Tinnitus overview - causes and diagnosis
Dr.Archana Jhawar, M.S.
Tinnitus is not a disease rather an annoying symptom of myriad of conditions, caused by minor changes in the sensitive hearing system (Cochlea and auditory nerve).
Tinnitus (means ringing in Latin) is sound sensation in the ear or head, in the absence of any external source of sound. Commonest types are hissing, roaring, swishing, rustling, buzzing, humming, or chirping. Tinnitus varies in pitch and loudness and is more annoying in quiet surroundings, particularly at night.
It can be quite disturbing leading to sleep deprivation, depression decreased work efficiency. Most important aspect of tinnitus is distress, irritation and distraction caused by the noise. Person often feels that such noise is a symptom of brain tumor or stroke. In most cases tinnitus is not harmful.
Patient with tinnitus should undergo thorough ENT evaluation and if required neurological examination. Nothing can be done and you have to live with it is to be avoided and patient should be investigated properly to find any treatable condition.
Most common cause for tinnitus is hearing loss because of aging, noise, drugs or chemicals.
Possible theory:
Because cochlea is no longer sending normal signals to brain, confused brain create own noise.
Made worse by anything that makes hearing worse like infection/wax.
Causes:
I. Related to ear (otologic)
Cause may be in the external, middle or inner ear
Subjective causes:
Impacted wax
Fluid in the middle ear
Acute and chronic otitis media
Otosclerosis
Menieres disease
Presbiacusis
Noise-trauma
Ototoxic drugs (such as ACE inhibitors, Antibiotics-ciprofloxacin, erythromycin, streptomycin, and vancomycin, Anti depressant-alprazolam, Anti-malarials-chloroquine and quinine, B-blockers, Diuretics-acetazolamide and amiloride, NSAIDs and Aspirin)
Objective causes are less frequent:
Aneurism of carotid artery (it is synchronous with pulse)
Vascular tumor of middle ear
Palatal myoclonus
Tinnitus synchronous with respiration may occur with abnormally patent Eustachian tube (mostly seen after weight loss).
II. Not related to ear
Disease of CNS, anemia, arteriosclerosis, hypertension, hypotension, hypoglycemia, epilepsy, migraine
III. Psychological
Assessment of tinnitus:
Most important is History and Identification of hearing loss and Clinical Examination of ear by otoscope/operating microscope with detail head and neck examination by specialist.
Investigations:
PT Audiometry
Brain-stem Evoked Response Audiometry
CT scan (especially if tinnitus is asymmetrical, 10% of cases it may be a tumor (Acoustic Neuroma).
Blood Investigations to test Anaemia- CBC, Hypothyroidism- TSH, Diabetes-sugar, Syphilis- FTABS and lipid profile.
Tinnitus pitch matching and masking.
Treatment of the cause should take care of tinnitus but tinnitus may persist even after the disease causing tinnitus has been cured, When a lesion or disease process is not identifiable, then tinnitus management is more difficult.
There is at present no effective surgery or medical therapy for the treatment of tinnitus.
In majority of cases our system adapts to noise over a period of time and is accepted as a part of normal environment. This process can be helped by proper reassurance and counseling. Relaxation and biofeedback help to improve coping with the condition.
Tinnitus maskers are sometimes recommended. These are similar to hearing aids and generate continuous noise. Their use is based on the fact that the patient is more comfortable in a noisy environment than in a quiet surrounding.
Research shows encouraging result on the effectiveness of pharmacological therapy for tinnitus, such as carbamazepine, lidocaine, and intravenous barbiturates, but potentially serious side effects limit their use.
Avoid irritants like smoke, alcohol, caffeine, loud noise.
Aspirin is one of the reversible causes, stop using it, and most important of all manage your stress as it makes tinnitus worse.
Management Of Tinnitus/ringing In Ears
There is no cure and no specific treatment is efficacious for noise/ringing in the ears/head; however person can opt from many options available. In some cases it can be quieted with treatment of underlying cause. In majority of sufferers there is no serious pathology and reassurance is all what is
needed.
Nothing can be done and you have to live with it is to be avoided and patient should be assessed and investigated properly by otolaryngologist, audiologist and neurologist if required, to find any treatable condition.
Manage treatable conditions
Stop medicines causing tinnitus.
Wax, foreign bodies can be removed.
Treatment of middle ear infections and fluid should be done.
Otosclerosis and tinnitus- Surgery and/or hearing aids; surgery may not cure tinnitus and a failed surgery can cause severe tinnitus but correcting conductive deafness (even with poor speech discrimination) allows masking effective.
Menieres disease- Tinnitus is difficult to treat in non functioning (dead) ear, so decision for destructive surgery should be taken with care. Abnormal patency of ET- Mostly seen after weight loss, can be corrected by minor surgical correction (25% silver nitrate or diathermy)
Surgery for tumor
Hearing aids for hearing loss
Treatment of blood pressure/thyroid disorder/other medical conditions causing tinnitus.
General measures and prevention, life style modification-
Prevention is the best way to ensure no worsening of disease.
Take care of the body by giving it enough rest, sleep and water.
Dietary supplements Vitamins A, C, E, and B group and Zinc
Micro nutrients to prevent noise induced hearing loss
Support and stress management; taking a positive step in controlling the condition and changing response to it
Regular exercise
Decrease intake of salt
Avoid food with high sugar
Limit exposure to loud noise, occupational and recreational
Avoid aspirin, and NSAIDS
Avoid ototoxic medicine
Avoid nicotine, alcohol, caffeine
Take steps to lower blood pressure and cholesterol
Ginkgo Biloba extract is an effective, well tolerated whilst not effective in every single patient, the proven benefits far outweigh any risks.
Medicines
There is no specific drug designed specifically for tinnitus. There is no active research going on because of high cost and high rate of failure involved in creating a new drug.
Anxiolytics, Carbamazepine, Lidocaine, and intravenous Barbiturates show encouraging results but potentially serious side effects limit usefulness. Relatively low doses may bee effective in tinnitus management.
Patient and clinician together determine right drug considering side effects if it is worth.
Tinnitus Retraining Therapy
Person can be habituated to sound in the environment, so aim is to train the brain to adapt to sound.
TRT has 2 elements- Direct counseling and sound therapy
Sound therapy-
Sound therapy is to be combined with other therapies like counseling to improve effectiveness.
Tinnitus is more noticeable and disturbing when environment is quiet. Person with tinnitus thinks that sound is because of or can cause some serious damage to brain or inner ear. This negative emotional response from our subconscious brain (limbic system) travels to conscious brain-cortex, so person reacts.
In sound therapy instead of treating patient surrounding sound is manipulated so that it becomes less noticeable, here are many ways to achieve the goal such as: -
Table top devices-environmental sound machine, water fountain, clocks, fan, radio
CD based system
Hearing aids
Masker
Combination of hearing aid and masker
Cochlear implant/electric stimulation
Table top devices;
Devices kept on side of bed such as ticking clock, adjusting radio in between two stations, or fan, may divert attention and make tinnitus less noticeable.
Hearing aids;
If a patient has a hearing loss in the frequency range of the tinnitus, hearing aids may be helpful in covering the tinnitus.
Masker;
The use of masking in the treatment of the tinnitus has mixed success, Patients perception of the pitch and loudness and the overall intensity of the masking signal should be well understood.
Tinnitus maskers introduce an external pleasant masking sound
into affected ear , thereby minimizing or eliminating the perception of the tinnitus.
Cochlear implant
Cochlear implant may mask tinnitus by ambient sound or may suppress tinnitus by the electrical stimulation sent through the auditory nerve. Some forms of electrical stimulation to the ear can stop tinnitus briefly.
Counseling
Effective counseling is most critical aspect of tinnitus management. Tinnitus sufferers are anxious and frightened by the presence of tinnitus and need a careful and clear explanation of the nature of the disorder.
It can be quite disturbing leading to sleep deprivation, depression decreased work efficiency. Most important aspect of tinnitus is distress, irritation and distraction caused by the noise. Person often feels that such noise is a symptom of brain tumor or stroke. Reassurance should be given by E.N.T. specialist, neurologist and audiologist.
Biofeedback
Distress caused by tinnitus is in correlation to degree of attention paid to tinnitus and shifting attention of person to a different signal is bio feedback. It is relaxation technique that teaches to improve coping ability and has 70-90% success rate.
Tinnitus patients have high levels of anxiety, tension, or other symptoms of chronic stress. Biofeedback is quite effective relaxation technique; it teaches person to control certain autonomic body functions such as pulse, muscle tension and skin temperature. Goal is to help person manage stress not by reducing stress but by changing the body reaction to it.
Controversies exist about role of alternate therapies.
Research results have not conclusively identified these treatments as helpful for tinnitus.
Hypnotherapy
Control of inhalational and food allergy
Bio feedback
Zinc, magnesium and vit-B12
Herbal ginkgo biloba have mixed result
Homeopathic remedies
Acupuncture
Hyperbaric O2
Music tharapy
Most important and essential aspect is educating person with respect to nature of tinnitus, keep in mind treat the patient not the tinnitus.
Source: ENT Care
