TINNITUS - Mydoctor.ca

TINNITUS
10/02/2005 01:48 PM
TINNITUS
Timothy C. Hain, MD
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Tinnitus Defined
Tinnitus defined Causes Diagnosis Treatment If You Have Tinnitus
Please read our disclaimer Return to Index. Page last modified: June 26, 2005
Tinnitus (pronounced "tin-it-tus") is an abnormal noise in the ear. 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. 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 (lowpitched
hissing). Some
persons hear chirping,
screeching, or even
musical sounds. Note
however that tinnitus
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
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auditory hallucination.
Tinnitus is commonly
accompanied by
hearing loss. Less
commonly, it may be
accompanied by
hyperacusis (an
abnormal sensitivity to sound).
Pulsatile tinnitus: people hear something resembling their heartbeat in their ear. The cause usually involves
vascular, tumor or muscular causes. A blood vessel may be close to the eardrum, a vascular tumor such as a
"glomus" may fill the middle ear, or a vein similar to a varicose vein may make enough noise to be heard.
Other possibilities include dehiscence of the jugular bulb, and an aberrantly located carotid artery. An
enlarged jugular bulb on the involved side is common in persons with venous type pulsitile tinintus.
What Causes Tinnitus? Most tinnitus comes from damage to the inner ear, specifically the cochlea (the
snail like thing on the right labelled '9'). Tinnitus can also arise from damage to the nerve between the ear
and brain (8th nerve, labeled 6, auditory nerve), much more rarely from injury to the brainstem (Lanska et
al, 1987), and extremely rarely, to the brain itself. There are specific causes. Ear wax can rarely cause
tinnitus. Other causes include middle ear infection or fluid, Meniere's disease, microvascular compression
syndrome, otosclerosis, and infections such as otosyphilis or labyrinthitis, and tumors of the 8th nerve.
There are small muscles in the middle ear (the tensor tympani and stapedius) that can start twitching and
cause tinnitus (Golz et al. 2003).
Patients with head or neck injury may have particularly loud and disturbing tinnitus (Folmer and Griest,
2003).
Patients with Meniere's disease often describe a low pitched tinnitus resembling a hiss or a roar. Pulsatile
tinnitus (tinnitus that beats with your pulse) can be caused by aneurysms, increased pressure in the head
(hydrocephalus), and hardening of the arteries. Anything that increases blood flow or turbulence such as
hyperthyroidism, low blood viscosity (e.g. anemia), or tortuous blood vessels may cause pulstitle tinnitus.
Vitamin B12 deficiency is common in tinnitus patients.
Loud noise is the leading cause of damage to the inner ear. Most patients with noise trauma describe a
whistling tinnitus (Nicholas-Puel et al,. 2002). In a large study of tinnitus, avoidance of occupational noise
was one of two factors most important in preventing tinnitis (Sindhusake et al. 2003). The other important
factor was the rapidity of treating ear infections.
Advancing age is often accompanied by inner ear damage and tinnitus. (Sindhusake et al. 2003)
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
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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
How is Tinnitus Diagnosed ? 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, hearing should be tested
with a tympanometer, and a long recording of ear drum compliance should be made with a tympanometer (a
screener won't work here). The audiogram sometimes shows a sensorineural deficit due to masking from the
tinnitus. Tympanograms can sometimes show a rhythmic compliance change due to a middle ear vascular
mass or due to contraction of muscles in the middle ear. An ABR test may be helpful in diagnosing tinnitus
due to a tumor of the 8th nerve or tinnitus due to a central process.
Inspection of the eardrum may sometimes demonstrate subtle movements due to contraction of the tensor
tympani (Cohen and Perez, 2003). Myoclonus causes a thumping sound.
Stapedius and Tensor Tympani Muscles
With permission, from: http://www.meddean.luc.edu/lumen/meded/grossanatomy/dissector/mml/images/stap.jpg
Myoclonus of the stapedius often results in visible contractions of the ear drum, which produce sounds
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audible to the examiner. An impedance bridge (tympanometer) can document rhythmic changes in ear drum
compliance. There should not be movement of the palate in the stapedius myoclonus syndrome (as this
would suggest palatal myoclonus).
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.
The TMJ joints of the jaw should be checked as about 28% of persons with TMJ syndrome experience
tinnitus. The physician may also request a BAER test (clicks in ears), an ECOG, an MRI/MRA test (scan of
the brain), and several blood tests (ANA, B12, FTA, ESR, SMA-24, HBA-IC, fasting glucose, TSH, antimicrosomal
antibodies).
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 effects. 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.
Vestibular tests such as ENG or posturography are generally not helpful in diagnosing tinnitus. Tinnitus is
rarely attributable to sinus disease and even if tests suggest that you have this common condition, it is
unlikely that treatment of it will affect tinnitus.
Based on these tests, tinnitus can be separated into categories of cochlear, retrocochlear, central, and tinnitus
of unknown cause.
How Is Tinnitus Treated ?
The bad news: 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 longterm
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 doctor may be able to eliminate the noise. Examples of
specific causes include medication, tumors, infections, Ménière'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,
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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).
Medicines
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). Medications to
deal with the psychological fallout of tinnitus is often useful -- antidepressants and anti-anxiety medications
can be very helpful.
Medications used in treatment of Tinnitus
Lorazepam or klonazepam (in low doses). These are "benzodiazepines" (Gananca et al, 2002; Dobie,
2003)
Amitriptyline or nortriptyline (again in low doses). These are "tricyclics".
cyclandelate (Cyclospasmol) -- a vasodilator that slightly reduced tinnitus (Dobie, 1999)
Mysoline or oxbamazepine in doses used for epilepsy
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. The effect of local anesthetics on tinnitus was discovered serendipitously
by Barany in 1935. Otsuka et al (2003) recently reported administration of Lidocaine to 117 ears over a 24
year period. The method was intravenous infusion, of between 80 and 100 mg. They report a transient
(several minutes) response in about 70% of treated ears. As responses are nearly always very temporary,
lidocaine does not have a role as a treatment of tinnitus. The mechanism appears to be central (Baguley et
al, 2005). According to Dobie (1999), the related drugs tocainamide, mexilitine and flecainamide have not
been shown superior to placebo.
Drugs in which it is uncertain whether they are effective
Flunarizine (not available in US)
Caroverine (not available in US, IV medication)
Eperisone (not available in US).
Drugs that are probably placebos for tinnitus (see additional comments at the beginning of the
treatment section)
Baclofen -- rarely helpful, has significant side effects.
B12 (1000 ug per week).
carbamazepine (Tegretol) -- an anticonvulsant. (Dobie RA, 1999)
cinnarizine (Dobie, 1999)
Dexamethoasone (Intratympanic) (Araujo et al, 2005)
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Ginkgo Biloba (Alternative medicine found in health food stores, 120-240 mg twice daily -- some
anecdotal evidence of efficacy) (Seidman and Keate, 2002)
lamotrigine (an anticonvulsant)
misoprostol, Cytotec (300 mg TID) -- we have never encountered a patient that responded to this
Serc (8mg TID) -- for Meniere's disease. Also other medical treatments of Meniere's disease may be
worth considering.
Tocainamide (more than 1200 mg/day) -- a cardiac drug related to the local anesthetics (Dobie, 1999)
Zinc supplements (50 mg daily)
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.
Surgical treatment of tinnitus:
Surgery is rarely indicated for tinnitus. It should be considered when there is a clear structural reason for
tinnitus that can be improved with surgery. Examples include Meniere's disease, microvascular compression
syndrome surgery, shunt surgery for hydrocephalus, closure of a dural sinus fistula. Rarely 8th nerve
sections are done for tinnitus. They are successful in about 50%, with the price of losing hearing in 100%.
What to do if you have tinnitus ?
1.
Avoid exposure to loud noises and sounds.
2.
Aim for a low-normal intake of salt.
3.
Avoid stimulants such as caffeine and nicotine.
4.
Exercise daily, get adequate rest, and avoid fatigue.
5.
Avoid ototoxic medications known to increase tinnitus such as aspirin, non-steroidals and quinine
containing preparations.
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.
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. 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.
Maskers are 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. Tinnitus maskers are fitted and sold
by audiologists. Controlled studies of maskers have shown some small effects (Dobie, 1999).
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
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do not seem to be harmful. 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.
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.
Tinnitus Retraining Therapy (TRT). This method of habituation of tinnitus is helpful for some (Wang et
al, 2003). It requires a considerable commitment of time.
Dubious, non-drug treatments
Acupuncture. This probably another placebo treatment although acupuncture is preferred to placebo (Dobie,
1999)
Electrical stimulation. Two randomized controlled trials in the 1980's found a device ineffective compared
with a placebo (Dobie, 1999). There is probably no harm other than to the pocketbook.
Electromagnetic stimulation. Again, no help. (Ghossaini et al, 2004).
Magnetic Stimulation: Of course, magnetic head-bands or the like are almost certainly placebos. Little data
is available (Dobie, 1999)
Surgery: Unlike some of the other treatments discussed here, surgery is not necessarily a placebo.
Nevertheless, only rarely is surgical treatment indicated, and even more rarely, is tinnitus relieved by
surgery. You should certainly consider surgery if your tinnitus is due to a tumor and also if it is due to a
venous source (usually pulsatile in this situation). For venous tinnitus, possibilities include jugular vein
ligation, occlusion of the sigmoid sinus, or closure of a dural fistula. Surgery may also be an option to
consider if your diagnosis is otosclerosis, fistula or Ménière's disease. Occasionally persons with Meniere's
disease have relief or reduction of tinnitus from transtympanic gentamicin. Microvascular compression
syndrome, in theory, may cause tinnitus, but we have had very little success when the few patients we have
seen with this syndrome have undergone surgery.
Ultrasound: No difference from placebo (Dobie, 1999)
Zinc. Zinc has been used for many years as a treatment of tinnitus. Most studies show no significant effect
(e.g. Arda et al, 2003). It seems most likely at this writing (2003) that Zinc is a placebo.
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Research Studies in Tinnitus
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.
links to other tinnitus materials:
Tinnitus poetry
References:
Andersson G, Vretblad P, Larsen H, Lyttkens L. Longitudinal follow-up of tinnitus complaints. Arch
Oto HNS 2001:127:175-179
Araujo MF and others. Intratympanic dexamethasone injection as a treatment for severe disabling
tinnitus. Arch Otol HNS 2005:131:113-117.
Bagulel DM and others. The inhibitory effect of intravenous lidocaine ... Otology & Neurotology,
26:169-176, 2005
H. Nedim Arda; Umit Tuncel; Ozgur Akdogan; Levent N. Ozluoglu. The Role of Zinc in the
Treatment of Tinnitus. Otology & Neurotology 2003; 24(1):86-89
Cohen D, Perez R. Bilateral myoclonus of the tensor tympani: A case report. Otolaryngol HNS
2003:128:441
Dobie RA. A review of randomized clinical trials in tinnitus. Laryngoscope 1999;109(8):1202-11.
Folmer RL, Griest SE. Chronic tinnitus resulting from head or neck injuries. Laryngoscope 2003
May;113(5):821-7
Ganaca MM et al. Clonazepam in the pharmacological treatment of vertigo and tinnitus.
International Tinnitus Journal, 8, 1,50-53 (2002)
GHOSSAINI SN, Spitzer JB, Mackins CC, Zschommler A, et al. High-frequency pulsed
electromagnetic energy in tinnitus treatment. Laryngoscope 2004;114:495-500.
Golz A, Fradis M, Martzu D, Netzer A and Joachims HZ (2003). "Stapedius muscle myoclonus." Ann
Otol Rhinol Laryngol 112(6): 522-4.
Gristwood RE, Venables WN Otosclerosis and chronic tinnitus. Ann Otol Rhinol Laryngol 2003
May;112(5):398-403
Lanska Dj, Lanska MJ, Mendez MF. Brainstem auditory hallucinosis. Neurology 1987, 37, 1685
Hesse G, Schaaf H. [Ginkgo biloba: ineffective against tinnitus?] HNO 2001; 49: 434-6.
Nicholas-Puel C and others. Characteristics of tinnitus and etiology of associated hearing loss: A
study of 123 patients. Int. Tinnitus J, 8, 1,, 37-44, 2002
Otsuka K, Pulec J, Suzuki M. Assessment of intravenous lidocaine for the treatment of subjective
tinnitus. ENT journal, 82, 10, 781-, 2003
Plewnia C, Bartels M, Gerloff C. Transient suppression of tinnitus by transcranial magnetic
stimulation. Ann Neurol 2003:53;263-266
Seidman. RE and Keate B.:Letter to the editor -- Myths in neurotology, revisited: smoke and mirrors
in tinnitus therapy. Otol Neurotol 23:1013-1016, 2002
Shea JJ Jr, Ge X. Lidocaine perfusion of the inner ear plus IV Lidocaine for intractable tinnitus
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(abstract). Available at: http://www.sheaclinicinc.com/HTML/abstract.html. May,2000
Sindhusake D, Golding M, Newall P, Rubin G, Jakobsen K and Mitchell P (2003). "Risk factors for
tinnitus in a population of older adults: the blue mountains hearing study." Ear Hear 24(6): 501-7.
Sindhusake D, Mitchell P, Newall P, Golding M, Rochtchina E and Rubin G (2003). "Prevalence and
characteristics of tinnitus in older adults: the Blue Mountains Hearing Study." Int J Audiol 42(5): 289-
94.
Wang H, Jiang S, Yang W, Han D. Tinnitus retraining therapy: a clinical control study of 117
patients.Zhonghua Yi Xue Za Zhi 2002 Nov 10;82(21):1464-7
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