Tinnitus is the term used to describe the condition of perceiving a ringing, buzzing or whooshing noise in the absence of an external sound source. This is typically only experienced by the person with tinnitus and has a variety of different causes.
In order to understand the possible causes of tinnitus, one must have some knowledge of the hearing mechanism. This mechanism is made up of five main divisions: the external ear, the middle ear, the inner ear, the nerve pathways and the brain.
External Ear: The external ear consists of the auricle and the external ear canal. These structures collect the sound waves and transmit them to the eardrum.
Middle Ear: The middle ear lies between the eardrum and the inner ear. This chamber contains three ossicles: the malleus, the incus, and the stapes (the hammer, anvil, and stirrup). Vibrations of the eardrum are transmitted across the middle ear space by these three small ear bones. Movement of the third bone (stapes or stirrup) results in fluid waves in the inner ear.
The middle ear chamber is lined by a membrane similar to the lining of the nose and contains secreting glands and blood vessels. This chamber is connected to the back of the nose by a small channel called the eustachian tube.
The eustachian tube serves to maintain equalization of pressure between the middle ear chamber and the outside atmosphere, as evidenced by the popping sensation noted in the ear during altitude changes.
Inner Ear: The inner ear is enclosed in dense bone and contains fluid and the tiny hearing cells. It is lined by a delicate transparent membrane supplied by microscopic blood vessels. In this small chamber, fluid waves resulting from movement of the stapes are transformed into electrical impulses in the nerve.
Nerve Pathways: The electrical impulses created in the inner ear chamber are transmitted to the brain by the hearing nerve. The nerve pathways leading to the brain are enclosed in a small boney canal along with the nerve of balance and the nerve which stimulated movement of the facial muscles.
Brain: The hearing nerve pathways divide as they reach the brain into an inter-communicating system far more complex than the most extensive telephone exchange. Nerve impulses are then transformed into recognizable sound.
Objective Tinnitus
Most tinnitus is audible only to the patient; this is called subjective tinnitus. Tinnitus audible to both the patient and others is called objective tinnitus, the least common form.
Objective tinnitus may be due to muscle spasms in the middle ear or eustachian tube or be due to abnormalities in the blood vessels surrounding the ear.
Muscular Tinnitus. Tinnitus may result from spasm of one of the two muscles attached to the middle ear bones or from spasm of muscles attached otothe eustachian tube, the channel which connects the middle ear to the back of the nose.
There are two muscles in the middle ear: the stapedius, attached to the stapes bone (stirrup) and the tensor tympani, attached to the malleus bone (hammer). These muscles normally contract briefly in response to very loud noise or a result of a startle reaction.
On occasions one or both of these muscles may begin to contract rhythmically for no apparent reason, for brief periods of time. Because the muscles are attached to one of the middle ear (hearing) bones these contractions may result in a repetitious sound in the ear. The clicking, although annoying, is harmless and usually subsides without treatment.
Should the muscle spasm continue, medical treatment (muscle relaxants) or surgery (cutting the spastic muscle) may be necessary.
Muscular tinnitus resulting from spasm from one of the various muscles of the throat attached to the eustachian tube is uncommon, but can also result in episodes of rhythmic clicking in the ear. This is called palatal myoclonus and usually responds to muscle relaxants.
Vascular Tinnitus. There are two large blood vessels intimately associated with the middle and inner ear: the jugular vein and the carotid artery. These are the major blood vessels supplying the brain.
It is not uncommon to hear one’s own heart beat or to hear the blood circulating through these large vessels. This may be particularly noticeable when an individual has a fever or a middle ear infection, or after engaging in strenuous exercise. The circulation sound in these instances is temporary and is not audible to others.
On occasion the sound of blood circulation will become audible to others. This can be due to thickening of the blood vessel wall (a normal occurrence as one grows older), a kink in the vessel or an abnormal growth on the vessel wall. Further testing may be necessary to determine the cause and treatment indicated in these uncommon cases.
External Ear Tinnitus
Obstruction of the external ear canal by wax, foreign bodies or swelling may produce a hearing impairment or pressure on the eardrum. This frequently results in a pulsating type of tinnitus.
Middle Ear Tinnitus
Disturbances of function of the middle ear may result from allergy, infection, injury, scar tissue or impaired motion of the three middle ear bones. These disturbances often result in hearing impairment and may lead to head noise. But there is no relationship between the degree of hearing loss and the intensity of the tinnitus.
Inner Ear Tinnitus
Any condition that disturbs the fluid pressure in the inner ear chamber may produce head noise. This may be due to infection, allergy, or circulatory disturbances that produce changes not only in the fluid but also in the encasing membranes of the inner ear.
Nerve Pathway Tinnitus
The nerve pathways are the most delicate structures of the hearing mechanism. The small hair cells that serve to transform fluid waves into nerve impulses are analogous to the cells that serve to transform fluid waves into nerve impulses. the slightest swelling or interference with these delicate cells from any cause readily produces impairment of functional and irritation. This may occur from a variety of causes: infection, allergic swelling, systemic diseases, either acute or chronic, with resultant toxic effects, sudden exposure to a blast of sound or prolonged exposure to high noise levels in susceptible persons, certain drugs to which the patient may be sensitive, and minute changes in the blood supply.
inflammation and pressure changes may produce swelling both from outside and within the nerve as it transverses the boney tunnel through which it passes to the brain. Viruses may cause inflammation in the hearing nerve without any symptoms of a flu-like illness. In these instances, the tinnitus occurs on one side of the head and because the boney tunnel cannot expand with the pressure phenomenon not only the function of the hearing nerve, but also the balance and facial nerves may become disturbed as they pass through this boney tunnel.
Interference of circulation in one of the small blood vessels occurring anywhere in the auditory pathway produces altered function. Consequently, sudden tinnitus, with or without partial or total loss of hearing function, may occur. If the circulatory change is minor, it may resolve with little or no permanent change. This condition, like the pressure phenomenon, occurs only on one side, and because it has occurred once doesn’t mean it would necessarily occur again on the same or opposite side.
Brain Tinnitus
Any disturbance, whether due to swelling ,pressure or interference with circulation, may occasionally involve one or more of the complex hearing pathways as they enter and terminate in the brain. In this instance, the brain can produce head noise or tinnitus. At times, head noise or tinnitus which has begun within the inner ear or along the hearing nerve, may change such that the sensation occurs from within the brain. In these instances, the tinnitus may be perceived as a diffuse sensation within the whole head.
Hearing Impairment
Head noise or tinnitus may or may not be associated with hearing impairment. After reviewing the many causes of this symptom, it is easy to understand why the hearing may at times be affected when tinnitus is present. If a hearing loss coexists with tinnitus, the severity of the head noise is not an index as to the future course of the hearing impairment. Many persons with tinnitus have the erroneous fear they are going to lose their hearing. This is an unnecessary fear.
Stress And Depression
Physical or emotional stress is present in everyone’s life periodically. In some, it is chronic, and can result in symptoms of depression. At times, a symptom such as tinnitus may, in itself lead to depression. This can make the tinnitus more bothersome. A vicious cycle may develop involving depression and symptoms of tinnitus in which both are aggravated by the other.
At times, we may recommend that a patient with severe tinnitus be treated with antidepressants or antianxiety medications. Patients of this type are also the ones who are most likely to benefit from biofeedback treatment.
Treating The Cause
If the examination reveals a local or general cause of the head noise, correction of the problem may alleviate the tinnitus. In most cases, efforts are directed toward control and management of the sensation of tinnitus.
General Measures:
- Avoid all forms of loud sound. If you must be exposed, use ear protectors such as ear plugs or ear muffs. If you are exposed to certain sounds that increase your head noise, make it a point not to repeat that experience.
- Wherever possible, make every effort to control or minimize stress, as this may reduce tinnitus.
- Make every attempt to obtain adequate rest and avoid overfatigue.
- The use of nerve stimulants is to be avoided. Therefore, excessive amounts of coffee (caffeine) and smoking (nicotine) should be avoided.
- Maintaining a positive attitude is important since tinnitus frequently improves with proper treatment over time and becomes an accepted part of life. The symptom of tinnitus does not lead to permanent hearing loss.
- Tinnitus is usually more marked after one goes to bed and his surroundings become quiet. Any noise in the room, such as a fan or FM radio static, will serve to mask the irritating head noises and make them much less noticeable. Various bedside noise masking devices are available that can be adjusted to various tones and volumes. The natural sounds of surf, rain, or wind may be selected at the desired volume. These devices are available online (soundoasis.com) and at stores. There are also many cell phone apps that are free or for fee that may help. Visit your itunes or play store and search “tinnitus”.
- Certain medications of various types may be used occasionally for temporary relief.
- At times we may recommend that you seek further relief through the guidance of a psychologist who is able to teach coping methods for dealing with the irritating sounds. This approach is oftentimes used in conjunction with other treatment options and together bring the patient relief.
What Treatments Are Available?
Depending on the cause of your tinnitus and other factors, several treatments are available (many by our specially trained Audiologist on staff) to relieve your tinnitus symptoms.
Hearing Aids
When tinnitus is associated with a hearing impairment, even a mild one, the use of a hearing aid in the involved ear is frequently very effective in reducing the awareness of the head noise.
Hearing aids are also popular treatment option for tinnitus even if hearing loss isn’t present. Hearing aids can be equipped with a tinnitus-masking feature to help individuals block out the noise and provide much-needed relief. Also with the advancements in bluetooth technology many hearing aids are able to stream tinnitus relief programs right from the patient’s cell phone directly into the ears. Many of these can be customizeable to the patients needs are are easily worn and used without bringing attention to yourself. These can be used in collaboration of hearing loss treatment as well.
Biofeedback Training
Biofeedback training is effective in reducing the intensity of tinnitus in some patients. Treatment consists of biofeedback exercises, in which the patient learns to relax muscles attached to the head. When a patient is able to accomplish this type of relaxation, tinnitus often subsides. Should you be interested in treatment, your otologist will refer you to a nearby office.
Tinnitus Masking
For individuals who have normal hearing but are severely distracted by their tinnitus, a tinnitus masker may be effective. The tinnitus masker is a small electronic instrument similar to a hearing aid that generates a noise that reduces or eliminates the head noise of the wearer.
The tinnitus masker is based on the principle that most individuals with tinnitus can better tolerate outside noise than they can their inner head noise. An attempt is made to identify the frequency (pitch) of the tinnitus. We then recommend a tinnitus masker that produces a nose matching this frequency as closely as possible. The masker is used on a trial basis so that the individual can determine whether or not it will be effective in masking the head noise.
Tinnitus Retraining Therapy (TRT)
One treatment that incorporates sound therapy is called tinnitus retraining therapy (TRT), also known as habituation therapy. This therapy attempts to retrain your brain into perceiving the tinnitus in a different way. Tinnitus perception is dependent on the difference between ambient (room) noise and the internal sound generated within the head. This is why tinnitus is louder in a quiet room and less noticeable in a noisy room. Tinnitus retraining therapy involves providing sound constantly to the affected individual through the use of “in the ear” devices and bedside noise generating devices. While the sound delivered to the ear is quite soft initially, over time the loudness is slowly increased. This program takes place over several months by retraining the brain to ignore the tinnitus. Most patients will experience either complete relief of the tinnitus or substantial improvement to the point where the tinnitus doesn’t interfere with daily activities or sleep. Information about this program is available at www.tinnitus-pjj.com
Additional Options
1. Neuromonics (www.neuromonics.com) is a modified version of tinnitus retraining therapy and is available through our office. It is an individual customized device using music and broadband noise to obtain tinnitus relief. A patient must have a tinnitus evaluation and then the device is ordered for the patient. The process consists of two phases lasting about six months. The device is used daily for 2-4 hours. For further information speak with one of our doctors.
Conclusion
The auditory (hearing) pathway is one of the most delicate and sensitive mechanisms of the human body. Tinnitus or head noise may result from a variety of disturbances within the ear, its neural pathways and the brain. In order for any treatment of tinnitus or head noise to be successful, it is imperative that the patient have a thorough understanding of this distressing symptom complex. With proper medical care, tinnitus and head noise can be controlled in most patients.