TINNITUS

Timothy C. Hain, MD

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Tinnitus defined Causes Diagnosis Treatment If You Have Tinnitus

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Tinnitus Defined

Tinnitus (pronounced "tin-it-tus") is an abnormal noise in the ear. Tinnitus is common -- nearly 36 million Americans have tinnitus and more than half of the normal population has intermittent tinnitus. About six percent of the general population has what they consider to be "severe" tinnitus. Tinnitus can come and go, or be continuous. It can sound like a low roar, or a high pitched ring. Tinnitus may be in both ears or just in one ear. Seven million Americans are so severely affected that they cannot lead normal lives.

The most common types of tinnitus are ringing or hissing ringing, whistling (high pitched hissing) and roaring (low-pitched hissing). Some persons hear chirping, screeching, or even musical sounds. Note however that tinnitus always consists of fairly simple sounds -- for example, hearing someone talking that no one else can hear would not ordinarily be called tinnitus -- this would be called an auditory hallucination. Tinnitus is commonly accompanied by hearing loss. Less commonly, it may be accompanied by hyperacusis (an abnormal sensitivity to sound).

Pulsitile tinnitus: people hear something resembling their heartbeat in their ear. The cause usually involves vascular, tumor or muscular causes. A blood vessel may be close to the eardrum, a vascular tumor such as a "glomus" may fill the middle ear, or a vein similar to a varicose vein may make enough noise to be heard. Other possibilities include dehiscence of the jugular bulb, and an abberently located carotid artery. An enlarged jugular bulb on the involved side is common in persons with venous type pulsitile tinintus.

What Causes Tinnitus? Most tinnitus comes from damage to the inner ear, specfically the cochlea (the snail like thing on the right). Tinnitus can also arise from damage to the nerve between the ear and brain (8th nerve, labelled 6, auditory nerve), much more rarely from injury to the brainstem (Lanska et al, 1987), and extremely rarely, to the brain itself. There are specific causes. Ear wax can rarely cause tinnitus. Other causes include middle ear infection or fluid, Meniere's disease, microvascular compression syndrome, and tumors of the 8th nerve. Patients with Meniere's disease often describe a low pitched tinnitus resembling a hiss or a roar. Pulsatile tinnitus (tinnitus that beats with your pulse) can be caused by aneurysms, increased pressure in the head (hydrocephalus), and hardening of the arteries. Anything that increases blood flow or turbulence such as hyperthyroidism, low blood viscosity (e.g. anemia), or tortuous blood vessels may cause pulstitle tinnitus. Vitamin B12 deficiency is common in tinnitus patients.

Loud noise is the leading cause of damage to the inner ear. Most patients with noise trauma describe a whistling tinnitus (Nicholas-Puel et al,. 2002) Advancing age may also be accompanied by inner ear damage and tinnitus. Many medications also can cause tinnitus (see list below). Generally this is thought to arise from their effect on the cochlea (inner ear).

Drugs that commonly cause or increase tinnitus

How is Tinnitus Diagnosed ? Persons with tinnitus should be seen by a physician expert in ear disease, usually an otologist or a neurotologist. There should be an examination of the ears, and hearing should be tested. The audiogram sometimes shows a sensorineural deficit due to masking from the tinnitus. Tympanograms can sometimes show a rhythmic compliance change due to a middle ear vascular mass.

The eyes should be examined for papilloedema (swelling of a portion of the back of the eye called the "optic disk") as increased intracerebral pressure can cause tinnitus..

The TMJ joints of the jaw should be checked as about 28% of persons with TMJ syndrome experience tinnitus. The physician may also request a BAER test (clicks in ears), an ECOG, an MRI/MRA test (scan of the brain), and several blood tests (ANA, B12, FTA, ESR, SMA-24, HBA-IC, fasting glucose, TSH, anti-microsomal antibodies).

In persons with pulsatile tinnitus, additional tests maybe proposed to study the blood vessels and to check the pressure inside the head. Gentle pressure on the neck can be performed to block the jugular vein but not the carotid artery. The Valsalva maneuver reduces venous return by increasing intrathoracic pressure. If there is a venous hum, this usually abates or improves markedly. If the pulsation is arterial, these tests have no effects. MRI/MRA or CT is often suggested in younger patients with unilateral pulsitile tinnitus. In older patients, pulsitile tinnitus is often due to atherosclerotic disease and it is less important to get an MRI/MRA. A lumbar puncture may be considered if there is a possibility of benign intracranial hypertension. More invasive testing includes the "balloon occlusion test", where a balloon is blown up in the internal jugular vein to see if it eliminates tinnitus.

Vestibular tests such as ENG or posturography are generally not helpful in diagnosing tinnitus. Tinnitus is rarely attributable to sinus disease and even if tests suggest that you have this common condition, it is unlikely that treatment of it will affect tinnitus.

Based on these tests, tinnitus can be separated into categories of cochlear, retrocochlear, central, and tinnitus of unknown cause.

How Is Tinnitus Treated ? If a specific cause for tinnitus is found, then your doctor may be able to eliminate the noise. Examples of specific causes include medication, tumors, infections, Ménière's disease, TMJ and otosclerosis. To find a specific cause it may require a fairly extensive workup including X-rays and blood tests. However, even after extensive workup, most causes of tinnitus go undiagnosed.

If a specific cause of tinnitus is not found, it is unlikely that the tinnitus can be gotten rid of. At best, one might get partial relief from some of the strategies to be described in the next few paragraphs. However, even though treatment may not be available, tinnitus should be checked into, as tinnitus may be a warning sign of a serious disorder such as a tumor of the 8th nerve, or other disorder which may impair hearing. Tinnitus does tend to gradually get better, but many persons with severe tinnitus still experience distress 5 years later. Tolerance of tinnitus increases with time. (Andersson et al, 2001).

Medicines may occasionally help lessen the noise even though no cause can be found. In general, we are not at all enthused about medication treatment as the side effects can be substantial and the results are often unimpressive. Medications to deal with the psychological fallout of tinnitus is often useful -- antidepressants and anti-anxiety medications can be very helpful.

Medications used in treatment of Tinnitus

What To Do If You Have Tinnitus ?

  1. Avoid exposure to loud noises and sounds.
  2. Decrease your intake of salt.
  3. Avoid stimulants such as caffeine and nicotine.
  4. Exercise daily, get adequate rest, and avoid fatigue.
  5. Avoid ototoxic medications known to increase tinnitus such as aspirin, non-steroidals and quinine containing preparations.

Diet: We recommend that persons with tinnitus limit salt (no added salt), and refrain from drinking caffeinated beverages, other stimulants (like tea), and chocolate. The salt restriction is intended for those who might have a subclinical form of Meniere's. Caffeine and similar substances increase tinnitus in a nonspecific fashion. Otherwise the diet should be balanced and have normal amounts of fruits and vegetables.

Hearing aids and other devices called "maskers" may also help alleviate tinnitus. This is a tricky business. If you have tinnitus associated with a hearing loss, a hearing aid is a reasonable thing to try. Be sure that you try the hearing aid before buying one, as tinnitus is not always helped by an aid. Nearly all states mandate a 1-month money-back guarantee built into hearing aid dispensing. It also seems possible that a hearing aid might exacerbate tinnitus, as many people develop "ringing" of their ears after exposure to loud noise.

Maskers are based on the idea that tinnitus is usually worst when things are very quiet. Listening to the interstation static on the FM radio, tapes of ocean surf, and the like may be helpful. Pillow speakers sold by Radio Shack may be helpful in order to avoid disturbing others. Tinnitus maskers are fitted and sold by audiologists. However, controlled studies of maskers have failed to clearly demonstrate efficacy.

Alternative medicine approaches. Ginkgo-Biloba, beta-histine (Serc), Zinc, and acupuncture are sometimes advocated as treatment for intractable tinnitus. There is little evidence that these agents work, but they also do not seem to be harmful. More discussion about alternative medications is available here.

Psychological help: Often, anxiety or depression which accompanies tinnitus may be as big a problem as the tinnitus itself. In this instance, consultation with a psychologist or psychiatrist expert in this field may be helpful. Hypnosis may be effective and increase tolerance to tinnitus. If you can ignore tinnitus rather than obsess about it, this may be the best way to handle it.

Self Help: You might consider joining the American Tinnitus Association. (PO Box 5, Portland, OR 97207, 503-248-9985). However, if your tinnitus has been well "worked up", and there is nothing more to be done, it might be best to attempt to ignore it rather than focus more attention on it.

Tinnitus Retraining Therapy (TRT). This method of habituation of tinnitus is helpful for some (Wang et al, 2003). It requires a considerable commitment of time.


Dubious treatments

Electrical stimulation. These devices are in the same dubious category as magnetic stimulation. There is probably no harm other than to the pocketbook.

Intravenous Lidocaine. No acceptable study supporting the use of lidocaine can be found in the literature. In May 2000, Shea and Ge presented a paper at the American Otologic Society meeting in which they described Lidocaine treatment of intractable tinnitus as safe and effective; however, their study was neither random nor double-blinded. It is difficult to comprehend why a transient injection of lidocaine (which wears of in a few hours), should cause a long-term change in tinnitus. It seems more likely that it is a placebo.

Surgery: Unlike most of the other treatments discussed here, surgery is not necessarily a placebo. Nevertheless, only rarely is surgical treatment indicated, and even more rarely, is tinnitus relieved by surgery. You should certainly consider surgery if your tinnitus is due to a tumor and also if it is due to a venous source (usually pulsitile in this situation). For venous tinnitus, possiblities include jugular vein ligation, occlusion of the sigmoid sinus, or closure of a dural fistula. Surgery may also be an option to consider if your diagnosis is otosclerosis, fistula or Ménière's disease. Occasionally persons with Meniere's disease have relief or reduction of tinnitus from transtympanic gentamicin. Microvascular compression syndrome, in theory, may cause tinnitus, but we have had very little success when the few patients we have seen with this syndrome have undergone surgery.

Magnets: Of course, magnetic head-bands or the like are almost certainly placebos.

Zinc. Zinc has been used for many years as a treatment of tinnitus. Most studies show no significant effect (e.g. Arda et al, 2003). It seems most likely at this writing (2003) that Zinc is a placebo.

 

Research Studies in Tinnitus

As of 4/2002, a visit to the National Library of Medicine's search engine, Pubmed, revealed more than 3,900 research articles concerning tinnitus published since 1966. In spite of this gigantic effort, very little is presently known about tinnitus, and often effective treatment is unavailable.

 

links to other tinnitus materials:

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