Tinnitus is a condition when a person hears a ringing sound or a different variety of sounds when no corresponding external sound is present and that other people cannot hear.[1] The wordtinnitus comes from theLatintinnire, "to ring".[3]
Tinnitus is usually associated withhearing loss and decreased comprehension of speech in noisy environments.[2] It is common, affecting about 10–15% of people. Most tolerate it well, and it is a significant (severe) problem in only 1–2% of people.[5][6]
The diagnosis of tinnitus is usually based on a patient's description of the symptoms they are experiencing.[3] Such a diagnosis is commonly supported by anaudiogram, and an otolaryngological andneurological examination.[1][3] How much tinnitus interferes with a person's life may be quantified with questionnaires.[3] If certain problems are found,medical imaging, such asmagnetic resonance imaging (MRI), may be performed. Other tests are suitable when tinnitus occurs with the same rhythm as the heartbeat.[3] Rarely, the sound may be heard by someone other than the patient by using astethoscope, in which case it is known as "objective tinnitus".[3] Occasionally,spontaneous otoacoustic emissions, sounds produced normally by theinner ear, may result in tinnitus.[11]
Measures to prevent tinnitus include avoiding chronic or extended exposure to loud noise, and limiting exposure to drugs and substances harmful to the ear (ototoxic).[2][12] If there is an underlying cause, treating that cause may lead to improvements.[3] Otherwise, typically, tinnitus management involves psychoeducation or counseling, such astalk therapy.[5]Sound generators orhearing aids may help.[2] No medication directly targets tinnitus.
Signs and symptoms
Simulation of a tinnitus
Tinnitus is often described as ringing, but it may also sound like clicking, buzzing, hissing, or roaring.[4] It may be soft or loud, low- or high-pitched, and may seem to come from either one or both ears, or from other parts of the head. It may be intermittent or continuous. In some individuals, its intensity may be changed by shoulder, neck, head, tongue, jaw, or eye movements.[13]
Course
Due to variations in study designs, data on the course of tinnitus shows few consistent results. Generally, prevalence increases with age in adults, and the ratings of annoyance increase with persistence at follow up.[14][15][16]
Adverse psychological effects
Although it is an annoying condition to which most people adapt, persistent tinnitus may cause anxiety and depression in some people.[17][18] Tinnitus annoyance is more strongly associated with the psychological condition of the person than the loudness or frequency range of the perceived sound.[19][20] Psychological problems such as depression, anxiety, sleep disturbances, and concentration difficulties are common in those with strongly annoying tinnitus.[21][22] One study found that complications can also include cognitive decline and difficulty communicating,[23] and 45% of people with tinnitus in that study had ananxiety disorder at some time in their lives.[24] Severe cases may lead some to consider suicide;[25][26] while suicidal behavior is complex, tinnitus can be a risk factor.[27] In a cross-sectional analysis, 15.75% of the 292 patients that attended a 2019 Tinnitus and Hyperacusis Clinic in the United Kingdom "expressed that they have been bothered by suicidal and self-harm ideations within the last 2 weeks."[28]
Psychological research has focused on the tinnitus distress reaction to account for differences in tinnitus severity.[21][29][30][31] The research indicates that among the cohort studied, conditioning at the initial perception of tinnitus linked it with negative emotions, such as fear and anxiety.[32]
Types
Commonly tinnitus is classified into "subjective and objective tinnitus".[3] Tinnitus is usually subjective, meaning that the sounds the person hears are not detectable by means currently available to physicians and hearing technicians.[3] Subjective tinnitus has also been called "tinnitus aurium", "non-auditory", or "non-vibratory" tinnitus.
In rare cases, tinnitus may be heard by someone else using astethoscope. Even more rarely, in some cases it may be measured as a spontaneousotoacoustic emission (SOAE) in the ear canal. This is classified as "objective tinnitus",[3] also called "pseudo-tinnitus" or "vibratory" tinnitus.
Subjective tinnitus
Subjective tinnitus is the most frequent type. It may have many causes, but most commonly it results from hearing loss. When it is caused by disorders of theinner ear orauditory nerve, it can be called "otic" (from the Greek word for ear).[33] Theseotological orneurological disorders include those triggered by infections, drugs, or trauma.[34] A cause is traumatic noise exposure that damages thesensory cilia, orhair cells, in the inner ear.[35] Some evidence suggests that long-term exposure to noise pollution from heavy traffic may increase the risk of developing tinnitus.[36]
When there does not seem to be a connection with a disorder of the inner ear or auditory nerve, tinnitus may be called "non-otic". In 30% of cases, tinnitus is influenced by thesomatosensory system; for instance, people can increase or decrease their tinnitus by moving their face, head, jaw, or neck.[37] This type is called somatic or craniocervical tinnitus, since it is only head or neck movements that have the effect.[33]
Some tinnitus may be caused byneuroplastic changes in the central auditory pathway. In this theory, the disturbance of sensory input caused by hearing loss results in such changes,[38] as ahomeostatic response of neurons in the central auditory system, causing tinnitus.[39]
When some frequencies of sound are lost to hearing loss, the auditory system compensates by amplifying those frequencies, eventually producing sound sensations at those frequencies constantly, even when there is no corresponding external sound.
Hearing loss
The most common cause of tinnitus ishearing loss. Hearing loss may have many different causes, but among those with tinnitus, the major cause iscochlear injury.[38]
In many cases, no underlying cause is identified.[2][40]
Ototoxic drugs also may cause subjective tinnitus, as they may cause hearing loss,[12] or increase the damage done by exposure to loud noise.[41] This damage may occur even at doses not considered ototoxic.[42] More than 260 medications have been reported to cause tinnitus as a side effect.[43]
Tinnitus may also occur from the discontinuation of therapeutic doses ofbenzodiazepines. It may sometimes be a protracted symptom ofbenzodiazepine withdrawal and may persist for many months.[44][45] Medications such asbupropion may also cause tinnitus.[46]
A specific type of tinnitus,objective tinnitus, is characterized by hearing the sounds of one's own muscle contractions or pulse, typically a result of sounds that have been created by the movement of jaw muscles or sounds related to blood flow in the neck or face.[52] This type of tinnitus is sometimes caused by an involuntary twitching of a muscle or a group of muscles (myoclonus) or by a vascular condition. In some cases, tinnitus is generated by muscle spasms around the middle ear.[52]
Spontaneous otoacoustic emissions (SOAEs)—faint high-frequency tones that are produced in the inner ear and may be measured in the ear canal with a sensitive microphone—may also cause tinnitus.[11] About 8% of those with SOAEs and tinnitus have SOAE-linked tinnitus,[need quotation to verify] while the percentage of all cases of tinnitus caused by SOAEs is estimated at 4%.[11]
Pediatric tinnitus
Children may be subject to pulsatile or continuous tinnitus, involving anomalies and variants of the vascular parts[53] affecting the middle/inner ear structures. CT scans may be used to check the integrity of the structures, and MR scans may evaluate nerves and potential masses or malformations. Early diagnosis may prevent long-term impairments to development.[54]
Pulsatile tinnitus
Some people experience a sound that beats in time with their pulse, known aspulsatile tinnitus orvascular tinnitus.[55] Pulsatile tinnitus is usually objective in nature, resulting from altered blood flow or increased blood turbulence near the ear, such as fromatherosclerosis or venous hum,[56] but it may also arise as a subjective phenomenon from an increased awareness of blood flow in the ear.[55]
Tinnitus may be caused by increased neural activity in the auditory brainstem, where the brain processes sounds, causing some auditory nerve cells to become overexcited. The basis of this theory is that many with tinnitus also havehearing loss.[63]
Tinnitus may cause stress by triggering afight-or-flight response in brain chemistry, as the brain may perceive it as dangerous and important, and in 2021 was documented as reported by study subjects as increasing during otherwise stressful situations.[64][65][66]
Three reviews in 2016 emphasized the large range and possible combinations of pathologies involved in tinnitus, which result in a great variety of symptoms and specifically adapted therapies.[67][68][69][70]
Diagnosis
The diagnostic approach is based on a history of the condition and an examination of the head, neck, and neurological system.[40] Typically an audiogram is conducted, and occasionallymedical imaging orelectronystagmography.[40] Treatable conditions may include middle ear infection, acoustic neuroma,concussion, andotosclerosis.[71]
Evaluation of tinnitus may include a hearing test (audiogram), measurement of acoustic parameters of the tinnitus such as pitch and loudness, and psychological assessment of comorbid conditions such as depression, anxiety, and stress that might be associated with severity of the tinnitus.[citation needed]
One definition of tinnitus, in contrast to normal ear noise experience, is that tinnitus lasts five minutes at least twice a week.[72] However, people with tinnitus often experience the noise more frequently than this. Tinnitus may be present constantly or intermittently. Some people with constant tinnitus might not be aware of it all the time, but only, for example, during the night or in situations when there is less environmental noise to mask it. Chronic tinnitus may be defined as tinnitus with a duration of six months or more.[73]
Audiology
Since most people with tinnitus also have hearing loss, apure tone hearing test resulting in an audiogram may help diagnose a cause. An audiogram may also facilitate fitting of a hearing aid in those cases where hearing loss is significant. The pitch of tinnitus is often in the range of the hearing loss.
Psychoacoustics
Acoustic qualification of tinnitus includes measurement of several acoustic parameters such as frequency in cases of monotone tinnitus orfrequency range and bandwidth in cases of narrow band noise tinnitus[clarification needed], loudness in dB above hearing threshold at the indicated frequency,mixing-point[clarification needed], and minimum masking level.[74] In most cases, tinnitus pitch or frequency range is between 5 kHz and 10 kHz,[75] and loudness between 5 and 15 dB above the hearing threshold.[76]
Another relevant parameter of tinnitus is residual inhibition: the temporary suppression or disappearance of tinnitus following a period of masking. The degree of residual inhibition may indicate how effective tinnitus maskers would be as treatment.[77][78]
Hyperacusis
An assessment ofhyperacusis, a frequent accompaniment of tinnitus,[79] may also be made.[80] Anari et al. (199) found that 86% of patients with hyperacusis also present with tinnitus.[81]
Hyperacusis is related to negative reactions to sound and may take many forms. One parameter that may be measured is Loudness Discomfort Level (LDL) in dB, which is the subjective level of acute discomfort at specified frequencies over the frequency range of hearing. This defines a dynamic range between the hearing threshold at that frequency and the loudness discomfort level. A compressed dynamic range over a particular frequency range may be associated with hyperacusis. The normal hearing comfort threshold is generally defined as 0–20 decibels (dB). Normal loudness discomfort levels are 85–90+ dB, with some authorities citing 100 dB. A dynamic range of 55 dB or lower is indicative of hyperacusis.[82][83]
Severity
Tinnitus is often rated on a scale from "slight" to "severe" according to the effects it has, such as interference with sleep, quiet activities, and normal daily activities.[84] Severe tinnitus has been associated with rarer variants.[6]
Assessment of psychological processes related to tinnitus involves measurement of tinnitus severity and distress, as measured subjectively by validated self-report tinnitus questionnaires.[21] Such questionnaires measure the degree of psychological distress and handicap associated with tinnitus, including effects on hearing, lifestyle, health, and emotional functioning.[85][86][87] A broader assessment of general functioning, such as levels of anxiety, depression, stress, life stressors, and sleep difficulties, is also important in the assessment of tinnitus due to higher risk of negative well-being across these areas, which may be affected by or exacerbate the tinnitus symptoms.[88]
Current assessment measures aim to identify levels of distress and interference, coping responses, and perceptions of tinnitus to inform treatment and monitor progress. However, wide variability, inconsistencies, and lack of consensus regarding assessment methodology are evidenced in the literature, limiting comparison of treatment effectiveness.[89] Questionnaires developed to guide diagnosis or classify severity of tinnitus may be treatment-sensitive outcome measures.[90][need quotation to verify]
Other potential sources of the sounds normally associated with tinnitus should be ruled out. For instance, two recognized external sources of high-pitched sounds might be electromagnetic fields common in modern wiring and various sound signal transmissions. A common and often misdiagnosed condition that mimics tinnitus is radio frequency (RF) hearing, in which subjects hear objectively audible high-pitched transmission frequencies that sound similar to tinnitus.[94][95]
Prevention
Safety sign from UK Government Regulations requiring ear protection
Prolonged exposure to loudsound or noise levels can lead to tinnitus.[96] Custom madeear plugs or other measures may help with prevention. Employers may use hearing loss prevention programs to help educate and prevent dangerous levels of exposure to noise. Government organizations set regulations to ensure employees, if following the protocol, should have minimal risk to permanent damage to their hearing.[97]
Certain groups are advised to wear ear plugs to avoid the risk of tinnitus, such as that caused by overexposure to loud noises such as wind noise for motorcycle riders.[98] This includes military personnel,[41] musicians,[99] DJs,[100] agricultural workers,[101] and construction workers[102] as people in those occupations are at a greater risk compared to the general population.
Several medicines haveototoxic effects, which can have a cumulative effect that increases the damage resulting from loud noise.[41] If ototoxic medications must be administered, close attention by the physician to prescription details, such as dose and dosage interval, may reduce the amount of damage.[12][103][104][105]
Management
If a specific underlying cause is determined, treating it may lead to improvements.[3] Otherwise, the primary treatment for tinnitus istalk therapy,[5]sound therapy, orhearing aids. There are no effective drugs that treat tinnitus.[3][106][107]
The application ofsound therapy by eitherhearing aids ortinnitus maskers may help the brain ignore the specific tinnitus frequency. Although these methods are poorly supported by evidence, there are no negative effects.[3][112][113] There are several approaches for tinnitus sound therapy. The first is sound modification to compensate for the individual'shearing loss. The second is tailored music therapy, notched at the tinnitus frequency, which may affectlateral inhibition of the notched neural region, suppressing tinnitus.[114][115]
There is some tentative evidence supportingtinnitus retraining therapy, which aims to reduce tinnitus-related neuronal activity.[3][116][115] An alternative tinnitus treatment uses mobile applications that include various methods includingmasking, sound therapy, and relaxation exercises.[117][118] Such applications can work as a separate device or as ahearing aid control system.[119]
Neuromonics is another sound-based intervention. Its protocol follows the principle of systematic desensitization and involves a structured rehabilitation program lasting 12 months. Neuromonics therapy employs customized sound signals delivered through a device worn by the patient, which aims to target the specific frequency range associated with their tinnitus perception.[120]
Physical therapy
Physical therapy for tinnitus focuses on relaxing jaw and neck muscles that may contribute to symptoms. Muscle tension, particularly in the jaw muscles such as themasseter andmedial pterygoid, may radiate to the ears, leading tosomatic tinnitus. Specialized physical therapists use neuromuscular techniques to alleviate tension in these areas, which may reduce tinnitus intensity and the associated pain in connected areas, such as the jaw, teeth, and ears.[121]
As of 2018[update] there were no medications effective for idiopathic tinnitus.[3][96][122] There is not enough evidence to determine whetherantidepressants[123] oracamprosate are useful to treat tinnitus.[124] There are conflicting studies regarding the effectiveness ofbenzodiazepines for tinnitus.[3][122][125][126] As of 2015, the usefulness ofmelatonin is unclear.[127] It is unclear whetheranticonvulsants are useful for treating tinnitus.[3][128] Steroid injections into the middle ear also do not seem to be effective.[129][130] There is no evidence to suggest that the use ofbetahistine to treat tinnitus is effective.[131]
Botulinum toxin injection has succeeded in some of the rare cases of objective tinnitus resulting from a palatal tremor.[132]
In 2009, use in a few countries ofcaroverine to treat tinnitus was published.[133] Upon review, the evidence for its usefulness was very weak.[134]
Neuromodulation
In 2020, information was reported about clinical trials indicating that bimodal neuromodulation may reduce the symptoms of tinnitus. It is a noninvasive technique that involves applying an electrical stimulus to the tongue while also administering sounds.[135] Equipment associated with the treatments is available through physicians. Studies with it and similar devices continue in several research centers.[citation needed]
The Lenire bimodal neuromodulation device marketed by Neuromod was approved as a treatment option for tinnitus in March 2023 by the United StatesFood and Drug Administration (FDA).[136][137][138] In June 2024, the United States Department of Veterans Affairs (VA) announced it would begin offering the treatment to veterans with tinnitus, making it the first bimodal neuromodulation device to be awarded a Federal Supply Schedule (FSS) contract from the U.S. Government.[138]
Research into treatments that may encourage the auditory nerve to repair itself through the use ofneurotrophins is under way.[140] Stéphane Maison, an auditory physiologist at Massachusetts Eye and Ear Infirmary, noted in 2023, "Our work reconciles the idea that tinnitus may be triggered by a loss of auditory nerve, including in people with normal hearing... We won't be able to cure tinnitus until we fully understand the mechanisms underlying its genesis. This work is a first step toward our ultimate goal of silencing tinnitus". The study follows studies that established that treatment with neurotrophins demonstrated encouragement for repair of the nerve in other mammals and the findings should lead to investigation of the potential for a treatment for tinnitus in humans.[141]
Alternative medicines not effective
A 2013 report indicated thatGinkgo biloba does not appear to be effective as a treatment for tinnitus.[122][142] TheAmerican Academy of Otolaryngology recommends against takingmelatonin orzinc supplements to relieve symptoms of tinnitus, and reported in 2014 that evidence for the efficacy of many dietary supplements (such as lipoflavonoids, garlic, traditional Chinese/Korean herbal medicine, honeybee larvae, and various other vitamins and minerals, as well as homeopathic preparations) did not exist for tinnitus.[96] A 2016 Cochrane Review also concluded that evidence was not sufficient to support taking zinc supplements to reduce symptoms associated with tinnitus.[143]
Prognosis
While there is no cure, over time most affected people adapt to living with tinnitus; for a minority, it remains a significant problem.[5]
Epidemiology
Adults
Tinnitus affects 10–15% of people.[5] About a third of North Americans over age 55 experience it.[144] Tinnitus affects one third of adults at some time in their lives, whereas 10–15% are disturbed enough to seek medical evaluation.[145] InEurope, 70 million people are estimated to have tinnitus.[146][147]
Children
Commonly thought of as typically affecting adults, tinnitus often is overlooked in children. Even though children do not express the condition or its effect on their lives, children with hearing loss have a high incidence of pediatric tinnitus.[148][149] Children do not generally report tinnitus spontaneously and their complaints may not be taken seriously.[150] Among children who do complain of tinnitus, there is an increased likelihood of associated otological or neurological pathology such as migraine, juvenile Meniere's disease, or chronic suppurative otitis media.[151]
Its reported prevalence varies from 12 to 36% in children with normal hearing thresholds, and up to 66% in children with a hearing loss. Approximately 3–10% of children have been reported to be troubled by tinnitus.[152]
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