Tinnitus (Noise in the Ear)

Tinnitus (Noise in the Ear           

Anatomy and Physiology of the Ear  Click here

What is Tinnitus?
The definition of tinnitus is the perception of a noise in the in the ear, ears or somewhere inside the head in absence of an external cause. Tinnitus is quite common, affecting up to 20 per cent of the population. Probably everyone could hear a noise if placed in a sufficiently quiet background.
There is a wide variation in the effects of tinnitus. Up to 0.5 per cent of the population find that tinnitus affects their daily life severely, and it is usually these patients who come to medical attention, many times for the psychologi¬cal aspects of tinnitus.

Tinnitus may manifest as a hum, buzzing, roaring, whistle or a hiss. It may come and go, or may be continuous. The type of tinnitus does not  give a clue to its cause, except with pulsatile tinnitus, which suggests a vascular cause or a conductive hearing loss. The hearing of voices or more complex sounds is not tinnitus, and the cause of such symptoms (auditory hallucinations)  lies within the realm of psychiatry or neurology.

In many instances there is an initial triggering event like trauma – acoustic or physical as in a head injury, sudden mental stress as loss of a family member. The initial site of generation of the noise is probably the coch¬lea, the sound itself may continue despite severing the cochlear nerve, implying that it must be perpetuated centrally.This suggests that tinnitus be considered to be a functional disorder of the entire auditory system.

What is the cause of Tinnitus?
Tinnitus may arise 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. In the elderly, advancing age is generally accompanied by increasing weakness of the hearing nerve with tinnitus. In younger people, exposure to loud noise is an important cause of tinnitus, and often hearing loss.

Middle Ear disease causing tinnitus – Otosclerosis stiffening of the middle ear bone stapes (otosclerosis).
Inner ear disease – A vila infection, blood vascular affection or tumor of the nerve of hearing or balance (Acoustic schwannoma) can cause tinnitus.
Medical conditions like allergy, high or low blood pressure (blood circulation problems), diabetes, thyroid problems, injury to the head or neck etc. Medications such as anti-inflammatories, antibiotics, sedatives, antidepressants. If you have tinnitus and are taking aspirin, a dosage adjustment may be required..

What are the investigations necessary
Hearing tests for the internal ear (Audiogram) and middle ear pressure tests (Tympanogram) balance test (ElectroNystagmogram)  to ellicit the cause of your tinnitus. An MRI scan of the brain is essential when there is a hearing loss only in the ear affected by the tinnitus.

How can one cope with Tinnitus?
    The following list of DOs and DON’Ts can help lessen the severity of tinnitus:
• Avoid exposure to loud sounds and noises.
• Get your blood pressure checked. If it is high, get your doctor’s help to control it.
• Avoid stimulants such as coffee, tea, cola, and tobacco. Decrease intake of salt. Adjust dose of aspirin.
• Exercise daily to improve your circulation.  Get adequate rest and avoid fatigue.
• Stop worrying about the noise. Recognize it as an annoyance and learn to ignore it as much as possible.

     Diagnosis:

     Imbalance or dizziness are frequently associated with tinnitus or hearing loss,although it is not always easy to establish their relevance. Acute attacks of true rotary vertigo are relevant, but the more common vague feeling of imbal¬ance is less significant.
     Psychological factors are certainly important and should be explored, particularly stress-related aspects or symptoms suggesting de¬pression.

     Use of medicines may cause tinnitus – many drugs. have tinnitus listed as a potential side-effect, although in reality this fortunately appears to be rare. It would be expected that stopping medication should stop the tinnitus, but as in the case of the division of the cochlear nerve, this may not happen. Persistent unilateral symptoms with hearing loss should always be investi¬gated.

     Examination of the ears may suggest a diagnosis.
     Impacted wax can lead to a conductive hearing loss that can then lead to tinnitus.
     A middle-ear effusion following flying or a URTI may precipitate tinnitus, again because of the con¬ductive loss.
     Audiometry establishes whether there is a hearing loss, whether it is ¬unilateral or bilateral, and quantifies any loss.

Common causes: Most patients will present with tinnitus alone or in combina¬tion with some degree of sensorineural hearing loss, usually as a result of presbyacusis. Examination will be normal, and audiometry will effectively give the diagnosis. Assessing any psychological factors will help. If hearing loss seems to be present, then obtaining a hearing aid may ameliorate the tinnitus.
The effect of high level of noise is well-recognised, and there are two groups where tinnitus is related to noise exposure. The first consists of patients with a long history of noise exposure. This may be occupational, such as in sheet metal or print workers. Despite awareness of noise risks and occupational health monitoring, Noise-Induced Hearing Loss (NIHL) still occurs, with asso¬ciated tinnitus. Musicians are another group at risk of NIHL. They are not usually subjected to monitoring, but are often very sensitive about their hearing and may find tinnitus quite disturbing. The second, smaller group have a sudden event leading to tinnitus with or without hearing loss. The classic ex¬ample is related to very loud music events. It is common for those attending to come out with both the ears ringing and blocked feeling. This shows as a temporary threshold shift on an audiogram. By the following morning these symptoms usually disappear, but for a small group of people the effects can be permanent. Avoiding further noise trauma is often the only action that can be taken to help ¬with both hearing loss and tinnitus.

Middle-ear effusions from any cause (infection, barotrauma) act in a similar fashion. If there is conductive loss due¬ to tympanic membrane perforation, surgical correction is not usually offered for tinnitus alone, but it is possible that correcting the associated hearing loss may help.

Rare causes: It is extremely rare for bilateral tinnitus to be a manifestation of any serious intracranial disease. The only time when imaging should be con¬sidered is when there is co-existing neurological symptoms. Occasionally patient anxiety is such that it necessitates imaging. MRI scans are best.

Unilateral tinnitus presents more of a dilemma. It is important because it may indicate the presence of an intracranial or retrocochlear lesion. Such lesions are usually benign, and treatment is more successful the smaller the tumour. In many cases, bilateral tinnitus begins as unilateral tinnitus for a variable time. In the absence of any other symptoms, waiting three months is reason¬able.
Acoustic neuroma, more appropriately called a vestibular schwannoma, is a benign tumour arising in the internal auditory canal or cerebellopontine angle. It occurs in 1:50,000 to 1:100,000 people per year. At least 90 per cent of  cases present with asymmetric hearing loss and possibly tinnitus.  Tinnitus alone as a presenting symptom is rare, although hearing loss may only mani¬fest itself as a blocked feeling. The tumours tend to grow slowly, with periods of no growth. Management options include serial observation by MRI, surgical removal or radiotherapy to control growth. Any patient with unexplained unilat¬eral sensorineural hearing loss (with or without tinnitus) needs an MRI to ex¬clude this condition.

Meniere’s disease classically presents a triad of symptoms: attacks of ver¬tigo, hearing loss and tinnitus. This presentation is usually easy to diagnose, but the diagnosis may be more difficult if; in particular, the attacks. of vertigo are infrequent but the tinnitus and hearing loss is always present.
The manage¬ment of these symptoms is along conventional lines. Vertigo is usually treated with drugs such as betahistine, diuretics and salt restriction. Refractory cases are now usually offered intratympanic gentamicin injections.

Management: Some people have an identifiable and correctable cause, but most patients will have tinnitus either as a sole complaint or in association with sensorineural hearing loss. They may be concerned about the implica¬tions of tinnitus and their future; establish exactly what bothers them first. Patients must be told that there is no magic pill, but there are many treatments that can help.
Treating hearing loss with an appropriate aid, may be beneficial. It may not improve the tinnitus directly, but may help any disability and handi¬cap secondary to the hearing loss. Tinnitus is usually most disturbing during night. A simple strategy is to increase background environment noise by lis¬tening to radio when going to sleep. Patients who are not satisfied with the initial explanation, express interest in further treatmetifs or have co-existing anxiety or depression require further intervention. Disordered mood may ben¬efit from drug treatment, tricyclic antidepressants may benefit selected pa¬tients. Empowering the patient to self-treat is worth while, but sometimes more specific interventions are needed. Specific treatments include counselling, re¬laxation therapy, cognitive behavioural therapy, masking and sound therapy. Most people are helped, but a few need psychiatric assessment, especially if suicide is a possibility.

What  is the treatment of Tinnitus?

Medical treatment Combinations of various drugs which nourish the delicate nerves of the inner ear may be tried. Initially, a mild tranquiliser should be taken. As adjustment to the noise occurs, the dose of this may be decreased. 

Concentration and relaxation exercises and Yoga can help to control muscle groups and circulation throughout the body. The increased relaxation and circulation can reduce the intensity of tinnitus in many patients.

Masking. Tinnitus is usually more bothersome in quiet surroundings. A competing sound at a constant low level, such as a ticking clock or soft music from a Walkman set may mask the tinnitus and make it less noticeable. Products that generate white noise are also available through catalogs and specialty stores.

Hearing Aids. If you have a hearing loss, a hearing aid(s) may reduce head noise while you are wearing it and sometimes cause it to go away temporarily. It is important not to set the hearing aid at excessively loud levels, as this can worsen the tinnitus in some cases. However, a thorough trial before purchase of a hearing aid is advisable if your primary purpose is the relief of tinnitus.

Tinnitus maskers combined within hearing aids. They emit a competitive but pleasant sound that can distract you from head noise. Some people find that a tinnitus masker may even suppress the head noise for several hours after it is used, but this is not true for all users.

 In tinnitus without definable cause     Learn to realize that –

 Tinnitus is a very common complaint.

 Tinnitus usually lessens over a period of time.

 Medical treatment works in many cases – if it does not, one has to learn to cope up with tinnitus without the help of medicines.

 Most people learn to live with it without much difficulty. Time is the best healer.

 Many methods are available in helping you to adapt to the noise, which while not curing it, would certainly assist in coping with it.

 Remember, tinnitus sounds are not in fact very loud by comparison with many everyday sounds.
                                                
 They can be irritating and frustrating like traffic noise, the dripping tap at night or the next door baby’s cry.
 
 It is therefore a matter of learning to control reactions to these irritations or to ignore them and not let them take control.

         Your present check up results show that there is no disease of the ears or suspicion of  brain disease like tumour or degeneration to explain the noise in the ears.

However, it is essential to assess the condition from time to time.

Do report for assessment if the tinnitus increases or symptoms like giddiness, vertigo, develop in which case, further investigations like a head and brain scan like  a C. T. or  M. R. I. Scan would be required.

Differential Diagnosis of Pulsatile Tinnitus

Cardiovascular disease
Vascular disease Arteriovenous fistula Caroticocavernous fistula ICA atheroma
ICA thrombosis
ICA dissection
Ectasia or stenosis Fibromuscular dysplasia Intrapetrous carotid aneurysm Intracranial aneurysm

Cardiac valvular disease

Cardiac high-output states Anemia
Thyrotoxicosis
  Beri-beri

Vascular tumor of temporal bone or cranium
Paraganglioma (Glomus jugulare tumor)
Meningioma
Hemangioma
Vestibular schwan noma
Vascular metastatic carcinoma
Parenchymal A VM

Other disorders of the temporal bone Paget’s disease
Otosclerosis (osteolytic phase)

 Congenital or developmental anomalies
     Anomalous ICA of middle ear
     Congenital arterial shunts
      Persistent stapedial artery
      Primitive otic artery
      Primitive hypoglossal artery
      Eagle syndrome
      Jugular megabulb
      Dehiscent jugular bulb
      Posterior condylar emissary vein

 Other conditions
       Benign intracranial hypertension