Tinnitus Ringing in the Ears

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Tinnitus: Ringing in the Ears An Overview By the Vestibular Disorders Association

What is tinnitus? to seek treatment.4 It can interfere with a Tinnitus is abnormal noise perceived in person’s ability to hear, work, and one or both ears or in the head. Tinnitus perform daily activities. One study (pronounced either “TIN-uh-tus” or “tin- showed that 33% of persons being NY-tus”) may be intermittent, or it might treated for tinnitus reported that it appear as a constant or continuous disrupted their sleep, with a greater sound. It can be experienced as a ringing, degree of disruption directly related to hissing, whistling, buzzing, or clicking the perceived loudness or severity of the sound and can vary in pitch from a low tinnitus.5,6 roar to a high squeal. Causes and related factors Tinnitus is very common. Most studies Most tinnitus is associated with damage indicate the prevalence in adults as falling to the auditory (hearing) system, within the range of 10% to 15%, with a although it can also be associated with greater prevalence at higher ages, other events or factors: jaw, head, or through the sixth or seventh decade of neck injury; exposure to certain drugs; life.1 Gender distinctions are not nerve damage; or vascular (blood-flow) consistently reported across studies, but problems. With severe tinnitus in adults, tinnitus prevalence is significantly higher coexisting factors may include hearing in pregnant than non-pregnant women.2 loss, dizziness, head injury, sinus and middle-ear infections, or mastoiditis The most common form of tinnitus is (infection of the spaces within the subjective tinnitus, which is noise that mastoid bone). Significant factors other people cannot hear. Objective associated with mild tinnitus may include tinnitus can be heard by an examiner meningitis (inflammation of the membra- positioned close to the ear. This is a rare nous covering of the brain and spinal form of tinnitus, occurring in less than 1% cord), dizziness, migraine, hearing loss, of cases.3 or age.7

Chronic tinnitus can be annoying, Forty percent of tinnitus patients have intrusive, and in some cases devastating decreased sound tolerance, identified as to a person’s life. Up to 25% of those the sum of hyperacusis (perception of with chronic tinnitus find it severe enough over-amplification of environmental © Vestibular Disorders Association ◦ www.vestibular.org ◦ Page 1 of 11

sounds) and misophonia/ phonophobia Objective tinnitus has been associated (dislike/fear of environmental sounds).8 with myoclonus (contraction or twitching) While most cases of tinnitus are of the small muscles in the middle associated with some form of hearing ear.14,15 Conductive hearing loss resulting impairment, up to 18% of cases do not from an accumulation of earwax in the involve reports of abnormal hearing.9 ear canal can sometimes cause tinnitus.

Ear disorders Vestibular disorders: Hearing Hearing loss from exposure to loud impairment and related tinnitus often noise: accompany dysfunction of the balance Acute hearing depends on the organs (vestibular system). Some ves- microscopic endings of the hearing nerve tibular disorders associated with tinnitus in the inner ear. Exposure to loud noise include Ménière’s disease and secondary can injure these nerve endings and result endolymphatic hydrops (resulting from in hearing loss. Hearing damage from abnormal amounts of a fluid called noise exposure is considered to endolymph collecting in the inner ear) be the leading cause of tinnitus. and perilymph fistula (a tear or defect in one or both of the thin membranes Presbycusis: Tinnitus can also be related between the middle and inner ear). to the general impairment of the hearing nerve that occurs with aging, known as Vestibulo-cochlear nerve damage presbycusis. Age-related degeneration of and central auditory system changes the inner ear occurs in 30% of persons The vestibulo-cochlear nerve, or eighth age 65–74, and in 50% of persons 75 cranial nerve, carries signals from the years or older.10 inner ear to the brain. Tinnitus can result from damage to this nerve. Such damage Middle-ear problems: Tinnitus is can be caused by an acoustic neuroma, reported in 65% of persons who have also known as a vestibular schwannoma preoperative otosclerosis (stiffening of (benign tumor on the vestibular portion the middle-ear bones),11 with the tinnitus of the nerve), vestibular neuritis (viral sound typically occurring as a high- infection of the nerve), or microvascular pitched tone or white noise rather than compression syndrome (irritation of the as a low tone.12 Otitis media (middle-ear nerve by a blood vessel). infection) can be accompanied by tinnitus, which usually disappears when The perception of chronic tinnitus has the infection is treated. If repeated infec- also been associated with hyperactivity tions cause a cholesteatoma (benign in the central auditory system, especially mass of skin cells in the middle ear in the auditory cortex.16 In such cases, behind the eardrum), hearing loss, tinni- the tinnitus is thought to be triggered by tus, and other symptoms can result.13 damage to the cochlea (the peripheral

hearing structure) or the vestibulo- Pulsatile tinnitus is a rhythmic pulsing cochlear nerve. sound that sometimes occurs in time with the heartbeat. This is typically a Head and neck trauma result of noise from blood vessels close Compared with tinnitus from other to the inner ear. Pulsatile tinnitus causes, tinnitus due to head or neck is usually not serious. However, trauma tends to be perceived as louder sometimes it is associated with serious and more severe. It is accompanied by conditions such as high or low blood more frequent headaches, greater pressure, hardening of the arteries difficulties with concentration and (arteriosclerosis), anemia, vascular memory, and a greater likelihood of tumor, or aneurysm. depression.17 Other possible causes Somatic tinnitus is the term used when Other conditions have been linked to the tinnitus is associated with head, neck, tinnitus: high stress levels, the onset of or dental injury—such as misalignment of a sinus infection or cold, autoimmune the jaw or temporomandibular joint disorders (such as rheumatoid arthritis (TMJ)—and occurs in the absence of or lupus), hormonal changes, diabetes, hearing loss. Characteristics of somatic fibromyalgia, Lyme disease, allergies, tinnitus include intermittency, large depletion of cerebrospinal fluid, vitamin fluctuations in loudness, and variation in deficiency, and exposure to lead. In the perceived location and pattern of its addition, excessive amounts of alcohol or occurrence throughout the day.18 caffeine exacerbate tinnitus in some people. Medications Many drugs can cause or increase Diagnosis tinnitus. These include certain non- Examination by a primary care physician steroidal anti-inflammatory drugs will help rule out certain sources of (NSAIDs, such as Motrin, Advil, and tinnitus, such as blood pressure or Aleve), certain antibiotics (such as medication problems. This doctor can gentamicin and vancomycin), loop also, if necessary, provide a referral diuretics (such as Lasix), aspirin and to an ear, nose, and throat specialist (an other salicylates, quinine-containing otolaryngologist, otologist, or drugs, and chemotherapy medications neurotologist), who will examine the ears (such as carboplatin and cisplatin). and hearing, in consultation with an Depending on the medication dosage, the audiologist. Their evaluations might tinnitus can be temporary or permanent.3 involve extensive testing that can include an audiogram (to measure hearing), a Vascular sources tympanogram (to measure the stiffness of the eardrum and help detect the

presence of fluid in the middle ear), approaches are available, including otoacoustic emissions testing (to provide medication, dietary adjustments, information about how the hair cells of counseling, and devices that help mask the cochlea are working), an auditory the sound or desensitize a person to it. brainstem response test (to measure how Not every treatment works for every hearing signals travel from the ear to the person. brain and then within parts of the brain), electrocochleography (to measure how Masking devices sound signals move from the ear along A masking device emits sound that the beginning of the hearing nerve), obscures, though does not eliminate, the vestibular-evoked myogenic potentials tinnitus noise. The usefulness of maskers (to test the functioning of the saccule is based on the observation that tinnitus and/or inferior vestibular nerve), blood is usually more bothersome in quiet tests, and magnetic resonance imaging surroundings20 and that a competing (MRI). Neuropsychological testing is also sound at a constant low level, such as a sometimes included to screen for the ticking clock, whirring fan, ocean surf, presence of anxiety, depression, or radio static, or white noise produced by a obsessiveness—which are understandable commercially available masker, may and not uncommon effects when tinnitus disguise or reduce the sound of tinnitus, has disrupted a person’s life. thus making it less noticeable. Some tinnitus sufferers report that they sleep Treatment better when they use a masker. In some If a specific cause of the tinnitus is users, maskers produce residual identified, treatment may be available to inhibition—tinnitus suppression that lasts relieve it. For example, if TMJ for a short while after the masker has dysfunction is the cause, a dentist may been turned off. be able to relieve symptoms by realigning the jaw or adjusting the bite Hearing aids are sometimes used as with dental work. If an infection is the maskers. If hearing loss is involved, cause, successful treatment of the properly fitted hearing aids can improve infection may reduce or eliminate the hearing and may reduce tinnitus tinnitus. temporarily. However, tinnitus can actually worsen if the hearing aid is set at Many cases of tinnitus have no an excessively loud level. identifiable cause, however, and thus are more difficult to treat. Although a Cochlear implants, used for persons who person’s tolerance of tinnitus tends to are profoundly deaf or severely hard-of- increase with time,19 severe cases can hearing, have been shown to suppress be disturbing for many years. In such tinnitus in up to 92% of patients.21,22 chronic cases, a variety of treatment This is likely a result of masking due to

newly perceived ambient sounds or from electrical stimulation of the auditory In one comparison of the effectiveness of nerve. tinnitus masking and TRT as treatments, masking was found to provide the Other devices under development may greatest benefit in the short term (three eventually prove effective in relieving to six months), while TRT provided the tinnitus. For example, the recently greatest improvement with continued introduced acoustics-based Neuromonics treatment over time (12–18 months).25 device involves working with an audiologist who matches the frequency Psychological treatments spectrum of the perceived tinnitus Chronic tinnitus can disrupt sound to music that overlaps this concentration, sleep patterns, and spectrum. This technique aims to participation in social activities, leading stimulate a wide range of auditory to depression and anxiety. In addition, pathways, the limbic system (a network tinnitus tends to be more persistent of structures in the brain involved in and distressful if a person obsesses memory and emotions), and the about it. Consulting with a psychologist autonomic nervous system such that a or psychiatrist can be useful when the person is desensitized to the tinnitus. emotional reaction to the perception of Assessing the true effectiveness of this tinnitus becomes as troublesome as the device will require further scientific tinnitus itself19 and when help is study, although observations from needed in identifying and altering an initial stage of clinical trials indicate negative behaviors and thought that the device can reduce the severity patterns. of symptoms and improve quality of life.23 Medication No drug is available to cure tinnitus; Tinnitus retraining therapy however, some drugs have been shown to Tinnitus retraining therapy (TRT) is be effective in treating its psychological designed to help a person retrain the effects. These include anti-anxiety brain to avoid thinking about the medications in the benzodiazepine family, tinnitus. It employs a combination of such as clonazepam (Klonopin) or counseling and a non-masking sound lorazepam (Ativan); antidepressants in that decreases the contrast between the the tricyclic family, such as amitiptyline sound of the tinnitus and the (Elavil) and nortriptyline (Aventyl, surrounding environment.24 The goal is Nortrilen, Pamelor); and some selective not to eliminate the perception of the serotonin reuptake inhibitors (SSRIs), tinnitus sound itself, but to retrain a such as fluoxetine (Prozac).26,27,28,29 person’s conditioned negative response (annoyance, fear) to it.

Other drugs have been anecdotally been shown to be very short term.35 associated with relief of tinnitus. These The effect of such tinnitus treatment include certain heart medications, is thought to occur in the central anesthetics, antihistamines, statins, auditory pathway rather than vitamin or mineral supplements, in the cochlea.36 vasodilators, anticonvulsants, and various . Scientists demonstrated that the homeopathic or herbal preparations. anticonvulsant gabapentin Scientific evidence is lacking to support (Neurontin) is no more effective than the effectiveness of many of these placebo in treatment of tinnitus.37,38 remedies.27,30,31 Some appear to be . When scientists reported their placebos, while some are possibly mildly finding that Ginkgo biloba extracts or temporarily effective but with potential and placebo treatments produce side effects that are serious. very similar results, they also noted that use of the extract could lead to Examples of recent research studies on adverse side effects, especially if some of these anecdotal treatments used unsupervised and with other follow, although this list is not medications.39,40 exhaustive: . In assessing the effectiveness of Some alternative approaches may atorvastatin (Lipitor) in the eventually yield helpful options in treatment of tinnitus, scientists tinnitus treatment. However, most observed a trend toward relief of scientists agree that additional well- symptoms; however, this trend was constructed research is needed before not statistically significant when any anecdotally associated preparation compared with results produced by can be applied as a proven and effective administration of a placebo.32 treatment option. . The relationship between low blood zinc levels and subjective tinnitus Surgery was inspected in a small placebo- Treating tinnitus with surgery is controlled study. Administration of generally limited to being a possible oral zinc medication produced results secondary outcome of surgery that is that prompted the researchers to used in cases when the source of the note that additional tests were tinnitus is identified (such as acoustic needed to investigate whether neuroma, perilymph fistula, or duration of treatment might be a otosclerosis) and surgical intervention is significant factor.33 required to treat that condition.41 . Immediate suppression of subjective tinnitus has been observed in Other proposed treatments patients administered intravenous Stress-reduction techniques are often lidocaine,34 although such relief has advocated for improving general health,

as they can help control muscle groups at home and avoiding listening to music and improve circulation throughout the at high volume can both help reduce body. Such relaxation training, risk.48 the use of biofeedback to augment relaxation exercises, and hypnosis have Other important factors are exercising been suggested as treatments for daily, getting adequate rest, and having tinnitus. Limited research is available on blood pressure monitored and controlled, the effectiveness of these methods. if needed. Additional precautionary measures include limiting salt intake, Acupuncture, electrical stimulation, avoiding stimulants such as caffeine and application of magnets, electromagnetic nicotine, and avoiding ototoxic drugs stimulation, and ultrasound have been known to increase tinnitus (some of found to be placebo treatments for which are listed above under “Causes and tinnitus or to have limited scientific Related Factors”). support for their effectiveness.27,30,42,43 Summary Recent and ongoing research studies Tinnitus is a common condition that can have attempted to assess whether disrupt a person’s life. Our understanding transcranial magnetic stimulation could of the mechanisms of tinnitus is be an effective tinnitus treatment. This incomplete, and many unknown factors application is based on the thought that remain. These limitations contribute to tinnitus is associated with an irregular the lack of medical consensus activation of the temporoparietal cortex about tinnitus management, stimulate (a part of the brain), and thus that continued research efforts, and motivate disturbing this irregular activation could anecdotal and commercially based result in transient reduction of speculation about potential but unproven tinnitus.44,45,46 treatments. Prior to receiving any treatment for tinnitus or head noise, it is Prevention important for a person to have a Precautionary measures to help lessen thorough examination that includes an the severity of tinnitus or help a person evaluation by a physician. Understanding cope with tinnitus are related to some of the tinnitus and its possible causes is an the causes and treatments listed above. essential part of its treatment. Avoiding exposure to loud sounds (especially work-related noise) and References getting prompt treatment for ear 1. Henry JA, Dennis KC, Schechter MA. General review of tinnitus: prevalence, infections have been identified as the two mechanisms, effects, and management. most important interventions for reducing Journal of Speech, Language, and the risk of tinnitus.47 Wearing ear Hearing Research 2005;48(5):1204– protection against loud noise at work or 1235. 2. Gurr P, Owen G, Reid A, Canter R.

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