Tinnitus

Understanding Tinnitus

* In this review, the term tinnitus will specifically refer to "non-pulsatile tinnitus." For information on "pulsatile tinnitus," please refer to this article.

 

Tinnitus is the perception of sound without any external source. This constant noise can take on many forms, including ringing, buzzing, humming, hissing or even a high-pitched tone. It affects millions of people worldwide, and while it can be a temporary or mild inconvenience for some, it can be a persistent, disruptive condition for others. This type of tinnitus can affect people of all ages and often occurs without any apparent external trigger.The severity and type of sound can vary widely among individuals.

There are different types of tinnitus. This article will focus specifically on "non-pulsatile tinnitus", which refers to a continuous, unchanging noise that isn't linked to the flow of blood or the heartbeat. People with non-pulsatile tinnitus often describe it as hearing a persistent sound that seems to come from inside the ear, even in quiet environments. It can affect one or both ears, and the intensity and frequency of the sound can vary greatly between individuals. Unlike environmental sounds, non-pulsatile tinnitus is not audible to others and is often described as an "invisible" sound.

 

Tinnitus Definitions

Tinnitus: The perception of sound without an external source.

Primary Tinnitus: Tinnitus that is idiopathic (no identifiable cause) and may or may not be associated with sensorineural hearing loss. This is the most common form of tinnitus.

Secondary Tinnitus: Tinnitus associated with a specific underlying cause (other than sensorineural hearing loss) such as otosclerosis, wax build-up, Ménière's disease, etc.) or an identifiable organic condition (see below).

Recent Onset Tinnitus: Tinnitus lasting less than 6 months.

Persistent Tinnitus: Tinnitus lasting 6 months or longer.

Bothersome Tinnitus: Tinnitus that distresses the patient, affects quality of life and/or functional health status. The patient seeks active therapy and management strategies.

Nonbothersome Tinnitus: Tinnitus that doesn't significantly affect quality of life but may cause curiosity about its cause or concern about its progression.

Recognizing the Signs and Symptoms

Beyond the constant ringing, buzzing, clicking, or hissing noise in the ears, tinnitus can be accompanied by a variety of symptoms depending on its cause. Some of the most common signs include:

• Hearing Loss: Tinnitus often occurs alongside hearing loss, especially in older adults or those with noise-induced hearing damage. People may notice that they struggle to hear in noisy environments or that certain sounds seem muffled.
• Ear Fullness: Some people experience a sensation of pressure or fullness in their ears, which may fluctuate with the intensity of the tinnitus.
• Hyperacusis: This is an increased sensitivity to everyday sounds. Patients with hyperacusis may find normal sounds uncomfortably loud, making social environments difficult to tolerate.
• Difficulty Concentrating: The constant noise can make it hard to focus, especially in quiet environments, which can affect work, school, or reading.
• Headache or Dizziness: In some cases, tinnitus is associated with other symptoms like headaches or dizziness, which can complicate the diagnosis.

While tinnitus itself is not typically life-threatening, it can have a significant impact on quality of life, particularly if these other symptoms are present.

The Mental Health and Quality of Life Impact of Tinnitus

Tinnitus can take a toll on mental health, especially when the noise becomes constant or intrusive. The brain’s constant awareness of the sound can lead to anxiety, stress, and even depression. The emotional distress is often linked to a feeling of loss of control; people feel they can't escape the noise, which can lead to frustration or helplessness. In severe cases, the constant sound can create a heightened emotional response, known as "catastrophizing," where the individual fixates on the tinnitus and perceives it as unbearable.

This mental strain can become a vicious cycle: stress and anxiety can exacerbate tinnitus, while tinnitus intensifies these emotions, making it difficult for the brain to "tune out" the noise. Studies show that people with chronic tinnitus are more likely to develop anxiety disorders or depression. Managing this mental health burden is critical, and counseling or therapy is often a key component of treatment.

Cognitive Impact
Many individuals with tinnitus report difficulties with concentration and memory. The persistent noise can interfere with cognitive processes, making it challenging to focus on tasks or retain information.

Communication Difficulties
Tinnitus can make it challenging to hear and understand speech, especially in noisy environments. This can lead to social isolation as individuals may avoid social situations or struggle to participate in conversations.

Work Performance
The combination of sleep disturbances, cognitive difficulties, and emotional stress can negatively impact work performance and productivity.

How Tinnitus Affects Sleep
One of the most common complaints from people with tinnitus is that it disrupts their sleep. During the day, ambient sounds, social interactions, and other distractions can help mask the ringing in the ears. However, at night when it's quiet, the brain becomes more aware of the tinnitus, making it harder to fall asleep. For some, the noise remains disruptive throughout the night, causing frequent awakenings and resulting in poor quality sleep. Sleep deprivation can, in turn, worsen tinnitus symptoms. Lack of rest heightens the brain's sensitivity to sound, increasing the perception of tinnitus and leading to fatigue, irritability, and difficulty concentrating during the day. Establishing good sleep hygiene and, in some cases, using sound machines to mask the tinnitus can help break this cycle.

Tinnitus Handicap Inventory

The Tinnitus Handicap Inventory (THI) is a widely used questionnaire designed to assess the impact of tinnitus on a person's quality of life. It consists of 25 questions that evaluate the emotional, functional, and catastrophic effects of tinnitus. The questions explore how tinnitus affects everyday activities, emotional well-being, concentration, and sleep, as well as any associated anxiety or depression. Each question is answered with "Yes," "No," or "Sometimes," and the total score reflects the severity of the tinnitus handicap. A higher score indicates a more significant impact on the individual’s daily life. his test helps doctors understand how severe your tinnitus is and helps track if it gets better or worse with treatment. It’s a useful tool to help find the best way to manage tinnitus.

The THI is a valuable tool for healthcare providers to understand how much tinnitus is affecting a patient's life and to track changes in symptoms over time, particularly before and after treatment interventions. This helps in tailoring personalized treatment plans and monitoring progress.

Potential Causes of Tinnitus

* It is important to understand that we unfortunately often do not find a cause for tinnitus. In such cases, we would consider the tinnitus as idiopathic.

 

The causes of non-pulsatile tinnitus are varied and can involve different systems in the body. Some of the most common causes include:

Auditory (otologic) causes:

• The most common cause of tinnitus is sensorineural hearing loss, particularly age-related hearing loss (presbycusis) or hearing damage from exposure to loud noise.
• Conductive hearing loss such as otosclerosis, ear infections and earwax buildup can also cause tinnitus.
• Ménière's disease would cause episodes of tinnitus but with vertigo and hearing loss.
• Rarely, a tumor on the hearing nerve (such as vestibular schwannoma) could cause tinnitus that would be affecting one ear only, and usually presents with hearing loss in that same ear.

Medical Causes:

• A common medical cause is excessive caffeine intake, which is a known neuro-stimulant.
• Head traumas, concussions and neck whiplash injuries are also common.
• Hormonal imbalances (such as hypo- or hyperthyroidism), less common
• Electrolyte or vitamine imbalances, less common
• Neurologic diseases (multiple sclerosis),
• uncontrolled hypertension,
• depression and anxiety.

Medication-related causes:

• High doses of aspirin can cause tinnitus, but it would usually be reversible.
• Chemotherapy drugs can be ototoxic and permanently damage the auditory system, leading to tinnitus.
• There are other ototoxic medications, see here. 

Proprioceptive (Somatosensory) Causes: Tinnitus can also result from problems with the muscles, nerves, or joints around the head and neck. In my practice, I've observed that this is a far more prevalent cause than people realize. This is especially common in young healthy individuals with tinnitus and a normal hearing test, and in older individuals who begin to develop neck and jaw arthritis. It is unfortunately often overlooked and under-treated.

• Temporomandibular joint (TMJ) disorders can cause or worsen tinnitus due to the close proximity of the jaw joint to the ear.
• Muscle tension or inflammation in the neck or upper spine can alter nerve signals, leading to tinnitus.

Psychogenic Causes: Psychological factors, such as stress, anxiety, or depression, can contribute to the onset or worsening of tinnitus. In some cases, the brain's perception of sound can be altered by emotional states, making tinnitus more noticeable or distressing.

Effects of Alcohol on Tinnitus

Temporary Worsening
Alcohol consumption can temporarily worsen tinnitus symptoms in some individuals. This effect is often noticed during or shortly after drinking.

Dehydration
Alcohol is a diuretic, which can lead to dehydration. Dehydration can affect the balance of fluids in the inner ear, potentially intensifying tinnitus symptoms.

It's important to note that the relationship between alcohol and tinnitus can vary significantly among individuals. While some people may experience worsened tinnitus symptoms after drinking alcohol, others may not notice any change or may even report temporary relief. For those who experience tinnitus, it may be beneficial to monitor how alcohol consumption affects their symptoms and consult with a healthcare professional for personalized advice.

When to Consult 

Generally speaking, tinnitus is rarely a sign of a serious condition. For that reason, you could wait up to a few months to see if the symptom disappears by itself. However, if you experience persistent tinnitus or if it significantly impacts your daily life, it is advisable to consult an ENT doctor or an audiologist.

It is especially important to consult an ENT specialist in certain situations, as these could be signs of a more serious underlying condition:

• The tinnitus is accompanied by sudden hearing loss or dizziness. 
• The tinnitus only affects one ear (unilateral tinnitus).
• The noise is getting progressively louder or more bothersome.
• There are additional symptoms, such as ear pain or discharge.
  
  

Work-up for Tinnitus

When you consult an ENT for tinnitus, the doctor will perform a thorough evaluation to determine the cause of the symptoms. This will typically involve several steps:

 

Medical History:

• Description of your tinnitus: pulsatile or not, high pitched (ringing or hissing), low pitch (roaring buzzing) or clicking?

• Side: one or both ears?
• Onset (when it started), and triggering event?
• Quality of the tinnitus: constant or intermittent, and any factors that seem to worsen or relieve it.
• Accompanying symptoms such as dizziness, hearing loss, ear pressure, ear pain or leakage, recent ear infections
• History of noise exposure, noise trauma or barotrauma 
• History of head or neck trauma
• List of your medications and use of recreational drugs
• Jaw or neck problems (clenching your teeth at night, neck tension, etc.)
• Depression, anxiety or other stressful life event
• Any relevant medical problem

Physical Exam: The ENT will conduct a focused head and neck exam and a detailed examination of your ears with otoscopy (a lighted instrument to look inside your ear canal) and tuning forks. A neuro-vestibular exam should also be performed. In some cases, a nasopharyngeal endoscopy (a flexible scope passed through the nose) might be done to assess the back of the nose and throat for problems like eustachian tube dysfunction. If relevant, the jaw (TMJ joint) could also be checked. 

 

Hearing Evaluations:

• An audiogram is most always the first step in the workup of a patient with any kind of tinnitus. It is performed to assess whether there is hearing loss, which often accompanies tinnitus. Even if the patient does not personally notice hearing loss, I would still advise conducting this test.
• A tympanometry is also done to look at middle ear pressure.
• We sometimes add high frequency audiometry (HFA) when the regular audiogram is normal to look for early signs of hearing damage or if the tinnitus is very high pitched. 

Imaging Studies: We do not recommend routine use of imaging for tinnitus with no risk factors.

• An MRI of the internal auditory canal is recommended only if there is confirmation of asymmetrical hearing loss on the audiogram or a tinnitus is persistently in one ear, and a cerebral MRI if there are unusual neurological symptoms or findings on the physical exam.
• We would order a CT scan of the temporal bones if we suspect conductive hearing loss.

Medical Evaluation: Due to the potential medical causes of tinnitus (as noted in the section above), a medical work-up might be advisable. I typically recommend that patients consult with their family doctor or general practitioner to initiate this evaluation. 

Potential Treatment Options for Tinnitus

While it's true there is no cure for tinnitus at time of writing, it does not mean that nothin g can be done to minimize its impact on daily living. I often see patients who are discouraged because they've met with other doctors who told them to "just live with it". There is no one-size-fits-all treatment for tinnitus, but several strategies can help manage and reduce the symptoms.

 

The American Academy of Otolaryngology has provided clinical practice guidelines for tinnitus management (see here for a summary of the guidelines), and treatment often involves a combination of approaches. Here is a summary of the recommendations:

What doesn't work

I regularly advise my patients, and would like to extend this advice to you as a reader, that the tinnitus treatment industry is very profitable as the condition affects such a large number of individuals. It's important to exercise caution when considering a purchase, as many products online or in pharmacies may not deliver the promised relief. I frequently encounter patients presenting brochures for new devices or medications that claim to cure tinnitus. While I cannot speak for everything out there, I can comfortably say that most of these products have not been robustly tested scientifically. I often tell my patients to try these options if they think they may help, but to do so cautiously and not to spend a large sum of money upfront as the chances of success are low. I take pride in giving evidenced-based recommendations, and so far the data does not support the following treatment approaches:

What has been shown to work

• Addressing Underlying Causes: The most important step. In cases where tinnitus is caused by an underlying condition, treating that condition can alleviate or reduce the tinnitus. For example, removing impacted earwax, treating TMJ disorders or neck arthritis, or adjusting medications that may be contributing to the tinnitus can provide relief. See the sections above for a list of potential underlying causes.
  
  
• Cognitive Behavioral Therapy (CBT): CBT is a type of psychological therapy that helps people change how they think about and react to their tinnitus. By reducing the emotional impact of tinnitus and teaching coping mechanisms, CBT can significantly improve quality of life for those affected by chronic tinnitus. Studies have shown that CBT is one of the most effective treatments for tinnitus-related distress.
  
  

• Sound Therapy: One of the most common treatments for tinnitus is sound therapy, which involves using external sounds to mask or reduce the perception of the internal noise and promote habituation (becomes less noticeable). They are divided into categories such as environmental enrichment devices (tabletop sound machines, fans, TV, radio), hearing aids (see below) and sound generators (ear level sound generators that match the tinnitus). Listed as an "Option" in the guidelines.

  
  
  
• Hearing aids: For people with hearing loss, hearing aids that amplify external sounds can also help reduce the awareness of tinnitus.(Listed an an "Recommendation" in the guidelines). This allows patients who have both hearing loss and tinnitus to benefit from a single device.
  
  
• Tinnitus Retraining Therapy (TRT): Tinnitus retraining therapy would be considered a specialized form therapy that combines sound therapy with counseling to help patients "retrain" their brain to ignore the tinnitus. This therapy can take several months to complete, but it has shown promising results for people with chronic and severe tinnitus.
  
  

• Empiric Treatment: In some cases, where the exact cause of tinnitus is unknown or multifactorial, doctors may recommend empiric treatments, which are therapies started based on clinical judgment. These might include trying sound therapy, adjusting lifestyle factors (like reducing caffeine or alcohol), and prescribing relaxation techniques to manage stress.

What may or may not work

This category is meant for treatment options that do not have enough quality scientific data to make a formal recommendation (either for or against its use). 

 

• Acupuncture:  Acupuncture has been explored as a potential treatment for tinnitus, drawing from traditional Chinese medicine principles. For tinnitus treatment, acupuncture points in and around the ear are often targeted, with the aim of reducing the intensity and severity of tinnitus sounds. the overall evidence for acupuncture's efficacy in treating tinnitus remains inconclusive, with more rigorous research needed. I always let my patients know that this treatment option is available and that while it might work for some, its effectiveness isn't guaranteed. It could be worth considering if other treatments have already been tried or if there is a curiosity in exploring alternative medicine approaches.