Tinnitus, what's all the noise about?

Imagine having a constant whistling, buzzing or ringing in your ears - all day. You can never escape it, it’s always there. It may seem better or quieter during the day, while watching the television, or while you’re on your favorite ride at the theme park.

But as soon as you lay your head on the pillow, in the quiet of your room, there it is - the annoying sound that won’t go away.

Tinnitus can be relentless and for some, may result in psychological, physical and even social ailments. Some have reported experiencing fatigue, stress and depression which, in turn, decreases their quality of life.

If you have experienced this incessant ringing you can rest assured that you are not alone. According to the American Tinnitus Association, just over 45 million Americans struggle with tinnitus. People with tinnitus hear a noise or sound in their ears, often described as ringing, that is not externally produced.

It is often difficult to explain to those around you because you are the only one that can hear it, even though it interrupts every conversation.

While both forms are equally debilitating, it is important to distinguish between objective and subjective forms of tinnitus.

Subjective tinnitus is a phantom auditory perception where there is no external or internal acoustic signal or sound that is being generated. This means that only you are able to hear your tinnitus.

Objective tinnitus can be caused by an acoustic signal generated within the body, often caused by turbulence in your blood vessels that is propagated and picked up by the ear. These pulsations are synchronous with the heart rate and their source can sometimes be located with a stethoscope.

What are the common causes of tinnitus?

Tinnitus is not a disease, it is a symptom of various underlying diseases. In most cases, tinnitus is associated with damage to the auditory system. It may also be associated with, injury, nerve damage, exposure to toxic medication or vascular problems.

Now let's unpack some of the other possible causes of tinnitus:

Noise-Induced Hearing Loss: Various studies have found that a leading cause of tinnitus is exposure to excessive noise. Sudden and/or long-term noise can injure the hair cells in your cochlear, which may result in a permanent hearing loss. This is absolutely preventable! People at risk for this type of hearing loss and resultantly having tinnitus are those who work in very loud industries such as mines - however, do keep in mind that going to a live loud rock concert could also damage your hearing as well. Therefore, it is of utmost importance for one to always protect their ears by wearing noise protective devices when in loud environments.

Presbycusis: Age related hearing loss, known as presbycusis, is also associated with tinnitus.

Middle-ear pathology: Middle ear problems resulting from otitis media, otosclerosis, a build up of cerumen (ear wax) and others can be accompanied by tinnitus. The tinnitus usually disappears after treatment.

Head, neck and jaw injury: Studies have shown that trauma related tinnitus can be more severe and perceived as louder and increase the likelihood of depression. This form is referred to as somatic tinnitus. It occurs in the absence of a hearing loss. Interestingly, movements of face, head or jaw, can change the perception of loudness for patients.  

Vestibular disorders: Some vestibular disorders such as Meniere’s disease have been associated with tinnitus.

Medication: Tinnitus may be exacerbated by certain medications such as aspirin and chemotherapy treatment and, depending on the dosage and frequency, tinnitus can permanent.

Blood pressure: Blood pressure may also be a factor. This is usually caused by noise from blood vessels that are close to the inner ear. Correct blood pressure management should reduce or eliminate the tinnitus completely.

Other common causes of tinnitus are stress, fatigue, alcohol consumption and allergies.

So What Is The Diagnosis

Tinnitus is complex. There are many causes and types of tinnitus (i.e buzzing/ringing) and it differs from person to person. Tinnitus can interfere with your hearing and quality of life. For some it is merely an irritation while others find it completely debilitating.

Knowing what could be causing your tinnitus is paramount to effective management.

For example, tinnitus that may be caused by excessive wax in the ear canal cannot and should not be treated or managed by administering antibiotics to a patient.

If you are suffering from tinnitus you will need to be examined so that the appropriate treatment/management plan can take place and your GP is always the first step. They will be able to rule out some of the causes such as blood pressure or medication. They would then refer you to an ear, nose, and throat specialist who will work hand-in-hand with an audiologist to examine the auditory system and hearing. Their assessments may include audiometry, tympanometry (to assess middle ear status), otoacoustic emissions (the status of the hair cells in the cochlea) and auditory brainstem response (a measurement of how signals travel from the ear to the brain). These tests help to eliminate possible causes. Blood tests and MRI scans could also be conducted. A referral to a psychologist for screening may also be necessary, at times, as tinnitus may lead to anxiety and/or depression.

Treatment

There are two main types of tinnitus treatment strategies: i) to reduce or eliminate the tinnitus perception and ii) to change the person’s reaction to the tinnitus.

If a specific cause of tinnitus is identifiable, for example, middle ear infection, treatment of the infection may reduce or eliminate the tinnitus completely. On the other hand, many tinnitus cases have no identifiable cause, making it very difficult to treat. In this case, a clinician and the patient may focus on increasing the patient’s tolerance. Different approaches are available such as dietary adjustments and masking devices to help the person mask the annoying tinnitus.

Some common treatment and management plans are as follows: 

Counselling: Counselling ranges from providing information to more engaging and emotional counselling sessions. Counselling may include strategies for improved coping, management and behavioral change. Patients may be helped to decrease their attention to their tinnitus, often with educational counselling and the use of background maskers. Studies have shown that most patients cope with their tinnitus better after being provided with information about it, however, this is not always the case - and some patients might require a much more collaborative intervention.

Masking devices: Masking devices emits sound that obscure the tinnitus noise. Though not eliminate. The idea behind these devices is based on the fact that tinnitus is perceived to be louder and is much more bothersome when in a very quiet environment. Therefore, these devices are able to emit sound such as ‘ocean water sound’ to distract the patient from focusing on their tinnitus. Hearing aids with masking abilities may also be used if the person suffering from tinnitus has a hearing loss. If a hearing aid is fitted properly, it may reduce the tinnitus drastically.

Tinnitus retraining therapy (TRT): The goal of TRT is to retrain the patient’s conditioned negative responses (such as fear, annoyance etc) to the tinnitus. Instead of eliminating the perception of the tinnitus itself. TRT is designed to train the patient’s brain to avoid constantly thinking about the tinnitus. In some studies evaluating the effectiveness of TRT, it was found that it offers long term benefits of more than a year as compared to masking devices that provide short term benefits.

Psychological treatment: Tinnitus can affect one’s quality of life as a whole. Affecting their sleep and their job or academic performance as well. Tinnitus may disrupt one’s social participation leading to anxiety and depression. When the emotional reaction to the tinnitus becomes as bothersome as the tinnitus itself, consulting with a psychologist or a psychiatrist may be useful.

Surgery: Treating tinnitus with surgery is generally a secondary outcome to treating a clearly identified cause of the tinnitus.  Surgery on an acoustic neuroma is an example of such a procedure.   

Medication: SSRIs (Selective serotonin reuptake inhibitors) have been shown to be effective in treating the effects of tinnitus, such as depression and anxiety. However, there is still no cure for tinnitus to date. Unfortunately, from one google search ‘’tinnitus treatment’’, more than half a million results show many products and companies that offer an ‘easy’ solution to the tinnitus problem. These products include vitamins and herbal supplements sold as liquids, pills and powders.

In conclusion...

There is a lack of evidence on the effectiveness of over the counter (OTC) ‘quick fix’ herbs for tinnitus, and none of them are FDA approved. They may even be harmful or may interact negatively with the medications that the patient is taking at the time. Clinicians (i.e. Audiologists) need to educate themselves on tinnitus and its associated management in order to give patients the best available care and to steer them away from OTC supplements.

There are various tinnitus management strategies such as relaxation strategies, exercise and modifying one’s diet. These are individual specific, and exploration of the possible management strategies is key to ensure that the patient gets the best possible management available.

 

 

Hlolo Ramatsoma

Written by Hlolo Ramatsoma

Hlolo is a clinical, research & support Audiologist at eMoyo. He is involved in many parts of the business, from consulting to R&D to supporting and training customers. He earned his BSc in Audiology from the University of Cape Town and is an experienced clinical audiologist specialized in ototoxicity monitoring, product specialist and training audiologist.

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