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Tinnitus: what can be done?

Lucy Handscomb
MA Certificate in Hearing Therapy
Audiologist
Chair of the Professional Advisers' Committee of the British Tinnitus Association

Tinnitus is a common complaint. About 7% of adults in the UK have seen a doctor about it at some time in their lives.(1) However, while most common complaints that turn up at GP surgeries, such as migraine, throat infection and hypertension, are widely known about, tinnitus is not. Many people who develop tinnitus have never heard of it before, some of their friends look at them as though they are crazy when they describe noises in their heads, and many practitioners seem to be at a loss as to how to help them. "The doctor said I just had to learn to live with it" is a frequent lament.
The Concise Oxford Dictionary defines tinnitus as "ringing in the ears". In fact, ringing is just one of a multitude of sounds heard by different people with tinnitus. Buzzing, whistling, roaring, hissing, sizzling and humming are a few of the other noises described, and some people hear more than one noise at a time. For some it is continuous, for others it comes and goes. Moreover, tinnitus is not always in the ears - it may be in just one ear or the other, or somewhere in the middle of the head. A more accurate definition of tinnitus was proposed by McFadden: ''The conscious expression of a sound that originates in an involuntary manner in the head of its owner, or may appear to him to do so."(2)

Hearing loss
People with hearing loss are about three and a half times more likely to have tinnitus than people with normal hearing, and whatever the cause of the hearing loss (noise, aging, trauma, infection) tinnitus may appear alongside it. It is associated with both sensori-neural and conductive hearing loss and affects people with slight hearing difficulty as well as those with severe deafness. However, not everyone with hearing loss has tinnitus, and not everyone with tinnitus has hearing loss; it affects people with normal hearing as well. In some cases the onset of tinnitus can be related to a specific event - an ear infection, for example, or a blow to the head. Sometimes ear syringing seems to be a trigger, but only in a small minority of cases. Ear syringing can also alleviate tinnitus if it improves hearing. In other cases emotional factors are associated with tinnitus onset; it is not uncommon for tinnitus to start after bereavement or during a time of anxiety about other health issues.(3)
In many cases, however, the onset is gradual and is not attributable to any specific event. Tinnitus is rarely caused by any sinister pathology, but if it is unilateral there is a small possibility that a vestibular schwannoma (a benign tumour of the neurilemma of a nerve) could be the cause, and an MRI (magnetic resonance imaging) scan is recommended. This normally has to be arranged through a hospital ENT department, so a routine referral to ENT that highlights the fact that tinnitus is unilateral is all that is required from primary care.
Some people hear pulsatile tinnitus, which may be described as a thudding or whooshing sound that keeps time with the heartbeat. This can sometimes be heard through a stethoscope placed on the neck or skull and could indicate a problem such as atherosclerosis, for which imaging can be carried out. Once these factors have been investigated, pulsatile tinnitus can be successfully treated in the same way as other forms of the condition.

Distress or no distress?
Two notable and surprising facts about tinnitus are that the majority of people who have tinnitus are not troubled by it and may not even mention it to a doctor, and the loudness of tinnitus does not correlate with the level of distress that it causes.(1) A number of experiments have been conducted in which people are asked to match the volume of their tinnitus to the intensity of a tone, and time and again there are people with tinnitus of high intensity who describe it as manageable, and others with tinnitus of very low intensity who describe it as unbearable.4 Similarly, the quality of the tinnitus sound - whether it is humming, buzzing or whistling - seems to have no bearing on how distressing it is for the person.  

Awareness
So if it is not the intensity or quality of the sound, what is it that determines whether a person is a tinnitus sufferer or simply a tinnitus experiencer? The crucial factor seems to be awareness - as opposed to presence - of tinnitus. A lot of people who have tinnitus simply do not notice it much of the time, because they are surrounded by other sounds and because they are not worried about it. It has about as much significance as the fridge humming away in the kitchen.
For others, however, the tinnitus is hugely significant. They may be worried about why they have it, whether it will get worse and whether it will drive them mad. They may be devastated about the loss of silence or angry with themselves or someone else for bringing it on - perhaps by going to a club or syringing their ears. They may be upset by the consequences of tinnitus such as lack of sleep, difficulty concentrating or increased irritability. All of these factors can contribute to making tinnitus a dominant and distressing problem in a person's life.
It follows then that much of the treatment available for tinnitus centres on giving people a greater understanding of it and an ability to reduce its impact. Most tinnitus clinics offer some form of habituation therapy, which works on the principle that it is possible for the brain to habituate to tinnitus in much the same way that it habituates to fridges, computer fans and passing cars in the surrounding environment. While some people habituate to their tinnitus quite naturally, others need help in overcoming barriers to habituation, which can be worries about the meaning of tinnitus, negative thoughts about it or a high level of stress and anxiety.(5) Clear information and reassurance about tinnitus (it isn't a brain tumour, it won't make you deaf, it won't get louder and louder as you get older) is a vitally important part of therapy, as is helping people to modify their negative thoughts about and emotional reactions to the noise. At least half of the people seen in tinnitus clinics have difficulty sleeping, so sleep management strategies are an important part of therapy, and relaxation techniques can help both those who have trouble sleeping and those who feel wound up during the day.(6)

White noise
Some patients attend clinics expecting to be offered tinnitus maskers. Use of white noise to drown out tinnitus - often delivered by a special device worn in the ear - was a popular technique in the past, and provided welcome relief for many. But the problem with masking is that it does not allow habituation to happen. The brain cannot habituate to a noise it cannot hear, and therefore it can only be a temporary measure.
These days the emphasis is on using other sounds at a lower level, so the tinnitus is still audible, but the brain has an alternative focus. White noise generators worn in the ears are one option, but many other sounds can be helpful too, and the mode of delivery is not particularly important. A lot of people with tinnitus find recordings of nature sounds, such as running water or birdsong, to be beneficial, especially when trying to sleep at night.(7) If the person's partner is disturbed by the sound, a pillow speaker can be used. This is preferable to earphones which can get uncomfortable when lying down. However, a number of partners without tinnitus find nature sounds equally soothing to listen to, and some want to keep using them after the person with tinnitus no longer feels the need!

Hearing aids
Most tinnitus clinics are based within an audiology department, where the hearing needs of patients can also be addressed. The majority of people with both tinnitus and hearing loss find that hearing aids reduce their awareness of the tinnitus significantly, because they give them better access to ordinary environmental sounds and because they reduce the need to strain to hear. Listening very hard all the time because of a hearing difficulty is one of the things that makes tinnitus more audible. In those who are profoundly deaf, a cochlear implant often reduces tinnitus as well as restoring some hearing ability.
Of course in some cases (such as otosclerosis) hearing loss is correctable surgically, and an improvement in tinnitus is often (but not always) reported along with an improvement in hearing. Contrary to what some patients believe, however, severance of the acoustic nerve does not eliminate tinnitus, and this course of action is never advised even in the most desperate of cases.

Treatment
As yet there is no effective drug treatment for tinnitus, although it is possible that this situation will change in future. There has been some excitement about the herbal remedy ginkgo biloba in recent years, but a couple of large-scale studies have shown it to be ineffective, at least in the majority of cases.(8,9) Where drugs can be helpful is in treating the co-symptoms of tinnitus. People who are depressed or anxious generally have a harder time coping with tinnitus than those who are not, and if the depression or anxiety is successfully treated with medication, the tinnitus is likely to become more manageable, particularly if the patient is getting a better night's sleep. 
However, a prescription for antidepressants alone is unlikely to make the patient leave the GP surgery feeling that the tinnitus he came in with has been properly addressed. Even if you have only a short time with each patient, a few words of reassurance and a demonstration that you understand how distressing the condition can be goes a long way. Too many patients suffer needlessly for months, worrying that their tinnitus will get worse and worse or is a sign of insanity; a few well chosen words can lay these fears to rest. Clear, accurate information, such as leaflets published by the British Tinnitus Association (BTA), should be easily available at every practice for patients to take home (see Resources). The most important message to get across is that help is at hand. People do have to learn to live with tinnitus, but there are ways of doing this successfully, and they don't have to do it alone.

References

  1. Davis A, El Refaie E. Epidemiology of tinnitus. In: Tyler R, editor. Tinnitus handbook. San Diego: Singular; 2000.
  2. McFadden D.  Tinnitus: facts, theories and treatments. Report of working group 89, committee on hearing bioacoustics and biomechanics. Washington DC: National Research Council National Academy Press; 1982.
  3. Jastreboff P, Hazell J. Tinnitus retraining therapy. Cambridge: Cambridge University Press; 2004.
  4. Lindberg P, Scott B, Melin L, Lytkkens L. Behavioural therapy in the clinical management of tinnitus. Br J Audiol 1988;22:265-72.
  5. Hallam R, Rachman S, Hinchcliffe R. Psychological aspects of tinnitus. In: Rachman S, editor. Contributions to medical psychology. Oxford: Pergamon Press; 1984.
  6. McKenna L. Tinnitus and insominia. In: Tyler R, editor. Tinnitus handbook. San Diego: Singular; 2000.
  7. Handscomb L. Use of bedside sound generators by patients with tinnitus-related sleeping difficulty: which sounds are preferred and why? Acta Otolaryngol 2006;556 Suppl;59-63.
  8. Rejali D, Sivakumar A, Belaji N. Ginkgo biloba does not benefit patients with tinnitus: a randomized placebo-controlled double-blind trial and meta-analysis of randomized trials. Clin Otolaryngol 2004;29:226-31.
  9. Drew S, Davies E. Effectiveness of ginkgo biloba in treating tinnitus: double blind, placebo controlled trial. BMJ 2001;322:73.

Resources
British Tinnitus Assocation (BTA)
W: www.tinnitus.org.uk
Helpline: 0800 0180527
Can provide
immediate reassurance and information about tinnitus clinics