Tinnitus or “head noise” is common. It may be intermittent or constant, mild or severe, or vary from a low roar to a high-pitched type of sound. It may be subjective (audible only to the patient) or objective (audible

Introduction

Tinnitus or “head noise” is common. It may be intermittent or constant, mild or seve
Tinnitus or “head noise” is common. It may be intermittent or constant, mild or severe, or vary from a low roar to a high-pitched type of sound. It may be subjective (audible only to the patient) or objective (audible to others).

Tinnitus must always be thought of as a symptom and not a disease, just as pain in the arm or leg is a symptom and not a disease. Because the function of the auditory (hearing) nerve is to carry sound, when it is irritated from any cause the brain interprets this impulse as a noise.

Tinnitus may or may not be accompanied by a hearing impairment.

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 less 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 spasms of one of the two muscles attached to the middle ear bones, or from spasms of muscles attached to the Eustachian tube, the channel which connects the middle ear to the back of the nose.

There are two muscles in the inner 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 as a result of a startle reaction. However, for no apparent reason one or both of these muscles may begin to contract rhythmically 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 spasms continue, medical treatment (muscle relaxants) or surgery (cutting the spastic muscle) may be necessary. Muscular tinnitus resulting from spasms 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 heartbeat or to hear the blood circulating through these large vessels. This may be noticeable when an individual has a fever, middle ear infection, or after engaging in strenuous exercise. This circulation increase is temporary and usually subsides when the exertion or fever is reduced. It is not audible to others.

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 in 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. There is no relationship between the degree of hearing loss and the intensity of the tinnitus.

Inner Ear Tinnitus

Any condition which disturbs the fluid pressure in the inner ear chamber may produce head noises. This may be due to infection, allergy, or circulatory disturbances, which 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, which serve to transform fluid waves into nerve impulses, are analogous to the cells of the eye in the retina, which serve to transform light waves into nerve impulses. The slightest swelling or interference with these delicate cells (from any cause) readily produces impairment of function 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 with resultant changes in nutrition.

Pressure changes may produce swelling both from outside, and within the nerve as it transverses the bony tunnel through which it passes to the brain. In these instances, the tinnitus occurs on one side of the head. Because the bony tunnel cannot expand with the pressure phenomenon, the function of not only the hearing nerve, but also the balance and facial nerves may become disturbed as they pass through this bony tunnel.

Rupture or spasm of one of the small blood vessels occurring anywhere in the auditory pathway produces pressure and interference with circulation. Consequently, sudden tinnitus, with or without partial or total loss of hearing function, may occur. If the blood clot is small, it may absorb with little or no permanent changes. This condition, like the pressure phenomenon, occurs only on one side and because it has occurred once does not mean it would necessarily occur again either 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 most of these instances, the symptoms are localized to one ear, and other symptoms and signs develop which aid the doctor in determining the cause and location of the disturbance.

Hearing Impairment

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 indication as to the future course of the hearing impairment. Many persons with tinnitus fear they are going to lose their hearing. This is usually an unnecessary fear.

Stress and Depression

Stress is present in everyone’s life periodically. There are five stress factors which may cause or aggravate existing tinnitus: chemical stress, acoustic stress, physical stress, pathological stress, and emotional stress. Examples of chemical stress include aspirin in high doses, caffeine, or some drugs used for chemotherapy. There are many examples of very loud sounds in our everyday lives that may increase tinnitus. Fatigue often contributes to the perception of tinnitus. As a result, tinnitus is often louder at the end of the day or after physical exertion.

In some cases, tinnitus is chronic, and can result in symptoms or lead to depression. At times, these symptoms may (by themselves) lead to depression, leading to a vicious cycle of even more bothersome tinnitus.

Knowing this, the physician may recommend that a patient with severe tinnitus be treated with antidepressants or anti-anxiety medications. Patients of this type are also the ones most likely to benefit from biofeedback treatment.

Treatment

If the medical examination reveals a local or general cause of the head noise, correction of the problem may alleviate it. In most cases, however, there is no medical or surgical treatment which will eliminate tinnitus.

General Measures

• Avoid all forms of loud sound. If you must be exposed, use ear protectors such as earplugs or earmuffs. If you are exposed to certain noises, which increase your head noise, make it a point not to repeat that experience.
• Make every effort to avoid nervous anxiety, for this only stimulates an already tense auditory system.
• Make every attempt to obtain adequate rest and avoid over fatigue.
• The use of nerve stimulants – excessive amounts of coffee (caffeine) and smoking (nicotine) – is to be avoided.
• Learn as quickly as possible to accept the existence of the head noise as an annoying reality and then promptly and completely ignore it as much as possible.
• Tinnitus cannot cause you to go deaf, will not result in you losing your mind or cause your death, so immediately forget such distracting and terrifying thoughts.
• Tinnitus is usually more marked after one goes to bed and his/her surroundings become quiet. Any noise in the room, such as a loud ticking clock or a radio, will serve to mask the irritating head noises and make them much less noticeable. It may be helpful to purchase a bedside noise masker or “tinnitus masker” that can be adjusted to various tones and intensities.
• If one sleeps in an elevated position with one or two pillows, less congestion to the head will result and the tinnitus may be less noticeable.
• Sedatives of various types may be used occasionally for temporary relief.

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 awareness of the head noise by masking it out.

Biofeedback Training

Biofeedback training is effective in reducing the intensity of tinnitus in some patients. Treatment consists of biofeedback exercises in hourly sessions. The patients learn to control circulation to various parts of the body and relax muscles attached to the head. When a patient is able to accomplish this type of relaxation, tinnitus often subsides.

Tinnitus Masking

In an individual with hearing impairment, the most effective treatment of tinnitus is the use of properly fitted hearing aids. The sound heard through the aid only improves the ability to perceive speech, and makes the head noise less noticeable by masking it out.

For individuals who have normal hearing but are severely distracted by their tinnitus, a tinnitus masker may be effective. The masker is a small electronic instrument built into a hearing aid case. It generates a noise which prevents the wearer from hearing his own head noise.

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. The masker is used to produce a noise matching this frequency as closely as possible.

Conclusions

The auditory (hearing) pathway is one of the most delicate and sensitive mechanisms in the human body. Since it is directly associated with the general nervous system, its responses are in direct proportion to the anxiety state of the person involved. In order for any treatment of tinnitus to be successful, it is imperative that the patient has a thorough understanding of this distressing symptom complex.