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Timothy C. Hain,
MD. 
Hearing Page Page last modified:
July 23, 2010
Tinnitus (pronounced "tin-it-tus") is an abnormal noise in the ear (note that it is not an "itis" -- or inflammation). Tinnitus is common -- nearly 36 million Americans have constant tinnitus and more than half of the normal population has intermittent tinnitus.
About six percent of the general population has what they consider to be "severe" tinnitus. That is a gigantic number of people ! In a large study of more than 2000 adults aged 50 and above, 30.3% reported having experienced tinnitus, with 48% reporting symptoms in both ears. Tinnitus had been present for at least 6 years in 50% of cases, and most (55%) reported a gradual onset. Tinnitus was described as mildly to extremely annoying by 67%.(Sindhusake et al. 2003)
Tinnitus can come and go, or be continuous. It can sound like a low roar, or a high pitched ring. Tinnitus may be in both ears or just in one ear. Seven million Americans are so severely affected that they cannot lead normal lives.
The most common types of tinnitus are ringing or hissing ringing, whistling (high pitched hissing) and roaring (low-pitched hissing). Some persons hear chirping, screeching, or even musical sounds.
Note however that tinnitus nearly always consists of fairly simple sounds -- for example, hearing someone talking that no one else can hear would not ordinarily be called tinnitus -- this would be called an auditory hallucination. Musical hallucinations in patients without psychiatric disturbance is most often described in older persons, years after hearing loss, but they have also been reported in lesions of the dorsal pons (Schielke et al, 2000).
Another way of splitting up tinnitus is into objective and subjective. Objective tinnitus can be heard by the examiner. Subjective cannot. Practically, as there is only a tiny proportion of the population with objective tinnitus, this method of categorizing tinnitus is rarely of any help. It seems to us that it should be possible to separate out tinnitus into inner ear vs everything else using some of the large array of audiologic testing available today. For example, it would seem to us that tinnitus should intrinsically "mask" sounds of the same pitch, and that this could be quantified using procedures that are "tuned" to the tinnitus.
Tinnitus is commonly accompanied by hearing loss. Less commonly, it may be accompanied by hyperacusis (an abnormal sensitivity to sound).
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| Structures of the ear. Most tinnitus is due to damage to the cochlea (#9 above) |
Most tinnitus comes from damage to the inner ear, specifically the cochlea (the snail like thing on the right labeled '9').
In pulsatile tinnitus, people hear something resembling their heartbeat in their ear. Click on the link above for more details.
In our opinion, people are very quick to blame drugs for their tinnitus, but it is rare that this is borne out.
Many medications also can cause tinnitus (see list below). Generally this is thought to arise from their effect on the cochlea (inner ear).
Drugs that commonly cause or increase tinnitus -- these are largely ototoxins.
- NSAIDS (motrin, naproxen, relafen, etc)
- aspirin and other salicylates
- Lasix and other "loop" diuretics
- "mycin" antibiotics such as vancomycin (but rarely macrolides such as azithromycin)
- quinine and related drugs
- Chemotherapy such as cis-platin
Often people bring in very long lists of medications that have been reported, once or twice, to be associated with tinnitus. This unfortunate behavior makes it very hard to care for these patients -- as it puts one into an impossible situation where the patient is in great distress but is also unwilling to attempt any treatment. Specialists who care for patients with ear disease, usually know very well which drugs are problems (such as those noted above), and which ones are nearly always safe.
Persons with tinnitus should be seen by a physician expert in ear disease, usually an otologist or a neurotologist.
There should be an examination of the ears with an otoscope. Wax should be removed, and the examiner should note whether the ear drum is intact, inflamed, scarred, or whether it is moving.
The eyes should be examined for papilloedema (swelling of a portion of the back of the eye called the "optic disk") as increased intracerebral pressure can cause tinnitus. Because papilloedema is so rare, and tinnitus is so common, it is very unusual to find this dangerous condition.
The TMJ joints of the jaw should be checked as about 28% of persons with TMJ syndrome experience tinnitus. TMJ is very common too.
Inspection of the eardrum may sometimes demonstrate subtle movements due to contraction of the tensor tympani (Cohen and Perez, 2003). Tensor tympani myoclonus causes a thumping sound.
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| Cartoon of the middle ear showing muscles that attach to ossicles (ear bones), and ear drum. The stapedius is attached to the stapes (of course -- horseshoe object above), while the tensor tympani is attached to the ear drum. While useful, be aware that there are multiple errors in this illustration from Loyola Medical School. With permission, from: http://www.meddean.luc.edu/lumen/meded/grossanatomy/dissector/mml/images/stap.jpg |
The tensor tympani syndrome is common. It sometimes results in visible contractions of the ear drum, and sometimes even produces sounds audible to the examiner. Patients usually indicate that it makes a "thumping" noise -- like a tympani drum ! An impedance bridge (tympanometer) can document rhythmic changes in ear drum compliance. A and a long recording of ear drum compliance should be made with a tympanometer (a screener won't work here).
There should not be movement of the palate in the stapedius myoclonus syndrome, as the stapedius does not insert onto the eardrum but rather onto the stapes.
In our experience (see recording below), the sound can be heard from the outside -- it is a high-pitched "tic". We were unable to hear with a stethascope however, possibly due to it's high pitch. There was no visible movement of the eardrum, in this case.
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| Rhythmic changes in impedance of the middle ear. Each bump was correlated with a high-pitched "tic" that can be heard from the outside, due to stapedius myoclonus. |
Click below to play recording of stapedius myoclonus.
A similar clinical picture may be associated with "typewriter tinnitus" as described by Levine (2006). He attributed this type of tinnitus to irritibility of the 8th nerve. This tinnitus is intermittent and has a staccato quality ('like a typewriter in the background, pop corn, Morse code'). It is responsive to carbamazepine. In our view, this clinical picture would be difficult to distinguish from stapedius myoclonus without careful clinical examination. TT myoclonus should be associated with a visible displacement of the ear drum during the sound. Stapedius myoclonus should be audible to the examiner.
Based on tests, tinnitus can be separated into categories of cochlear, retrocochlear, central, and tinnitus of unknown cause.
Patients with tinnitus often undergo the tests listed above.
The audiogram sometimes shows a sensorineural deficit due to masking from the tinnitus.
Tinnitus matching is helpful to identify the frequency and intensity of the tinnitus. This is a simple procedure in which the audiologist adjusts a sound until a patient indicates that it is the same as their tinnitus.
ABR (ABR) testing may show some subtle abnormalities in otherwise normal persons with tinnitus (Kehrle et al, 2008). The main use of ABR (ABR test) is to assist in diagnosing tinnitus due to a tumor of the 8th nerve or tinnitus due to a central process. A brain MRI is used for the same general purpose and covers more territory, but is roughly 10 times more expensive.
Tympanograms or acoustic reflex tests can sometimes show a rhythmic compliance change due to a middle ear vascular mass or due to contraction of muscles in the middle ear.
The physician may also request an OAE test (which is very sensitive to noise induced hearing damage), an ECochG (looking for Meniere's disease and hydrops, an MRI/MRA test (scan of the brain), a VEMP (looking for damage to other parts of the ear) and several blood tests (ANA, B12, FTA, ESR, SMA-24, HBA-IC, fasting glucose, TSH, anti-microsomal antibodies).
Sweep OAE testing can be very helpful in medicolegal contexts, as noise induced tinnitus should be accompanied by a "notch" in the sweep OAE.
We occasionally recommend neuropsychological testing using a simple screening questionnaire -- depression, anxiety, and OCD (obsessive compulsive disorder) are common in persons with tinnitus. This is not surprising considering how disturbing tinnitus may be to ones life. Persons with OCD tend to "obsess" about tinnitus. Treatment of these conditions may be extremely helpful.
In persons with pulsatile tinnitus, additional tests maybe proposed to study the blood vessels and to check the pressure inside the head. Gentle pressure on the neck can be performed to block the jugular vein but not the carotid artery. The Valsalva maneuver reduces venous return by increasing intrathoracic pressure. If there is a venous hum, this usually abates or improves markedly. If the pulsation is arterial, these tests have no effect. MRI/MRA or CT is often suggested in younger patients with unilateral pulsatile tinnitus. In older patients, pulsatile tinnitus is often due to atherosclerotic disease and it is less important to get an MRI/MRA. A lumbar puncture may be considered if there is a possibility of benign intracranial hypertension. More invasive testing includes the "balloon occlusion test", where a balloon is blown up in the internal jugular vein to see if it eliminates tinnitus.
The algorithm that we use in our practice to diagnose and treat tinnitus is here (a pdf graphic). After a diagnostic step, there are many branch points involving treatment trials.
The bottom line is that it is unusual (although not impossible) for people to get substantial relief from medication, devices, or surgery. In fact, "obsessing" about tinnitus, generally tends to make it more persistent and worse. Thus paradoxically enough, doctors tend to discourage reading of web pages like this one, or joining of support groups. Most people "get used" to tinnitus, and learn to "tune it out". When this doesn't happen, the treatments that work the best for tinnitus are those that alter ones emotional state -- antidepressants and antianxiety drugs, and ones that allow you to get a full night's sleep.
The bad news in more detail : Dobie (1999) reviewed the 69 randomized controlled trials of tinnitus treatments. According to Dr. Dobie, no treatment can yet be considered "well established" in terms of providing replicable long-term reduction of tinnitus impact, in excess of placebo effects. Support and counseling are probably helpful as are tricyclic antidepressants in severe cases. Benzodiazepines, newer antidepressants and electrical stimulation deserve further study. But don't lose all hope: Dobie made the point that tinnitus is likely multifactorial, and the usual study design is likely not well chosen for this situation. A study design where initially an open-label study is performed, followed by a randomized placebo controlled trial might find patient groups that respond to a medication. This seems very logical.
If a specific cause for tinnitus is found, then your physician may be able to eliminate the noise. Examples of specific causes include medication, tumors, infections, Meniere's disease, TMJ and otosclerosis. Tinnitus due to the tensor tympani can be treated by transection of that muscle. To find a specific cause it may require a fairly extensive workup including X-rays and blood tests. However, even after extensive workup, most causes of tinnitus go undiagnosed.
If a specific cause of tinnitus is not found, it is unlikely that the tinnitus can be gotten rid of. At best, one might get partial relief from some of the strategies to be described in the next few paragraphs. However, even though treatment may not be available, tinnitus should be checked into, as tinnitus may be a warning sign of a serious disorder such as a tumor of the 8th nerve, or other disorder which may impair hearing. Tinnitus does tend to gradually get better, but many persons with severe tinnitus still experience distress 5 years later. Tolerance of tinnitus increases with time. (Andersson et al, 2001).
Medications may occasionally help lessen the noise even though no cause can be found. In general, we are not at all enthused about medication treatment as the side effects can be substantial and the results are often unimpressive. In randomized clinical trials, for the most part, the agents under study have failed to demonstrate elimination of tinnitus more frequently than have placebos (Dobie RA, 1999). Medication to deal with the psychological fallout of tinnitus is often useful -- antidepressants and anti-anxiety medications can be very helpful.
Medications that are well accepted in treatment of Tinnitus
- Lorazepam or klonazepam (in low doses). These are "benzodiazepines", mainly used for anxiety (Gananca et al, 2002; Dobie, 2003)
- Amitriptyline or nortriptyline (again in low doses). These are "tricyclic antidepressants".
Comment. Benzodiazepines and tricyclics probably mainly change emotional responses to tinnitus. Any sort of relief, however, is important.
We have also had some patients get relief from other antidepressants including the SSRI family.
The anticonvulsants such as mysoline may affect some patients who have tinnitus due to 8th nerve irritation. Mysoline contains phenobarbital, which is sedating.
Local anesthetics:
There is a small literature concerning use of intravenous and local anesthesia for tinnitus. See this link for more.
Atorvastatin (Lipitor). A recent trial in older people showed that atorvastatin had no effect on the rate of hearing deterioration but there was a trend toward improvement in tinnitus scores over several years. (Olzowy et al, 2007)
Campral, is a medication FDA approved for treatment of abstinent alcoholics. A paper from south america reported that it is effective for tinnitus. This is an off-label use of this medication. At this writing (4/09), we think it is ineffective. Because it is easily available in the US, and has a rather benign side effect profile, we think that it is a good candidate for medication trials. We have had no success with it in a few patients.
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| Homeopathic preparation for tinnitus -- contains aspirin ! Most if not all homeopathic preparations are placebos. |
Trimetazidine. This is a drug designed for heart disease, that is marketed in Europe for vertigo and tinnitus. It's brand name is Vasterel. The author of this page has had no experience with this medication for Meniere's. Some authors indicate that it is a placebo. (anon, 2000)
Comment: Some of these drugs may be worth considering depending on ones personal situation. The ones with the least adverse effects would seem most logical. If one understands the mechanism of one's tinnitus, it seems more likely that a drug like this might work.
Hearing aids and other devices called "maskers" may also help alleviate tinnitus. This is a tricky business. If you have tinnitus associated with a hearing loss, a hearing aid is a reasonable thing to try. Be sure that you try the hearing aid before buying one, as tinnitus is not always helped by an aid. We see no reason to get 2 hearing aids at the same time, for treatment of tinnitus. Nearly all states mandate a 1-month money-back guarantee built into hearing aid dispensing.
It also seems possible that a hearing aid might exacerbate tinnitus, as many people develop "ringing" of their ears after exposure to loud noise.
We are generally in favor of maskers (see below). We try them in nearly 100% of our patients in our tinnitus clinic.
Maskers
These are devices based on the idea that tinnitus is usually worst when things are very quiet. Listening to the interstation static on the FM radio, tapes of ocean surf, fans, and the like may be helpful. Pillow speakers sold by Radio Shack may be helpful in order to avoid disturbing others. This is a very cheap method.
Tinnitus maskers are fitted and sold by audiologists. Controlled studies of maskers have shown small effects (Dobie, 1999).
CD's are available that contain masking sounds, for example, the "DTM-6B" system sold by Petroff Audio Research. This is a collection of 6 CD's found by Mike Petroff, an individual with tinnitus, to be helpful for him, and marketed for this purpose. They are endorsed by Jack Vernon, a tinnitus practitioner associated with the ATA. Our thought is that these CD's are probably good masking sounds, but we wonder if they are worth $139+$6 S/H (here is a site that sells these CDs). We suspect that there are much less expensive alternatives.
We are presently experimenting in our practice with customized masking. After matching the patient's tinnitus, for those who are maskable, using a program called Matlab, we produce a sound file that is customized to the frequency of the tinnitus. This sound is mixed in with music provided by the patient. The idea is similar to the "Neuromonics" device below, but the implentation is much simpler and less expensive..
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| Neuromonics device |
Neuromonics device
There are many devices that have been offered as treatments for tinnitus. One of the most recent is the Neuromonics device. It is presently being sold in the US, through select audiologists, for about $5000. Unfortunately, you can't use the device to play anything other than preprogrammed cartridges, that we are told, sound somewhat like "new age" music.
The principle of the device is to present a masking noise, spectrally adjusted to match an audiogram. On top of this is added music intended to relax the listener. In our conversations with patients who use this device, they generally think (after 6 months of listening and counseling visits to the dispensing audiologist) that it is modestly helpful.
The literature about the Neuromonics device is very positive but the opportunities for bias in the studies has been very high.
Davis and Paki (2007), recently published an article in Ear Hear, indicating that it is the 3rd clinical trial for this device. This study, which appears to be done by the inventors or perhaps the manufacturers of the device, is small (n=35), unblinded and uncontrolled. The claims for the device are very positive, and the opportunities for bias are substantial.
Davis, Wilde, Steed and Hanley (2008) published a second article in the ENT journal. As disclosed in the fine print associated with this study, this was an industry funded study. Both Dr. Davis and Hanley are employees of the company that sells this device (Neuromonics), and Dr. Wilde and Steed are employees of the patent holder for the device (Curtin University). This was an unblinded study -- there was no placebo group. The outcome measures were questionnaires. According to the study description, the questionnaires were completed "unassisted so that they would not be subjected to any rater bias". Of a total of 88 patients recruited, 39 were excluded due to various reasons. Thus this was not an "intent to treat" design and in fact, almost half of the individuals recruited were not included in the results The result reported were very positive -- a strong treatment effect was seen that improved over 12 months. To summarize, this trial reported very positive results for this device, but the possibility of bias was very large. We hope that rigorous studies, not funded by the manufacturer, randomized, with intent to treat methodology, and with at least single-blinding will follow.
Bottom line for the Neuromonics device
The general idea that listening to something that gives you pleasure and sounds somewhat like your tinnitus may "desensitize" you to your tinnitus, seems reasonable. One of the audiologists in our practice has experience with this device.
In general, whether you are considering buying a "Neuromonics" device, a magnetic or electrical device or ultrasound generators, we advise caution.. There is a very long history of placebos for subjective complaints such as dizziness and tinnitus.
TMS -- transcranial magnetic stimulation.
This is an investigational approach, which presently seems promising. TMS involves brain stimulation using very high intensity magnetic pulses. It is somewhat similar to a "gentle" electroshock treatment, and clearly works on the brain rather than the inner ear. TMS seems to be somewhat helpful for depression and migraine, and one would think that a modality that worked for these, would also work to some extent for tinnitus. There is presently some evidence that it is helpful (Smith et al, 2007; Kleingjung et al, 2007; Mennemeier et al, 2008). This treatment is available only in persons who are in research environments.
Friedland and associates (2008) reported results of brain electrical stimulation in 8 patients. This was an uncontrolled study. The authors concluded that this technique "warrants further investigation". Two patients had persistent improvement of pure tone tinitus, and 6 had short periods of suppression.
Again, bad news. Surgery should be considered when there is a clear structural reason for tinnitus that can be improved with surgery. It is also worth considering if hearing can be improved by surgery. Generally though, hearing aids or implantable devices are much more successful than surgery.
Diet: We recommend that persons with tinnitus limit salt (no added salt), and refrain from drinking caffeinated beverages, other stimulants (like tea), and chocolate. The salt restriction is intended for those who might have a subclinical form of Meniere's. Caffeine and similar substances increase tinnitus in a nonspecific fashion. Otherwise the diet should be balanced and have normal amounts of fruits and vegetables.
Alternative medicine approaches. Ginkgo-Biloba, betahistine (Serc), Zinc, and acupuncture are sometimes advocated as treatment for intractable tinnitus. There is little evidence that these agents work, but they also do not seem to be harmful. In our clinical practice, we have occasionally encountered persons with very good responses to betahistine. More discussion about alternative medications is available here.
Psychological help: Often, anxiety or depression which accompanies tinnitus may be as big a problem as the tinnitus itself. In this instance, consultation with a psychologist or psychiatrist expert in this field may be helpful. Hypnosis may be effective and increase tolerance to tinnitus, but randomized controlled trials are not encouraging (Dobie, 1999). If you can ignore tinnitus rather than obsess about it, this may be the best way to handle it. Medications that help people with obsessive compulsive disorder (such as the SSRI family) may be helpful. Tinnitus Retraining Therapy (TRT) is a method of habituation of tinnitus is helpful for some (Wang et al, 2003). It requires a considerable commitment of time. We sometimes refer patients for this.
Self Help: You might consider joining the American Tinnitus Association. (PO Box 5, Portland, OR 97207, 503-248-9985). However, if your tinnitus has been well "worked up", and there is nothing more to be done, it might be best to attempt to ignore it rather than focus more attention on it. Joining of these sorts of organizations intrinisically draws more attention to ones illness.
As of 4/2002, a visit to the National Library of Medicine's search engine, Pubmed, revealed more than 3,900 research articles concerning tinnitus published since 1966. In spite of this gigantic effort, very little is presently known about tinnitus, and often effective treatment is unavailable.
| © Copyright July 23, 2010 , Timothy C. Hain, M.D. All rights reserved. Last saved on July 23, 2010 |
