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Tinnitus
SpecialtyOtorhinolaryngology, audiology

Tinnitus (/ˈtɪnɪtəs/ or /tɪˈnaɪtəs/) 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, anxiety or interferes with concentration.[2]

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

The diagnosis is usually based on the person's description. Occasionally, the sound may be heard by someone else using a stethoscope: in which case, it is known as objective tinnitus. A number of questionnaires exist that assess how much tinnitus is interfering with a person's life.[3] People should have an audiogram and neurological exam as part of the diagnosis.[1][3] If certain problems are found, medical imaging such as with MRI may be recommended. Those who have tinnitus that occurs with the same rhythm as their heartbeat also need further testing.[3]

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.[4] Sound generators or hearing aids may help some.[2] As of 2013, there are no effective medications.[3] It is common, affecting about 10-15% of people. Most, however, tolerate it well with its being a significant problem in only 1-2% of people.[4] 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 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 and, in some cases, pressure changes from the interior ear.[5] It has also been described as a "whooshing" sound because of acute muscle spasms, as of wind or waves.[6] Tinnitus can be intermittent or it can be 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.[7]

Most people with tinnitus have some degree of hearing loss:[8] they are often unable to clearly hear external sounds that occur within the same range of frequencies as their "phantom sounds".[9] 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.[10]

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 from the movement of muscles near to one's ear, changes within the canal of one's ear or issues related to blood flow of the neck or face.[11]

Course

There has been little research on the course of tinnitus and most research has been retrospective. An Australian study of participants aged 49–97 years found that 35% of participants reported that their tinnitus was present all the time and 4% rated their tinnitus as annoying. Findings from a retrospective National Study of Hearing found that, for 25% of people surveyed, the perceived volume of their tinnitus increased over time while, for 75%, it did not. The rate of annoyance decreased for 31% of people from onset of tinnitus to the middle time. A study of the natural history of tinnitus in older adults found that, for women, tinnitus increased for 25%, decreased in 58%, leaving 17% unchanged. The study found that, for men, tinnitus increased in 8%, decreased in 39%, leaving 53% unchanged. Information about the course of tinnitus would benefit from prospective studies investigating change over time as these studies may potentially be more accurate.[12]

Psychological

Persistent tinnitus may cause irritability, fatigue and, on occasions, clinical depression[13][14] and musical hallucinations.[15]

Tinnitus annoyance is more strongly associated with psychological condition than loudness or frequency range.[16][17][18] Other psychological problems such as depression, anxiety, sleep disturbances and concentration difficulties are common in those with worse tinnitus.[19][20][21]

As part of the idea that the central-auditory-system may be implicated into the tinnitus development, serotonin has also been implicated. Indeed, serotonin has been postulated to be involved in plastic changes in the brain. Serotonin re-uptake inhibitors (such as some anti-depressant drugs) have often been used for this reason.[22] However those medications do not benefit in a consistent fashion on non-depressant people.[23]

Psychological research has looked at the tinnitus distress reaction (TDR) to account for differences in tinnitus severity.[19] Research has stigmatized people with severe tinnitus by implying they have personality disorders, such as neuroticism, anxiety sensitivity, and catastrophic thinking, which all predispose increased TDR.[24][25][26] 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.[27]

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 been also called "tinnitus aurium" "nonauditory" and "nonvibratory" tinnitus. Occasionally, tinnitus may be heard by someone else using a stethoscope: in which case, it is objective tinnitus.[3] Objective tinnitus has been 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, results from hearing loss.

There is a lot of evidence 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.[28] Hearing loss could indeed cause a homeostatic response of neurons in the central auditory system, and therefore cause tinnitus.[29]

Despite the opinion amongst researchers that tinnitus is primarily a central nervous system pathology, there certainly exists a class of people whose tinnitus is peripherally based.[30]

Hearing loss

The most common cause of tinnitus is noise-induced hearing loss. Hearing loss may be implicated even for people with normal audiograms.[29]

Hearing loss may have many different causes; but among tinnitus subjects, the major cause is cochlear damage.[28]

Ototoxic drugs (such as aspirin) 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.[31] Tinnitus 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.[32] In many cases, however, no underlying cause can 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.[33][34]

Associated factors

Factors associated to tinnitus include:[35]

Objective tinnitus

In some cases, tinnitus is generated by a self-sustained oscillation within the ear. This is called objective tinnitus which can arise from muscle spasms around the middle ear.[39] Homeostatic control mechanisms exist to correct the problem within a minute after onset and is normally accompanied by a slight reduction in hearing sensitivity followed by a feeling of fullness in the ear.[40]

Objective tinnitus can most often can be heard as a sound outside the ear, as spontaneous otoacoustic emissions (SOAEs) that can form beats with and lock into external tones.[41] The majority of the people are unaware of their SOAEs; whereas portions of 1-9% perceive a SOAE as an annoying tinnitus.[42]

Pulsatile tinnitus

Some people experience a sound that beats in time with their pulse (pulsatile tinnitus, or vascular tinnitus).[43] Pulsatile tinnitus is usually objective in nature, resulting from altered blood flow, increased blood turbulence near the ear (such as from atherosclerosis, venous hum,[44] but it can also arise as a subjective phenomenon from an increased awareness of blood flow in the ear.[43] Rarely, pulsatile tinnitus may be a symptom of potentially life-threatening conditions such as carotid artery aneurysm[45] or carotid artery dissection.[46] Pulsatile tinnitus may also indicate vasculitis, or more specifically, giant cell arteritis. Pulsatile tinnitus may also be an indication of idiopathic intracranial hypertension.[47]

Pathophysiology

One of the possible mechanisms relies on otoacoustic emissions. The inner ear contains thousands of minute inner hair cells with stereocilia which vibrate in response to sound waves and outer hair cells which convert neural signals into tension on the vibrating basement membrane. 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, then, tinnitus results. Exposure to excessive sound kills hair cells and studies have shown that, 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, it is believed that, in mammals, 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.[48][49] 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 dysfunction 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.[50]

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 most people with tinnitus also have hearing loss,[8] and the frequencies they cannot hear are similar to the subjective frequencies of their tinnitus.[9] 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.[10]

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 they hear. 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 their ear, they 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. However, pulsatile tinnitus can be a symptom of intracranial vascular abnormalities and should be evaluated for bruits by a medical professional with auscultation over the neck, eyes and ears. If the exam reveals a bruit, imaging studies such as transcranial doppler (TCD) or magnetic resonance angiography (MRA) should be performed.[51]

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.[52] 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.

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.[53]

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.[19] These questionnaires measure the degree of psychological distress and handicap associated with tinnitus, including effects on hearing, lifestyle, health and emotional functioning.[54][55][56][57] 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.[58] 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.[59] Developed to guide diagnosis or classify severity, most tinnitus questionnaires have also been shown to be treatment-sensitive outcome measures.[60]

Auditory evoked response

Tinnitus 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 but the most common description of the tinnitus is a pure tone sound. Tinnitus affects one third of adults at some time in their lives, whereas ten to fifteen percent are disturbed enough to seek medical evaluation.[61]

Tinnitus can be classified as either subjective or objective. Objective tinnitus can be detected by other people and is usually caused by myoclonus or a vascular condition. Subjective tinnitus can only be heard by the affected person and is caused by otology, neurology, infection or drugs.[62] A frequent cause of subjective tinnitus is noise exposure which damages hair cells in the inner ear causing tinnitus. Tinnitus can be associated with many emotions. It is best illustrated by Jastreboff’s Neurophysiological model.[63]

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.[64]

Prevention

Prolonged exposure to sound or noise levels as low as 70 dB can result in damage to hearing (see noise health effects). This can lead to tinnitus.[65] Ear plugs can help with prevention.

Avoidance of potentially ototoxic medicines. Ototoxicity of multiple medicines can have a cumulative effect and 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.[66]

Management

If there is an underlying cause, treating it may lead to improvements.[3] Otherwise, the primary treatment for tinnitus is talk therapy[4] and sound therapy with there being little support for 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.[4][67] It decreases the amount of stress those with tinnitus feel.[68] These benefits appear to be independent of any effect on depression or anxiety in an individual.[67] Relaxation techniques may also be useful,[3] including the playing of white noise.[69][70] A program has been developed by the United States Department of Veterans Affairs.[71]

Physical

Ear wax conditions can cause hearing loss, aggravating the focus of tinnitus, and medical professionals can identify solutions to chronic ear wax. Certain sufferers of tinnitus may also experience immediate relief, or partial relief over a few days, using the "Finger Drumming" technique. The technique, simple to demonstrate through video, has the patient place their palms over their ears, place their middle fingers so they touch high behind the head, and then place their index fingers over their middle fingers. Patients flick or snap their index fingers down gently on the base of the skull for 40 repetitions. Unfortunately this technique, again, does not work for all cases and often is not permanent.[69][72]

Medications

There are no medications as of 2014 that are effective for tinnitus and, thus, none is recommended.[3][65] There is not enough evidence to determine if antidepressants[73] or acamprosate is useful.[74] While there is tentative evidence for benzodiazepines, it is insufficient to support usage.[3] Anticonvulsants have not been found to be useful.[3]

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, which makes them a reasonable option.[3][75] There is some tentative evidence supporting tinnitus retraining therapy.[3] There is little evidence supporting the use of transcranial magnetic stimulation.[3][76] It is thus not recommended.[65]

Alternative medicine

Ginkgo biloba does not appear to be effective.[77] Tentative evidence supports zinc supplementation[78] and in those with sleep problems, melatonin.[79] The American Academy of Otolaryngology, however, recommends against melatonin and zinc.[65]

Objective tinnitus

Prognosis

Most people with tinnitus get used to it over time;[4] for a minority, it remains a significant problem.[4]

Epidemiology

Tinnitus affects 10-15% of people.[4]

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.[81] Children do not generally report tinnitus spontaneously and their complaints may not be taken seriously.[82] 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.[83] 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.[84]

See also

References

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