Tinnitus is the complaint of noises in the ears in the absence of a sound stimulus. Most patients will report this as ringing, buzzing, crackling or hissing. It is not a disease but a symptom. Most people experience transient tinnitus at some time, particularly after exposure to loud noise. The exact cause is unknown but it is thought to be due to inappropriate activity in the hair cells of the cochlea. There are multiple possible causes but most cases are idiopathic . It is especially com- mon in diseases such as presbycusis which affect hair cell function. It can be a very unwelcome feature of advancing age. Most tinnitus patients notice that the noises are worse in quiet surroundings. Tinnitus is aggravated by fatigue, anxiety and depression.
Local and general causes of tinnitus
Local causes
Tinnitus may be a symptom of any abnormal condition of the ear and may be associated with any form of deafness.
• Presbycusis – often causes tinnitus.
• Menière’s disease – tinnitus is usually worse with the acute attacks.
• Noise-induced deafness – tinnitus may be worse immediately after exposure to noise.
• Aneurysm, vascular malformation and some vascular intracranial tumours, e.g. glomus jugulare tumour can cause ‘pulsatile’ tinnitus, which may even be heard by an examiner. Listen to the side of the head with a stethoscope.
General causes
Tinnitus is often a feature of general ill-health as in:
• fever;
• cardiovascular disease – hypertension, atheroma, cardiac failure;
• blood disease – anaemia, raised viscosity;
• neurological disease – multiple sclerosis, neuropathy;
• drug treatment – aspirin, quinine, ototoxic drugs;
• alcohol abuse.
Management:-
Management focuses on excluding treatable causes and helping patients cope. Tinnitus due to chronic degeneration, such as presbycusis, ototoxicity or noise-induced deafness, is usually permanent. With time, the tinnitus will obtrude less as the patient adjusts to it and avoids circumstances that aggravate it. It very rarely goes away completely.Take the patient’s fears and complaints seriously. Take a thorough history and examine the patient properly. Many patients fear that tinnitus indicates serious disease of the ear or a brain tumour. Always test the hearing. If you find an abnormality of the ear such as impacted wax or otitis media, treatment will often cure the tinnitus.
Patients with depression are particularly susceptible to the effects of tinnitus. Severe tinnitus may precipitate depression and patients may need expert help.Drug treatment, such as sedatives and antidepressants, may help the patient but will not eliminate tinnitus. Anticonvulsant drugs and vasodilators may be of benefit but their effectiveness cannot be predicted.
If the patient with tinnitus is also deaf, a hearing aid is very helpful not only to rehabilitate the hearing loss but in ‘masking’ the tinnitus.‘Tinnitus maskers’ or ‘white noise generators’ will also make tinnitus less obtrusive. A typical device looks like a post-aural or ‘behind the ear’ hearing aid and its output characteristics can be adjusted to obtain the most effective frequency and intensity.If the patient is kept awake by tinnitus, a radio with a time switch may help. Many patients use a ‘pillow masker’ obtainable in most electrical stores, which emits a constant low intensity sound that helps patients to focus on a sound other than the tinnitus that is often easier to tolerate.
Many patients use relaxation techniques, acupuncture and herbal remedies. Patients will often read of new ‘cures’ for tinnitus in the popular press.Sadly these will almost always prove useless and cause more distress and disappointment when it transpires they don’t work.Patients who are very distressed may find counselling by a skilled hearing therapist helpful.It is helpful for patients to understand that this is an extremely common problem and the British Tinnitus Association website (www.tinnitus.org.uk) can be a useful resource.
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