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Tinnitus
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Can other people hear the noise in my head? Not usually, but sometimes they are able to hear certain type of tinnitus. This is called objective tinnitus and it is caused either by abnormalities in blood vessels around the outside of the ear or by muscle spasms which may sound like clicks or cracklings inside the middle ear.
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What
causes tinnitus? In many cases it is impossible to find the cause of the tinnitus. In general, 50% of patients have no idea what started their tinnitus or even what was associated with its start up. Noise exposure accounts for 25%, ear pathology 5% and head injury 5%. The remaining 5% are distributed over a wide variety of causes including 2% due to whiplash. Even in cases where the cause of the tinnitus is known it is often not possible to treat that cause. In addition the underlying mechanism of the tinnitus is usually unknown; this makes potential treatment even more difficult. There are a variety of medical conditions that either cause or affect the presentation of tinnitus. These include
1. Ear disease 2. Cardiovascular disease 3. Metabolic illnesses 4. Neurological disorders 5. Pharmacological or drug induced symptoms 6. Dental factors 7. Psychologic or emotional factors
Ear Causes for Tinnitus: This is the most common cause of tinnitus in any age group. Over 90% of people who complain of tinnitus have some form of ear disease. Most tinnitus comes from damage to the microscopic endings of the hearing nerve in the inner ear. The health of these nerve endings is important for acute hearing and injury to them brings on hearing loss and often tinnitus. Advancing age is generally accompanied by a certain amount of hearing nerve impairment - and even tinnitus. Exposure to loud noises is probably the leading cause of tinnitus in today's world and it often damages hearing as well. Unfortunately, many people are unaware or, or unconcerned about, the harmful effects of excessively loud industrial noise, firearms noise, high intensity music and other loud noise. Stereo head sets played too loudly appear to be an increasing cause of ear damage in otherwise healthy young people. This high frequency hearing loss is most often a result of aging or prolonged noise exposure. Improvement of the tinnitus can often be achieved with the use of hearing aids or masking devices. There are many other specific ear disorders that can cause tinnitus and that may or may not result in high frequency hearing loss. Meniere's disease, chronic suppurative otitis media(chronic draining ear), recurrent viral infections of the ear, otosclerosis and sudden hearing loss are all factors in causing moderate to severe tinnitus. The first symptom in many patients with acoustic neuroma (a benign tumour of the ear nerve) may be tinnitus.
Cardiovascular Disorders: High blood pressure can be a factor in the onset or severity of some patient's complaints. Other vascular problems that must be excluded in a medical evaluation include anaemia (in which tinnitus is secondary to increased heart rate and cardiovascular output) and extensive arteriosclerosis in which calcific plaques frequently cause vascular turbulence. Rarely alteration in venous blood flow in the head will result in a low frequency soft hum.
Metabolic Disease: Diabetes and thyroid disease may be factors resulting in tinnitus, but rarely will the patient or individual identify these disorders as instigating their ear noise. In diabetes the development of arteriosclerotic plaques and the development of neurosensory loss is more common. In hyperthyroidism, the cardiac output is increase causing a tinnitus that tends to be rushing or pulsatile in nature.
Neurologic Disease: Head trauma can cause tinnitus. This is a result of damage to the internal structure of the inner ear with nerve or hair cell damage. Generally tinnitus as a result of trauma will diminish over a period. Tinnitus may also be noted in patients who have had whiplash injury suggesting that nerve input form the neck and shoulders along with concussion damage suggesting that nerve input from the neck along with concussion damage to the inner ear may be involved.
Drug Factors: A relatively high percentage of patients will relate the onset of their tinnitus to a change or initiation or specific medications for other illnesses. All types of drugs can be considered as a possible cause for increased tinnitus. The most frequent medications causing these symptoms are 1. antiinflammatory drugs 2. antibiotics 3. sedatives or antidepressants
Dental Factors: It is felt by most physicians that disorders of the jaw joint can be associated with tinnitus. Tinnitus, which is secondary to jaw joint problems is usually of a lower pitch and may be related to jaw activity or jaw trauma. Grinding of teeth, misalignment and painful teeth are frequent complaints. Ear pain is common.
Psychological Factors: Fatigue
and stress play a major factor in the severity of tinnitus rather than
cause it. Patients with severe intractable tinnitus suffer from depression
however it is difficult to know which comes first. |
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Treatment: In
most cases, there is no specific treatment for noises in the ear or
head. If your doctor finds on examination that your tinnitus has a specific
cause, he may be able to remove the cause and thus eliminate the noise.
In most cases the cause of tinnitus cannot be identified. Occasionally,
medicines may help the noise event though no cause can be identified.
The medicines used are many. |
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What
is the treatment of tinnitus? Most treatments that are practiced lack any consensus as to the cause of the tinnitus or the mechanisms that underlie its occurrence. A large variety of treatments have been practiced. It is interesting to observe that a number of patients report having benefited by these treatments. Not infrequently it is impossible to determine what is meant by benefited. Because tinnitus is probably due to a variety of causes it is understandable that many different kinds of treatment ultimately will be required to treat tinnitus. The role of a variety of these treatments will be discussed.
Drinks, Food, Alcohol, Tobacco and Medications: Tinnitus people are sometimes advised not to drink tea and coffee because of their high content of caffeine and to avoid red wines, ports and such like and to avoid foods. But to tell tinnitus people generally to avoid a list of foods usually has no effect on the tinnitus and merely detracts further from their quality of life. The same also goes for smoking and alcohol; the evidence that these cause tinnitus being controversial. There are of course other reasons for advice against smoking, but tinnitus is not one of them. What people need to do if they wish to try and search out whether some particular food or drink, or tobacco or alcohol is temporarily aggravating their tinnitus is to go on a system of withdrawal and rechallenge. You withdrawal from the suspected aggravators for a matter of one or two weeks. If the tinnitus then seems to be rather better, then deliberately go back on them. But tinnitus can fluctuate so much at times, and particularly with some helpful expectation of benefit, that you need to do this withdrawal and rechallenge at least three times before you can be sure that they are really upsetting your tinnitus. You can then consider the degree of relief given by avoidance of these things and decide on whether the advantage outweighs the loss of enjoyment in doing without them. With respect to medications you need to be a little more careful. The drugs are presumably being taken for some good reason and to stop them could be more hazardous to health. So any trial withdrawal and challenge from a particular drug suspected of causing (temporarily) or aggravating tinnitus has to be done in consultation with your doctor. Many drugs have tinnitus listed as a side effect. This is simply because tinnitus can arise as a temporary symptom of distress from the body against something that is upsetting it. The drugs that most commonly blamed for doing this are the nonsteroidal antiinflammatories, the kinds of drugs you take for chronic arthritis, also the beta blockers most commonly taken to control the heartbeat and blood pressure; and also some of the antidepressants.
Magnets in the Ear Canal: This technique developed in Japan. Controlled scientific studies have shown no benefit. Electromagnetic stimulation with a particular form of stimulator has been advertised and patients do report benefit from it. The treatment is unlikely to cause harm but once again scientific studies have shown no benefit.
Lignocaine(Xylocaine): This is a local anaesthetic, which when injected into a vein of a tinnitus patient will abolish tinnitus in about half of the cases and reduce it in many others. The duration of relief is only a matter of minutes up to perhaps a couple of hours, occasionally longer. There has been a search for a drug that can be taken by mouth that has the same side effect and is relatively free of side effects. Lignocaine is thought to work by what can be called a membrane stabilising action. The two main groups of such drugs are those that act on the central nervous system and are or can be used in the treatment of epilepsy; and those that are used in the treatment of overactivity of the heart muscles causing irregularities of the heart beat. Of the first group, the tranquilizers seem to help. It may work by calming the person and reducing tension rather than by any direct effect on the tinnitus. Carbazepine(Tegretol) also reduces tinnitus but it is quite an unpleasant drug for many people and also have some effects on the blood quality that need careful monitoring. People have also tried to get lignocaine into the ear using a technique called iontophoresis and by direct injection. There is no evidence that either works.
Ginko Bilboa: Extract of ginko bilboa is probably the most popular of herbal treatments that have frequently been thought to be helpful for tinnitus. Rigorous scientific studies have shown not benefit however a few patients do report it helps. It is unlikely to cause harm and perhaps some people may get benefit.
Vitamin B12: Some people report that using multiple B vitamin preparations; these patients do not have any symptoms of a Vitamin B deficiency. A study of military personnel in Israel has shown that those with measured B12 deficiencies were more susceptible to noise induce hearing loss and noise induced tinnitus.
Frusemide: Frusemide is primarily used as a diuretic(increases urine flow). There is a subgroup of tinnitus sufferers who are responsive to taking this medication. The benefit of the treatment has to be weighed up with the disadvantages of taking the medication.
Antihistamines: Some patients note that while taking antihistamines there is a slight to mild suppression of their tinnitus. The subjects reporting the greatest improvement have generally had allergy problems in the past.
Aspirin: There are rare cases where patients have measurable spontaneous acoustic emissions. In those patients with these emissions aspirin has been postulated as a possible treatment for their tinnitus.
GDEE(Glutamic acid diethyl ester) and Carovine: These medications have been shown to reduce tinnitus when given intravenously. Their use is still largely experimental.
Biofeedback Control for Tinnitus: Tinnitus is well known as a stress related disorder. Stress control is therefore an essential element in the management of tinnitus regardless of aetiology. EMG(electromyogram) biofeedback is a technique used to train people in relaxation techniques.
Psychological Treatments: Relaxation therapy, biofeedback, cognitive therapy and to some extent hypnotherapy have all been assessed in careful clinical trials. The results of these trials have been mostly but not universally positive. Patients in general do not report a lessening of their tinnitus but report improvements in the unpleasant emotions associated with their tinnitus. Patients report an increase in their tolerance of tinnitus and a reduction in the annoyance associated with it.
The Masking of Tinnitus: Tinnitus is usually more bothersome when the surroundings are quiet, especially when you are in bed. A competing sound such as a ticking clock or a radio may help to mask head noises, making the less noticeable. Some doctors suggest listening to FM music at low volume. Many patients have been helped by dialling between two FM stations for the purpose of picking up subdued static again at low volumes. Such static may be extremely soothing, with a soft rushing kind of sound known as white noise. Other patients prefer small electrical devices which produce soothing background noise. The tinnitus masker is a small electronic device built into or combined with a hearing aid. It generated a competitive but pleasant sound which for some individuals masks the tinnitus by reducing the awareness of head noise. The result is similar to successful use of white noise - by helping a patient overcome his awareness of tinnitus before going to sleep at night. The concept of masking tinnitus using an external sound is not new. Tinnitus patients differ considerably in their ability to benefit from a masking program. Relief of tinnitus by masking can be accomplished in two ways. First the external sound of the masker is generally a more acceptable sound than the patient's tinnitus and can be substituted for the tinnitus. Second a small number of patients can control their tinnitus through the extension of residual inhibition. These latter patients upon removal of the masking stimulus experience a period of time in which the tinnitus is either reduced or completely absent. It is also important to mention that many patients cannot benefit from a masking program.
Tinnitus and the Jaw Joint(TMJ): There is an association between problems in the jaw joint and tinnitus. Improvement in the jaw joint function does lead to an improvement in some tinnitus in some patients. The mechanism of the association of TMJ problems and tinnitus is unknown. |
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Treatment
of Tinnitus based on a Neurophysiological Model:
1. enrichment of environmental sounds 2. enrichment and enhancement of environmental sounds using hearing aids 3. introducing broadband noise produced by wearable noise generators
Effectively the brain is taught not to hear the tinnitus. |
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Conclusion: Prior to any treatment of tinnitus or head noise, it is important that you have a thorough medical examination . Once your doctor has completed this evaluation, an essential part of the treatment will be to help you to understand your tinnitus, what has caused it and how it may best be treated. Your hearing is too precious to treat carelessly. |
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Further Information: NZ Tinnitus Association North Shore Hospital, Shakespeare Rd., Takapuna 486 5359 |