Tinnitus treatment Dublin – Tinnitus is defined as perception of auditory sensation in the absence of any external stimulation. The auditory sensation could be ringing or other head noises that are not produced by an external source. Tinnitus can occur in one or both ears, range from very low to very high pitch, and may be continuous or intermittent. Its perceived volume varies and can range from subtle to shattering. Continuous tinnitus can be annoying and distracting, and in severe cases it can cause psychological distress and interfere with normal life. Most people would experience tinnitus or sounds in the ears at some time or another. The incidence of Tinnitus in the general adult population has been estimated from 4% to as high as 32% (Jastreboff, 1994; Tyler, Aran, & Dauman, 1992; Stouffer & Tyler, 1990). This disorder is not uncommon in the pediatric population, however children generally do not complain instinctively of having tinnitus.

There are few various ways Tinnitus has been classified. One classification system classified as vibratory and non-vibratory types, while another group classified as subjective and objective types of Tinnitus.

It is the most common types which mean the only person can hear the sound but cannot be heard by others. The most common causes for subjective tinnitus are otologic disorders or some conditions that causes hearing loss. The exact mechanism for this tinnitus is still not clearly understood however many possible causes have been proposed.

It is uncommon and means that the sound in the ear can be heard by others. The possible causes for resulting objective tinnitus are blood flowing through jugular vein (Vernon, 1998)or middle ear muscle spasm (Schleuning, 1998).

Tinnitus is a symptom of underlying condition and not a disease. It can arise in the outer ear, the middle ear, the inner ear or any abnormality in the auditory cortex.

• Otologic
  • Conductive hearing loss
    • Ear wax, middle ear effusion, superior canal dehiscence
  • Sensorineural hearing loss
    • Presbycusis (age-related hearing loss), Meniere’s disease, loud noise, acoustic neuroma, ototoxic medications
• Neurologic
  • Multiple sclerosis, head injury

• Metabolic
  • Thyroid disorder, hyperlipidemia, vitamin B12 deficiency

• Psychogenic
  • Depression, anxiety

• Vascular
  • Vascular tumour
  • Arteriovenous malformation

• Neurologic
  • Idiopathic stapedial muscle spasm, patulous Eustachian tube

Since there are many factors that can cause tinnitus, it is then difficult to pinpoint pathophysiology behind tinnitus. There has been various possible mechanism explained which causes tinnitus. Some of them are discussed here.

A normal cochlea emits sound all the time but it’s not been heard because outside noise masks them. If one goes into a sound proof room where normal external noise is diminished then these emitted sounds from ear can be heard.

One of the possible mechanisms is loud noise damage inner ear hair cells causes different neurons to get activated which activate auditory cortex and give perception of sound.

A full medical and audiological assessment should be done in order to provide best management of tinnitus. Since tinnitus is a symptom so any medical disease should be ruled out. Medical examination should be carried out with special attention given to identify factors associated with tinnitus such as disease involving auditory system, noise exposure, drug intake, mental or emotional stress, allergies, blood pressure etc.

Audiological evaluation is very important to be completed on a patient with tinnitus and should be carried out by a qualified audiologist/audiological scientist. Since tinnitus can be associated with number of conditions that may occur at any level of the auditory system, the audiological evaluation can demonstrate information regarding cause and options for treatment. It should begin by taking thorough case history which would include onset, duration, laterality, severity, pattern, associated symptoms etc. Audiological assessment includes basic audiometric testing, speech audiometry, tympanogram, acoustic reflexes and decays, oto-acoustic emissions (OAEs), auditory brainstem response (ABR). Each of these tests can possibly help Audiologist identify nature and cause of tinnitus and may indicate site of lesion. For example, the audiogram will help in determining degree and type of hearing loss, the tympanogram will determine middle ear status and the oto-acoustic emissions will assess cochlear function. The acoustic stapedial reflexes and reflex decay and ABR will distinguish between cochlear and retro-cochlear auditory dysfunction. Some patients with tinnitus will have dyssynchronous all or part of ABR waveform (Shulman, 1997).

There are other audiological measurements for tinnitus which gives an information about its pitch, loudness etc. and they also provide some information if tinnitus can be masked by an external noise. These measurements are pitch matching, loudness matching, minimal masking level and residual inhibition. Pitch matching is measuring the frequency of the tinnitus with a variety of stimuli, loudness matching is measuring the loudness of tinnitus, minimal masking level is threshold to mask the tinnitus and residual inhibition is presenting masking stimuli at the pitch and intensity of the tinnitus in order to relieve tinnitus.

There are various different treatment options available for tinnitus with varying degrees of statistical reliability and satisfaction. The most effective way to treat tinnitus is to eliminate the underlying cause. If the tinnitus is symptom of a treatable medical condition, then treating the condition will eliminate tinnitus. However unfortunately, in many case the cause of tinnitus can not be identified and hence it becomes difficult to treat medically or surgically. These cases can then be pursued by an audiologist for treatment of tinnitus through different therapeutic techniques. Generally audiologist decides on his or her treatment preferences.

The electrode array inserted into the cochlea sends an electrical signal to the auditory cortex and it is theorised that these frequency signal of the electrical stimulation mask the tinnitus. The masking effect of tinnitus may last even in the absence of stimulation. There are studies which show that half of tinnitus sufferer relieved from tinnitus after the cochlear implant. However these implants are advised only to certain group of patients as electrode implantation destroys whatever healthy hair cells were left inside cochlea.

There are some other forms of electrical stimulation to the ear as well however I have not come across any study which shows extraordinary improvement from tinnitus.

There are various drugs or medications used to relieve tinnitus, but there is none that has been designed specifically to treat tinnitus. The drugs that have been studied to relieve tinnitus are antidepressants, anti-anxiety drugs, anticonvulsants etc. However the studies show that the drug therapy reduces associated symptom of tinnitus such as, annoyance, frustration and depression rather than tinnitus itself.

Tinnitus is greatly correlated with stress and depression. It has been reported that the tinnitus is worse in patients who experience great amount of stress and depression. If the stress and depression can be minimised then tinnitus can be relieved. Biofeedback is a relaxation technique that is designed to teach patient to control certain autonomic body functions, such as pulse, muscle tension, and skin temperature. The goal of this technique is to help patient control his/her stress level by changing the body’s reaction to it and ultimately, the tinnitus.

Each patient reacts differently to their tinnitus. It’s often seen that the patient with severe tinnitus describes as having additional emotional problem such as depression or anxiety. Cognitive therapy is a psychotherapeutic approach that aims to treat emotional reaction to tinnitus by changing patients thought process. By managing patient’s emotional reaction to the tinnitus, they are helped to learn coping strategies that often help patient to deal with his/her tinnitus. The aim of cognitive therapy is not to treat tinnitus but to help patient cope better with tinnitus.

Some tinnitus patients with hearing aid experience reduction in their tinnitus. The exact reason for this is not known and there are many variables that determine success.  One possibility may be is that amplified environmental sound mask tinnitus. Another possibility is that the hearing aid makes communication easier, thus reduces stress which in result may ease tinnitus.

Sound therapy includes wearing hearing aid like devices and also non-wearable devices like table top sound machines. These electronic devices produce an external sound which is designed to override patient’s tinnitus.

TRT is designed based on neurophysiological model of tinnitus. It uses combination of directive counseling and sound therapy in strict framework.

In summary, there are various different treatment options are available for tinnitus. However it is important to note that these options do not work for everyone neither does work at same degree for each individual patient. This is the reason it becomes highly important to discuss individual tinnitus situation with a qualified health professional.

• Avoid or limit exposure to loud noise such as music, gun shot, industrial machineries, power tool etc.
• Wear ear plugs or ear muffs if you can not avoid or limit noise exposure. For musicians and DJs, special ear plugs play an important role in preventing tinnitus.
• Keep the volume of personal stereo headphone not too high. If other can hear your music clearly or you can’t hear other sound that means the volume of your personal stereo headphone is too high.
• Check medication for potential ototoxicity. If ototoxic medications are must to administer then close monitor by the physician is important.
• Some studies suggest that cut back on alcohol, smoking and beverages containing caffeine may help in preventing tinnitus.
• Exercise regularly as it improves blood flow which may help in preventing tinnitus.
• Maintain a healthy weight as occurrence of tinnitus is higher in obese adults.
• Get your blood pressure checked. If abnormal then seek medical attention to control it.
• Control intake of salt as it impairs blood circulation.
• Get adequate rest and avoid fatigue.