All about Tinnitus

Tinnitus is very common. According to NICE, in the UK, around 13% of adults (that’s 7.1 million people) experience persistent tinnitus. Its prevalence increases with age but it can happen no matter how old a person is – even some children experience tinnitus! A cross-sectional study involving 12 European countries found a similar prevalence of 14.7%. Severe tinnitus was recorded in 1.2% of the participants.

Given its prevalence, it’s important to understand a little more about tinnitus, who is at risk, possible causes and symptoms, and whether it can be prevented as well as any effective treatments.

What is tinnitus?

According to NICE, tinnitus is not a disease in itself but rather a symptom. It is the “perception of sound in the absence of any external auditory stimulus”. In other words, a person can hear a sound when there is no sound externally from their environment.

 The sound is often perceived as:

• Buzzing.
• Humming.
• Whistling.
• Pulsing.
• Tonal.
• Clicking.
• Ringing.
• Roaring.
• Hissing.

Tinnitus can be unilateral (affecting one ear only) or bilateral (affecting both ears). It can also be intermittent or constant.

Furthermore, tinnitus can be classified in other ways:

• Subjective tinnitus if only the individual can hear the perceived sound.
• Objective tinnitus if an examiner can also hear the sound as well as the individual affected.

Regardless of the type of tinnitus, it can be very distressing and can interfere with a person’s daily activities.

Who is at risk of tinnitus?

Tinnitus can affect people of all ages but the risk of it developing increases as we age. There are several things that can increase a person’s risk or likelihood of developing tinnitus.

These include:

• Exposure to loud noise: Exposure to loud noises either through our leisure activities such as nightclubs or music concerts and festivals is a common cause of tinnitus. If you work in a noisy environment, use tools or machinery that are very loud, or even use firearms as a part of your role, you are more likely to suffer from tinnitus, especially if you do not wear adequate hearing protection.
• Age: As mentioned, older people are more commonly affected by tinnitus. This is because the inner ear that is responsible for hearing can become damaged over time. So, the older you are, the more at risk you are of developing tinnitus.
• Sex: Whilst tinnitus is said to affect just as many men as women, research has shown that the distress that chronic tinnitus causes is said to be more profound in women overall.
• Genetics: Although there is not a lot of research available that proves a genetic link in tinnitus, genetic factors are thought to play a role.
• Medical conditions: As detailed below, certain medical conditions such as diabetes, thyroid problems and high blood pressure can increase a person’s risk of developing tinnitus.
• Medications: Certain types of antibiotics, diuretics, cancer drugs and known ototoxic drugs can all enhance or cause tinnitus and those who take these drugs are more at risk of developing it as a result. There is more information on this in the causes of tinnitus section below.
• Injuries to the head, neck and ear: People who have had injuries to these structures may have an increased risk of developing tinnitus. This includes rugby players who often suffer from such injuries such as former England player Ben Cohen.

What causes tinnitus?

What causes tinnitus exactly is not fully understood. However, it is related to abnormal neural activity that is generated somewhere within the auditory system. The brain then interprets this ‘false’ signal as a sound.

There have been some suggestions as to how this comes about physiologically:

• It may be that the tinnitus is the result of increased neural synchrony between discharges or an increased “firing rate” of signals from the ear to the auditory part of the brain.
• Most cases of tinnitus are believed to be linked with some level of damage to the cochlear.
• The process may be:
  – Conductive – i.e., associated with vibrations in the middle ear.
  – Sensorineural – i.e., associated with hair cells in the ear (both inner and outer), the auditory nerves and/or the extrasensory structures.
  – Central – i.e., abnormal central processing, which could have been triggered by hearing loss.

Causes of subjective tinnitus

Subjective tinnitus may have some distinct causes itself.

These include:

• Infections in the ear including otitis external and otitis media.
• Impacted ear wax.
• Noise-induced loss of hearing.
• Meniere’s disease.
• Otosclerosis.
• Sensorineural hearing loss.
• A perforated eardrum.
• Using certain drugs known as “ototoxic drugs”. These drugs include:
  – Loop diuretics (such as bumetanide and furosemide).
  – Non-steroidal anti-inflammatory drugs (NSAIDs).
  – Aspirin.
  – Anti-malarial drugs such as chloroquine and quinine.
  – Tetracycline drugs like minocycline and doxycycline.
  – Valproate.
  – Certain antibiotics like erythromycin and gentamicin.
  – Cytotoxic drugs such as cisplatin.

Aside from these causes, subjective tinnitus is also linked with other conditions such as:

• Metabolic disorders such as diabetes, thyroid disorders, Vitamin B12 deficiency, zinc deficiency and hyperlipidaemia.
• Mechanical disorders such as head and neck trauma or TMJ dysfunction (jaw problems).
• Neurological disorders such as multiple sclerosis.
• Neoplastic conditions such as meningioma or acoustic neuroma.
• Vascular disorders including venous hums or arterial bruits.
• Psychological disorders – although the link here is unclear. It could be that those with depression and anxiety are more prone to tinnitus or it could be the case that those with tinnitus are more prone to psychological disorders. Anxiety may also exacerbate existing tinnitus.

Causes of objective tinnitus

Objective tinnitus is extremely rare. It is caused by conditions that produce audible sounds either within the ear or near it. It is mostly associated with abnormalities within the blood vessels.

Other causes include:

• Anaemia or other causes of increased cardiac output.
• Benign intracranial hypertension.
• Acoustic neuroma (also called vestibula schwannoma).
• Contractions in certain muscles in the ear or palate.
• Otosclerosis or Paget’s disease.
• Patulous eustachian tube – clicking sounds when swallowing (which can occur after adenoid removal or weight loss).
• Jaw disorders.
• Thyroid disorders.

Symptoms of tinnitus

As mentioned, tinnitus itself is a symptom of a condition rather than a condition in itself. The sound that someone hears in their ear(s) may well be different for individuals. You can hear examples of what tinnitus may sound like to someone on the Tinnitus UK website.

People describe their tinnitus as being like a buzzing, ringing, pulsating, hissing, roaring, clicking, swooshing, humming, or whistling sound. It is different for everyone.

The volume, duration and pitch often vary too. It may be a high-pitched sound or sound more like white noise or static from the TV/radio. It may only be heard in certain environments such as in quiet places or whilst trying to fall asleep.

Complications of tinnitus

The impact that tinnitus has is variable. The majority of those affected are not considered to have severe tinnitus, but some individuals find concentration difficult and they may also suffer from insomnia, depression, anxiety and social isolation as a result. Rarely, it can lead to suicide if a person struggles to cope with severe tinnitus.

Normally, tinnitus is rather harmless, although annoying. One of the more common symptoms that people with tinnitus report is sleep disturbance. Moving from a noisy environment in the daytime to the quietness of your bedroom can heighten a person’s awareness of their tinnitus, making it much more noticeable.

Aside from the perceived sound in their ears, tinnitus sufferers often report sensitivity to other sounds or frequencies.

There are circumstances where you should be referred for further assessment. However, no matter the severity, all those with tinnitus should have an audiological assessment.

Urgent referrals for further assessment are normally arranged if a person’s tinnitus is associated with other symptoms.

These include:

• Mental health concerns that persist and are exacerbated by tinnitus.
• Hearing loss that is worsening rapidly.
• Persistent ear discharge (otorrhoea) or pain in the ear (otalgia) that has not resolved with conventional treatment.

Some people need very urgent referrals for further assessment. For example, those experiencing sudden pulsatile tinnitus or tinnitus that occurs after a head injury should be referred immediately for assessment. Likewise, if tinnitus has occurred with sudden hearing loss, a very urgent referral should be put in place.

However, for people presenting with certain symptoms, immediate referral (including fast-tracking via Accident and Emergency) should be considered.

 These symptoms include:

• Those with a high risk of suicide.
• Sudden onset of severe neurological signs or symptoms.
• Suspected stroke.
• Uncontrolled, acute vestibular symptoms.

Preventing tinnitus

Whilst not all tinnitus can be prevented, several steps can be taken to help reduce the risk of developing it:

• Exposure to extremely loud noise (especially repeated noise or daily noise) can lead to tinnitus, so it is important to wear ear defenders or earplugs when exposed to loud noise. This may be at a place of work when operating loud machinery or when attending music concerts or sporting events with loudspeakers.
• Limit your exposure to loud music. Aside from the risk of attending loud music concerts, there are other ways that loud music can damage your ears and may lead to tinnitus. Listening to music at a high volume through headphones or earbuds can increase the risk of tinnitus developing. Limiting the use of headphones and keeping music volumes to a reasonable level can help prevent this.
• Avoid taking ototoxic medications. Ototoxic means that something has a toxic effect on the ears or on the nerves that supply the ears. A list of ototoxic drugs is listed above. Ototoxic medications can damage the sensory cells in the inner ear and cause tinnitus. If you need to take these medications, it is wise to speak to a healthcare provider about alternative options.
• Manage stress. Stress and anxiety, whilst not proven to cause tinnitus, can certainly heighten its presence and worsen the effects that it has on you. Managing stress through meditation, deep breathing or yoga can help reduce this.
• Maintain a healthy lifestyle. Leading a healthy life can reduce the risks of someone developing health conditions from which tinnitus may result. Eating a balanced diet, exercising regularly and getting enough sleep are all incredibly important to our health and help us reduce our risk of developing medical conditions or health problems that may result in tinnitus.

Whilst it may not be possible to prevent all cases of tinnitus, taking these steps may help reduce the risk of developing it as well as help manage the symptoms for those who already experience tinnitus.

How is tinnitus diagnosed?

Most people experiencing tinnitus visit their GP who will take a medical history and ask questions about the onset of the tinnitus, its qualities such as its duration, severity and how often it is experienced. They will also establish whether the tinnitus affects one or both ears, whether it is episodic or continuous, and/or pulsatile in nature.

The GP will also assess whether there are any associated symptoms such as vertigo, dizziness, hearing loss, jaw problems, balance problems, sensitivity to other noises, facial weakness, headache, stress or visual changes. Any aggravating or relieving factors will also be noted including the effect of or on sleep, head positioning, background noise, stress or jaw movements.

Essentially, a GP can diagnose tinnitus themselves as it is a symptom rather than a condition. There may be certain circumstances where they will refer the person for further assessment or support and often this is related to the impact that tinnitus has on their life.

This may include:

• Discussing tinnitus with the person and their family members if appropriate and how it affects their home and social life, leisure activities and work.
• Using the tinnitus questionnaire or the Tinnitus Function Index to see if further assessment is warranted.

Because tinnitus is a symptom rather than a disease, the GP will also explore the causes or refer for further testing and assessment if necessary. They will also assess the impact of any medications the individual is taking or if there has been exposure to excessive noise due to the person’s work or leisure activities. Furthermore, any comorbidities will be highlighted such as metabolic disease, mental health disorders or cardiovascular diseases.

Often, an examination is performed to examine the ears as well as the nose and throat. Tests may also be carried out to assess a person’s hearing. If any underlying condition is suspected as a cause of tinnitus, such as thyroid disease or anaemia, blood tests may be ordered.

In terms of prognosis, if the tinnitus is relatively mild in severity, it often improves by itself over time or following treatment. However, for many people, it can persist for years and cause significant distress. If tinnitus persists for at least six months, it is less likely to spontaneously improve. About 20% of tinnitus sufferers will require some form of treatment.

Treatments for tinnitus

Most people with tinnitus will be managed in primary care. However, if it is indicated, the GP would refer someone for more specialist assessment and management.

Treatments in primary care include:

• Reassurance
  Tinnitus is quite a common condition that may resolve by itself. Although it can be associated with hearing loss, this is not always the case. There are a variety of ways that people can learn to live with or treat their tinnitus.
• Treating the underlying cause (if known)
  If tinnitus has been caused by a known underlying condition, then treating this condition will be the first port of call. This could be removing impacted wax, treating ear infections, or treating TMJ dysfunction (jaw problems).
• Reviewing medications
  A GP will review a person’s medications to see if they are exacerbating or potentially causing tinnitus.
• Sound therapy
  Sound therapy can reduce the impact that tinnitus has on a person. They can try having alternative continuous, unobtrusive, low-level sounds playing in the background as a form of distraction from the tinnitus. This can be quiet music, a fan, or the trickle of water from a fountain, for example. You can find further information on sound therapy here. Furthermore, a GP can refer you to Audiology or Hearing Therapy Services who can help advise on the type of sounds to listen to and which might help the most.
• Psychological therapies
  If someone is suffering from significant distress as a result of their tinnitus, they may need psychological support. Psychologists can provide tinnitus-related CBT (Cognitive Behavioural Therapy) to help a person learn to cope with their condition. Alternatively, there are sometimes group-based psychological interventions specifically for tinnitus.
• Hearing aids
  For people with hearing loss who also have tinnitus, offering a hearing aid may help to alleviate how noticeable their tinnitus is. Even if a person does not have any difficulties in communicating, wearing a hearing aid for their hearing loss may also alleviate their tinnitus.
• Addressing other conditions such as depression, anxiety or insomnia
  If tinnitus has led to or is a contributory factor in conditions such as anxiety, depression or insomnia, treating those symptoms is crucial.
• Information on self-care
  Primary care practitioners should be able to provide resources about tinnitus as well as information regarding possible treatments, self-care strategies and the outlook.
• Information on support groups and charities
  GPs often signpost sufferers of tinnitus to appropriate support groups or charities to help them cope with their symptoms. Charities and support services include:
  – RNID – Tinnitus, British Tinnitus Association, ENT UK
• Arranging follow-up appointments
  A GP will also arrange follow-up appointments or referrals to secondary care if the tinnitus or its associated symptoms warrants referral.