Tinnitus   Dr. Robert Sweetow, FAAA University of California, San Francisco, CA Dr. Allan S. Mehr, FAAA Private Practice, Salem, OR     What is tinnitus? The symptom of tinnitus represents one of the most elusive mysteries facing hearing health care professionals. Tinnitus refers to any auditory perception not directly produced by sound. It is commonly described as a sensation of hissing, roaring, or ringing. It can be tonal, ranging from high pitch to low pitch, multi-tonal, or noise-like (having no tonal quality). Tinnitus may be constant, pulsed, or intermittent. Tinnitus may begin suddenly, or may come on gradually. It can be perceived in one ear, both ears, or in the head. Tinnitus can be broadly classified into two categories: objective and subjective. Objective tinnitus, which may or may not be audible to the patient, but is audible to an observer (either with a stethoscope, or simply by listening in close proximity to the ear) is present in less than 5% of overall tinnitus cases. Objective tinnitus, often associated with vascular or muscular disorders, is frequently described as pulsatile, synchronous with the heartbeat. In most instances, the cause of objective tinnitus can be determined, and treatment, either medical or surgical, can be prescribed. Subjective tinnitus (audible only to the patient) is far more common, occurring in over 95% of patients. Subjective tinnitus is a symptom that is associated with almost all ear disorders and is, in fact, reported to be present in over 80% of individuals with sensorineural (inner ear) hearing loss. Who has Tinnitus? Some 50 million adults experience tinnitus, with more than 10 million seeking help for the condition. Because tinnitus, like pain, is subjective, two individuals may report similar tinnitus characteristics yet be affected in significantly different manners. The severity of the tinnitus is largely a function of the individual's reaction to the tinnitus. Many tinnitus sufferers have difficulty sleeping, or concentrating; many are depressed and anxious and may report additional problems at work or at home which may contribute to the distress caused by tinnitus. Most report a correlation with tinnitus perception and stress. It is often difficult to determine whether the emotional status of tinnitus patients existed before the onset of tinnitus, or whether it is a result of the tinnitus.  What Causes Tinnitus? The exact mechanism underlying tinnitus is unknown. Some of the causes are: disorders in the outer ear such as: ear wax (cerumen), a hair touching the eardrum, a foreign body, or a perforated eardrum; disorders in the middle ear such as: infection, otosclerosis, or benign tumors; disorders in the inner ear such as: nerve damage due to noise exposure, presbycusis (hearing loss from aging), labyrinthitis (inner ear infection), Meniere's disease (associated with hearing loss and dizziness); medications, such as: anti-inflammatories including aspirin and quinine, and from sedatives and antidepressant; and it can be permanently produced by certain antibiotics and chemotherapeutic agents; systemic disorders, such as: high or low blood pressure, anemia, diabetes, thyroid dysfunction, glucose metabolism abnormalities, vascular disorders, growth on jugular vein, acoustic tumors, and head or neck aneurism; non-auditory disorders, such as: trauma to the head or neck, temporomandibular (jaw joint) disorders, and cervical (neck) misalignment. Current research suggests that even though tinnitus may initially be caused by an injury to the ear, ultimately, an auditory pattern is established in the brain. Thus, many treatment approaches are directed at the brain, not the ear. Although the majority of tinnitus sufferers also have hearing loss, the presence of tinnitus does NOT mean that one is losing hearing. What Treatments are Available for the Tinnitus Patient? Tinnitus is a symptom, not a disease. As such, the optimal treatment should be directed toward eliminating the disease, rather than simply alleviating the symptom. Because tinnitus may be symptomatic of a more serious disorder, it is important to try to find the medical cause before deciding on the treatment. While there is no known cure for most forms of tinnitus, it is not true that "nothing can be done about it". A variety of tinnitus management procedures are available. None are universal cures, but most tinnitus sufferers can find varying degrees of relief from one or a combination of the following procedures: Medications...there is no single medication that works on all tinnitus patients. Some of the antidepressants and anti-anxiety medications have proven helpful for certain tinnitus patients, however, more research is needed in this area. Masking...the use of an externally produced sound to either cover up, inhibit, or alter production of tinnitus can offer relief for some tinnitus sufferers. There are four main methods of providing masking: a tinnitus masker (an ear level electronic noise producing device housed in a hearing aid case); a tinnitus instrument (a combination hearing aid and tinnitus masker), bedside noise generators; and hearing aids. Auditory Habituation (Re-training)...a technique based on the principles of neural plasticity. A noise is presented via a hearing aid-type device at a soft enough level so that the brain perceives both the noise and the tinnitus. Eventually, the brain may relearn a pattern that will de-emphasize the importance of the tinnitus. Amplification...hearing aids are among the most effective tools for minimizing tinnitus. Counseling...If a person is not "bothered" by the tinnitus, it ceases to be a problem. Psychological intervention aimed at successfully reducing the stress, distress, and distraction associated with the tinnitus can be very productive is a necessary part of any treatment plan. Peer support groups offer can emotional support to patients by sharing experiences and useful strategies with others. Stress management, relaxation, and biofeedback...the very high correlation between stress and tinnitus disturbance underscores the need to maintain one¹s composure and logic when trying to cope with tinnitus. Also, a balanced diet is important. Surgery...is appropriate if, and only if, the cause of the tinnitus is known and has been proven to be amenable to surgical intervention. Even the surgical destruction of the inner ear does not guarantee a reduction of tinnitus. Alternate approaches ...there are no scientific data showing consistent benefit from approaches such as hypnosis, acupuncture, naturopathy, vitamin supplements, or chiropractic, but anecdotal reports indicate benefit for some patients What Can Be Done to Prevent or Minimize Tinnitus? Avoid loud noises Decrease salt intake Check blood pressure Avoid stimulants, such as caffeine and nicotine Exercise, avoid being overly fatigued Control stress; learn to relax Educate yourself about tinnitus   What Should You Do If You Have Tinnitus? In most cases, tinnitus is a sign of a disorder of the ear. If you have tinnitus, see an audiologist for a complete evaluation. Your audiologist may advise you to consult a physician to determine if a cause can be found, and subsequently treated. Educate yourself about the nature of tinnitus and methods for coping with it and relieving your anxiety. Numerous references about tinnitus can be accessed by searching the Internet. One of the most comprehensive resources on the topic can be found at the American Tinnitus Association.