there's something there I say in terms of the tinnitus condition and there's a young man telling us about his tinnitus condition is happy for us to see this this evening and to talk about it he's in a much better place now he's seven he has no hearing loss if not had a head injury it's got no particular reason to have tinnitus but you can see his tennis is like a hot band across his head when I've seen children in the clinic are very often get them to draw a picture of themselves to tell me their parents their teachers about their tinnitus situation a very good way of articulating it and what I can see here is that he's physically uncomfortable and he's emotionally distressed so that's an articulation now I think of the profound sadness now what's the scale of the problem thankfully we've got good data and we've got good data that was first collected about two hundred yards from here in the Institute of hearing research by Professor Adrian Davis who did an epidemiological study so a population study of about 34,000 people with hearing experiences and he asked them about tinnitus here if T which I was a member for a very short period of time but a third of adults in the UK said they've had tinnitus at some time or other but one in ten said yep that lasted more than five minutes no particular reason for it about one in twenty really annoyed me and who's been referred between two and four percent of adults that's very variable the less commonly referred if you're in an area of deprivation the less commonly referred if there are no services around for you to be referred to common sense but we know that information now and that's a big argument for tinnitus services being available across the United Kingdom now that's adults what about children well one of my PhD students just last year did a systematic review of what's known about tinnitus in children picking up every bit of published information that she could find and she could find papers that said 7 percent of children have tinnitus other papers that say 60 percent of children have some time or other so a range that was too wide to be credible and when she looked at why that was it was because everybody used a different definition different age ranges some of whom went up to 19 years old which is not a child in Cambridge never mind knotting on and also different methodological problems so too wide really to be credible so study from Bristol that I was involved in looked at an interesting cohort there a group of children in Bristol who get tested medically clinically every couple of years and in their 11th year somebody put a hearing test and some questions about tinnitus and about hearing sensitivity and well-defined questions not perfect so they were sitting on the data and we had a look at the data and found that 3 percent of those children had clinically significant tinnitus that is it was bothersome and it was persistent so 3 percent one child in every primary school class in England given that there about 30 children and some interesting associations with mild hearing loss will talk about hearing loss again in a few minutes but some further work to be done there I think a mild and moderate hearing loss or a big research theme within the wider groups that I'm part of and dr.

Melanie Ferguson is here is a leading light and a pioneer in that regard sticking with the tinnitus many people experience more than one sound and often tinnitus is highly complex highly variable left side of tinnitus for some reason is more common than right that's the case even when you factor out the fact that many people are right-handed and Hammer with their right hand and shoot from their right shoulder there is something else going on there women are more likely to report than men but maybe there is more sensible in talking about medical symptoms in general prevalence increases with age but we've talked about children already and increases with hearing loss Prenton complicated subtle ways many people with hearing loss don't have tinnitus many people is quite mild hearing losses of severe tinnitus so there's something complex there that we need to start to unravel an unraveling is really one of the key things we need to do because everybody returned at us is different different in their experience different in their type of tinnitus different in their cause different in the effects and that's a real medieval research it's a real constraint to research in trying to get some really good answers to these very very important questions now what then of tinnitus in the past what do we know well the earliest reference to tinnitus that's known are in some cuneiform tablets from the library of ancient Babylon there are six that mention a disease and one of them is extensively about tinnitus this is not the actual tablet an example of the type of tablet Genesis at the time was thought to be one of two things this thought either to be warring insects in your ear in which case you would infuse your ear with lotions and potions or it was thought to be a spiritual affliction and you would drive away the malevolent spirits by repeated whispered incantations and if you look in research clinics at the moment and look at what people are doing well later we're going to be talk about infusing the ear with drugs and we're going to be talking about the use of quiet meditative sound to try and reduce the starkness of the tinnitus so maybe we're not so very far away and then Hippocrates epoxies of course the father of modern medicine very interested in a disease seven mentions of tinnitus in his writing and various different theories and thoughts and he mentions a treatment for tinnitus that became very popular in ancient Rome but you had to do was to get the strongest fortified wine that you could find warm it up it's almost much opium in it as you could possibly and drink this on as regular basis as you could manage stupefying but when you look at what the most common treatment is the tinnitus in the United States of America this year citric called alprazolam which is benzodiazepine it says addictive as an addictive thing that's really addictive and it is owns you out it stupefies you so maybe we're not quite as far on as we thought the jean-marie he told his famous in audiology for two things first person to call himself an otologist that's not particularly what he's famous for he was famous because he used to try and teach deaf children to speak so the way she used to do that we would now think were cruel but he had some expertise in that area and the the villagers in the little area where he lived found a boy aged seven who have been living wild since he was lost since eighteen months old probably living with the wild dogs and the boy did not speak but the boy could hear and eat hard tried to teach the boy to speak and failed and tried again and failed and he said I wonder if I wonder if there's a critical window when you can learn to speak and when that's gone you can't ever then learn to think and of course now that seems to be the case and that's why we moon have an earth to find young deaf children as soon as we can to feed their brains with sound so they learn to speak in the critter called window for the acquisition of language but Attard was also famous for having written about tinnitus was the first person to say take your therapy sound and match it to your tinnitus so he said if you have a high pitched in to collect green sticks from the forest burn them on your fire and the hissing and sizzling of the sticks will drive your high-pitched hissing and sizzling from your head and if you have a low pitch tinnitus go and live next to a watermill because the rumbling of the watermill will drive the tinnitus from your head and it's only now actually that we have the ability to modulate therapy sound for clintus that cloak it around the tinnitus signal to make it similar to the tinnitus signal with new digital combination devices again being researched elsewhere within the biomedical research center that unparticles and again that's another example of us looking back and looking forward and then finally Toynbee time baby was an otologist who works at Queen Mary's Hospital in London and he's famous because he had a large connection of temporal bones that's the bone that your ear is in it's the hardest bone in your body and he had a whole library of temporal bones from people with different conditions interesting he was also the father of Arnold Toynbee who is a famous social reformer and Tony had terrible tinnitus and tried and tried to improve his situation and eventually hit upon the idea one Saturday afternoon I believe of taking a mixture of ether and chloroform and breathing in as much of it as he could possibly manage and he died so a tentative martyr but actually anybody even is read the papers in the last couple of weeks I know that people still do die with tinnitus I'm not going to talk about that particular tragic case that was recently in a lot of the papers but actually maybe we're not so far on in terms of some of the things we know as well now what then about tinnitus in the present day what's our present understanding and then I'll take it on to have a look at some future things and firstly our modern understanding of hearing wants to talk about why on earth we here because my mammals hearing is a very evolutionary expensive sense it's difficult to develop and mammal bodies invest a lot of time and energy in hearing so it must be doing something absolutely fundamental so survival and the suggestion is that it's our early warning danger detection sense the small mammals that fear the barn owl in the tree here have developed with a an evolutionary understanding that the barn owl is able to camouflage itself visually but it's not able to camouflage itself acoustically so the sense of sound develops so that the small balls and mice that the barn owl wants to eat will hear the barn owl approaching and then react and move away at the earliest possible opportunity so hearing has to be sensitive it has to be on alert all the time and has to be plugged in to systems of reaction and arousal and emotion and it is now some of you will know your auditory and as to me that the area of great interest is the cochlea transducing the vibration of sound into electrical nerve energy with it having trouble down the ear canal and across the acicular chain and smallest bones in your body in the middle ears we look inside the cochlea here's the cochlea from the kreski Institute in Ann Arbor where the bone is being dissected away from the cochlea this is a left ear so you can see the cottage bone a pro appearance to the cochlea there and the beautiful appearance the vestibular labyrinth there with the semicircular canals set orthogonal to each other to capture movement in any plane and to capture acceleration as well if we look inside the cochlear this is from the day finesse and the late Carol Hackney in Kiel what they've done here take a guinea-pig cochlea and to take away all the gelatinous membrane above it and you can see here the two rows of hair cells and in a hair cell and an outer hair cell which are positioned thus within the organ of Corti the flow is called hair cells that's the only thing essentially that they have in common and neither of them are actually has these little nerve cells sensitive to sound stimulation and the inner hair cells which number 3000 when stimulated speak up to the brain and tell the brain that a sound is present and each is tuned to a particular frequency the outer hair cells paradoxically are much greater in number about 12,000 and their nerve supply comes from the brain to the ear and there they is controlling the brains control early hand on the ear controlling the sensitivity of the ear the frequency selectivity and the discrimination of the ear and the ear then the cochlea is then connected to the auditory brain which is this beautiful cascading system of different junctions and relay stations taking sound up until the points where in the auditory cortex you're recognizing it interpreting it analyzing it and making sense of it and as I said there's a pathway down from the cortex down to the cochlea controlling analyzing supporting the cochlea in its job of transducing sound and this kind of course go here's some age-related damage where both the inner and outer hair cells have started to degenerate and here's some noise related damage some normal outer hair cells there and some noise affected outer hair cells there you can see the devastating effect that the noise has had on the structure of the outer hair cells and these processes of cochlear degeneration can cause the ignition over tinnitus could cause the point at which the tinnitus begins but an important distinction to say is then what is the mechanism of the tinnitus be perceived within the brain and essentially the research scientists are looking at three mechanisms the first is that the amount of noise within the auditory brain has increased that said a good theory but unhelpfully many of the things that seem to be involved in tinnitus like hearing loss at the level of the cochlea decrease the amount of spontaneous activity within the brain another inconvenient truth so the further elaboration of that theory is perhaps the spontaneous activity is not increased necessarily but perhaps it's become more synchronized it's more in step with each other the metaphor is of some squaddies walking to the probe on a Friday night and they're walking as a rabble and within three or four steps they're walking in step with each other or all the lovely people who walked on the Millennium Bridge in London remember the rich walking at random and before long they were talking in step with each other and the bridge would resonate to the extent it would potentially throw a small child off the bridge into the Thames bad idea so current thinking of tinnitus is the perhaps the auditory system has somehow got in step with itself it's correlating its activity so the brain thinks that must be sound there's a compelling reason for me to think of other sound and perceive the tinnitus more important than any other sound around as it's more correlated or more organized and then a much more modern view is looking at networks within the brain of the group of Newcastle looking at this some very innovative work looking at how networks within the auditory system but also extrinsic – that are outside that a holding the tinnitus promoting the tinnitus remembering the tinnitus that's a rather interesting idea as I went onward clinically had many patients who had same when I wake in the morning I'm not sure it's there and then I listen for it and there it is again as if the brain was somehow remembering and maintaining the tinnitus but what are the upset what are the paradoxical sadness that we talked about well here's the modern understanding of that the suggestion of the electrical activity in the ear or the auditory nerve perhaps increased perhaps correlated perhaps promoted by networks but that felt as filters that should be blocking that should be stopping at in its tracks let it in and once you feel the build-up anxiety fear and disparate the persistent awareness of it and the increase in autonomic or automatic nervous system arousal your autonomic nervous system does rest and digest or fight-or-flight if you're the member of an audience at an inaugural lecture you had a glass of nice wine and you read something nice you're resting and digesting if you're the poor benighted fool is going to give the lecture you'll fight your slides so those things are held in balance with each other but in tinnitus it's that increase in the agitation and arousal and the source of course is that these things are not separate but is speaking to each other and to each other and to each other building up a self-reinforcing persistent loop that people can get stuck in and our hope is that we can take them back to a point of habituation that process by which you become aware you become unaware of sensory stimuli when you came out to listen to me this afternoon you put your shoes on and you felt the shoe on your right foot and you haven't felt it since but the nerve firing is still there or people who live next to the a52 had to learn some local examples of this how do you live here we don't hear it you're a liar we don't hear it they forbid to a teacher or fireworks night you hear the first key fireworks you look out of the window half an hour later the council can do what they like you're not interested your brain doesn't register it does this happen with tinnitus often yes not always is it possible to help it happen in tinnitus often yes not always so what can a person do to move in that direction firstly get some decent information and get some information rather than myths there are ways of doing it the British tinnitus Association is an excellent source of information I'm going to be giving you their details at the end and this little book is is an attempt to try and give concentrated information for people in trouble so that as they're free and that's widely available get an informed and positive medical opinion and if your doctor ain't informed and isn't positive change the doctor sound enrichment means avoiding silence the tinnitus will be stark and clear in a quiet environment so have some sound around you a fan hearing aids if you have hearing loss we'll talk about that in just a second and to reduce your agitation and reaction many many simple techniques of either relaxation or mindfulness meditation the two are different quite distinct both of them have got very high value for tinnitus and if you're having trouble sleeping with your tinnitus the British Genesis Association have got a very very good leaflet on something called sleep hygiene that we don't have time to get to today but we can't switch it off often with the reduce impact improve sleep sometimes improve concentration reduce distress reduce awareness now what are the techniques that are used in the clinic some of the clinicians from local cows and queens medical are here just now bedside sound generators that use the sound at the rain and the ocean by the bed or in the pillow blending with the tinnitus rather than masking X hearing aids for hearing loss and there are now combination devices that include hearing aid circuits and sound generators again to blend with the tinnitus very new so new we're not quite sure how to fit them we're not quite sure who will benefit from them again really good research planned in that area but an area where things are developing and then the psychology community have stepped up remark and are talking about using cognitive behavior therapy for tinnitus their argument is that your beliefs about something affects how you perceive it and how you behave they asked us to imagine somebody standing on a busy Tube platform in London and let's say it's a bit of an unpleasant part of London and suddenly you feel a poke in the small of your back how are you all feeling about that not happy being imposed upon is there another one coming is there something bad going to happen and you turn around and the person who did it is a blind person we've seen advertently hit you with their stick or their umbrella and how did you now feel foolish compassionate relieved and the psychologist say look the poke in the back is a poke in the back is a poke in the back what's changed is your interpretation of it so how about a tinnitus is a tinnitus tinnitus letters at these patients and we can change their interpretation of it interesting in some reasonable research work actually indicating benefit there but what really does seem to work is combining the audiology with the psychology so this is a paper in The Lancet I was really honored to be part of this research group from Maastricht and that looked at comparing standard audiology care for tinnitus with with audiology care that involved psychology care or so what we did was to take a group that had standard care so a hearing test basic information a hearing aid or a sound generator and importantly going to talk to somebody who had been nice to you but not psychologically trained and not directive and comparing that with a group that had the standard care and then tinnitus counseling for exactly the same amount of time just doing something different so this was a design that for the first time controlled for the counseling effect good numbers in the groups well-designed study and at 12 months the specialized caring group improved in terms of quality of life in terms of the severity of the tinnitus in terms of their impairment with the tinnitus so the headline users if we manage distress and fear as well as managing hearing maybe there's benefit there maybe there is benefit there and later work went on to say well this was more expensive but was it cost-effective and answer was it was because the benefits were sustained so patients didn't need to come back to see another audiologist or another ENT or another doctor of some other kind to try and get some benefit on their tinnitus journey what then of the future what future hope do we have in regard for tinnitus firstly there's hope in that the community now is collaborating and sharing knowledge this is a review paper there are many other tinnitus review papers but one that I wrote and again in a decent journal with an ENT and with Professor Deb hall who's one of mine colleagues within the biomedical research unit and with Michael is the other professor of hearing science and not animal we threw everything we knew into this paper so people could critique it get frustrated with it be provoked by it to end – in order to get the attention of the wider medical community some indications that it has started to work so what's happening well one of the first things that's happening is there a good number of new technology approaches that have time to go quite through them all but let's just pick up a couple mute button was invented in Southern Ireland and if you have troublesome tinnitus you listen to a tone being played while you electrically stimulate your tongue a thought by the researchers being that they are able there somehow to unlock the plasticity of the brain to try and detune the tinnitus antigenic if there's a little patch that you were behind your ear with a local anesthetic in it which has been shown to work on tinnitus if it's infused into the bloodstream but is very very dangerous but does the patch get into the ear the others you can see there are some techniques that put a notch in your favorite music and around the tinnitus frequencies there are others that boost the frequencies of your favorite music around the tinnitus very different approaches now what else is you well if this cognitive behavior stuff therapy stuff works and why can't it be more available and one of the reasons it can't be more available is because there are very few psychologists who are interested in doing that work so there are two emergent approaches here the first that I've been involved in is icbt which is internet delivered CBT this is a program where somebody with tinnitus works through a series of modules guided by an audiologist who's available for them by phone or via email it's password-protected and they move between these different modules and we're assessing in a clinical trial and the whether this is the same better or worse than standard care indications at the moment are encouraging but I would say that because I'm one of the people who developed it and Nottingham a different approach is being taken and dr.

Derek quarry city just that they're providing audiologists with a manual for doing cognitive behavior therapy in audiology clinics so it can be done safely and effectively and cheaply where the tinnitus patients are and that's being very rigorously evaluated to get it absolutely right and drug trials are going on the general there are two approaches one is infusing drugs within the ear particularly a very new tinnitus a drug recently was trialed which seemed to have some benefits for people with very severe tinnitus and people with tinnitus due to infection didn't have benefit in the wider tinnitus population disappointing and then another drug which looked at changing the way the brain stem responded to tinnitus whether an auditory nerve comes into the spinal cord and joins the brain that was changing the way that potassium is used between nerve fibers to signal to each other again disappointing but real drugs in real people in real clinics and I think getting the drug companies involved here is very very important now in my last few minutes of closing let me tell you about the work that I'm particularly going to be doing and then we can have time for some general discussion and you know the cancer is immensely common around the world but treatment is better than it has ever been people with cancer are living longer and more of them are living and there are large numbers of them on that's growing majority of them are adults not relevant to me well a lot of the treatments that are used particularly the chemotherapy that's based on platinum drugs which is immensely helpful and effective is toxic to the inner ear and can lead to hearing loss and tinnitus and 20% of them receiving cisplatin and surviving testicular cancer have a severe profound hearing loss for in ten of them develop tinnitus and the oncologists used to justify this you can justify it well by saying look I've saved your life but then some patients say yes but this is not a life or this is not a life with quality of life because of hearing loss and tinnitus so there's a clinical issue here to do with the way that these things are done and in particular the cisplatin the most commonly used platinum OSA toxicity gives people a progressive bilateral so both ears high frequency hearing loss causing difficulty hearing in noise isolation communication that people perhaps were already burdened and the tinnitus that it can cause can lead to insomnia agitation and reduce mood when people who are always already carrying a burden of their cancer disease and treatment is it quote from some oncologists who are waking up to this what may seem to be trivial drug-induced toxicity as the potential to change quality of life and functional capacity drugs meant to treat can become the source of interference in activities of daily living and treatment compliance may be jeopardized people might step away from these chemotherapy treatments because of the toxicity that's being caused and here's a case that came to me just about seven months ago in the clinic I was in in Cambridge should I continue with my treatment she asked to us 24 the relatively late stage ovarian cancer planning a marriage planning a house move was a waiting round three of six chemotherapy treatment she developed a high-frequency hearing loss so her inner ear is affected that was mild but what was not mild was the bilateral both ear killer tiss that she was having causing her sleep to collapse her mood to collapse the marriage was on hold the move was on hold she wasn't working and I'm prepared to stop my treatment because if there's got any worse at all I couldn't manage will it will further treatment make it worse and we don't know we can't populate that equation thankfully in her case it didn't she went on with treatment without it she'd have lived 18 months with it she has a good life expectancy of 5 years but we can't populate that equation unless we know who what why where and when and here's a case for an adult patient drawing themselves in the midst of platinumath therapy on steroids so she's driven she's drawn the puffy face that she had but you can see the cacophony of the tinnitus around her defining her in that difficult challenging situation what's causing the hearing loss and the tinnitus well the the organ of Corti this area here is well sealed and well protected the body does not want viruses or toxins in there but the root into the cochlea is through this area here which is like a coating around the wall of the snail shell of the cochlea called the stre avascular s and it's the metabolic engine of the cochlea it's where lots of metabolic processes so so processes that enable the cochlea to work with energy and to work as effectively as it does taken and that's the way that these drugs can enter into the endolymph or the cochlea fluid there and affect the inner the inner and the outer hair cells there it's most commonly the outer hair cells that are affected as they're slightly more vulnerable due to the way that they work but there's a big problem with the large numbers of studies that we're looking at looking at the moment on particular chemotherapy drug called carboplatin because I thought there'd be fewer papers written about carboplatin and hearing and research group that I work with and I I've got a thousand papers to read as quickly as we can to try and work through that there's a lot of work in this area but it's not good the numbers are small the testing hasn't been right they have made enough account of the complexity of things that people having you can see the other issues there there are big problems with the literature the best study is some work that comes from the states group based in Indianapolis and they've calculated the cumulative dose of cisplatin in 488 patients surviving testicular cancer and they met power much hearing loss you have where the low dose and it's sharing loss you have with the high dose with the higher dose which is the more usual dose 55 percent of these men had a moderate hearing loss or worse that's life-changing it is hard to live a modern professional family life with a moderate hearing loss after these four hundred and eighty eight patients exactly 1.4 percent of them have been given hearing aids so there's a clinical problem here that people aren't there's a big problem and people aren't getting the care that they need so what we're going to be looking at is the who what where when how and why is this who is susceptible is it genetic is it the fact you have a hearing loss already isn't your age it appears to be the very young very elderly are more susceptible and when does it happen that's rather important in particular reason I'll tell you about in a moment does it happen later on in the chemotherapy cycle what is it happening earlier on so we're pulling out every bit of research we can find to try and get to the bottom of this secondly there are some ways now that patients can test their own hearing and this is important because every oncologist knows their patients on these drugs should be being tested but vanishingly few of them have the tests because the test is hard to do involves a soundproof room and an audiologist and these patients are often tired and sick and don't want to go to hospital again another time just a hearing test so what we're trying to do is to find a hearing test that patients can do just like the blood tests they do just like the blood pressure test they do just like the temperature that's taken every time they have the drug there are at least four different types of self testing that can be done so we're urging in reviewing the technology there and then we're looking at when does the hearing loss occur with chemotherapy what pattern does it follow and how much long-term trouble does it cause in terms of tinnitus and hearing loss so applying for money for each of those areas to try and get research seems there but the overall aim of protecting the cochlea at the moment anything you do to protect the cochlea protect the cancer reduces the efficacy of the anti-cancer drug but we've got to look at ways of protecting the cochran we're starting to get an idea there may be some ways of phasing that in time that would allow the the platinum-based chemotherapy to reduce the tumor but we then later protect the cochlea as it becomes vulnerable but a team of people working with me John and Bonnie are over in that corner Christus starting to work on the self-test area and colleagues within the university the University Hospital trust really stepping up with very very great interest there now if I pick your interest there are some ways of chasing this conversation further progressing it further forward the British Tennis Association would love to hear from you there's their website if you're interested in joining a tinnitus support group they'd love to hear from you their ways of organizing those and supporting those whether you're the person today that's come from Henley or the person that has come from Crawley thank you very much is doing your motorway travel to come and hear me if you're interested in research then they produce what's effectively a free book about tinnitus research every we're just finishing the 2017 version there so in summary what I hope to have told you is that past present and future tinnitus a fascinating topic but a tremendous amount of work going on to move this area forward at them for us to get some really effective treatment and prevention thank you very much for your kind attention now we do have some time for questions Michael Jun to chair that importance understanding treaty and transfer emptiness many of us on Flores recognize we'll get it when you have any no that will cure it quickly she possibly have and Dave and his team of the PRC the forfox of international intensifying [Music] thank you the microphone is making its way to people but I'll repeat that question and thank you for making it a general question because clearly I can't answer personal or treatment questions across the floor here so the question was has been any research into environmental or dietary factors that have a remember dollars lifestyle factors there has been again it's not been particularly good there are some suggestions that people with ongoing chronic stress in their lives react more strongly to tinnitus when they get it and have less resilience there and that's common sense really there are some factors that have been linked with increased tinnitus like blood pressure or smoking or recreational drug use but often these aren't properly controlled so it's all a bit murky as a result there are quite a lot of myths around and you'll see lots of do not do lists the tinnitus I think one list that I saw had red wine cheese red meat milk almost anything that's any fun to have in life whatsoever chocolate really no risk coffee no research basis for that most things have been looked at in particular it collapses but it takes a lot of time energy and money to look seriously each of those things and it's only relatively recently that the tinnitus research community has gone from being a mature into being professional collaborative and all the things that I hope I've shared for you so thank you yeah the tinnitus aya vibra-pulse laburnum and is completely separate to me area now better hearing test and the test of fire well no problem with that you didn't read what you went up we would associated everything there with the area in through you is that usual it didn't go up in that okay so let's generalize your question if I may and I worth making the implication that an awful lot of tinnitus is associated with the inner ear and the brain and the way that they do their dance together both the hearing brain and the emotional brain as well there are some other types of tinnitus that are not related to that there are some types of tinnitus that are due to problems in the middle ear so the muscles contracting and going into spasm very particular sensations people get of clicking sound and fluttering in their ears and then there are other types of tinnitus that appeared to be pulsatile so mimicking the sound of the pulse in your head or in your body and that's worth a good medical opinion in that case because there are some things that need excluding in that situation sometimes it turns out to be postulated so cardiac synchronous are the times it seems to be completely dissociated and to be mimicking the pulse but it's worth asking the question I'm really pleased that you mentioned children in your presentation I'm just wondering about whether there's been any research into the links between dyslexia and churches and whether that's something that's going to be looked at but also about the support groups for children because a lot of the support is around adults and not children with quite severe tinnitus thank you so the suggestion was over specific research linking dyslexia until is there's been some speculation but I haven't seen anything that's rigorously rigorously looked at that but it may well be that I just haven't seen it but one of the great pioneers of dyslexia work Dorothy Bishop then quite a lot of hearing work in the past and does talk to the hearing community so there's an interplay there then you spoke about supports for children now the British tinnitus Association run a course for professionals dealing with tinnitus in children so people our expertise is starting to be spread and are looking at the resources that might be available there are some books that they produce for children with tinnitus written in age-appropriate language and for the first time is really decent design so it looks as good as the books that the kid would be reading and what kids read these days my kids read Captain Underpants which was a particularly good artwork but these that these are are are well produced so so that again the community is waking up to realize there's an issue here the people we're not necessarily taking this with as yet is the education community the teachers and get the one child in every class perhaps as a way into saying to the education community you will have some children in your school with these issues yeah you've mentioned cancer and the treatment of Internet reflect on tinnitus and I'm wondering what researcher is though on noise as a cause of kinases when we break barriers to a lot of noise thank you there's a tremendous amount of research into noise as a provocation for tinnitus and some of it is good one of the big areas of research at the moment is in the people have been exposed to noise and think that they have got away with it because their hearing test hasn't changed and the suggestion is in those cases the hair cells might be intact but they might not be the most vulnerable part of the inner ear and the nerve it may well be that the nerve sign-ups Azur junctions have deteriorated and there's a lot of work going on around the world looking at that particular population and beki here in the wavy hunt has got a big project looking at patients like that testing them very rigorously and using magnetic resonance imaging famously invented not far from here as well and trying to draw out some of the things that's happening there because this in a sense is a ticking time bomb of people are being exposed to noise now not noticing a hearing loss particularly but storing up fragility and vulnerability later on in life and if I got that light you can buy me a cup of tea and I forgot it wrong you can tell me in the morning I pick up on one of your slides there where you mentioned avoiding silence now I have acoustic trauma and pretty like no doubt other people they have very bad very loud tinnitus but I have noticed occasionally when I've been in the bathroom I won't say what I'm doing there I'm contemplating my toenails basically and I've found that actually that concentrate on trying to reduce the sound I can actually get it down to what appears to me to be something like 10% I never quite get it there all the way but it seems that to me that the soil and saw the acoustics in the silence of the acoustics we like in the bathroom are somehow reducing it just temporarily I think don't know whether you could comment on it's very helpful indeed avoiding silence is a general advice and there are two big flaws with it it's good advice the two big flaws of it one is that people can become obsessed by avoiding silence and carry sound with them all the time and fear being in the presence of their tinnitus which of course potentiates it makes it worse because you're frightened of having it if you don't even go to the loo because the tennis will be there with the TV not on then you're going to carry some kind of sound generating device with you just in case you hear it but there are several approaches now that are looking at whether you should consciously pay attention to your tinnitus and try and reduce it and in particular mindfulness meditation says that if you have a problem a fear a pain an issue in your life then you should lean into it become aware with of it coexist with it and by doing so you will manage it and that potentially is part of what you're doing is difficult to know but I've certainly heard that sort of situation before it's excellent you've got that kind of conscious control over it and what that means for some people again generalizing it is if you feel you've got some conscious control over something you no longer feel helpless and vulnerable because you know you can influence it and that's very important so thank you I few months ago I think it was last summer I went on a study at the hearing Research Center of the way there and was fed a sound through headphones that have been sort of assembled over a period of time with with test sounds so in effect it was white noise had the remarkable effect of removing the tinnitus albeit for three or four seconds but you mentioned little earlier about a new generation of hearing aids I'll call them with the possibility of noise generation what is the current state of play on those okay so several several responses so you and you were in the biomedical research unit if it was then in the summer which was before my time so like every new prime minister and they talked about the failings of their predecessors I could say before my time so but it sounds as though it's beneficial for you because you experienced something called residual inhibition in the 1980s we used to test attendance of patients this all the time get them to listen to a minute of sound and time how long they let tinnitus was reduced for or sometimes absent for before it broke back in and then this became really really unfashionable but it's become an area of interest again and people are looking at that so that's called residual inhibition now you asked about the combination sound generators the technologies are fantastic we can shape sound we can use sound the latest devices with can Bluetooth sound are not available in the health service quite yet but they will be in time and we can Bluetooth sound like the rain and the ocean into the devices so the sound of your choice is with you but we don't yet know quite what protocols to use to fit them who will benefit for them how cost effective they are and what the long-term benefits are so we're applying it for work and Magda is here doctor sir ada is for a large grant to look at that to try and work out the feasibility of a study that would address some of those questions so that we in the clinical community don't do the same thing that the technologies are doing of pushing things out there before we really know what the benefit is maybe once we just take one more I love that I like to ask about sleep we're hearing less about sleep that it's difficult if you've got tinnitus and therefore we can try and mask eat etc but I'd like to ask honestly actually make little Smurfs by increasing the brain activity while you're asleep thank you I think there is the there is an effect and certainly I sort of patient last week where there tennis has changes every time they sleep and they wait faithfully not knowing what state they're going to be in but I think it's not necessarily asleep so much that changes it's the process of waiting and when you awake sick after a catnap and a lot of times as people say cat naps are disastrous because when they wake from a cat nap the tinnitus is reignited by that and you are nodding and agreeing so I think we need to look at what happens in the brain when we wake from sleep and what those processes of a rapid activation are and how they are drawing the tinnitus up in their wake and pulling the tinnitus up with it so I think that that's an area of interest but people are already looking at my to-do list and saying you might be being a bit ambitious there David so I think I'll leave that to some of my colleagues to look at my project the one thing as we close is to say I think the drinks and some of the food is still available until 7:30 okay that case I will hold off the very last question quite quite quickly Dave you said that clinical reports of dentists go back three and a half thousand years the ancient Babylonians what's your guess of us us actually never do something about tinnitus in the next five or ten years you can always trust your framing stores for those difficult question silently okay you're off the Christmas list when I started working with tinnitus which was over 30 years ago I used to go to lectures and said in five years with a practice I go to lectures down people say in five years we'll have cracked it and we are further on and the community is talking and there are really good programs of research getting funded and going forward not enough not nearly enough but there are there are signs of progress but so I'm not sure I can put a figure on it I think five years would be highly optimistic particularly if a drug is involved you're probably talking ten or fifteen there but Tilly I think cautious optimism has to be the order of the day okay thank you David um just so everybody knows this has been recorded so it will be available online soon so you can rewatch it and pass it on to everybody else that you see

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