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Tinnitus

Last updated date: 01-Dec-2021

CloudHospital

13 mins read

Tinnitus meaning

Tinnitus

Tinnitus is described as a sound that a person hears that is produced by the body rather than from an external source. Tinnitus is often defined as the presence of high-pitched ringing or buzzing that is generally exclusively audible to the person who is affected.

The majority of tinnitus is subjective, which means that the examiner cannot hear it, and there are no instruments to test or hear it. However, objective tinnitus might occur as a result of an aneurysm and be heard by the examiner.

Tinnitus is one of the most frequent and bothersome otologic diseases, causing a variety of physical and psychological illnesses that impair quality of life.

Tinnitus is also a frequent symptom in children with hearing loss. Tinnitus is a subjective experience that is difficult to scientifically analyze, as it is only measured, quantified, and reported based on patient responses.

Although tinnitus can be caused by a variety of factors, it is most often caused by otologic diseases, with noise-induced hearing loss being the most prevalent cause. Because the different treatment methods to tinnitus have had varied outcomes, it is widely thought that tinnitus has a variety of physiological reasons.

 

Tinnitus causes

There are many causes of tinnitus:

  • Noise trauma is the most prevalent cause of subjective tinnitus. For example, an individual working in a loud sector may experience hearing loss at the 4000 Hz tone. The employee now hears a sound comparable to the 4000 tone.
  • Tinnitus is linked to metabolic disorders such as heart disease, hypertension, and diabetes. Various medications are ototoxic to some people or at high enough dosages. Tinnitus, for example, is caused by high dosages of aspirin, and the problem goes away when the aspirin is discontinued.
  • Tinnitus is caused by ear disorders such as Meniere's disease or lesions affecting the eighth cranial nerve.

20% of people who visit tinnitus clinics have normal hearing. Some people suffer from somatosensory tinnitus. In this case, cervical or TMJD stimulation has engaged the dorsal cochlear nucleus, which transmits impulses to the auditory region. The stimulation that causes whiplash or TMJD has been found to produce structural alterations in the dorsal cochlear nucleus.


Trigger factors

Tinnitus can be triggered by small transient changes in the outer hair cells (OHCs) following noise exposure by raising the gain of the central auditory system. Tinnitus is a threshold phenomenon in which any single trigger factor, such as chronic progressive hearing loss, is insufficient to elicit its emergence-two or more trigger factors (i.e., psychosocial stress, noise exposure, and somatic factors) can act synergistically to produce symptomatic tinnitus. Approximately 75% of new cases are caused by emotional stress rather than by precipitants affecting cochlear lesions.

 

Epidemiology

Tinnitus affects almost everyone at some point in their lives. According to the American Tinnitus Association, ten million individuals suffer with tinnitus. It is also widespread in less-developed countries.

Tinnitus is common among military personnel as a result of loud explosions and shooting. It is also found in movie and stage workers who prepare explosives and shooting sequences. Tinnitus affects musicians who are exposed to loud noises, such as drummers and those who perform in front of loudspeakers.

Tinnitus may occur in children, although it is often undiagnosed since they do not identify the problem. The typical narrative involves a worker who was subjected to extremely loud manufacturing noise, forcing workers to yell in order to be heard. Many employees experience high-tone hearing loss, but only a tiny number additionally experience tinnitus.

Tinnitus can be accompanied with hyperacusis. Certain everyday sounds, such as shutting doors, moving chairs, and books falling, are so loud and powerful in these circumstances that they are highly uncomfortable, if not painful.

 

Pathophysiology

Tinnitus is not an illness in and of itself, but rather a symptom of a number of underlying conditions. Noise-induced hearing loss, presbycusis, otosclerosis, otitis, impacted cerumen, abrupt deafness, Meniere's illness, and other causes of hearing loss are all otologic.

Head injury, whiplash, multiple sclerosis, vestibular schwannoma (also known as an acoustic neuroma), and other cerebellopontine-angle tumors are all neurological causes. Infectious causes of hearing loss include otitis media and Lyme disease sequelae, meningitis, syphilis, and other infectious or inflammatory diseases.

Some oral medicines, such as salicylates, nonsteroidal anti-inflammatory drugs, aminoglycoside antibiotics, loop diuretics, and chemotherapeutic treatments, can cause tinnitus (e.g., platins and vincristine).

When faced with a danger or threat, humans often respond with the classic fight or flight response. This is why the beginning of tinnitus may be so upsetting. This response is not always triggered by a broken finger, but it is triggered by tinnitus. Cognitive therapy is used to prevent the undesired reaction.

Tinnitus, on the other hand, is not caused by stress. The etiology of tinnitus is unknown since humans cannot objectively measure it. Tinnitus can be caused by lesions that impose pressure on the eighth cranial nerve. Tinnitus is caused by an increase in fluid pressure in the inner ear. Hearing loss, vertigo, tinnitus, and a sensation of pressure in the ear are all symptoms of elevated inner ear pressure.

Tinnitus affects various regions of the brain, including the cognitive, emotional, and auditory areas, according to MRI. Sound enters the brain through the amygdala region first. As a result, understanding that tinnitus is not dangerous is therapeutic.

Many current antineoplastic medications, including bleomycin, cis-platinum, methotrexate, and bumetanide, are ototoxic. These can result in irreversible hearing loss and tinnitus.

  • Ethacrynic acid, acetazolamide, are diuretics listed as ototoxic
  • Tinnitus is caused by taking too much aspirin. This is, thankfully, reversible. Other NSAID medicines have been linked to tinnitus.

Because of the relatively high prevalence of tinnitus in the community, care must be taken while evaluating tinnitus from a new medication. Tinnitus may be reported in the placebo group in a double-blind research. When anti-neoplastic medicines are taken, hearing tests are performed on a frequent basis to monitor for the development of hearing loss or tinnitus so that the treatment can be stopped if possible.

 

Signs and symptoms 

Tinnitus sound

Tinnitus sound

Tinnitus symptoms include ringing, buzzing, roaring, hissing, or whistling in the ears. The noise might be either intermittent or constant. Most of the time, only the individual suffering with tinnitus is able to hear it.

The ear and nerve system should be the focus of a physical evaluation. Examine the ear canal for discharge, foreign bodies, and cerumen. Infection and tumors should be looked for on the tympanic membrane.

Tinnitus sufferers may hear anything from a faint background noise to a noise that is discernible over loud external sounds. Tinnitus is classified into two types: objective and subjective.

Tinnitus that is audible to another person as a sound emanating from the ear canal is defined as objective tinnitus, whereas subjective tinnitus is audible only to the patient and is usually considered to be devoid of an acoustic etiology and associated movements in the cochlear partition or cochlear fluids. Many doctors use the term tinnitus to refer to subjective tinnitus and somatosound to refer to objective tinnitus.

Most tinnitus noises have been reported as being similar to cicadas, crickets, breezes, falling tap water, grinding steel, escaping steam, fluorescent lights, running motors, and so on. These kinds of perception are thought to be the outcome of aberrant neural activity at a subcortical level of the auditory system. 

Tinnitus has a pattern that is connected to the library of patterns recorded in auditory memory and is also associated with emotional states via the limbic system. Tinnitus symptoms are typically unrelated to the kind or severity of any accompanying hearing impairment, thus the latter has limited diagnostic relevance.

The majority of tinnitus sufferers associate their tinnitus with a pitch greater than 3 kHz. The roaring tinnitus that characterizes Meniere's illness corresponds to a low-frequency tone that typically ranges from 125 to 250 Hz. Tinnitus in the advanced "burned-out" stage of Meniere's illness, on the other hand, is frequently higher in pitch and tonal quality.

Most patients with tinnitus with hearing loss indicate that the frequency of the tinnitus coincides with the severity and frequency characteristics of their hearing loss, and that the strength of the tinnitus at that frequency is generally less than 10 dB over the patient's hearing threshold.

Some individuals with central auditory processing problems who have difficulty comprehending speech in noise report hearing tinnitus while having normal pure-tone audiometric thresholds.

Less common types of tinnitus, such as those involving well-known musical tunes or voices without understandable speech, are found in older people with hearing loss and are thought to represent a central type of tinnitus involving reverberatory activity within neural loops at a high level of processing in the auditory cortex.

Somatic tinnitus is a kind of subjective tinnitus in which the frequency or severity is changed by movements of the body, such as clenching the jaw, moving the gaze, or applying pressure to the head and neck. Tinnitus is reported to be louder upon awakening, implying the involvement of somatic processes such as bruxism.

Tinnitus disappears during sleep but reappears within a few hours, suggesting that psychosomatic variables, such as neck muscular contractions in an upright position or jaw clenching, have etiological roles.

 

Associated symptoms

Concentration issues, sleeplessness, and reduced speech discrimination are the most prevalent related symptoms or subjective discomforts. Tinnitus irritation is unrelated to acoustic features, however it is connected to psychological symptoms.

The distinction between just hearing tinnitus and becoming disturbed or upset by it is solely determined by the activation of the limbic and autonomic nerve systems. The majority of patients with substantial tinnitus have trouble falling asleep owing to the accompanying anxiety, which also makes it difficult to return to sleep during periods of waking during the night.

 

The auditory system constantly monitors the sound environment, therefore there is significant neuronal activity in the auditory pathways during sleep. Noise exposure, being in a quiet area, emotional stress, sleep deprivation, and physical weariness are all common harmful behaviors and/or circumstances.

Patients with Meniere's illness have higher annoyance, sadness, and sleep disturbance, and their tinnitus is louder than those with tinnitus from other causes. Furthermore, good vertigo management in individuals with Meniere's illness might lead to their focusing more on their tinnitus and being more disturbed by it.

 

Diagnosis 

  • X-rays and MRIs are rarely used to diagnose tinnitus unless there is a significant change in hearing and balance in the ears.
  • An audiogram is a hearing test that measures hearing levels in order to diagnose hearing loss. The patient is asked to identify which of the tones corresponds to their tinnitus. The audiologist introduces the sound in terms of loudness, and the patient judges how loud their tinnitus is. An air-bone test compares hearing through the bone of the ear to hearing via earphones. If the patient hears better after the bone test, this indicates a curable disease termed otosclerosis.
  • Patients suffering from otosclerosis, in which the stapes fails to move properly, can have surgery to repair the otosclerosis and restore air conduction. Tinnitus is alleviated in some people. Tinnitus persists or worsens in others.
  • The audiologist determines how long masking tone relieves tinnitus. The longer tinnitus is suppressed, the better the prognosis.

 

Tinnitus treatments

Tinnitus treatments

Tinnitus treatments can be divided into two categories:

  1. Those aimed at directly reducing the intensity of tinnitus and
  2. Those aimed at relieving the annoyance associated with tinnitus. 

Pharmacotherapy and electrical suppression are examples of the former, whereas pharmacotherapy, cognitive and behavioral therapy, sound treatment, habituation therapy, massage and stretching, and hearing aids are examples of the latter.

The American Academy of Otolaryngology has issued clinical practice guidelines for tinnitus. These include:

  • Stress Reduction: This involves the use of biofeedback, monitored breathing, and other techniques. Although stress is not a cause of tinnitus, like with any illness, stress and worry can exacerbate it.
  • Cognitive Therapy: The more the patient's understanding of what tinnitus is and is not, the less negative the effect. Tinnitus symptoms are decreased if the patient completely comprehends - realizes that tinnitus is akin to itching.
  • Masking: When the body hears the same sound from the mobile phone or sound device, the symptoms subside. Masking comes in a variety of types. These masking noises, in essence, divert attention away from the internal tinnitus sound and replace it with calming tones.
  • Sleep improvement: Tinnitus can interfere with regular sleep, thus therapy should focus on improving sleep hygiene.

Official recommendations emphasize that no medicine can cure tinnitus. However, numerous combinations of magnesium, alpha-lipoic acid, N-acetyl cysteine, and other compounds have been tried for noise protection. When they are helpful, it is difficult to distinguish between the placebo effect and the influence of having a program in which the patient feels in control, bringing the brain into the healing process.

Deep brain stimulation has recently been shown to provide positive outcomes. This, in principle, changes undesirable brain pathways.

The most important aspect of care is that tinnitus patients should never be advised to live with it. The emphasis should be on stress reduction, with a regimen to follow. Tinnitus Retraining Treatment and Neuronomics are two typical programs used in therapy by people who have been trained in their usage.

Tinnitus Retraining involves the patient adapting to hearing the tinnitus; Neuronomics involves the patient learning to ignore the tinnitus.

When tinnitus is accompanied with hearing loss, a hearing aid is usually beneficial. Some assistive devices provide soothing or masking noises. Success is a moving target.

Medication such as alprazolam might alleviate symptoms, however it can also have negative side effects such as habituation. Patients who do not respond to routine treatment may benefit from antidepressants.

 

Cognitive and behavioral therapy

Cognitive therapy is based on how one thinks about tinnitus and how to prevent negative thoughts, whereas behavioral therapy employs the systematic desensitization technique used to treat many phobias. Cognitive therapy teaches people how to live with tinnitus by replacing negative thinking with more optimistic thinking. Counseling and cognitive restructuring are both components of cognitive therapy. Counseling should contain the following:

  1. Informing patients that it is unlikely that their annoyance with tinnitus will improve dramatically,
  2. Informing patients about the usefulness of tinnitus self-help groups 
  3. Assisting patients in minimizing time spent on activities and/or situations that increase tinnitus severity and maximizing time spent on activities and/or conditions that decrease tinnitus intensity, and
  4. Highlighting the importance of avoiding noise exposure since noise-induced hearing loss and tinnitus are linked.

 

Cognitive restructuring entails altering tinnitus-related thinking. Patients are urged in this setting to embrace the concept that tinnitus does not deserve all of the attention it receives. Positive imagery, attention management, and relaxation training are key components of behavioral therapy. Positive imagery entails focusing thoughts on something pleasurable, thereby diverting attention away from tinnitus. 

When tinnitus becomes irritating, attention must be diverted away from it. This procedure may begin by juxtaposing two images and then providing two auditory stimuli (e.g., a fan noise and conversational voice) originating from an adjacent room.

Following that, an image and the tinnitus are coupled, followed by a thought and the tinnitus. Relaxation training employs a guided procedure to teach individuals how to utilize progressive muscle relaxation, which includes tensing and relaxing the arms, face, neck, shoulders, belly, legs, and feet.

 

Sound therapy

Sound therapy reduces the intensity of tinnitus-related neuronal activity within the auditory system by using sounds present in natural settings, such as those linked with streams, rain, waterfalls, and wind. To that purpose, the auditory system's background neuronal activity is enhanced by exposing the patient to a low-level, continuous, neutral sound that is nonintrusive, not unpleasant, and simple to ignore.

Such a sound should not be significant, pleasant, or stimulating in such a manner that it draws attention away from watching television, listening to the radio, or listening to music. Neutral sounds should be steady and not overpowering; hence, wave sounds are not advised. Some patients are easily distracted by the sounds of bird cries, crickets, or thunderstorms, so use caution while using these noises.

 

Differential Diagnosis

  • Cytomegalovirus
  • Hypercholesterolemia
  • Lyme disease
  • Measles
  • Meningitis
  • Neoplasm
  • Neurosyphilis
  • Rubella
  • Sickle cell anaemia
  • Small vessel disease
  • Stroke
  • Tumour

 

Conclusion 

Tinnitus is frequently a symptom of another illness process. Recent studies have used cutting-edge imaging and measuring technologies to investigate tinnitus-related activity in the ear, auditory nerve, and auditory pathways of the brain. The complexities of the neural system alterations involved with tinnitus may explain why this illness has proven so resistant to therapy.

Tinnitus is diagnosed and managed by an interprofessional team that includes a primary care physician, nurse practitioner, ENT surgeon, audiologist, and an internist. Tinnitus should be treated according to the American Academy of Otolaryngology's recommendations. At the same time, the patient should be informed on the benefits of good sleep hygiene.

There is currently no medicine that can treat tinnitus. Several supplements have been studied, but their effectiveness is still debatable. Deep brain stimulation has been advocated in the last decade, but the therapy is not only intrusive and pricey, but it also has the potential to create consequences that are worse than the tinnitus.

Patients should be urged to reduce their stress levels, and some may benefit from a hearing device that can conceal other sounds. Tricyclic antidepressants are sometimes utilized, however they have a lot of side effects that aren't always well tolerated. Overall, tinnitus sufferers have a low quality of life.

Regardless of the management strategy used for a specific patient, counseling is an important element of treatment. Most patients' conditions improve over time with an informative explanation of tinnitus and comfort.

Cognitive and behavioral therapy, supplemented by pharmaceutical intervention, may be the most promising treatment regimen for people with chronic tinnitus. Most essential, a good doctor-patient connection is the foundation of successful management and high levels of patient satisfaction.

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