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Tinnitus

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Tinnitus
2010-07-20 Black windup alarm clock face.jpg
Tinnitus often results in the sound of ringing.
Pronunciation
Specialty Otorhinolaryngology, audiology
Symptoms Hearing sound when no external sound is present[1]
Complications Depression, anxiety, poor concentration[2]
Usual onset Gradual[3]
Causes Noise-induced hearing loss, ear infections, disease of the heart or blood vessels, Ménière's disease, brain tumors, emotional stress[2][4]
Diagnostic method Based on symptoms, audiogram, neurological exam[1][3]
Treatment Counseling, sound generators, hearing aids[5][2]
Frequency ~12.5%[5]

Tinnitus is the hearing of sound when no external sound is present.[1] While often described as a ringing, it may also sound like a clicking, hiss or roaring.[2] Rarely, unclear voices or music are heard.[3] The sound may be soft or loud, low pitched or high pitched and appear to be coming from one ear or both.[2] Most of the time, it comes on gradually.[3] In some people, the sound causes depression or anxiety and can interfere with concentration.[2]

Tinnitus is not a disease but a symptom that can result from a number of underlying causes.[2] One of the most common causes is noise-induced hearing loss.[2] Other causes include: ear infections, disease of the heart or blood vessels, Ménière's disease, brain tumors, emotional stress, exposure to certain medications, a previous head injury, and earwax.[2][4] It is more common in those with depression.[3]

The diagnosis of tinnitus is usually based on the person's description.[3] A number of questionnaires exist that may help to assess how much tinnitus is interfering with a person's life.[3] The diagnosis is commonly supported by an audiogram and a neurological examination.[1][3] If certain problems are found, medical imaging, such as with MRI, may be performed.[3] Other tests are suitable when tinnitus occurs with the same rhythm as the heartbeat.[3] Rarely, the sound may be heard by someone else using a stethoscope, in which case it is known as objective tinnitus.[3] Spontaneous otoacoustic emissions, which are sounds produced normally by the inner ear, may also occasionally result in tinnitus.[6]

Prevention involves avoiding loud noise.[2] If there is an underlying cause, treating it may lead to improvements.[3] Otherwise, typically, management involves talk therapy.[5] Sound generators or hearing aids may help some.[2] As of 2013, there were no effective medications.[3] It is common, affecting about 10–15% of people.[5] Most, however, tolerate it well, and it is a significant problem in only 1–2% of people.[5] The word tinnitus is from the Latin tinnīre which means "to ring".[3]

Signs and symptoms

Tinnitus can be perceived in one or both ears or in the head. It is the description of a noise inside a person’s head in the absence of auditory stimulation. The noise can be described in many different ways. It is usually described as a ringing noise but, in some patients, it takes the form of a high-pitched whining, electric buzzing, hissing, humming, tinging or whistling sound or as ticking, clicking, roaring, "crickets" or "tree frogs" or "locusts (cicadas)", tunes, songs, beeping, sizzling, sounds that slightly resemble human voices or even a pure steady tone like that heard during a hearing test.[4] It has also been described as a "whooshing" sound because of acute muscle spasms, as of wind or waves.[7] Tinnitus can be intermittent or continuous: in the latter 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.[8] Most people with tinnitus have some degree of hearing loss.[9]

The sound perceived may range from a quiet background noise to one that can be heard even over loud external sounds. The specific type of tinnitus called pulsatile tinnitus is characterized by hearing the sounds of one's own pulse or muscle contractions, which is typically a result of sounds that have been created by the movement of muscles near to one's ear, or the sounds are related to blood flow of the neck or face.[10]

Course

Due to variations in study designs, data on the course of tinnitus showed few consistent results. Generally the prevalence increased with age in adults, whereas the ratings of annoyance decreased with duration.[11][12][13]

Psychological

Persistent tinnitus may cause anxiety and depression.[14][15] Tinnitus annoyance is more strongly associated with psychological condition than loudness or frequency range.[16][17] Psychological problems such as depression, anxiety, sleep disturbances and concentration difficulties are common in those with strongly annoying tinnitus.[18][19] 45% of people with tinnitus have an anxiety disorder at some time in their life.[20]

Psychological research has looked at the tinnitus distress reaction (TDR) to account for differences in tinnitus severity.[18][21][22][23] These findings suggest that at the initial perception of tinnitus, conditioning links tinnitus with negative emotions, such as fear and anxiety from unpleasant stimuli at the time. This enhances activity in the limbic system and autonomic nervous system, thus increasing tinnitus awareness and annoyance.[24]

Causes

There are two types of tinnitus: subjective tinnitus and objective tinnitus.[3] Tinnitus is usually subjective, meaning that others cannot hear it.[3] Subjective tinnitus has also been called "tinnitus aurium", "non-auditory" or "non-vibratory" tinnitus. In very rare cases tinnitus can be heard by someone else using a stethoscope, and in less rare - but still uncommon - cases it can be measured as a spontaneous otoacoustic emission (SOAE) in the ear canal. In such cases it is objective tinnitus,[3] also called "pseudo-tinnitus" or "vibratory" tinnitus.

Subjective tinnitus

Subjective tinnitus is the most frequent type of tinnitus. It can have many possible causes, but most commonly it results from hearing loss. A frequent cause of subjective tinnitus is noise exposure that damages hair cells in the inner ear. Subjective tinnitus can only be heard by the affected person and is caused by otological and / or neurological conditions, including those triggered by infections or drugs.[25]

There is a growing body of evidence suggesting that tinnitus is a consequence of neuroplastic alterations in the central auditory pathway. These alterations are assumed to result from a disturbed sensory input, caused by hearing loss.[26] Hearing loss could indeed cause a homeostatic response of neurons in the central auditory system, and therefore cause tinnitus.[27]

Hearing loss

The most common cause of tinnitus is noise-induced hearing loss. Such hearing loss may also be present in a hidden form, i.e. in persons showing a normal audiogram.[27]

Hearing loss may have many different causes; but among tinnitus subjects, the major cause is cochlear damage.[26]

Ototoxic drugs can also cause subjective tinnitus, as they may cause hearing loss, or increase the damage done by exposure to loud noise. Those damages can occur even at doses that are not considered ototoxic.[28] Over 260 medications have been reported to cause tinnitus as a side effect.[29] In many cases, however, no underlying cause could be identified.[2]

Tinnitus can also occur due to the discontinuation of therapeutic doses of benzodiazepines. It can sometimes be a protracted symptom of benzodiazepine withdrawal and may persist for many months.[30][31] Medications such as bupropion may also result in tinnitus.[32]

Associated factors

Factors associated with tinnitus include:[33]

Objective tinnitus

Objective tinnitus can be detected by other people and is sometimes caused by an involuntary twitching of a muscle or a group of muscles (myoclonus) or by a vascular condition. In some cases, tinnitus is generated by muscle spasms around the middle ear.[10]

Spontaneous otoacoustic emissions (SOAEs), which are faint high-frequency tones that are produced in the inner ear and can be measured in the ear canal with a sensitive microphone, may also cause tinnitus.[6] About 8% of those with SOAEs and tinnitus have SOAE-linked tinnitus, while the percentage of all cases of tinnitus caused by SOAEs is estimated at about 4%.[6]

Pulsatile tinnitus

Pulsatile tinnitus can be a symptom of intracranial vascular abnormalities and should be evaluated for irregular noises of blood flow (bruits). Some people experience a sound that beats in time with their pulse (pulsatile tinnitus, or vascular tinnitus).[38] Pulsatile tinnitus is usually objective in nature, resulting from altered blood flow, increased blood turbulence near the ear (such as from atherosclerosis, venous hum,[39] but it can also arise as a subjective phenomenon from an increased awareness of blood flow in the ear.[38] Rarely, pulsatile tinnitus may be a symptom of potentially life-threatening conditions such as carotid artery aneurysm[40] or carotid artery dissection.[41] Pulsatile tinnitus may also indicate vasculitis, or more specifically, giant cell arteritis. Pulsatile tinnitus may also be an indication of idiopathic intracranial hypertension.[42]

Pathophysiology

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 dysfunction) are difficult to explain.

It may be caused by increased neural activity in the auditory brainstem, where the brain processes sounds, causing some auditory nerve cells to become over-excited. The basis of this theory is that many with tinnitus also have hearing loss.[9]

Three reviews of 2016 emphasized the large range and possible combinations of pathologies involved in tinnitus, which in turn result in a great variety of symptoms demanding specifically adapted therapies.[43][44][45]

Diagnosis

Even when tinnitus is the primary complaint, audiological evaluation is usually preceded by examination by an ENT to diagnose treatable conditions like middle ear infection, acoustic neuroma, concussion, otosclerosis, etc.[46]

Evaluation of tinnitus will include a hearing test (audiogram), measurement of acoustic parameters of the tinnitus like pitch and loudness, and psychological assessment of comorbid conditions like depression, anxiety, and stress that are associated with severity of the tinnitus.

The accepted definition of chronic tinnitus, as compared to normal ear noise experience, is five minutes of ear noise occurring at least twice a week.[47] However, people with chronic tinnitus often experience the noise more frequently than this and can experience it continuously or regularly, such as during the night when there is less environmental noise to mask the sound.

Audiology

Since most persons with tinnitus also have hearing loss, a pure tone hearing test resulting in an audiogram may help diagnose a cause, though some persons with tinnitus do not have hearing loss. An audiogram may also facilitate fitting of a hearing aid in those cases where hearing loss is significant. The pitch of tinnitus is often in the range of the hearing loss.

Psychoacoustics

Acoustic qualification of tinnitus will include measurement of several acoustic parameters like frequency in cases of monotone tinnitus or frequency range and bandwidth in cases of narrow band noise tinnitus, loudness in dB above hearing threshold at the indicated frequency, mixing-point, and minimum masking level.[48] In most cases, tinnitus pitch or frequency range is between 5000 Hz and 10.000 Hz,[49] and loudness between 5 and 15 dB above the hearing threshold.[50]

Another relevant parameter of tinnitus is residual inhibition, the temporary suppression and/or disappearance of tinnitus following a period of masking. The degree of residual inhibition may indicate how effective tinnitus maskers would be as a treatment modality.[51][52]

An assessment of hyperacusis, a frequent accompaniment of tinnitus,[53] may also be made.[54] The measured parameter is Loudness Discomfort Level (LDL) in dB, the subjective level of acute discomfort at specified frequencies over the frequency range of hearing. This defines a dynamic range between the hearing threshold at that frequency and the loudnes discomfort level. A compressed dynamic range over a particular frequency range is associated with subjectve hyperacusis. Normal hearing threshold is generally defined as 0–20 decibels (dB). Normal loudness discomfort levels are 85–90+ dB, with some authorities citing 100 dB. A dynamic range of 55 dB or less is indicative of hyperacusis.[55][56]

Severity

The condition is often rated on a scale from "slight" to "catastrophic" according to the effects it has, such as interference with sleep, quiet activities and normal daily activities.[57] In an extreme case a man committed suicide after being told there was no cure.[58]

Assessment of psychological processes related to tinnitus involves measurement of tinnitus severity and distress (i.e. nature and extent of tinnitus-related problems), measured subjectively by validated self-report tinnitus questionnaires.[18] These questionnaires measure the degree of psychological distress and handicap associated with tinnitus, including effects on hearing, lifestyle, health and emotional functioning.[59][60][61][62] A broader assessment of general functioning, such as levels of anxiety, depression, stress, life stressors and sleep difficulties, is also important in the assessment of tinnitus due to higher risk of negative well-being across these areas, which may be affected by and/or exacerbate the tinnitus symptoms for the individual.[63] Overall, current assessment measures are aimed to identify individual levels of distress and interference, coping responses and perceptions of tinnitus in order to inform treatment and monitor progress. However, wide variability, inconsistencies and lack of consensus regarding assessment methodology are evidenced in the literature, limiting comparison of treatment effectiveness.[64] Developed to guide diagnosis or classify severity, most tinnitus questionnaires have also been shown to be treatment-sensitive outcome measures.[65]

Pulsatile tinnitus

If the examination reveals a bruit (sound due to turbulent blood flow), imaging studies such as transcranial doppler (TCD) or magnetic resonance angiography (MRA) should be performed.[66]

Auditory evoked response

Tinnitus can be evaluated with most auditory evoked potentials: however, results may be inconsistent. Results must be compared to age and hearing matched control subjects to be reliable. This inconsistent reporting may be due to many reasons: differences in the origin of the tinnitus, ABR recording methods and selection criteria of control groups. Since research shows conflicting evidence, more research on the relationship between tinnitus and auditory evoked potentials should be carried out before these measurements are used clinically.

Differential diagnosis

Other potential sources of the sounds normally associated with tinnitus should be ruled out. For instance, two recognized sources of high-pitched sounds might be electromagnetic fields common in modern wiring and various sound signal transmissions. A common and often misdiagnosed condition that mimics tinnitus is radio frequency (RF) hearing, in which subjects have been tested and found to hear high-pitched transmission frequencies that sound similar to tinnitus.[67]

Prevention

Prolonged exposure to loud sound or noise levels can lead to tinnitus.[68] Ear plugs or other measures can help with prevention.

Several medicines have ototoxic effects, and can have a cumulative effect that can 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.[69]

Management

If there is an underlying cause, treating it may lead to improvements.[3] Otherwise, the primary treatment for tinnitus is talk therapy[5] and sound therapy; there are no effective medications.[3]

Psychological

The best supported treatment for tinnitus is a type of counseling called cognitive behavioral therapy (CBT) which can be delivered via the internet or in person.[5][70] It decreases the amount of stress those with tinnitus feel.[71] These benefits appear to be independent of any effect on depression or anxiety in an individual.[70] Acceptance and commitment therapy (ACT) also shows promise in the treatment of tinnitus.[72] Relaxation techniques may also be useful.[3] A clinical protocol called Progressive Tinnitus Management for treatment of tinnitus has been developed by the United States Department of Veterans Affairs.[73]

Medications

As of 2014 there were no medications effective for tinnitus.[3][68] There is not enough evidence to determine if antidepressants[74] or acamprosate is useful.[75] While there is tentative evidence for benzodiazepines, it is insufficient to support usage.[3] Anticonvulsants have not been found to be useful.[3] Steroid injections into the middle ear also do not seem to be effective.[76][77]

Botulinum toxin injection has been tried with some success in cases of objective tinnitus from a palatal tremor.[78]

Other

The use of sound therapy by either hearing aids or tinnitus maskers helps the brain ignore the specific tinnitus frequency. Although these methods are poorly supported by evidence, there are no negative effects.[3][79] There is some tentative evidence supporting tinnitus retraining therapy.[3] There is little evidence supporting the use of transcranial magnetic stimulation.[3][80] It is thus not recommended.[68]

Alternative medicine

Ginkgo biloba does not appear to be effective.[81] The American Academy of Otolaryngology recommends against taking melatonin or zinc supplements to relieve symptoms of tinnitus.[68] In addition, a 2016 Cochrane Review concluded that evidence is not sufficient to support taking zinc supplements to reduce symptoms associated with tinnitus.[82]

Prognosis

While there is no cure, most people with tinnitus get used to it over time; for a minority, it remains a significant problem.[5]

Epidemiology

Tinnitus affects 10–15% of people.[5] About a third of North Americans over 55 experience tinnitus.[83] Tinnitus affects one third of adults at some time in their lives, whereas ten to fifteen percent are disturbed enough to seek medical evaluation.[84]

Children

Tinnitus is commonly thought of as a symptom of adulthood, and is often overlooked in children. Children with hearing loss have a high incidence of tinnitus, even though they do not express the condition or its effect on their lives.[85] Children do not generally report tinnitus spontaneously and their complaints may not be taken seriously.[86] Among those children who do complain of tinnitus, there is an increased likelihood of associated otological or neurological pathology such as migraine, juvenile Meniere’s disease or chronic suppurative otitis media.[87] Its reported prevalence varies from 12% to 36% in children with normal hearing thresholds and up to 66% in children with a hearing loss and approximately 3–10% of children have been reported to be troubled by tinnitus.[88]

See also

References

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