After 21 years of practice, I’m still amazed at how often I hear a new and different description of tinnitus reported by a patient. No two tinnitus patients are alike and each patient has a unique description as well as a unique history in regard to when the noise in their ears started, what it sounds like, what caused it and how much it bothers them. Some patients report no complaints regarding their hearing while others do. Some patients report no issues with dizziness or vertigo while others do. Some patients have tinnitus in one ear while others hear it in both ears. Some patients describe their head noise as annoying, others tell me it’s bothersome and for a few it’s reported as debilitating. Many patients tell me that their tinnitus is constant while just as many tell me that it comes and goes. Even the way that tinnitus is pronounced varies from patient to patient with some people pronouncing tinnitus as tin-NYE-tus as they might with other itis conditions while others pronounce it as TIN-ni-tus with no hard I and placing the emphasis placed on the first syllable.
What Is Causing My Tinnitus?
Tinnitus is commonly caused by damage to your auditory system including but not limited to: Age-related hearing loss, exposure to loud noise, earwax buildup, abnormal bone growth in the ear, Meniere’s disease, stress and depression, head or neck injuries, benign tumor of cranial nerve VIII and some medications. Damage to the auditory system creates a deficit of sound at specific frequencies and since the brain is still
looking for neural input from those frequencies it creates what is called central gain or “phantom sound”. Think of phantom limb pain experienced by amputees except that it’s damaged inner ear anatomy as opposed to a missing limb.
Exposure to loud noise is the most common cause of tinnitus with over 80% of people that report having tinnitus also experiencing some degree of noise induced hearing loss. Unfortunately, the noise exposure causes damage to hair cells of the inner ear and consequently the neural fibers of the auditory pathway become deprived of that sensory input leading to the presentation of phantom sounds that patients hear but are not audible to the outside world.
Also of note is that several prescription and non-prescription drugs have tinnitus listed as a potential side effect. The most well known non-prescription drug with tinnitus cited as a potential side effect is aspirin. Several antibiotics, antidepressants, quinine drugs and loop diuretics also list tinnitus as a potential side effect.
What Are the Treatments for Tinnitus?
No discussion regarding the treatment of tinnitus would be complete without mentioning that currently there is no medical cure for tinnitus. That being said however there are several accepted and FDA cleared treatments for tinnitus that have up to an 80% success rate in eliminating or reducing the perception of and the impact of tinnitus on individuals.
Clinically, tinnitus is greatly helped in most cases by treating the underlying hearing loss. Although many patients experiencing tinnitus deny reduced hearing or concerns regarding their hearing they do indeed have hearing loss. Remember that tinnitus is the perception of a phantom sound, “Central Gain”, which stems from the brains’ response to not receiving input from the damaged anatomy of the inner ear, the outer hair cells. This phenomenon is very similar to the phantom pain reported by individuals that have lost limbs in which the brain is still looking for input from nerve endings at the site of the missing limb. Even though the limb is absent the pain felt by the amputee is extremely real to them just like the phantom sound, “Tinnitus” is to the patient with the damaged inner ear anatomy. 80% of patients fit correctly with appropriate hearing devices that report suppression and / or elimination of their tinnitus simply due to the fact that their brain is now receiving adequate input at damaged frequencies reducing the need of the brain to create “Central Gain”, phantom sounds. Additionally, sound therapies have been reported to assist tinnitus patients as well with reducing their perception of tinnitus and are #2 on my list of treatment choices right after treating a patient’s hearing loss. Sound therapies utilize external noises to stimulate the auditory system with goal being to reorganize the auditory cortex. This should not be confused with masking in which sound is used to completely block tinnitus noise from being heard by the patient. Sound therapy is extremely common and a recent review of various treatments shed light on their effectiveness.
Haiyan Wang and team in 2020 reviewed research conducted on masking, tinnitus retraining therapy, music therapy Heidelberg neuro-music therapy, tailor made notch music therapy, tinnitus pitch matched therapy, acoustic coordinated reset neuromodulation, neuromonics tinnitus treatment, modulated wave therapy, auditory discrimination training and hearing aids for tinnitus.
Their conclusions are consistent with what occurs anecdotally in the clinic, in that a majority of patients respond very well to treating their tinnitus secondary to treating their hearing loss. Additionally, should hearing devices not resolve a patient’s perception of their tinnitus to their satisfaction all of the other sound therapies mentioned were proven to help patients to some degree.
There is also some evidence to suggest that home remedies and self-treatment of tinnitus may work for some patients. Obviously, tinnitus when first identified and ruled out as being secondary to a potentially life-threatening medical condition via a complete audiological work up impacts people differently. So for those patients that have no underlying hearing loss and find their tinnitus to be more annoying or novel as opposed to bothersome,self-treatment without the assistance of a professional may be appropriate for some individuals. Again, this should only be considered after your tinnitus has been diagnosed as benign.
Self-treatment includes doing nothing, using hearing protection when exposed to loud sounds, turning down the volume of things that you’re listening to, limiting alcohol, caffeine and nicotine. Additionally, attending a support group, educating yourself on what others have found successful and utilizing stress management techniques would also be considered self-treatment and have proven helpful for some individuals.
Patients often see us clinically and tell us that they have previously been told that their nothing that can be done for their tinnitus and this just isn’t true, treatments not only exist but have been proven to some people reduce or eliminate the impact of their tinnitus immediately or over time.
Are there medications for tinnitus?
There are no approved drug treatments to treat tinnitus specifically today but thankfully there does exist medication that can be used to help manage patients that are experiencing stress, depression and / or anxiety as a result of their tinnitus. Again, it’s important to point out that tinnitus should be evaluated at onset and as well as over time, especially when changes in pitch, intensity, numbness in face or extremities and / or vertigo develop in order to confirm that your tinnitus is indeed benign. Once your tinnitus is confirmed to be benign the associated stress, depression and / or anxiety can be managed medically if need be via a referral to a physician that specializes in the use of anti-depressants and anti-anxiety medication. Audiologists will treat your hearing loss and tinnitus via therapies already mentioned but when tinnitus remains or becomes debilitating due to these other factors medical intervention is not only ideal but required.
How Can I Prevent Tinnitus?
Avoiding loud noise is the number one best thing that you can do to avoid tinnitus. Remember that just one exposure to loud noise can typically cause temporary episodes of tinnitus and that repeated exposure to loud noise can lead to permanent tinnitus.
So avoiding loud noise is your best prevention. If you cannot avoid loud noise or choose not then protecting your hearing health via hearing protection is the next best preventive step that you can take to avoid tinnitus. Hearing protection comes in all shapes and sizes so please pay attention to operational instructions and do consider seeing a doctor of audiology for custom made and professionally fitted hearing protection. If you opt for over the counter protection, definitely consider wearing in the ear protection coupled with over the ear protection for maximum protection.
Also of note in terms of limiting noise damage is to protect yourself from loud inputs when streaming from your devices via earbuds and other Bluetooth audio devices. Any sound over 85 decibels is damaging and for reference, average conversation levels measure around 65dB. Fortunately, there are many apps available to measure decibel level so take advantage of them to monitor what you are listening to.
When is tinnitus a medical emergency?
Any time tinnitus is first identified it warrants a visit to audiology for a complete tinnitus evaluation so that its status can be confirmed as benign which is most often the case. That being said, tinnitus is considered a medical emergency when it is pulsatile in nature, only occurs in one ear, bothersome to the point that it cannot be ignored and / or it is accompanied by vertigo.
Pulsatile tinnitus can be caused by atherosclerosis, blood vessel disorders, blood vessel malformations, ear abnormalities, high blood pressure, head and neck tumors, intracranial hypertension and sinus wall abnormalities. Although several of these sound like things that you really don’t want, the good news is that the occurrence of tinnitus due to these conditions that subsequently become fatal is extremely rare. That being said a complete work up is critical to ruling out worst case scenarios so do not delay.
Unilateral tinnitus, tinnitus in only one ear is cause for concern since it’s a common presentation of cranial nerve VIII tumors, again a very rare condition but since the possibility exists and could be life threatening it needs to be ruled out via a complete evaluation.
Severe tinnitus that is impossible to ignore and bothersome to the point of interfering with quality of life, depression, substance use and / or suicidal thoughts is cause for it to be considered a medical emergency. Fortunately, less than four percent of people experiencing tinnitus suffer from debilitating tinnitus making the need for emergent care low but again the need for a complete audiological work up when tinnitus is reported cannot be overstated.
Tinnitus accompanied by vertigo should be considered emergent when first reported for the same reason as unilateral tinnitus since they are common symptoms of cranial VIII nerve tumors which although benign and slow growing can displace anatomy in the head causing severe damage over time. As with the other emergent presentations discussed, a complete work up by audiology will help triage patients accordingly.
How is tinnitus diagnosed?
Tinnitus can be self-diagnosed simply due to the head noise heard by the patient. Audiologists as well as other doctors that see patients with tinnitus will also diagnose tinnitus based on the reported symptom of noises in their ear or head. However in order to further diagnose the underlying cause of tinnitus and to aid in the development of a treatment plan for the tinnitus the patient will be asked to undergo additional evaluation.
Most commonly these additional tests begin with a complete audiological evaluation and hearing tests. Your doctor may do a physical exam involving movement of your eyes, jaw, neck, arms and legs in order to determine if the movement of different body parts intensifies or lessens your reported tinnitus. Changes in your tinnitus with different movements can aid in the differential diagnosis. Depending on your symptoms and hearing test results imaging studies may be ordered to further assist with ruling out conditions that could be causing your tinnitus. The most common imaging study due to reported tinnitus is an MRI of the brain, with and without contrast looking for tiny tumors in the Cerebellopontine angle area of the brain. Additionally, lab tests may be ordered to further assist with the differential diagnosis and to rule out vitamin deficiencies, thyroid issues, heart disease and / or anemia.
Bottomline
We could write an entire book on tinnitus, in fact several exist but the goal of this overview is to ensure that the reader takes away the following key points:
Tinnitus is typically benign but-worst case scenarios must be ruled out. The best place to start the process of ruling out worst case scenarios is your local doctor of audiology who is uniquely qualified to diagnose and triage you for further evaluation when warranted.
There is no medical cure for tinnitus but several effective and FDA cleared treatment therapies exist. Treating your underlying hearing loss with appropriate hearing devices, properly fit using best practices is over 80% effective at reducing or eliminating your bothersome tinnitus.
