Tinnitus
What is Tinnitus?
Tinnitus (pronounced ti-NIGHT-us or TIN-i-tus) refers to hearing sounds in one or both ears, or in the head that are not coming from an outside sound source. It is described in various ways, including the following:

• Ringing
• Buzzing
• Chirping
• Whistling
• Cricket sound
• Seashell or ocean sound
• Pulsation, like a heartbeat
• Roaring
• Roaring pulse
• Hissing
• Hissing plus a tone
• Popping

Virtually everyone at one time or another experiences tinnitus. The American Tinnitus Association (ATA) www.ata.org is probably the best information resource on this topic. They report that more than 50 million Americans experience tinnitus. Tinnitus can be constant or intermittent. It can sometimes be noticeable mainly at night when it is quiet and there are no other noises to "mask" or cover it. It can occur in one or both ears, or it can seem to be in a person's head (not the ears). It can be very faint or incredibly loud. Often, people with tinnitus consider it a non-bothersome fact of life or only somewhat bothersome. A number of other people consider it bothersome but can tolerate it. To a small percentage of sufferers, tinnitus can be experienced as tremendously stressful, upsetting, and even debilitating.

What to Do if You Have Tinnitus
If you have any of the following symptoms relating to or in addition to your tinnitus, a consultation with your audiologist and/or physician or otolaryngologist (ENT physician) is recommended. If you see a physician first, you will likely be referred to an audiologist for a complete audiologic evaluation. This will help your physician rule out possible causes of your tinnitus. If you have hearing concerns and seek an audiological consultation first, your audiologist will help to determine whether your tinnitus complaints and other ear symptoms warrant referral to an ENT specialist.

Symptoms That Warrant Further Evaluation Include the Following:
• Tinnitus that is bothersome and of concern to you
• Tinnitus that developed suddenly
• Tinnitus in only one ear
• Tinnitus that is different in one ear than the other (louder or different sounding)
• Difficulty hearing in addition to tinnitus
• A feeling of fullness or pressure in the ear(s) or head accompanying the tinnitus
• The presence of dizziness or imbalance in addition to tinnitus
• Tinnitus that fluctuates along with hearing fluctuation
• Tinnitus that has a pulsing sound (like hearing your heartbeat in your ear)

What Causes Tinnitus?
The exact mechanism by which tinnitus is produced is not fully understood. Tinnitus is a symptom of whatever is causing it. It is not a disease in itself. Some causes of tinnitus can be treated immediately to clear up the tinnitus. Sometimes earwax impaction or an ear infection is the culprit and when these problems are resolved, so is the tinnitus. There are many possible causes of tinnitus. It can be the result of very small changes occurring anywhere in the auditory system or in related body systems that interact with the auditory system such as the nervous and vascular systems.

Some Possible Causes Include:
• Wax impaction of the ear canal
• Noise-induced or other hearing loss (inner ear damage)
• Medications which are damaging to the inner ear (ototoxic drugs) such as aspirin, some antibiotics, some chemotherapy drugs, and some diuretics (water pills)
• Medications that cause tinnitus as a side-effect (there are more than 200 such medications)
• Ear infections or ear fluid
• Disorders of the middle ear bones such as otosclerosis
• Anemia
• Hypothyroidism (underactive thyroid)
• Temporomandibular joint problems (TMJ) or jaw misalignment problems
• Cardiovascular disorders
• Cervical vertebrae problems
• Tumors (rare, often benign and slow growing tumors of the cochlear, vestibular or facial nerves)
• Physical trauma to the head or neck

Factors That Can Aggravate or Intensify Tinnitus:
• Noise exposure without use of appropriate hearing protection
• Caffeine
• Nicotine
• Alcohol
• Medications such as aspirin products, ibuprofen, salicylates and many mycin drugs
• Anxiety or depression
• Fatigue (many sufferers report increased symptoms at night before bed)
• Paying attention to the tinnitus (many people report that it grows louder as they are talking about it or if they think about it and focus on it).

Note: Tinnitus deserves medical attention to rule out possible causes when it is bothersome or occurs in just one ear, but paying it undue attention can definitely increase its severity.

Tinnitus Prevention
The best way to protect yourself from getting tinnitus, or from having existing tinnitus worsen, is to protect your ears from loud noise. Loud noise is damaging and is a very common cause of tinnitus. Repeated or prolonged exposure to noise is likely to lead to tinnitus, but even one-time exposures can sometimes cause severe tinnitus. You can protect your ears by wearing ear plugs, earmuffs or custom-fitted noise protection plugs available from our audiologists at Arkansas Center for ENT and Allergy. Specialty plugs such as motorcycle plugs that can be worn comfortably under a helmet are also available.

Treatments for Tinnitus
The most effective treatment for tinnitus would be to treat the cause if the cause can be determined and if it is treatable. For example, if a medication is causing the tinnitus, stopping the medication or switching to another one may relieve the tinnitus. Likewise, hypertension, hypothyroidism, anemia, TMJ and middle ear fluid are examples of causes that can be pinpointed and treated to hopefully eliminate the symptom of tinnitus.

Sometimes a "treatable" cause cannot be determined. For example, noise exposure and sensorineural hearing loss are frequent culprits, but the damage they cause to the outer and/or inner hair cells of the cochlea cannot be repaired per se. In these cases, the tinnitus and its effects on a person's life can still be addressed, and the prognosis is generally good. Treatments that have been shown to be effective in providing various degrees of relief for some patients (depending on the cause of their tinnitus, of course) include the following:

Amplification (if hearing loss is present):
For tinnitus sufferers with a hearing loss, use of appropriate amplification often alleviates or reduces tinnitus because it counters the "auditory deprivation effect," the reaction of the central auditory nervous system to a lack of sound input because of the hearing loss.

When there is a hearing loss, the hearing part of the brain does not get adequate sound stimulation. It may therefore become more attentive to the auditory nerve signals that reach it. Sometimes the brain may perceive and focus on small changes in the system such as nerve conduction rates that are very slightly irregular due to subtle damage related to the cause of the hearing loss. The auditory part of the brain may fixate on this "internal noise" because of the lack of adequate sound stimulation. Sometimes the "internal noise" that the brain focuses on may even be of non-auditory origin (i.e. vascular or muscular fiber sounds). Normally, these tiny, internal "sounds" or irregularities are ignored by the brain, but when there is hearing loss, the lack of stimulation can cause the brain to tune in on these small changes and even "turn up the volume" on them and then these sounds may then be experienced as tinnitus.

A hearing aid can often help in these cases! By giving increased auditory stimulation to the auditory part of the brain, the brain can be re-trained to "turn down the volume" of the tinnitus. This is called residual habituation. Many tinnitus sufferers find that wearing a hearing aid alleviates or markedly decreases their tinnitus and that this relief is long-lasting, continuing even after removing the hearing aid.

Masking:
This involves providing sound that may "cover up" the tinnitus, but more importantly it can re-train the brain to "turn down the volume" of the tinnitus through the process mentioned above called residual habituation.

This Can Be Accomplished in a Number of Ways:
• Environmental noise, such as music or other background noise
• Using a "noise machine" that can provide a sound like a waterfall, babbling brook or other "relaxing" sound, which may mask the tinnitus quite effectively
• Use of air purifiers or fans to provide extra background noise
• Tuning the radio between stations to provide a "white noise" type sound
• Masking CDs, designed to provide many choices of masking sounds so that the ideal sound to mask the tinnitus can be found, and then that track can be played on a continuous loop on your CD player
• Wearable masking devices (like an in-the-ear or behind-the-ear hearing aid) which provide a masking sound but no amplification for persons with normal hearing or who have some hearing loss but are not candidates for a hearing aid
• Combination hearing aid-masker devices for persons who need amplification and a masking sound at the same time. It should be noted that excellent, programmable masker-hearing aids are now available, which allow the masking sound to be fine-tuned to best mask the sound of the tinnitus.
• Hearing aids (without a masking sound provided) provide natural masking for persons with hearing impairment. The use of a hearing aid provides inherent masking because it amplifies the sounds of life which are natural maskers for persons who are able to hear them. As discussed above, many times this intervention alone will cause the tinnitus to either disappear or decrease significantly to the point where it is no longer bothersome.
• Medical and Audiological Evaluation and Counseling
This is often helpful to tinnitus sufferers. It helps to know that medically significant causes of tinnitus have been ruled out or received appropriate follow-up. This can decrease the worry and concern that tinnitus sufferers often feel. It also helps to understand the mechanism and cause of the tinnitus (as much as can be determined by the physician-audiologist team).

Experiencing tinnitus can cause concern, worry and sometimes fear. This can cause the Limbic System (the primitive, emotional part of the brain that is involved in the "fight or flight" response) to be activated, causing a powerful link between the concern about the tinnitus and the level of loudness or severity to be forged.

By learning that the tinnitus does not mean that there is cause for alarm-that it is a benign symptom and not a disease in itself-the link between the concern (the Limbic response) and the experience of the tinnitus (the auditory brain perception) can be broken. The process of residual habituation can then begin, as discussed above. The brain can begin to turn down the volume on the tinnitus once it no longer holds any more emotional importance than the sound of a refrigerator or air conditioner running.

Medications
There are no known medications that will cure tinnitus. There are some medications that may sometimes provide temporary relief. These generally fall in three main categories: anti-depressants, anti-anxiety medications and local anesthetics. For information on options that may be considered in your particular case, consult your ENT physician.

Dental Treatment
Tinnitus can often be relieved by treating jaw alignment in cases where temporomandibular joint (TMJ) problems are involved in its cause.

Lay Counseling and Self-Help Organizations
Support groups, newsletters, friendships and contacts with others with tinnitus can all be extremely helpful. For this reason, and because of the tremendous volume of up-to-date information they can provide, we urge our patients who suffer stress, concern or distress because of their tinnitus to contact the American Tinnitus Association. They offer a number of helpful services. They can be contacted at 1 (800) 634-8978 or at their website: www.ata.org.

Cognitive-Behavioral Therapy
This is counseling that focuses on modifying thoughts and behaviors to change how a person feels. By changing the way that tinnitus sufferers react to and cope with their tinnitus, its impact on their lives can be reduced, helping them to feel better. As discussed above, reducing the level of fear, worry or alarm may help the residual habituation process, thus causing the tinnitus to subside or decrease over time.

Biofeedback
Monitoring and controlling physiological processes such as blood pressure and heart rate in order to promote relaxation can help, because tinnitus is exacerbated by stress and can cause additional stress to the tinnitus sufferer who feels concerned or worried about it. This may help the residual habituation process.

Relaxation Training Therapy
This intervention can yield positive benefits for the same reasons that Biofeedback is helpful.

Scientifically Unproven Treatment Methods
Tinnitus sufferers looking for hope to make their tinnitus go away sometimes spend large amounts of money on unproven tinnitus treatments. As discussed above, the prognosis for persons with tinnitus is generally good. Tinnitus often goes away-sometimes gradually, sometimes suddenly-without any intervention. When a person with tinnitus notices improvement while trying a particular treatment or supplement, they may believe that whatever they were doing caused the improvement when, in fact, the improvement was going to occur at that point without any intervention. This is why scientifically researched treatments are your best bet. Stories supporting various alternative treatment methods abound, but the proof to support the claims does not exist.

It is important to remember that no particular treatment-conventional or alternative-works for every patient with tinnitus and there are no magic pills, drops or creams that can be used to eliminate your tinnitus. However, there is no shortage of people seeking to make a profit by selling false hopes in the form of unproven "cures." The following is a list of alternative methods that are sometimes claimed to help tinnitus. We do not claim that there are no alternative treatments that could be of any benefit, but strong, scientific support for these methods is not available as yet. In some cases, the treatment has been researched repeatedly and no significant benefit has been seen, disproving claims of usefulness in treating tinnitus. Some tinnitus sufferers may report improvements from some of these methods. We encourage consumers to be cautious, do their homework, and consider the costs and any potential risks that may be involved in using unproven therapies. And finally, before undertaking a course of treatment, consult with a physician.

Some Unproven Treatments:
• Acupuncture
• Chiropractic or Osteopathic Adjustments-certainly, if the cause of the tinnitus is a cervical vertebral misalignment, chiropractic or osteopathic care may be helpful, but otherwise, it is not likely to improve tinnitus
• Ginko Biloba or other herbal supplements
• Hypnosis
• Vitamin supplements, such as Niacin (a B vitamin)
• Drops, pills or other "tinnitus remedies" sold over-the-counter in drug stores or health food stores or on the internet.
• Ear candling-this has been proven through solid, scientific research to be dangerous and to provide no ear-related benefits whatsoever.