WHAT IS TINNITUS
Tinnitus is the perception of a ringing, humming, cooing, or buzzing sound inside one or both ears. It does not have an external source, so is not audible to others. It has been seen to occur in 15-20% of the population over 40-45 years of age and is slightly more common in men.
The sound may vary in pitch for different people and may be present all the time, or come and go. The intensity of its perceiving tinnitus depends a lot on surrounding noises, distractions, and state of mind. Therefore, the disturbance it causes in day-to-day life can range from none, mild to severe, disturbing work and concentration, and even causing anxiety-depression in some cases.
WHAT CAUSES IT
Delicate hairs in our inner ear receive sound waves and transmit them through the auditory nerve as electrical impulses to the brain. Tinnitus is caused when some of these hairs degenerate or get damaged, and then begin to ‘leak’ random electrical impulses to the brain.
Often no obvious or specific cause may be found. It is important to look for associated symptoms like hearing loss, dizziness, vertigo, loss of balance, feeling fullness or pain in the ear, headache, etc. while assessing tinnitus. Some of the possible causes are listed below:
- Increasing age, chronic exposure to loud noises, routine earphone use, lifestyle factors like tobacco and alcohol, etc. can cause some of these hairs to degenerate or get damaged.
- Ear infection or ear canal blockage with earwax can cause changes in the pressure in the ear and can cause temporary tinnitus. Ear infections should be promptly treated.
- Meniere’s disease is an inner ear disorder that may be caused by abnormal inner ear fluid pressure. It presents with episodes of vertigo and loss of balance, with hearing loss and low-pitched ocean roar type of tinnitus.
- Eustachian tube dysfunction is a condition where the tube connecting the middle ear to the upper throat remains expanded all the time, which makes the ear feel full.
- Medications associated can include nonsteroidal anti-inflammatory drugs (NSAIDs) and certain antibiotics, cancer drugs, diuretics, antimalarial drugs, and tricyclic antidepressants. The tinnitus increases as the drug dose is stepped up and can disappear after the drug is stopped.
- Chronic diseases like diabetes, thyroid problems, cardiovascular disease (CVD), high blood pressure, migraines, anemia, and autoimmune disorders have also sometimes been associated with tinnitus.
- Head or neck injuries can damage the inner ear organs, especially the hairs and nerves involved in hearing thereby producing hearing loss and tinnitus in the ear of the affected side.
Rare causes include:
- Stiffening of the bones in the middle ear (otosclerosis) due to abnormal bone growth is a rare condition that tends to run in families. The most prominent symptom is gradual hearing loss over a year with dizziness, low-pitched tinnitus, and loss of balance.
- Muscle spasms in or around the inner ear can result in tinnitus (clicking type), hearing loss, and a feeling of fullness in the ear. This may happen for no explainable reason, but can also be caused by neurologic diseases like multiple sclerosis.
- Temporomandibular joint (TMJ) disorders that is inflammation of the joint of the lower jawbone and skull, can cause tinnitus. There will be difficulty or pain in opening and closing the jaw.
- Acoustic neuroma is a noncancerous (benign) tumor that develops on the nerve that runs between the brain and inner ear, and controls balance and hearing. It presents with hearing loss over time or sometimes suddenly as the main symptom along with vertigo, loss of balance, high-pitched tinnitus, and associated weakness or paralysis of facial muscles. Rarely other head, neck, or brain tumors can also cause tinnitus, but other signs like seizures, headache, dizziness, loss of balance, nausea-vomiting, etc will also be present.
- Blood vessel disorders causing a significant partial blockage due to atherosclerosis or kinking due to an aneurysm can cause blood to move forcefully through the narrow part of the blood vessel. The tinnitus in such cases may be whooshing or pulsatile, and sometimes externally audible. If tinnitus is due to CVD or high blood pressure, it may vary with exercise and posture change.
HOW TO EVALUATE TINNITUS
The person should be asked for the type of tinnitus – low/high pitched, type of sound humming/buzzing, ringing, cooing, or whooshing, whether it is constant/variable, and changes with posture, neck movement, or exercise.
The presence of associated symptoms like hearing loss, dizziness, vertigo, ear pain or fullness, loss of balance, and headache, can give a clue as to whether an underlying disease is present. A complete history including symptoms, personal and lifestyle history, and family history should be recorded.
A general physical exam should be done with a blood pressure check and palpation of the head and neck region for any pain, swelling, or abnormality.
An ear examination may reveal impacted wax that can be removed, and tinnitus may settle down a few days to weeks after its removal. The ear examination can also show the state of the Eustachian tube and eardrum.
Tests for hearing loss are performed that include tuning folk and audiometry tests.
Routine blood tests including complete blood counts, sugar, thyroid, lipid profile, and any markers of particular diseases if suspected.
Finally imaging tests like CT/MRI are performed if the presence of other symptoms suggests a specific underlying cause.
HOW TO MANAGE TINNITUS
If there are other associated symptoms, and an underlying disease or coexisting medical condition is diagnosed, then that has to be treated or well-controlled.
If tinnitus is the only symptom and no other obvious cause is found after evaluation, then it is likely to just go away or its perception reduced over time, and reassurance is all that is needed. In some cases, it may persist indefinitely too, however, the assurance that it is neither damaging to the ear function and hearing nor to any other bodily or lifestyle function, is very important.
Despite such reassurance, in some people, tinnitus may cause stress, trouble concentrating, anxiety-depression, irritability, fatigue, and sleep problems, which may impact the quality of life.
Avoiding extremely quiet environments, and maintaining low-grade sound distractions that are environment (nature sounds) or device-generated (fan, light pleasant music, white noise machines, or masking devices/hearing aids) may be recommended.
Lifestyle changes include limiting alcohol and caffeine, stopping smoking, exercising regularly, and eating a healthy diet.
Maintaining good ear hygiene by avoiding loud earphones or noise exposure, and periodic checking for wax build-up is advised.
Medications being taken for other conditions may need to be changed or stopped one at a time to ascertain the possibility of them causing tinnitus.
Relaxation techniques, breathing exercises, music, yoga, mindfulness techniques, and meditation, may also help reduce perception and improve coping.
Psychological counseling as Cognitive Behavioral Therapy (CBT), and TRT (Tinnitus Retraining Therapy), an individualized program that is usually administered by an audiologist, are useful to manage tinnitus. TRT combines sound masking and counseling and involves wearing an ear device that helps mask tinnitus symptoms while receiving directive counseling. Over time, CBT and TRT help reduce how much one notices and feels distressed due to tinnitus.
ARE THERE MEDICINES FOR TINNITUS
Usually, no medicines are required specifically for tinnitus, and there are no FDA-approved drugs for the same. However, if it is causing anxiety-depression or disturbing sleep, medicines for the same may be prescribed for some time, along with the above therapies.
At a neurological level, tinnitus is possibly related to excess activity of the neurotransmitter glutamine through influx of calcium and receptors called NDMA, and loss of inhibitory action of the neurotransmitter GABA. Therefore, drugs given in tinnitus are based on these pathways.
Antianxiety medicines increase neurotransmitter GABA (alprazolam, clonazepam, lorazepam, etc), while antidepressants increase serotonin (SSRI – selective serotonin reuptake inhibitors), both of which may help reduce hyper-electric signals that cause tinnitus. Other drugs like caroverine, and memantine act as antagonists of glutamate receptors like NDMA and influx of calcium. Anticonvulsant drugs that increase GABA action like carbamazepine, vigabatrin, valproate, and gabapentin have also been tried in some cases.
Sometimes nutritional supplements are added that are usually a combination of herbs and vitamins, often including zinc, ginkgo biloba, vitamin B-12, and other vitamins-minerals, alpha lipoic acid, etc. but convincing scientific evidence is lacking. Melatonin supplements for sleep have also been shown to help in some patients.
Overall, the above drugs work in some not all cases, and different drugs may work for different people. It is also important to monitor side effects and these medicines should be taken only under thorough medical evaluation, prescription, and monitoring. More clinical evidence is needed for many of these medicines, and there are also new medicines under research.
Also Read:
Hearing Loss – 5 Important Points of Awareness and Understanding
Reference: Research in Tinnitus Drugs