The last year has seen a notable increase in the degree of worrisome tinnitus. This is predominantly explained by the close association of generalised stress with the level of tinnitus.
Tinnitus is the perception of a sound or sounds that is not associated with an external stimulus. There are rarer subtypes of tinnitus, often classified as pulsatile tinnitus or conductive tinnitus which is the result of sound transmitted from within the body which includes infections, tumours and vascular abnormalities.
Otherwise the vast majority of tinnitus is the result of some damage somewhere within the auditory pathway. It is impossible to have tinnitus without such damage. It is important to realise that this can be minor and you can have essentially normal hearing. Conversely you can have severe hearing loss and minimal tinnitus. As a general rule however the worse the hearing the worse the tinnitus can become.
What then results in the tinnitus ? A good explanation is that following some damage the ear and the brain sets up a series of alternate neural pathways. These ultimately reach the auditory cortex and so you actually hear the sound. A number of years ago it was dismissed as a fictitious or imaginary sound.
The problem is that these alternate neural pathways travel through different parts of the brain including those that control the neck and jaw muscles and an area called the limbic system. This area controls our fight and flight response and as such is our ‘stress’ centre.
What this means is that any form of muscular, emotional or psychologic, hormonal, metabolic, chemical stressor can modulate the way in which the brain perceives the degree of tinnitus. Unfortunately, sometimes the intrusiveness of the tinnitus leads to a feed back loop to the limbic system where this further increases the level of the tinnitus.
Once this occurs tinnitus has become essentially a brain or neurologic problem. The model is very similar to the generation of chronic pain, or phantom limb sensation.
Whilst we (ENT surgeons) are important (or think we are) in the initial assessment of tinnitus, in the vast majority of cases the holistic approach of downregulating physiologic and emotional stress in combination with sound stimulation is the management plan. This requires a multi-disciplinary team involving GPs, audiologists, clinical psychologist (tinnitus retraining therapy), physiotherapists, chiropractors, acupuncturists, dieticians.
The ultimate goal is not to ‘cure’ the tinnitus but to use a number of tools to have the brain not focus or register the tinnitus.
What is important initially ? Anyone with persistent tinnitus requires a formal hearing test, even if there is no sensation of hearing loss. A comprehensive medical assessment is important often involving blood tests, blood pressure check and awareness of muscular issues. Obviously otologic examination (ear) is essential and if there are any concerns, an ENT surgeon should become involved. What we worry about is asymmetry: either in the sensation of tinnitus, level of hearing or otologic examination. This is when we would arrange an MRI scan of the brain and inner ear to exclude the unlikely presence of more serious pathology such as a vestibular schwannoma (acoustic neuroma). The other role of an ENT surgeon is the correction or improvement in hearing if possible.
In summary the management after assessment and exclusion of serious pathology can be divided into otologic (ear) and non-otologic streams.
The 2 absolute evidence based components of tinnitus management are the use of hearing aids if there is a degree of hearing loss and tinnitus retraining therapy (TRT), a form of cognitive behavioural therapy (CBT).
The otologic options include stimulating the auditory pathway to assist the brain to ignore the tinnitus. This starts with sound stimulation which is often as simple having a broad spectrum noise (fan on at night, white noise, waves breaking etc) all the way to fitting of hearing aids, a very important and often under recognised component if you have anything more than mild hearing loss. Maintaining ear health: avoid significant noise exposure, manage wax and minimise ear infections. Occasionally there are medical and surgical options to improve hearing.
The non-otologic components are improving overall physical and emotional health, with sleep a very important factor. Tinnitus retraining therapy (managed by a clinical pyschologist with a subspeciality interest in the area) is central. Then anything that can minimise neck and jaw tension can be important.
Sudden Onset of Tinnitus: This should be treated as an otologic (ear) emergency. An urgent formal hearing test within a few days is very important to ensure that there has not been a sudden sensorineural hearing loss.