Tinnitus

Tinnitus is a perception of sound that does not have an external source. Tinnitus falls into two categories: Subjective tinnitus (common) and objective tinnitus (rare). Tinnitus can also have different characteristics, such as being pulsatile or non-pulsatile, which helps clinicians uncover the cause. Tinnitus can be difficult for patients to describe and can be high-pitched, low-pitched, varying levels of volume.

Subjective Tinnitus

Subjective tinnitus is the perception of sound that has no electrical, acoustic, or external stimulation. It is most commonly associated with high-frequency sensorineural hearing loss (SNHL), and the pitch of the tinnitus generally reflects the region of hearing loss (usually between 3000 and 5000 Hz.

Pathophysiology: unknown, thought to be due to maladaptation of auditory cortical pathways after a cochlear event.

Objective Tinnitus

Objective tinnitus is the perception of sound that has an origin within the body, it may be due to internal vibrations or turbulent blood flow. This form of tinnitus may be exacerbated by conductive hearing loss (CHL).

Pathophysiology: generally due to an underlying mechanical or vascular disorder, superior semicircular canal dehiscence, or idiopathic intracranial hypertension.

Diagnostic Workup

Similar to those with a chief complaint of hearing loss, those with tinnitus should have an audiogram, tympanogram, and a thorough medical and surgical history. If the tinnitus is pulsatile (meaning it pulses and may sound like a heartbeat) and/or unilateral, further workup for intracranial pathologies (including masses, vascular anomalies, and bony defects) may be warranted. This imaging may include Magnetic Resonance Imaging (MRI), or Computed Tomography Angiogram (CTA).

Tinnitus can be further divided into primary and secondary. Primary tinnitus refers to an unknown cause of the tinnitus (generally associated with SNHL). Secondary tinnitus refers to a known cause, including earwax (cerumen) impaction, eustachian tube dysfunction, vascular anomalies, or anatomical defects. While each can be equally distressing to the patient, the treatment is different. The objective in treating secondary tinnitus is to remove/treat the provoking factor (earwax, vascular anomalies, etc.). In some cases of secondary tinnitus, this resolves the distressing sound.

Treatment

The treatment of tinnitus can involve multiple modalities to approach the three different contributing aspects of tinnitus. After a thorough diagnostic workup, the initial treatment is to treat anything that may provoke secondary tinnitus. If a surgical cause of tinnitus is identified (intracranial mass, superior semicircular canal dehiscence, etc.) your surgeon will discuss treatment options and the risks and benefits of surgical intervention.

Once this has been done, or all provoking factors have been ruled out, other treatments can begin. For tinnitus associated with sudden sensorineural hearing loss, intratympanic injections of steroids can be used to restore hearing and, therefore, improve tinnitus. With no identifiable cause of tinnitus, we address three aspects of tinnitus: sensation, cognition, and emotion.

Sensation: this component of tinnitus is addressed by either addressing underlying hearing loss with a sound amplifier (i.e., hearing aid) or by using a sound generator that creates a sound that can mask the frequency of the patient’s tinnitus. Both of these interventions can decrease the patient’s sensation of tinnitus.

Cognition: this component of tinnitus is comprised of the negative associations tinnitus can have. Patients with tinnitus may have negative thoughts associated with tinnitus. One approach for the management of this aspect of tinnitus is cognitive behavioral therapy (CBT), which can help address these negative thoughts surrounding tinnitus.

Emotion: this component of tinnitus is very common, as patients report sadness, tension, stress, poor sleep, and generally feeling down. Tinnitus can impact many aspects of a patient’s life, including daily activities and hobbies. The sympathetic nervous system is thought to be implicated in the emotional distress patients report. Deep breathing or other techniques that activate the parasympathetic nervous system, which “cools down” the nervous system, may help regulate this autonomic nervous system response. CBT can also help patients understand their emotional reaction to the noise.

Other approaches can help decrease the perception of tinnitus, including using background noise in quiet environments (ex., white noise at bedtime). Additionally, there are hearing aids, which are designed specifically to “cancel out” a person’s tinnitus, thus decreasing their perception of the sound. Some studies show that there may be a benefit to taking antioxidants (ex, vitamins A, C, E, zinc, acaí) with regard to tinnitus. The treatment of tinnitus is varied, and each patient should be seen by a professional who can assess their situation and create an appropriate treatment plan.