DEFINITION
Tinnitus is extraneous noise that a person hears without actually existing. It can be whistling, buzzing or clicking, for example, They can be perceived in one or both ears, but also seem to be present inside the head itself, in the front or in the back. Tinnitus can be occasional, intermittent or continuous. They result from a dysfunction of the auditory nervous system. This is a symptom that can have many causes.
Temporary tinnitus can occur after exposure to very loud music, for example. It usually resolves without intervention. This sheet is dedicated to chronic tinnitus, that is to say, those that persist and can become extremely bothersome for those who have it. However, in the vast majority of cases, tinnitus does not have a significant impact on quality of life.
PREVALENCE
In general, it is estimated that 10% to 18% of the population suffers from tinnitus. The proportion is 30% in adults. 1% to 2% of the population is severely affected.
In Quebec, approximately 600,000 people are affected by this problem, including 60,000 seriously. The widespread use of walkmans and MP3 players among young people raises fears of an increase in prevalence in the medium term.
KINDS
There are 2 main categories of tinnitus.
Objective tinnitus. Some of them can be heard by the doctor or the specialist consulted, because they are caused by disorders that, for example, make the blood flow more audible. They can also sometimes manifest as repeated clicks, sometimes related to abnormal movements of the muscles of the ear, which those around you can hear. They are rare, but usually the cause is identifiable and we can then intervene and treat the patient.
Subjective tinnitus. In their cases, the sound is only audible to the affected person. These are the most common types of tinnitus: they represent 95% of cases. Their causes and their physiological symptoms being for the moment very poorly understood, they are much more difficult to treat than objective tinnitus. On the other hand, the patient's tolerance to these internal noises can be improved.
The intensity of tinnitus varies from person to person. Some people are little affected and do not consult. Others hear noises all the time, which can affect their quality of life.
Note. If you hear voices or music, this is another disorder, called auditory hallucination.
CAUSES
Hearing tinnitus is not a disease in itself. Rather, it is a symptom very often linked to hearing loss. According to one of the hypotheses put forward by specialists, it would be a phantom signal generated by the brain in response to damage to the cells of the inner ear. Another hypothesis evokes the dysfunction of the central auditory system. Genetic factors could be involved in some cases.
The most common factors related to the onset of tinnitus are:
- In the elderly, hearing loss due to aging.
- In adults, excessive noise exposure.
Among the many other possible causes are the following:
- Long-term use of certain medications that can damage inner ear cells.
- An injury to the head (such as head trauma) or neck (whiplash, etc.).
- Spasm of a small muscle in the inner ear (stapedius muscle).
- Obstruction of the ear canal by an earwax plug.
- Certain disorders or illnesses:
- - Ménière's disease and sometimes Paget's disease;
- - otosclerosis (or otosclerosis), a disease that reduces the mobility of a small bone in the middle ear (the stapes) and can lead to progressive deafness (see diagram);
- - ear or sinus infections (recurrent ear infections, for example);
- - a tumor located in the head, neck or auditory nerve;
- - poor alignment of the temporomandibular joint (which allows jaw movements);
- - diseases affecting the blood vessels; they can cause so-called pulsatile tinnitus (about 3% of cases). These diseases, such as atherosclerosis, hypertension or an abnormality of the capillaries, carotid or jugular, can make blood flow more audible. This tinnitus is of the objective type;
- - objective non-pulsatile tinnitus can be caused by an abnormality of the eustachian tube, by neurological disorders or by abnormal contractions of the muscles of the throat or the middle ear.
EVOLUTION AND POSSIBLE COMPLICATIONS
Some tinnitus manifests very gradually: before becoming permanent, it is perceived intermittently and only in quiet places. Others appear suddenly, following a particular event, such as a sound trauma.
Tinnitus is not dangerous, but when it is intense and continuous, it can become very disturbing. In addition to causing insomnia, irritability and difficulty concentrating, they are sometimes associated with depression.
TINNITUS SYMPTOMS
The list of types of noise heard by people with tinnitus is long. It seems that the most frequently mentioned noise is hissing, but patients also name the following sounds:
- heartbeat
- rattling
- buzzing
- hissing
- ringing
- whirring
- rustling, etc.
Depending on its cause, tinnitus can be accompanied by hearing loss, nausea, drowsiness, dizziness, pain, or a persistent feeling of having a plug in the ears.
Many sufferers also suffer from an intolerance to loud noises or have a loud or painful perception of sounds perceived as normal or quiet by healthy people. This disorder is called hyperacusis.
In general, tinnitus is less bothersome during the day because it is masked by other noises present in the workplace or at home. On the other hand, they are more noticeable in the evening and can cause sleep disturbances in many people.
PEOPLE AT RISK FOR TINNITUS
- Old people. Aging often causes hearing mechanisms to deteriorate, which can lead to the onset of tinnitus.
- Men. They are more affected than women by this type of symptom.
- People exposed to noise:
- people working in an industrial environment;
- truck drivers and all those whose profession obliges them to use a car often;
- automobile mechanics;
- construction workers;
- soldiers in conflict zones;
- the musicians;
- residents of cities with a high population density;
- people who regularly go to discos, nightclubs, concert halls and raves, or who listen to music at high volume with their walkman or MP3 player;
TINNITUS RISK FACTORS
Excessive exposure to noise. The inner ear is lined with a few thousand auditory cells. These cells are fragile and, once destroyed, they cannot regenerate. These are provided with vibrating cilia, whose function is to transmit the sound vibration. When high intensity sounds are perceived by the ear, these cilia lower before straightening after a while. However, regular exposure to too high a number of decibels (dB) sooner or later leads to permanent damage to the auditory cells and their vibrating cilia.
It can also happen that a single exposure to a particularly violent sound (the detonation of a rifle or a firecracker, for example) very close to the ear causes irreversible damage to the auditory cells. This causes permanent hearing damage and can therefore cause tinnitus.
Physical activity and head movement increase pulsatile tinnitus.
The use of certain medications. When taken long term, some medications can cause tinnitus. Here are a few :
- high doses of acetylsalicylic acid (Aspirin®) or nonsteroidal anti-inflammatory drugs such as ibuprofen (Advil®, etc.);
- antimalarials, such as quinine;
- certain diuretics, such as furosemide (Lasix®, etc.);
- various drugs used in chemotherapy;
- certain antibiotics.
Note. Resistance to the adverse effects of noise and drugs varies greatly from person to person.
The stress. Stress is not a risk factor for tinnitus, but it can increase the perception of tinnitus and therefore worsen its impact on quality of life.
According to Health Canada and the World Health Organization (WHO), continuous exposure to noise of 70 dB or less does not cause hearing loss. However, an ambient sound level exceeding 85dB for more than 8 hours, every day and for several years, can be harmful to hearing. The WHO also states that an adult's ear can withstand an occasional sound level of up to 140 dB, but in the case of a child, this exposure should never exceed 120 dB.
decibels
The decibel (dB) scale is logarithmic, not arithmetic. Thus, a 3dB increase doubles the sound level, and a 10dB increase multiplies it by 10.
On the other hand, the decibels of two washing machines placed close to each other do not add up: if each emits 60 dB, the noise level will be 63 dB and not 120 dB.
TINNITUS PREVENTION
Basic preventive measures
Pay attention to the noise. Avoid exposing yourself unnecessarily and too often to very high or even moderately high sound volumes. If necessary, use earplugs®, protective shells or foam earmuffs, whether at work, on the plane, during a rock concert, when using noisy tools, etc.
Beware of certain medications. Avoid prolonged use of high doses of nonsteroidal anti-inflammatory drugs such as acetylsalicylic acid (Aspirin®, for example) and ibuprofen (Advil®, etc.). See the partial list of medications potentially toxic to the ears (ototoxic) above. If in doubt, ask your pharmacist or doctor.
Measures to prevent aggravation
Avoid very noisy places.
Identify aggravating factors. Alcohol, caffeine, or tobacco increase tinnitus in some people. Very sugary foods or beverages containing low amounts of quinine (Canada Dry®, Quinquina®, Brio®, Schweppes®, etc.) may have this effect on other individuals. These aggravating factors vary from person to person.
Reduce and manage stress. Practicing relaxation, meditation, yoga, physical activity, etc., can reduce stress and anxiety, which are both consequences and aggravating elements of tinnitus.
Avoid absolute silence in case of hyperacusis. When you suffer from this intolerance to loud noises, it is best not to seek silence at all costs or to wear earplugs, as this can make the auditory system even more sensitive, therefore lowering the discomfort threshold.
Measures to prevent complications
Submit to regular medical monitoring in case of severe tinnitus. When tinnitus is loud and constant, it can become intolerable and lead to depression. It is therefore important to consult a doctor to obtain adequate care.
MEDICAL TREATMENTS FOR TINNITUS
As tinnitus has many different origins, there is no single treatment. In general, tinnitus is difficult to treat, but there are methods that offer good results.
Treatment of the underlying disease
In the case where tinnitus is linked to a well-defined disease, it is possible to obtain an improvement or even a cure by treating the disease in question: otitis or other infection, otosclerosis, Paget's disease, Ménière's disease, etc. However, not all of these diseases are easily curable. Removing an earwax plug or removing a tumor can also end tinnitus.
Change in medication
When medications are the cause of the problem, a change in treatment or a decrease in dosage can reduce or eliminate tinnitus.
Medications
If tinnitus is caused by hearing loss or hearing damage from excessive noise exposure, there is currently no specific treatment. Different medications have been used (vasodilators, baclofen, cinnarizine, benzodiazepines like clonazepam), but most have more side effects than positive ones.
In special cases, medications aimed at controlling stress or depression (such as amitriptyline) may be prescribed with good results.
Some people have had some relief with niacin (vitamin B3) supplements, but the results are unpredictable (to be taken under medical supervision only).
Injections of corticosteroids (dexamethasone) through the eardrum may also be effective in some cases.
The doctor may suggest various drugs, but without any guarantee of effectiveness.
Tinnitus masking
The white tone generator. This device plays a white sound (similar to that produced by a radio tuned between 2 stations) at a low volume into the affected ear. This sound masks the tinnitus and reduces the inconvenience to the patient. This device looks like a hearing aid; an audiologist can provide one. White tone generators are recommended for patients with normal or near normal hearing.
The hearing aid. The use of a hearing aid may reduce the discomfort of some patients with mild to moderate hearing loss by making their tinnitus less audible. When the prosthesis is insufficient, they can also resort to a white tone generator.
Avoid complete silence
At home, fan noise, soft music, or other ambient noise can partially mask tinnitus.
Most people with tinnitus are particularly bothered at bedtime because of the lack of noise. Using a low-volume radio placed on a nightstand can sufficiently mask tinnitus. An analog alarm clock, which emits a ticking sound, can also help, as well as the crackle of a radio tuned to a frequency that does not correspond to any transmission frequency.
THERAPIES AND TECHNIQUES
Acoustic habituation therapy (AHT). This approach, developed by an American specialist (Jastreboff), is often referred to by its English name: Tinnitus Retraining Therapy (TRT). It includes therapeutic meetings allowing the affected person to live better with their tinnitus. They are explained the mechanism of tinnitus and the influence of emotional factors, they are taught relaxation and attention diversion techniques, etc. This involves, among other things, reprogramming his brain so that it filters sounds selectively. The goal is for the person to hear only useful sounds and ignore unnecessary sounds.
HAT also includes exposure to noise to avoid silence, as well as the wearing, as appropriate, of a white tone generator or a hearing aid. This therapy is spread over approximately 18 months and includes around 16 hours of personalized follow-up. This is ideally offered by a multidisciplinary team including an otolaryngologist, an audiologist and an occupational therapist. In 2010, a clinical study of 123 patients concluded that TAH was more effective than tinnitus masking.
Cognitive-behavioral therapy. This psychological approach can markedly improve the quality of life of a person with tinnitus. It is based on relaxation, visualization and attention diversion techniques, and on reshaping thoughts and beliefs about tinnitus. Swedish researchers have even had some success with subjects participating in a cognitive-behavioral therapy program offered over the Internet. The duration of treatment is usually 3 months. Cognitive-behavioral therapy can be supplemented with noise therapy: this includes avoiding silence, wearing a white tone generator, making sure to maintain ambient noise, etc. According to a meta-analysis published in 2010, cognitive behavioral therapy does not reduce the strength of tinnitus, but it is effective against depression and improves quality of life.
Experimental treatment: transcranial magnetic stimulation (TMS). This technique is used in particular to treat major depression in people who do not respond to the usual treatments. A painless magnetic pulse is transmitted through the skull. In the case of tinnitus, we seek to reduce the activity of neurons dedicated to hearing by using a specific stimulation technique.
Avoid isolation. Being part of a support group (see below) and maintaining a friendly and social network can reduce anxiety and depression and prevent isolation.
Complementary approaches to tinnitus
Biofeedback. A few studies have looked at the effectiveness of biofeedback in relieving tinnitus. The biofeedback techniques used vary, but the results are generally positive. For example, a 2008 trial with 130 people showed that a series of 12 biofeedback sessions over 3 months provided lasting relief from tinnitus and improved the tolerance threshold of sufferers.
Hypnotherapy or self-hypnosis. Several clinical trials have yielded encouraging results. Hypnotherapy does not cure tinnitus, but can improve the quality of life of people who suffer from it. See our Hypnotherapy sheet.
Acupuncture. Although acupuncture is popular with tinnitus sufferers, the authors of 2 clinical trial reviews (in 2000 and 2004) concluded that it was not effective. Later trials, however, indicated that it may provide some relief.
Melatonin. At least 4 preliminary trials show that taking 3 mg of melatonin daily can not only improve sleep for people with tinnitus, but also reduce their perception of disturbing sounds.
Zinc. According to some researchers, aging people with tinnitus are often deficient in zinc. Supplementation could therefore relieve them. However, the role of this mineral in causing the problem is not well known and some people with tinnitus do not have a zinc deficiency. The results of the studies carried out so far do not make it possible to conclude clearly on the usefulness of zinc supplementation.
Chinese pharmacopoeia. In Traditional Chinese Medicine, there are preparations intended to treat diseases that cause tinnitus. For example, the preparation Tian Ma Gou Teng Yin Wan, used in cases of high blood pressure, may relieve tinnitus that results from this condition. The same applies to the preparations Da Zao Wan and Liu Wei Di Huang Wan, used to relieve certain symptoms of menopause, including tinnitus. See our Chinese Pharmacopoeia section.
Ginkgo (Ginkgo biloba). The German Commission E recognizes the effectiveness of ginkgo biloba leaf extracts in treating tinnitus of vascular origin (a minority of tinnitus cases). It is thought that the effectiveness of ginkgo is due to the fact that it improves blood circulation in the capillaries supplying the brain. However, the results of all the clinical studies point to the lack of efficacy of this plant.
Dosage
Take 120 mg to 160 mg per day of an extract standardized to 24% or 25% glucoflavonoids and 6% terpeno-lactones.