3. Tinnitus

Tinnitus

This PatientPlus article is written for healthcare professionals so the language may be more technical than the condition leaflets. You may find the abbreviations list helpful.

Tinnitus is the perception of sound originating from within the head rather than from the external world.

It can be divided into two main types:

Objective

There is actually a noise to be heard being generated within the head. These can be:

  • Pulsatile: due to movement of blood - eg, carotid stenosis, vascular anomalies or tumours, valvular heart disease, high cardiac output states.
  • Muscular or anatomical: palatal myoclonus, spasm of tympanic muscles, patulous Eustachian tube.
  • Spontaneous: otoacoustic emissions.

Subjective

There is no acoustic stimulus. Common causes are:

  • Otological: noise-induced and other forms of hearing loss, presbyacusis, otosclerosis, impacted cerumen, ear infection, Ménière's disease.
  • Neurological: head injury, multiple sclerosis, acoustic neuroma and other similar tumours.
  • Infectious: meningitis, syphilis.
  • Drug-related: salicylates, non-steroidal anti-inflammatory drugs (NSAIDs), aminoglycosides, loop diuretics, cytotoxicity.
  • Jaw disorders: temporomandibular joint dysfunction.

Tinnitus is a common complaint. The British Tinnitus Association estimates 1 in 10 people suffer from this symptom.[1] It is more common in males.

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Symptoms

Patients often take a long time before seeking medical attention. Most common sounds are:

  • Ringing
  • Buzzing
  • Cricket-like
  • Hissing
  • Whistling
  • Humming

The condition is reported to be unilateral in 22%, equal in both ears in 34% and one side dominant in the rest, usually the left.[2]

  • Thorough examination of the head, neck, ears and jaw should be made.
  • Hearing test.
  • Other examinations suggested by clinical findings.

Although patients report sound as being loud, hearing tests demonstrate that they are at an intensity that is only just louder than the softest sound audible at that frequency - usually above 3 kHz.

NB: exclude an acoustic neuroma in unilateral tinnitus.

General measures

  • Explanation and reassurance that the condition will not progress and that there are no sinister findings.
  • There is a strong association between tinnitus and stress; relaxation techniques or relaxing background music can distract or mask some tinnitus.
  • Tinnitus retraining therapy shows improvement in 75-82% of patients. It links negative emotional associations with tinnitus-related neural activity.[3][4] It may take over a year to complete the therapy, with a goal of habituating the patient to the tinnitus rather than abolishing it. Results are sustained in the long term.[5]
  • Masking devices can be used in those patients who obtained relief from masking during the hearing test. Tinnitus maskers create and deliver constant low-level white noise to the ear. Patients should be advised to wear the device during their waking hours, but successful wearers may wear the device while sleeping.[6]

Pharmacological

There are few treatments with good quality evidence of efficacy.[7]

Consider antidepressants for associated depression, but SSRIs have been shown significantly to reduce tinnitus severity, as well as anxiety and depression symptoms.[8]

Surgical

Microvascular decompression of auditory nerve/nerve resection is controversial.[9][10]

As tinnitus is an integral part of Ménière's disease, treating that condition may provide relief from tinnitus.

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Further reading & references

  1. Luxon LM; Tinnitus: its causes, diagnosis, and treatment, BMJ; June 1993
  2. Axelsson A, Ringdahl A; Tinnitus--a study of its prevalence and characteristics. Br J Audiol. 1989 Feb;23(1):53-62.
  3. Berry JA, Gold SL, Frederick EA, et al; Patient-based outcomes in patients with primary tinnitus undergoing tinnitus retraining therapy. Arch Otolaryngol Head Neck Surg. 2002 Oct;128(10):1153-7.
  4. Herraiz C, Hernandez FJ, Plaza G, et al; Long-term clinical trial of tinnitus retraining therapy. Otolaryngol Head Neck Surg. 2005 Nov;133(5):774-9.
  5. Seydel C, Haupt H, Szczepek AJ, et al; Long-Term Improvement in Tinnitus after Modified Tinnitus Retraining Therapy Enhanced by a Variety of Psychological Approaches. Audiol Neurootol. 2009 Aug 4;15(2):69-80.
  6. Folmer RL, Carroll JR; Long-term effectiveness of ear-level devices for tinnitus. Otolaryngol Head Neck Surg. 2006 Jan;134(1):132-137.
  7. Langguth B, Salvi R, Elgoyhen AB; Emerging pharmacotherapy of tinnitus. Expert Opin Emerg Drugs. 2009 Aug 27.
  8. Zoger S, Svedlund J, Holgers KM; The effects of sertraline on severe tinnitus suffering--a randomized, double-blind, placebo-controlled study. J Clin Psychopharmacol. 2006 Feb;26(1):32-9.
  9. Vasama JP, Moller MB, Moller AR; Microvascular decompression of the cochlear nerve in patients with severe tinnitus. Preoperative findings and operative outcome in 22 patients. Neurol Res. 1998 Apr;20(3):242-8.
  10. De Ridder D, Ryu H, De Mulder G, et al; Frequency specific hearing improvement in microvascular decompression of the cochlear nerve. Acta Neurochir (Wien). 2005 May;147(5):495-501; discusssion 501. Epub 2005
Original Author: Dr Hayley Willacy Current Version: Peer Reviewer: Dr Helen Huins
Last Checked: 28/02/2013 Document ID: 2873  Version: 22 © EMIS

Disclaimer: This article is for information only and should not be used for the diagnosis or treatment of medical conditions. EMIS has used all reasonable care in compiling the information but make no warranty as to its accuracy. Consult a doctor or other health care professional for diagnosis and treatment of medical conditions. For details see our conditions.