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Tinnitus
SpecialtyOtorhinolaryngology Edit this on Wikidata

Tinnitus (Template:PronEng or /ˈtɪnɪtəs/, from the Latin word tinnītus meaning "ringing") is the perception of sound within the human ear in the absence of corresponding external sound.

Tinnitus is not a disease, but a symptom that can result from a wide range of underlying causes: abnormally loud sounds in the ear canal for even the briefest period (but usually with some duration), ear infections, foreign objects in the ear, nose allergies that prevent (or induce) fluid drain, or wax build-up. Withdrawal from a benzodiazepine addiction may cause tinnitus as well. In-ear headphones, whose sound enters directly into the ear canal, without any opportunity to be deflected or absorbed elsewhere, are a common cause of tinnitus when volume is set beyond modest or moderate levels.

Tinnitus can also be caused by natural hearing impairment (as in aging), as a side effect of some medications, and as a side effect of genetic (congenital) hearing loss. However, the most common cause is noise-induced hearing loss.

As tinnitus is usually a subjective phenomenon, it is difficult to measure using objective tests, such as by comparison with noise of known frequency and intensity, as in an audiometric test. The condition is often rated clinically on a simple scale from "slight" to "catastrophic" according to the practical difficulties it imposes, such as interference with sleep, quiet activities, and normal daily activities.[1]

Tinnitus is common; about one in five people between 55 and 65 years old report symptoms on a general health questionnaire, and 11.8% on more detailed tinnitus-specific questionnaires.[2]

Characteristics

Tinnitus can be perceived in one or both ears or in the head. It is usually described as a ringing noise, but in some patients it takes the form of a high pitched whining, electric, buzzing, hissing, screaming, humming, tinging or whistling sound, or as ticking, clicking, roaring, "crickets" or "tree frogs" or "locusts (cicadas)", tunes, songs, beeping, or even a pure steady tone like that heard during a hearing test.[3] It has also been described as a "wooshing" sound, as of wind or waves.[4] Tinnitus can be intermittent or it can be continuous, in which case it can be the cause of great distress. In some individuals, the intensity can be changed by shoulder, head, tongue, jaw, or eye movements.[5]

Most people with tinnitus have some degree of hearing loss,[6] in that they are often unable to hear clearly external sounds which occur within the same range of frequencies as their "phantom sounds."[7] This has led to the suggestion that one cause of tinnitus might be a homeostatic response of central dorsal cochlear nucleus auditory neurons that makes them hyperactive in compensation to auditory input loss.[8]

The sound perceived may range from a quiet background noise to one that can be heard even over loud external sounds. The term "tinnitus" usually refers to more severe cases. Heller and Bergman (1953) conducted a study of 100 tinnitus-free university students placed in an anechoic chamber, and found 93% reported hearing a buzzing, pulsing or whistling sound. Cohort studies have demonstrated damage to hearing (among other health effects) from unnatural levels of noise exposure is very widespread in industrialized countries.[9]

For research purposes, the more elaborate Tinnitus Handicap Inventory is often used.[10] Persistent tinnitus may cause irritability, fatigue, and on occasions, clinical depression[11][12] and musical hallucinations.[13]

As with all diagnostics, other potential sources of the sounds normally associated with tinnitus should be ruled out. For instance, two recognized sources of very high pitched sounds might be electromagnetic fields common in modern wiring, and various sound signal transmissions. A common and often misdiagnosed condition which mimics tinnitus is Radio Frequency (RF) Hearing [14], in which subjects have been tested and found to hear high pitched transmission frequencies that sound similar to tinnitus.

Causes

Objective tinnitus

In some cases, a clinician can perceive an actual sound (e.g., a bruit) emanating from the patient's ears. This is called objective tinnitus. Objective tinnitus can arise from muscle spasms that cause clicks or crackling around the middle ear.[15] Some people experience a sound that beats in time with the pulse (pulsatile tinnitus or vascular tinnitus).[16] Pulsatile tinnitus is usually objective in nature, resulting from altered blood flow or increased blood turbulence near the ear (such as from atherosclerosis or venous hum,[17]) but it can also arise as a subjective phenomenon from an increased awareness of blood flow in the ear.[16] Rarely, pulsatile tinnitus may be a symptom of potentially life-threatening conditions such as carotid artery aneurysm[18] or carotid artery dissection.[19] Pulsatile tinnitus may also indicate vasculitis, or more specifically, giant cell arteritis.

Subjective tinnitus

Subjective tinnitus can have many possible causes, but most commonly results from otologic disorders – the same conditions that cause hearing loss. The most common cause is noise-induced hearing loss, resulting from exposure to excessive or loud noises. But tinnitus, along with sudden onset hearing loss, may have no obvious external cause. Ototoxic drugs can cause subjective tinnitus either secondary to hearing loss or without hearing loss, and may increase the damage done by exposure to loud noise, even at doses that are not in themselves ototoxic.[20]

Subjective tinnitus is also a side effect of some medications, such as aspirin, and may also result from an abnormally low level of serotonin activity. It is also a classical side effect of quinidine, a Class IA anti-arrhythmic. Over 260 medications have been reported to cause tinnitus as a side effect.[21] In many cases, however, no underlying physical cause can be identified.

Tinnitus can also occur due to the discontinuation of therapeutic doses of benzodiazepines as part of the benzodiazepine withdrawal syndrome. It can sometimes be a protracted symptom from benzodiazepines withdrawal, and persist for many months.[22][23]

Causes of subjective tinnitus include:[24]

Pathophysiology

One of the possible mechanisms relies on otoacoustic emissions. The inner ear contains thousands of minute hairs, called stereocilia, which vibrate in response to sound waves, and cells which convert neural signals back into acoustical vibrations. The sensing cells are connected with the vibratory cells through a neural feedback loop, whose gain is regulated by the brain. This loop is normally adjusted just below onset of self-oscillation, which gives the ear spectacular sensitivity and selectivity. If something changes, it is easy for the delicate adjustment to cross the barrier of oscillation, and tinnitus results. Listening to loud music kills hair cells, and studies have shown as hair cells are lost, different neurons are activated, activating auditory parts of the brain and giving the perception of sound.[citation needed]

Another possible mechanism underlying tinnitus is damage to the receptor cells. Although receptor cells can be regenerated from the adjacent supporting Deiters cells after injury in birds, reptiles, and amphibians, in mammals it is believed they can be produced only during embryogenesis. Although mammalian Deiters cells reproduce and position themselves appropriately for regeneration, they have not been observed to transdifferentiate into receptor cells except in tissue culture experiments.[29][30] Therefore, if these hairs become damaged, through prolonged exposure to excessive sound levels, for instance, then deafness to certain frequencies results. In tinnitus, they may relay information that an externally audible sound is present at a certain frequency when it is not.

The mechanisms of subjective tinnitus are often obscure. While it is not surprising that direct trauma to the inner ear can cause tinnitus, other apparent causes (e.g., temporomandibular joint disorder (TMJD or TMD) and dental disorders) are difficult to explain. Research has proposed there are two distinct categories of subjective tinnitus: otic tinnitus, caused by disorders of the inner ear or the acoustic nerve, and somatic tinnitus, caused by disorders outside the ear and nerve, but still within the head or neck. It is further hypothesized somatic tinnitus may be due to "central crosstalk" within the brain, as certain head and neck nerves enter the brain near regions known to be involved in hearing.[31]

Studies by researchers at the University of Western Australia suggest tinnitus is caused by increased neural activity in the auditory brainstem where the brain processes sounds, causing some auditory nerve cells to become overexcited. The basis of this theory is most people with tinnitus also have hearing loss,[6] and the frequencies they cannot hear are similar to the subjective frequencies of their tinnitus.[7] Models of hearing loss and the brain support the idea a homeostatic response of central dorsal cochlear nucleus neurons could result in them being hyperactive in a compensation process to the loss of hearing input.[8] This, in turn, is related to changes in the genes involved in regulating the activity of those nerve cells. This proposed mechanism suggests possible treatments for the condition, involving the normalization or suppression of overactive neural activity through electrical or chemical means.[32]

While most discussions of tinnitus tend to emphasize physical mechanisms, there is strong evidence the level of an individual's awareness of his or her tinnitus can be stress-related, and so should be addressed by improving the state of the nervous system generally, using gradual, unobtrusive, long-term treatments.[33]

Since some tinnitus mimics electronic sounds, some recent research is focusing on electronics, the use of cell phones,[34] and other modern electronic devices as possible causes.

Diagnosis

The basis of quantitatively measuring tinnitus relies on the brain’s tendency to select out only the loudest sounds heard. Based on this tendency, the amplitude of a patient's tinnitus can be measured by playing sample sounds of known amplitude and asking the patient which he or she hears. The volume of the tinnitus will always be equal to or less than that of the sample noises heard by the patient. This method works very well to gauge objective tinnitus (see above.) For example: if a patient has a pulsatile paraganglioma in his ear, he will not be able to hear the blood flow through the tumor when the sample noise is 5 decibels louder than the noise produced by the blood. As sound amplitude is gradually decreased, the tinnitus will become audible, and the level at which it does so provides an estimate of the amplitude of the objective tinnitus.

Objective tinnitus, however, is quite uncommon. Often patients with pulsatile tumors will report other coexistent sounds, distinct from the pulsatile noise, that will persist even after their tumor has been removed. This is generally subjective tinnitus, which, unlike the objective form, cannot be tested by comparative methods.

If the attention of a subject is focused on a sample noise, he can often detect it at levels below 5 decibels, which would indicate his tinnitus would be almost impossible to hear [citation needed]. Conversely, if the same test subject is told to focus only on the tinnitus, he will report hearing the sound even when test noises exceed 70 decibels, making the tinnitus louder than a ringing phone. This quantification method suggests subjective tinnitus relates only to what the patient is attempting to hear [citation needed]. Whilst it is tempting to assume patients actively complaining about tinnitus have simply become obsessed with the noise, this is only partially true. The noises are often present in both quiet and noisy environments, and can become quite intrusive to their daily lives. The problem is involuntary; generally, complaining patients simply cannot override or ignore their tinnitus.

Subjective tinnitus may not always be correlated with ear malfunction or hearing loss. Even people with near-perfect hearing may still complain of it. Tinnitus may also have a connection to memory problems, anxiety, fatigue or a general state of poor health.[citation needed]

Prevention

Tinnitus and hearing loss can be permanent conditions. If a ringing in the ears is audible following lengthy exposure to a source of loud noise, such as a music concert or an industrial workplace, it means lasting damage may already have occurred.[citation needed]

Prolonged exposure to sound or noise levels as low as 70 dB can result in damage to hearing (see noise health effects). For musicians and DJs, special musicians' earplugs play an important role in preventing tinnitus; they can lower the volume of the music without distorting the sound and can prevent tinnitus from developing in later years. For anyone using loud electrical appliances, such as hair dryers or vacuum cleaners, or who work in noisy environments such as building sites, where earmuffs are impractical, earplugs are also helpful in reducing noise exposure. This is also the case for while riding motorcycles, mopeds etc. While operating lawn mowers, hammer drills, grinders, and similar, earmuffs may be more appropriate for hearing protection.

It is also important to check medications for potential ototoxicity. Ototoxicity of multiple medicines can have a cumulative effect, and can greatly increase the damage done by noise. If ototoxic medications must be administered, close attention by the physician to prescription details, such as dose and dosage interval, can reduce the damage done.[35]

Treatment

Many treatments for tinnitus have been claimed, with varying degrees of statistical reliability:

Objective tinnitus:

Subjective tinnitus:

Prognosis

The prognosis of tinnitus depends on the type and severity of the cause.

For tinnitus due to acute acoustic trauma, approximately 35% of cases report subsiding tinnitus at 3 months after the trauma, with approximately 10% of these cases being the degree of complete disappearance of the tinnitus, as studied among young men having acquired tinnitus from gunshots.[77]

Notable individuals

Notable individuals with tinnitus include:

See also

References

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Further reading

  • McKenna, Laurence; Andersson, Gerhard; Baguley, David (2005). Tinnitus: A Multidisciplinary Approach. London: Whurr Publishers. ISBN 1-86156-403-1.
  • Hogan, Kevin; Battaglino, Jennifer (2007). Tinnitus: Turning the Volume Down (Revised and Expanded ed.). Eagan: Network 3000 Publishing. ISBN 1-93426-603-5.
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