Often referred to as “ringing in the ears,” tinnitus is a medical term for the perception of sound in one or both ears when no external sound can be detected by others. Some people who suffer from tinnitus hear hissing, roaring, whistling, chirping, or clicking rather than ringing. Tinnitus can be intermittent or constant with single or multiple tones, and its perceived volume can range from subtle to shattering.
The American Tinnitus Association estimates that over 50 million Americans suffer from this condition and that about 12 million have severe enough tinnitus to seek medical attention.
Tinnitus must always be thought of as a symptom and not a disease, just as pain in the arm or leg is a symptom and not a disease. Because the function of the auditory (hearing) nerve is to carry sound, when it is irritated from any cause the brain interprets this impulse as a noise. This phenomenon is similar to the sensation nerves elsewhere. If one pinches the skin, it hurts because the nerves stimulated carry pain sensation.
CAUSES OF TINNITUS
In many cases the cause of tinnitus cannot be determined. There are many potential catalysts that are known to trigger or worsen tinnitus The accumulation of earwax, exposure to loud sounds, head or neck injuries, problems with blood circulation, jaw misalignment, ear or sinus infections certain types of tumors, cardiovascular disease, and even certain medications can trigger tinnitus. The majority of people who suffer from tinnitus also have hearing loss.
TYPES OF TINNITUS
Most tinnitus is audible only to the patient; this is called subjective tinnitus. Tinnitus audible to both the patient and others is called objective tinnitus, the least common form.
Objective tinnitus may be due to muscle spasms in the middle ear or eustachian tube, or may be due to abnormalities in the blood vessels surrounding the ear.
Tinnitus may result from spasm of one of the two muscles attached to the middle ear bones, or from spasm of muscles attached to the eustachian tube, the channel which connects the middle ear to the back of the nose.
There are two muscles in the inner ear: the stapedius, attached to the stapes bone (stirrup) and the tensor tympani, attached to the malleus bone (hammer). These muscles normally contract briefly in response to very loud noise or as a result of a startle reaction. However, for no apparent reason, one or both of these muscles may begin to contract rhythmically for brief periods of time. Because the muscles are attached to one of the middle ear (hearing) bones, these contractions may result in a repetitious sound in the ear. The clicking, although annoying, is harmless and usually subsides without treatment.
Should the muscle spasm continue, medical treatment (muscle relaxants) or surgery (cutting the spastic muscle) may be necessary. Muscular tinnitus resulting from spasm from one of the various muscles of the throat attached to the eustachian tube is uncommon, but can also result in episodes of rhythmic clicking in the ear. This is called palatal myoclonus and usually responds to muscle relaxants.
There are two large blood vessels intimately associated with the middle and inner ear: the jugular vein and the carotid artery. These are the major blood vessels supplying the brain.
It is not uncommon to hear one’s heartbeat or to hear the blood circulating through these large vessels. This may be noticeable when an individual has a fever, a middle ear infection, or after engaging in strenuous exercise. This circulation increase is temporary and usually subsides when the exertion or fever are reduced. It is not audible to others.
On occasion, the sound of blood circulation will become audible to others. This can be due to thickening of the blood vessel wall (a normal occurrence as one grows older), a kink in the vessel, or an abnormal growth on the vessel wall. Further testing may be necessary to determine the cause and treatment indicated in these uncommon cases.
External Ear Tinnitus
Obstruction of the external ear canal by wax, foreign bodies or swelling may produce a hearing impairment or pressure on the eardrum. This frequently results in a pulsating type of tinnitus.
Middle Ear Tinnitus
Disturbances of function of the middle ear may result from allergy, infection, injury, scar tissue, or impaired motion of the three middle ear bones. These disturbances often result in hearing impairment and may lead to head noise. But there is no relationship between the degree of hearing loss and the intensity of the tinnitus.
Inner Ear Tinnitus
Any condition which disturbs the fluid pressure in the inner ear chamber may produce head noises. This may be due to infection, allergy, or circulatory disturbances which produce changes not only in the fluid, but also in the encasing membranes of the inner ear.
Nerve Pathway Tinnitus
The nerve pathways are the most delicate structures of the hearing mechanism. The small hair cells which serve to transform fluid waves into nerve impulses are analogous to the cells of the eye retina which transforms light waves to nerve impulses. The slightest swelling or interference with these delicate cells from any cause readily produces impairment of function and irritation. This may occur from a variety of causes: infection; allergic swelling; systemic diseases, either acute or chronic, with resultant toxic effects; sudden exposure to a blast of sound or prolonged exposure to high noise levels in susceptible persons; certain drugs to which the patient may be sensitive; and minute changes in the blood supply with resultant changes in nutrition.
Pressure changes may produce swelling both from outside and within the nerve as it transverses the boney tunnel through which it passes to the brain. In these instances, the tinnitus occurs on one side of the head and because the boney tunnel cannot expand with the pressure phenomenon, not only the function of the hearing nerve, but also the balance and facial nerves may become disturbed as they pass through this boney tunnel.
Rupture or spasm of one of the small blood vessels occurring anywhere in the auditory pathway produces pressure and interference with circulation. Consequently, sudden tinnitus, with or without partial or total loss of hearing function, may occur. If the blood clot is small, it may absorb with little or no permanent changes. This condition, like the pressure phenomenon, occurs only on one side and because it has occurred once doesn’t mean it would necessarily occur again either on the same or opposite side.
Any disturbance, whether due to swelling, pressure or interference with circulation, may occasionally involve one or more of the complex hearing pathways as they enter and terminate in the brain. In most of these instances, the symptoms are localized to one ear, and other symptoms and signs develop which aid the doctor in determining the cause and location of the disturbance.
AFFECTS OF TINNITUS
Stress and Depression
Stress is present in everyone’s life periodically. There are five stress factors which may cause or aggravate existing tinnitus: chemical stress, acoustic stress, physical stress, pathological stress, and emotional stress. Examples of chemical stress include aspirin in high doses, caffeine, or some drugs used for chemotherapy. There are many examples of very loud sounds in our everyday lives that may increase tinnitus. Fatigue often contributes to the perception of tinnitus. As a result, tinnitus is often louder at the end of the day or after physical exertion.
In some, tinnitus is chronic, and can result in symptoms or lead to depression. At times these symptoms, such as tinnitus, may in itself lead to depression and this can then make the tinnitus more bothersome; a vicious cycle develops.
Knowing this, we may recommend that a patient with severe tinnitus be treated with antidepressants or anti-anxiety medications. Patients of this type are also the ones who are most likely to benefit from biofeedback treatment.
Head noise or tinnitus may or may not be associated with hearing impairment. After reviewing the many causes of this symptom, it is easy to understand why the hearing may at times be affected when tinnitus is present. If a hearing loss coexists with tinnitus, the severity of the head noise is not an index as to the future course of the hearing impairment. Many persons with tinnitus have the erroneous fear they are going to lose their hearing. This is an unnecessary fear.
TREATMENT OF TINNITUS
If the examination reveals a local or general cause of the head noise, correction of the problem may alleviate the tinnitus. In most cases, however, there is no medical or surgical treatment which will eliminate tinnitus.
Avoid all forms of loud sound. If you must be exposed, use ear protectors such as ear plugs or earmuffs. If you are exposed to certain sounds which increase your head noise, make it a point not to repeat that experience.
Make every effort to avoid nervous anxiety, for this only stimulates an already tense auditory system.
Make every attempt to obtain adequate rest and avoid over fatigue.
The use of nerve stimulants is to be avoided. Therefore, excessive amounts of coffee (caffeine) and smoking (nicotine) should be avoided.
Learn as quickly as possible to accept the existence of the head noise as an annoying reality and them promptly and completely ignore it as much as possible.
Tinnitus will not cause you to go deaf, will not result in you losing your mind or cause your death, so immediately forget such distracting and terrifying thoughts.
Tinnitus is usually more marked after one goes to bed and his surroundings become quiet. Any noise in the room, such as a loud ticking clock or a radio, will serve to mask the irritating head noises and make them much less noticeable. Tinnitus Maskers and Sound Conditioners are also available (see below).
If one sleeps in an elevated position with one or two pillows, less congestion to the head will result and the tinnitus may be less noticeable.
Sedatives of various types may be used occasionally for temporary relief.
When tinnitus is associated with a hearing impairment, even a mild one, the use of a hearing aid in the involved ear is frequently very effective in reducing the awareness of the head noise by “masking out” the tinnitus.
Biofeedback training is effective in reducing the intensity of tinnitus in some patients. Treatment consists of biofeedback exercises in hourly sessions, in which the patients learn to control circulation to various parts of the body and relax muscles attached to the head. When a patient is able to accomplish this type of relaxation, tinnitus often subsides.
Should you be interested in treatment, your otologist will refer you to a nearby office.
In an individual with hearing impairment, the most effective treatment of tinnitus is the use of properly fitted hearing aids. The sound heard through the aid not only improves the ability to perceive speech, but makes the head noise less noticeable by “masking out” the inner head noise.
For individuals who have normal hearing but are severely distracted by their tinnitus, a tinnitus masker may be effective. The tinnitus masker is a small electronic instrument built into a post-auricular (behind-the-ear) hearing aid case. It generates a noise which prevents the wearer from hearing his own head noise.
The tinnitus masker is based on the principle that most individuals with tinnitus can better tolerate outside noise than they can their inner head noise. An attempt is made to identify the frequency (pitch) of the tinnitus. We then recommend a tinnitus masker which produces a noise matching this frequency as closely as possible, and refer the patient to a hearing aid dealer who stocks this type of device. The masker is made available on a rental basis so that the individual can determine whether or not it will be effective in masking the head noise.
Sound conditioners are small devices that project sound in a quiet room to help cover up the noise from tinnitus. Most patients find that tinnitus is always worse at night or in a quiet environment and find relief in the use of sound conditioners or by simply using a fan or playing soft music.