Tinnitus: Care and management strategies

Ten million Americans are bothered by severe tinnitus and visit health professionals, seeking relief. Two million are significantly debilitated and need care now. You can help.

We live in a noisy world, and it isn't going to get quieter any time soon. Both prolonged and impulse exposure to noise — whether part of civilian work, military duty, recreation, or entertainment — carry a significant risk of tinnitus, abnormal sound sensitivity (hyperacusis), and hearing loss. Tinnitus — the perception of sound in the absence of an external acoustic stimulus — is often the most annoying symptom. The sound is frequently described as a ring, buzz, cricket hiss, hum, roar, or pulse.

How does tinnitus present?

Transient spontaneous tinnitus, or tinnitus flare, is a ringing tone that may come on suddenly in one ear, with or without ear fullness or dullness of hearing. The flare lasts about 20 seconds. Patients should be reassured that a pathologic process is unlikely.

Subjective tinnitus can be heard only by the patient and is most commonly associated with hearing loss and outer hair-cell cochlear dysfunction. Other causes include structural lesions, head and neck injury, vascular loop syndromes causing “typewriter tinnitus” or other paroxysmal spells of tinnitus, pseudotumor cerebri, vertebrobasilar dolichoectasia, arteriovenous malformations, and temporal-lobe epilepsy.

Objective tinnitus can be heard by the doctor with a stethoscope and may result from carotid stenosis, glomus jugulare tumor of the middle ear, palatal myoclonus, stapedial muscle spasm, and other causes, necessitating an otoneurologic or neuro-otologic referral.

Tinnitus can also occur with Meniere's disease and migraine attack. Migraine variants are typically not accompanied by headache. Duration of complicated migraine symptoms can range from seconds to days. The conditions can occur simultaneously and mimic each other, so diagnostic evaluation must be done carefully.

What causes variations in tinnitus?

Tinnitus may be the first sign of permanent and irreversible microscopic injury to the outer and inner hair cells of the cochlea. The symptom may fluctuate or even cycle in intensity and timbre unpredictabiy. Exacerbating factors include stress, noise, fatigue, lack of sleep, migraine, hearing fluctuations, tobacco, caffeine, salt, head injury, muscle tension in the jaw and neck, bruxism, dental problems, sinus disease, wax impaction, and certain medications. Increases in tinnitus have been noted on awakening from a short nap.

Extended exposure to loud music or other noise via earphones, headphones, loudspeakers, music venues, arena rock shows, racetracks, discos, raves, motorbikes, etc., can cause both subtle ear damage that accumulates over time and significant permanent injury as a result of a single exposure. Young members of rock bands who rehearse in small garages or basements and perform loudly in small clubs should visit an audiologist for a baseline hearing test and be fitted with custom-made musician's earplugs for high-fidelity ear protection.

The adverse effects of noise exposure are cumulative. Temporary hearing problems (dullness of the highs, or “treble fatigue,” after noise exposure) are warning signs of hair-cell damage that is in the process of being repaired. It is impossible to predict just how many hair cells will survive the insult. Hearing loss may be subtle, or hearing may even be grossly normal in the early stages of injury. Otoacoustic emissions can help further quantify outer hair-cell function and may be the only test that shows an abnormality in the early stages of tinnitus.

Carbon monoxide, and possibly benzene, from cigarettes also has deleterious effects on outer hair-cell structure and function. The combined toxic effects of carbon monoxide and noise are not to be underestimated. Prolonged exposure is more dangerous than intermittent exposure, but both can potentially cause harm.

Can patients take preventive measures?

Patients can help themselves by limiting excessive noise exposure, using hearing protection, and ending tobacco use. Minimizing the consumption of caffeine (vasoconstrictor) and salt (retains water in the cochlea) is recommended only if those substances tend to exacerbate ear fullness or tinnitus. Combining alcohol, caffeine, tobacco, or illegal drugs with noise is hazardous to hearing health and can potentially facilitate premature hair-cell degeneration.

When listening to music players, earbuds that block out background sounds achieve better signal-to-noise ratio and help users avoid the temptation to turn the music up for enhanced clarity. Despite this, prolonged use of earbuds can lead to ear fatigue and tinnitus. Car stereos can quickly reach dangerous sound-pressure levels within a small enclosed space. Ear protection is crucial anytime one enters a very noisy environment, e.g., dance clubs, rock concerts, bars with live amplified music, etc.

Ears can toughen up when exposed to noise — but only to a point. Thresholds for damage differ. Parents should strongly encourage their children to take breaks from loud noise, and adults should exercise common sense and restraint when subjecting aging and fragile ears to occupational and recreational noise.

Can drugs cause tinnitus?

Aspirin as well as other salicylate analgesics, nonsteroidal anti-inflammatory drugs, loop diuretics (furosemide), aminoglycoside antibiotics, quinine, risedronate (Actonel), and chemotherapeutic agents like cisplatin can cause tinnitus. The Physicians' Desk Reference lists more than 500 medications with tinnitus as a side effect, but that association does not necessarily indicate a direct cause-and-effect relationship.

What studies and tests can be helpful?

Tests that can help quantify certain parameters include audiometric evaluation; loudness discomfort levels to assess for abnormal sound sensitivity (hyperacusis); tinnitus pitch, volume, and minimum masking levels; otoacoustic emissions; carotid Dopplers; MRI; and magnetic resonance angiography. Occasionally, a lumbar puncture is necessary when pulsatile tinnitus is encountered in the setting of a normal MRI with or without visual-field abnormalities. Neurology referral is recommended at this point.

Which tests can potentially exacerbate tinnitus?

Patients with hyperacusis can be particularly sensitive to audiologic and radiologic test sounds. Ear fullness and tinnitus exacerbation can follow acoustic reflex tests, auditory brain stem responses, vestibular evoked myogenic potentials, and MRI scans. Caution should be used when running certain loud tests. Audiologists may have to turn down the volume significantly prior to testing the patient. Radiology techs should routinely supply earplugs and earmuffs to the patient (and the spouse if in the scanning suite). If patients report sensitivity to sound, tests should be stopped at once to avoid discomfort and prolonged exacerbation of symptoms. Usually, symptoms return to a baseline level within 1-21 days after being exacerbated by test noise. Sometimes, dramatically low levels of sound sensitivity can be detected in patients — suggesting erroneously that their sensitivity is psychosomatic — when, in fact, it is physiologic due to compensatory changes in central auditory gain.

Do hearing aids reduce tinnitus?

Hearing aids are the first line of defense against tinnitus even if the patient denies any hearing difficulty. With hearing aids, the brain does not have to work as hard to hear, so internal noise diminishes as the “volume knob” in the brain stem is turned down (reduction in central auditory gain). Second, the hearing aid allows more background sound from the environment to reach the brain, thus reducing the relative volume of the tinnitus percept.

When are prescription medications indicated?

In my clinical experience, immediate- and extended-release benzodiazepines reduce tinnitus loudness and distress during the early stage of treatment. As habituation therapy progresses, patients can taper the medicine without experiencing a rebound. Others take the medicine as needed for tinnitus spikes or exacerbations related to stress, noise, or unknown factors. The extended-release form can help patients overcome uncomfortable withdrawal. Some patients tolerate benzodiazepines chronically without any adverse effects on memory. Short-acting hypnotics can serve as effective sleep aids, but customized sound therapy facilitates sleep without need for medication and is the preferred strategy.

Most often, counseling and sound therapy are sufficient to reduce anxiety and depression scores by more than 50% within two weeks to six months. I do not routinely use medications for disturbances of mood and sleep secondary to tinnitus. Habituation-based therapies are well-accepted by patients because they avoid the complications and side effects of prescription medication.

Nevertheless, some patients present with severe levels of anxiety, panic, depression, obsessive-compulsive tendencies, phobias, and other complex disorders of mood, personality, and sleep that either predate the onset of tinnitus or develop de novo from the tinnitus. In those instances, both conditions should be managed carefully in a multidisciplinary fashion. The compassionate primary-care physician can help tremendously by acting as the initial pillar of positive counseling, direction, and hope.

What is sound therapy?

Sound therapy is the frequent use of a wide-spectrum or true broadband sound (20-20,000 Hz soothing signal) played via earphones, sound pillows, speakers, or wearable sound generators — with or without music. Appropriate sound therapy has the potential to interfere with tinnitus and weaken its emotional associations. The alarming tinnitus is paired with the relaxing sound therapy, which eventually helps the brain declassify the tinnitus down to a benign, neutral status. Masking (tinnitus suppression) or partial masking of tinnitus is often possible. Use of broadband sound within a therapeutic range allows the brain to continue to hear the original but weakened timbre of the tinnitus, thus promoting habituation.

What advice will aid patients in distress?

Primary-care physicians have the potential to significantly alleviate patients' distress with a few minutes of artful, positive counseling on the neurophysiologic model of tinnitus by Jastreboff (www.tinn.com, (www.tinnitus.org, www.tinnitus-pjj.com) and a recommendation for sound therapy. A directory of tinnitus treatment devices is available from Tinnitus Today, an informative quarterly publication of the American Tinnitus Association (ATA) (www.ata.org, phone: 800.634.8978). Provided the patient is not severely or profoundly hearing-impaired, ask whether the tinnitus is completely masked when he is in the shower. If so, then portable sound therapy can make a tremendous difference by reducing relative tinnitus loudness and facilitating habituation of reaction and perception.

The following steps can offer immediate relief while more specialized care is being arranged: (1) Orchestrate a thorough workup of the hearing and balance system, (2) explain how the brain can be retrained to interpret a new sound as neutral, and (3) recommend modern sound therapy, with or without music, on disc or wearable device.

Be sure patients understand that ongoing research worldwide is drawing us closer to a cure and that there are presently several ways to obtain relief. Even if you ultimately refer the patient, initial brief, positive counseling can work miracles.

Can supplements help?

Important supplements for good ear health include antioxidants (l-glutathione, N-l-acetylcysteine, acetyl-l-carnitine, d-methionine, and several others), magnesium, and zinc. Studies have shown certain antioxidants to be otoprotective to inner hair cells and to prevent outer hair-cell death after noise or cisplatin exposure. The first 10 days following noise injury are crucial for hearing health, and it is during this window of opportunity that rescue antioxidants in combination with steroids, vasodilators, and other novel neuroprotective medications (such as N-methyl-d-aspartate glutamate antagonists and calcium channel blockers) could theoretically preserve hearing by limiting damage and preventing cellular apoptosis and necrosis. The finest pharmaceutical-grade antioxidants of which I am aware are the patented formulas of neuro-otologist Michael D. Seidman, MD (www.bodylanguagevitamin.com) and microbiologist/immunologist Myron W. Wentz, PhD (www.usana.com).

Can tinnitus be reduced or eliminated surgically? Tinnitus resulting from otosclerosis, wax impaction, vascular loop syndrome, otitis media, carotid artery stenosis, vascular malformations, some tumors, and hydrocephalus (pseudotumor cerebri) may be effectively treated with surgery. Cochlear implants may eliminate tinnitus in up to one third of patients. Unfortunately, there is no effective surgery yet for the most common type of tinnitus, i.e., that which is secondary to mild to severe sensorineural hearing loss.

Where can physicians obtain more specific education and training on the management of tinnitus?

Customized tinnitus care is typically provided by a hearing and tinnitus specialist within the fields of audiology, otolaryngology, neurology, and psychology. Lists of tinnitus treatment clinics as well as conferences and training courses are available at: www.neuromonics.com, www.tinnitus-pjj.com, www.ata.org, www.generalhearing.com (also see “Helpful Web sites,”, and “Tinnitus conferences and training courses,” below). The nonprofit ATA is committed to a cure and has been funding tinnitus research for 30 years. Donations to the ATA are used to fund research and provide assistance for those in need. This summer, the Information Television Network and PBS will launch a yearlong special entitled Tinnitus: Healthy Body/Healthy Mind Series.

Dr. Robb is a hearing, balance, and tinnitus specialist dedicated to patient care, student teaching, and clinical research. He completed a Fife fellowship in oto-neurology/medical neuro-otology at the Barrow Neurological Institute in Phoenix and is currently in solo private practice at the Robb Oto-Neurology Clinic, also in Phoenix. Further information and a more extensive bibliography are available at Dr. Robb's Web site (www.robbmd.com).

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