Tinnitus

What is Tinnitus?

Tinnitus refers to a condition where the patient “hears noises” in their ears even when there is no outside source of the sounds. These sounds may be soft or loud.

Sometimes tinnitus may sound like ringing, buzzing, humming, hissing, whistling, sizzling, clicking, knocking, roaring or blowing.

The sounds may be heard in one or both ears.

What does Tinnitus sound like?

Some patients compare the sounds to those of insects like crickets, cicadas, or compare them to winds, falling water, gushing, grinding steel, escaping steam, running engines, chain saws, fluorescent lights, etc.

Many patients describe it to be coming from “the middle of their head”.

Tinnitus may be continuous or constant or may wax and wane. It may range from soft quiet sounds at times to loud disturbing sounds. (1, 2)

Who does Tinnitus affect?

This is a common condition and almost everyone experiences tinnitus once in a while that only lasts a few minutes.

This may commonly occur to all individuals after exposure to loud sounds like at a sports arena or loud concert.

It may also be a temporary condition brought on by a cold or a blow over the head.

How common is Tinnitus?

The tinnitus or ringing in the ears usually goes away after a short while. However in some individuals – in around 1 or 2 out of every 10 people - the condition may recur and persist.

This may interfere with ability to sleep or concentrate.

About 1 in 200 people may have tinnitus that disrupts their normal living.

Tinnitus is more common in older people but children and young adults can have it too.

A look at adults aged 48 to 92 years showed that 8.2% suffered from tinnitus at the beginning of the study and 5.7% new cases were added in a course of 5 years. With age the risk of tinnitus rises. (1, 2, 3)

Causes of Tinnitus

Tinnitus may be caused due to various underlying pathologies. These include ear infections, foreign bodies or wax in the ear, injury to the ear caused by loud noises or a diseased condition called Meniere’s disease.

Meniere’s disease is a disease of the inner ear that leads to dizziness and hearing loss.

Tinnitus may also result from alcohol, caffeine, antibiotics, and aspirin and other drugs.

This condition may appear along with hearing loss and sometimes may be a primary symptom of another disease such as high blood pressure, anemia or an allergic condition.

Sometimes it may indicate a tumor called acoustic neuroma or a blood vessel deformity that is shaped like a balloon called aneurysm. (1, 2, 3, 4)

Categories of Tinnitus

Tinnitus is divided into two categories (2) –

  • Objective tinnitus – In this the tinnitus is audible to another person as a sound that is coming from the ear canal of the patient.
  • Subjective tinnitus – In this case the sound is heard only by the patient.

How long does Tinnitus last?

The tinnitus in sufferers may go on for months or years and is more of an annoyance than disease.

However, when they start interfering with sleep or concentration or signify an underlying condition, treatment is needed.

Sometimes tinnitus is closely associated with symptoms of depression.

Treatment is not simple and comprises of a wide range of approaches each of which may not work for all individuals. (1)

Edited by April Cashin-Garbutt, BA Hons (Cantab)

Causes of Tinnitus

Tinnitus or “ringing of the ears” is a symptom of an underlying condition rather than a disease in itself.

Patients complain of hearing sounds or noises even when there are no actual sounds in the background.

Anatomy of the ear

In the normal course sounds pass through the ear canal and fall on the ear drum that marks the end of the outer ear and beginning of the middle ear.

The middle ear amplifies and passes on the sound information to the inner ear.

The inner ear contains the cochlea and the auditory nerve.

The cochlea looks like a sea shell and is a coiled, spiral tube that contains a large number of sensitive hair cells.

The nerve picks up sound information and relays it to the brain.

If some parts of the cochlea are damaged the brain tries to seek out information from other healthy parts of the cochlea.

This over-representation of sounds leads to the symptoms of tinnitus.

Cause of temporary Tinnitus

Tinnitus could be temporary or a chronic annoying or distressing condition. A temporary tinnitus is caused by exposure to a loud noise like being in a sports arena or loud concert.

Sometimes a bout of cold or flu or a blow to the head may also lead to tinnitus.

Cause of prolonged or recurring Tinnitus

Prolonged or recurring tinnitus may occur due to (1, 2, 3, 4, 5): –

  • Ear infections – Infections of the inner ear called Acute otitis media or Chronic otitis media
  • Foreign bodies or wax impaction in the ear
  • Ear injury caused by loud noises may lead to tinnitus
  • Meniere's disease - a disease of the inner ear that is characterized by loss of hearing, dizziness and tinnitus
  • Alcohol, caffeine and certain drugs like aminoglycoside antibiotics (like gentamycin, amikacin etc.), aspirin, loop diuretics, cancer chemotherapeutic agents etc. especially when taken in an overdose
  • Underlying disease like high blood pressure, allergy or anemia
  • Sometimes there may be no cause for the tinnitus wherein it is termed “idiopathic tinnitus”
  • Presbyacusis – This is basically age related hearing loss. Tinnitus is often accompanied with hearing loss in the elderly.
  • A severe head injury, whiplash injury etc.
  • Some disease like multiple sclerosis or brain tumors like cerebellopontine-angle tumors
  • Brain infections like meningitis, syphilis, Lyme disease etc. may lead to tinnitus
  • Temporomandibular-joint (the joint connecting the lower jaw to the skull at the base of the ears) dysfunction and dental disorders
  • A rapid change in environmental pressure while travelling to high altitudes
  • Psychosocial stress and noise exposure

Deeper causes of Tinnitus

Tinnitus may be a primary sign of a deeper problem like a tumor of the inner ear called acoustic neuroma or an aneurysm that is a deformity of a blood vessel within the inner ear.

This deformity leads to ballooning of the blood vessel that carries a risk of rupture.

If there is hearing loss in one ear, difficulty in understanding speech and dizziness, there is a chance of an acoustic neuroma that is also known as vestibular schwannoma.

There is also a risk of a meningioma – a brain tumor.

Edited by April Cashin-Garbutt, BA Hons (Cantab)

Symptoms of Tinnitus

Tinnitus is a symptom of an underlying disease rather than being a disease itself. It is characterized by various soft or loud sounds in the ears of the patient when there is no such sound in the environment.

Around 15 per cent of people experience tinnitus at some stage of life and it's more likely to occur beyond the age of 60.

Some people are mildly affected by the condition while some are severely affected.

Types of Tinnitus

There are two types of Tinnitus: objective and subjective:-

  • Objective tinnitus is present in less than 5 percent of overall tinnitus cases. Here the examining physician may hear sounds in the patient’s ear canal.

    This is usually associated with a blood vessel or muscle related condition. The tinnitus may be pulsatile or in rhythm with the heartbeat.

  • Subjective tinnitus is seen in 95 percent of tinnitus cases. Here the patient alone can hear the sound.

Common Symptoms of Tinnitus

Symptoms of tinnitus include (1, 2, 3, 4) :–

  • Sounds like ringing, buzzing, humming, hissing, whistling, sizzling, clicking, knocking, roaring or blowing.

    Patients complain of sounds similar to calling of crickets or cicadas or blowing winds, falling or gushing water, grinding steel, escaping steam, running engines, chain saws, fluorescent lights, etc.

  • Some patients may hear high pitched loud sounds while others may hear soft whispering noises. Most patients describe the sounds over 3KiloHertz in frequency.

    In Meniere’s disease the frequency of the tinnitus may be as high as 125-250 KHz.

  • Some patients may hear musical hallucinations. These are common with long term sufferers who also have hearing loss. They hear musical refrains continuously.
  • The sounds may be heard in one or both ears. When heard from both ears the sound is described to come from the “middle or the head”.

    If it is heard in the ears it is called tinnitus aurium and if it is heard in the head it is called tinnitus cranii.

  • Tinnitus may be short episodes of the sounds, waxing and waning courses of the sounds or constant and continuous sounds.
  • Sometimes tinnitus may be pulsatile. The sounds beat a rhythm with the heart or blood flow to a vessel within the ear.

Aggravation of the symptoms of Tinnitus

Tinnitus may be aggravated with certain postures like lying or sitting down or on turning the head.

The movements cause pressure changes in the nerves and fluids within the inner ear leading to this aggravation.

Some may also find increased sensitivity to other sounds. For example, those with tinnitus find radio or television painfully loud even at normal volumes. This is called hyperacusis.

Problems caused by the symptoms of Tinnitus

Prolonged sounds may cause sleep problems and lack of ability to concentrate.

They may lead to anxiety disorders and depression. If it persists for more than 2 years, it is considered permanent and irreversible. This type of tinnitus is difficult to treat.

Edited by April Cashin-Garbutt, BA Hons (Cantab)

Diagnosis of Tinnitus

Tinnitus is a symptom of an underlying disease or a disorder.

Sometimes it may be without any specific cause. In these cases it is termed “idiopathic tinnitus”.

In most people tinnitus means hearing low pitched background noises or sounds even when there is no such sound in the environment.

When does diagnosis of Tinnitus occur?

If the symptom does not cause annoyance or difficulty in concentration or sleep, most sufferers do not visit the physician.

However, help of a health care provider maybe sought if the symptoms cause disturbance of daily activities or if the symptoms point towards a disease deeper than apparent.

Who carries out diagnosis of Tinnitus?

Diagnosis and treatment is usually under the care of an ENT surgeon or otolaryngologist (dealing with Ear, nose and throat diseases) (1)

Initial assessment of Tinnitus

Initial assessment includes a complete history assessment of the patient. The health care provider will ask questions like (1) –

  • What type of noise is heard?
  • Is it in one or both ears?
  • Is the noise rhythmic or throbbing?
  • Are there any other symptoms?

Physical examination

A detailed physical examination will be performed.

Some causes such as hypertension, anemia and so forth may be detected on physical examination.

Tests for detection of underlying causes of Tinnitus

Some tests may be prescribed to detect underlying causes of tinnitus.

These tests includes (1, 2, 3, 4) –

  • Tests to assess hearing loss. These tests are called audiology or audiometry.
  • CT scan images of the brain. This is done to assess the disease process in the brain
  • An MRI scan of the brain also shows in detail the disease process, tumor or aneurysm that may be causing the tinnitus
  • An angiography is a blood vessel study that looks for aneurysms or blood vessel abnormalities.
  • An X-ray of the head may also be prescribed if a CT scan or MRI is not possible.

    Tinnitus may also be caused due to abnormality of the jaw joint or Temporomandibular joint. This may be examined on an X ray.

  • Balance tests may be performed to check the performance and functions of the cochlea in the inner ear. Cochlea is responsible for maintenance of the balance.
  • A spinal tap or lumbar puncture may be performed to assess the cerebrospinal fluid or CSF. The CSF bathes the brain and the spine.

    If tinnitus is caused due to a brain tumor or other brain pathology, a spinal tap of CSF may provide clues to the diagnosis.

  • An Auditory Brain Stem Response or ABR is sometimes prescribed. This is a computerized test that looks at the nerve pathways that connects the brain with the ear.

Edited by April Cashin-Garbutt, BA Hons (Cantab)

Treatment of Tinnitus

Tinnitus is usually a symptom of a deeper problem. The cause may lie in the ear, brain or other organs.

If the problem is not severe and the sufferer tends to have tinnitus off and on treatment may not be sought.

The condition however needs to be evaluated by an ear, nose, and throat surgeon or an otolaryngologist.

Two specific approaches to Tinnitus treatment

Tinnitus therapy includes two specific approaches (1) –

  1. Those that reduce the cause and intensity of the tinnitus – This includes medication and electrical suppression.
  2. Those that reduce the annoyance caused by tinnitus – This includes behavioural therapy etc.

Treatment to reduce the cause and intensity of Tinnitus

Treatment of tinnitus that reduces the cause and intensity include (1-6) :–

  • If there is impaction of wax or foreign body that is causing tinnitus, it needs to be removed.
  • White noise sometimes helps in blocking out the sound of tinnitus. Some hearing aids and devices help patients with tinnitus with making a constant humming noise in the background called white noise.
  • Stress, alcohol, caffeine etc. may increase tinnitus. Relaxation techniques and avoidance of drugs that cause tinnitus like aspirin, loop diuretics etc. may relieve the condition. Loud noises are triggers for tinnitus and need to be avoided.
  • If tinnitus is caused due to other problems like high blood pressure, anemia, or rare problems like tumors or aneurysms, the underlying problem is treated.
  • Sometimes drugs like Niacin are recommended for treatment of tinnitus. However it may not always be effective.

    Antiepileptic medication Gabapentin or another drug Acamprosate may also be prescribed.

    Other alternatives like Ginkgo biloma has also been tried in tinnitus.

    The only beneficial agents in tinnitus are antidepressants like nortriptyline, amitriptyline and anti anxiety agents like alprazolam, clonazepam, and oxazepam.

    If there is associated depression or anxiety, antidepressants or antianxiety drugs are also prescribed.

  • Electrical suppression of tinnitus may be attempted. The cochlea is stimulated with trains of pulses at 5,000 pulses per second. This may suppress the tinnitus in some.

    Similarly Transcutaneous electrical nerve stimulation may be attempted around the ear to reduce tinnitus.

Treatment to reduce the annoyance caused by Tinnitus

Treatment that reduces the annoyance caused by tinnitus include (1-6) –

  • Cognitive behavioral therapy (CBT) has been found to be effective in patients with idiopathic tinnitus where no cause for the condition is detected.

    It is done by a psychotherapist who has had special training in CBT.

    Patients are informed that it is unlikely that their condition will improve dramatically.

    They are informed about the usefulness of tinnitus groups and helped to reduce activities that may aggravate their condition.

  • Sound therapy - Sounds found in natural settings like waterfalls, streams, rain, or wind are used to reduce the intensity of the tinnitus.
  • Habituation and music therapy - Tinnitus retraining therapy or TRT. These are forms of habituation therapy.

    A repeated heard stimulus is given to habituate to the tinnitus and reduce discomfort.

  • Massage and stretching of the neck and jaw muscles may also help.
  • Hearing aids
  • Alternative techniques like biofeedback, acupuncture, hypnosis, yoga etc. may help some patients of tinnitus.

    Electromagnetic stimulation or ear magnets are small electrical devices that send electromagnetic pulses through the ear and may help tinnitus.

  • Hyperbaric oxygen therapy involves putting the patient in a pressurized chamber with pure oxygen to breathe.

    The aim is to increase the flow of oxygen to the ears and brain. It may help a person with hearing loss as well as tinnitus

Edited by April Cashin-Garbutt, BA Hons (Cantab)