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Information About Tinnitus: General Information and Prevalence
Kimberly Langer-Roedel, M.S.--F.A.A.A.
Clinical Audiology Consultant
The EAR Foundation of Arizona
Tinnitus can be defined as ringing in the ears, or other head noises that occur independentfrom an external noise source (Yost, 1994). Studies conducted by the National Center forHealth Statistics estimate that 32% of the general population is affected by tinnitus. Theprevalence of tinnitus increases to 70% to 85% of the hearing impaired population. Thisindicates that over 80% of the patients who have tinnitus, also have some degree of hearingloss. Of the individuals who suffer from tinnitus, both hearing impaired and not, roughly75 percent aren’t seriously bothered by their tinnitus. However, 25 percent of tinnitussufferers are bothered enough by their tinnitus to seek medical attention. This relates toapproximately 1 million tinnitus sufferers who say that their condition seriously disruptstheir lives.
Types Of Tinnitus
Tinnitus can be classified into two categories, objective and subjective forms. The
objective form of tinnitus is less prevalent than subjective tinnitus, and its causes are
simpler to ascertain. Objective tinnitus is noise in the ears that can be heard by an observer
as well as by the sufferer with special listening devices. These noises are usually caused by
inner ear structural defects such as hair cell damage. Objective tinnitus can also be caused
by vascular anomalies or repetitive muscle contractions of the muscles in the middle ear.
Objective tinnitus sufferers may hear rhythmic rushing noise caused by their own pulse,
due to the close proximity of an artery to the middle ear space. This is called pulsatile
tinnitus
. Any structure from the ear canal to the brain can be involved or produce objective
tinnitus, or other sensations of noise. This type of tinnitus can usually be medically
treated, thus relieving the sufferer of tinnitus, or at least assessing a structure that is likely
the cause of the objective tinnitus.
Subjective tinnitus is more common, and is much less understood that the objective form
of tinnitus. Subjective tinnitus is a phenomenon in which the sufferer hears noise in the
head or ears, which cannot be heard by an outside observer (Hazell, 1987). Subjective
tinnitus may be constant and unrelenting, or it may change with respect to frequency or
intensity. Subjective tinnitus may be in one or in both ears, and may also come and go.
Some tinnitus sufferers report that their tinnitus sounds like a high pitched background
squeal, very similar to that emitted by some computer monitors, fluorescent lights and
television sets. Some tinnitus sufferers report that their tinnitus sounds like chirpingcrickets, hissing steam, bells, breaking glass or even chainsaws (Yost, 1994). Theperceptions of the volume, frequency, and handicap caused by tinnitus seem to varygreatly with each sufferer. There is no general agreement about the definition of tinnitus, aclassification system for tinnitus or the mechanism of tinnitus production or perception(Goldstein & Shulman, 1999). Etiology (Causes) of Subjective Tinnitus
Tinnitus is a multifaceted disorder that can affect an individual's hearing, health, emotion,and lifestyle (Kuk, Tyler, Russell & Jordan, 1990). For 43% of tinnitus sufferers there isno known cause for their suffering (McFadden, 1982). For other sufferers, tinnitus maybe caused in part to noise exposure. Many sufferers who are afflicted with tinnitus havebeen exposed to loud noise and also suffer from noise induced hearing loss (Kuk, Tyler,Russell & Jordan. 1990). Repeated exposure to noise such as firearms, artillery, aircraft,lawn mowers, movie theaters, loud music, heavy construction equipment, etc. can causenoise induced hearing loss. A study of 4000 San Francisco Bay rock musicians, performedby the Hearing Education and Awareness for Rockers (H.E.A.R.) organization, indicatedthat nearly 50% of those surveyed indicated the presence of tinnitus. At the NazarethCollege of Rochester, it was found that significantly more music majors than non-musicmajors had some form of tinnitus. This increased prevalence of tinnitus among those whoare routinely exposed to loud levels of sound indicates that tinnitus may be related to noiseexposure, as well as to noise induced hearing loss. It is estimated that 24% of tinnitussufferers can attribute their tinnitus to noise exposure and noise induced hearing loss (McFadden, 1982; Vernon, Johnson, Schleuning & Mitchell, 1980). Another of the many potential causes of tinnitus is cerumen (debris) accumulation in theear canal. The sufferer’s physician can easily ascertain this cause of tinnitus during anotoscopic examination. If there is excessive cerumen or debris this problem can beremedied by using manual removal, irrigation, suction or cerumenilytics to remove theaccumulated debris (Kitahara, 1988). If the tinnitus was caused exclusively by waxaccumulation, the removal of the accumulation should completely eradicate the tinnitus.
A more serious cause of tinnitus is acoustic neuroma. Acoustic neuromas are small, slowgrowing benign tumors that press against or invade the auditory nerve (Clark & Yanick,1984). If the sufferer's tinnitus is unilateral in nature, an acoustic neuroma must first beruled out as the cause of the tinnitus. The undiagnosed acoustic tumor can eventuallyinterfere with the sufferer's hearing mechanism resulting in hearing impairment or moresevere health problems.
Ototoxic drugs are also a common cause of tinnitus. Some analgesics, antiarhythmics,antidepressants, antiemetics, antihistamines, anti-inflammatory agents, anti-ulcer agents, sedatives and muscle relaxants can cause hearing loss, and/or tinnitus. The tinnitus may be
reduced as the medication dosage is reduced or eliminated. It is important for a person who
is experiencing tinnitus to investigate the potential role of medication in the perception of
tinnitus, and to discuss alternative treatments with their physician (Kitahara, 1988; Hazell,
1987). To date there are many medications on the market, both over the counter and
prescription, which list tinnitus as a possible side effect in the Physician’s Desk
Reference
.
Many people experience tinnitus following the onset of a severe ear infection. Thesubsequent tinnitus may be due to the ear infection itself, or to the medication prescribedto combat the infection (e.g., Garamycin). High cholesterol, vascular abnormalities andtempo-mandibular joint disorders have also been found to cause the perception of tinnitus.
Traumatic brain injury, cochlear implant surgery, middle ear surgery, tympanoplasty andfood allergies can also cause or exacerbate tinnitus.
Vertigo and imbalance are not uncommon in the individual who suffers from tinnitus.
When the chief complaint of a patient is tinnitus, clinical experience at the MarthaEntenmann Tinnitus Research Center, Health Sciences Center at Brooklyn StateUniversity, indicates that approximately 60% of tinnitus patients, with or without vertigo,demonstrate a vestibular abnormality when tested (Goldstein & Shulman, 1999). Thisfinding indicates some sort of relationship between the vestibular, or balance system, andthat system which is responsible for either tinnitus production or tinnitus perception. While a causative relationship has not been found, there does seem to be a statisticalcorrelation (Goldstein & Shulman, 1999).
Determining Severity
The severity of a sufferer's tinnitus has been very difficult to determine. Currently thereare two methods to determining the severity of subjective tinnitus, self-assessment toolsand tinnitus loudness matching.
Tinnitus Matching
It has been suggested by Fowler (1940), that tinnitus loudness could be determined by
matching the perceived tinnitus to the known loudness of a pure tone presented to the ear
contralateral to the tinnitus. This method of tinnitus assessment is known as "tinnitus
loudness matching." The intensity of the contralateral comparative tone is determined, and
the "loudness" is interpreted as the dB sensation level of the pure tone (Tyler, Conrad-Armes, 1983). However, as noted previously, there are many factors, which influence asufferer's perception of the tinnitus loudness (e.g., stress, anxiety, annoyance).
Self Assessment Tools
Self-assessment tools are another method for assessing tinnitus severity. Self-assessment
methods are designed for the sufferer to rate the severity of tinnitus using a set of
questions, which correlates with a numeric scale. The numeric scale attempts to represent
the tinnitus as a numerical value on a continuum compared to other tinnitus sufferers. This
form of measure is the most widely used method to determine the severity of tinnitus.
Possible Treatments
Alternative Treatments: The use of magnesium, zinc, B vitamins and Ginkgo biloba has
reduced the severity of tinnitus in some sufferers. Acupuncture, chiropractic care and
magnet therapy have also helped some sufferers. There is little research on the
effectiveness of these treatments; however, the medical risks associated with these
treatments are very few. Therefore, it is prudent to consult your physician to get clearance
to try these treatments.
Amplification: If you have hearing loss, which could benefit from hearing aids, you may
experience complete or partial relief from your tinnitus. The tinnitus generally returns after
the amplification is discontinued, however, some tinnitus sufferers maintain residual benefit
after they remove their hearing aids.
Biofeedback: Biofeedback is a relaxation technique, which allows the patient to control
certain autonomic body functions, such as muscle tension, pulse and level of brain activity.
The goal of biofeedback therapy is to help people control their physiological reaction to
their tinnitus. Controlling their body’s reaction to the tinnitus will hopefully reduce their
perceived handicap associated with their tinnitus.
Cognitive Therapy is a behavioral counseling technique designed to modify a person’s
emotional reaction to tinnitus. This treatment is most effective when used in conjunction
with other tinnitus treatments.
Masking Devices look very much like a hearing aid, however, the masker can be used if
the sufferer does not have hearing loss. The masker emits a low level constant noise, which
distracts the brain from the tinnitus noise. The masking technique may give partial or
complete relief from tinnitus, and also provide some residual benefit after the masker is
removed.
TMJ Treatment: If your tinnitus is likely due to TMJ (temporomandibular joint
dysfunction), bite realignment or dental treatment may relieve some of the pain associated
with TMJ and reduce the tinnitus as well.
Tinnitus Retraining Therapy utilizes both directive counseling and masking devices.
The goal of retraining therapy is to allow the patient to become unaware of their tinnitus
through the natural habituation process. This therapy may take 1-2 years to become
effective.
It is important to remember when evaluating various tinnitus treatment techniques that nosingle treatment method works for everyone. Determining the appropriate and effectivetreatment plan for you may take some effort as well as trial and error. New treatmentplans are becoming available through expanded research in this area, so there is reason tomaintain a positive outlook about overcoming your tinnitus. How Bad is Your Tinnitus?
Does tinnitus make you feel irritable, nervous or insecure? Does tinnitus make you feel tired, ill or depressed? Does tinnitus make it difficult for you to relax or fall asleep? Does tinnitus interfere with work or social activities? Does tinnitus make it difficult to concentrate? Does tinnitus make it uncomfortable to be in quiet? Does tinnitus cause you to avoid some situations? Does tinnitus make it more difficult to interact with others pleasantly? Has your tinnitus gotten worse over the years? Does tinnitus interfere with the overall enjoyment of your life? Where to go for Help
Otolaryngologist: If you are suffering from tinnitus, you should first see your
otolaryngologist (ENT) to determine if your tinnitus is caused by a medical condition. Your ENT (EAR, Nose & Throat) physician will be able to determine if your tinnitus ismedically treatable and discuss those treatments with you. Your ENT may suggest acomplete audiological evaluation performed by an Audiologist. Audiologists are non-medical professionals who specialize in the diagnosis and treatment
of hearing and balance problems. Your audiologist will work in conjunction with your ENT
to determine if a medical or non-medical approach to your tinnitus is most appropriate.
Self Help Groups often give a great deal of needed emotional support to those with
tinnitus. Self Help Groups are not only a great comfort for the tinnitus sufferer, but also
they are a great network to obtain more information on tinnitus and local professionals who
specialize in the treatment and diagnosis of tinnitus.
Associated Web Sites
References
American Tinnitus Association. (1992). Results of the 1992 tinnitus patient survey [On-line]. Available: www.ata.org.com.
American Tinnitus Association. (2000). Drugs with tinnitus side effects [On-line].
Available: www.ata.org.
Chung, D., Gannon, R. & Mason, K. (1984). Factors affecting the prevalence of Tinnitus. Audiology, 23, 441-452.
Clark, J.G. & Yanick, P., Jr. (Ed.). (1984). Tinnitus and its management: A clinical text for audiologists. Springfield, IL: Charles C. Thomas.
Dennis, K. (1993). Development of tinnitus handicap battery. Department of Veteran Affairs, HSR&D Project Report 42, 54.
Feldman, H. (Ed.). (1987). Proceedings: Third international tinnitus seminar. Fowler, E.P. (1944). Head noises in normal and in disordered ears: Significance, measurement, differentiation and treatment. Archives in Otolaryngology, 30, 490-503.
Goldstein, B. & Shulman, A. (1999). Tinnitus targeted therapy: A medical/audiological approach. Tinnitus Today, 24, 8-11.
Habets, B. (1995). The tinnitus handbook: A self-help guide. United Research Publisher: Great Britain.
Hazell, J. (1987). Tinnitus. New York, NY: Churchill Livingstone.
Henry, J.L. & Wilson, P.H. (1995). Coping with tinnitus: Two studies on psychological and audiological characteristics of patients with high and low tinnitus-related distress. International Tinnitus Journal, 2, 85-92.
Jakes, S.C., Hallam, R.S., Chambers, C. & Hinchcliffe, R. (1985). A factor analytical study of tinnitus complaint behavior. Audiology, 24, 195-206.
Kitahara, M. (Ed.). (1988). Tinnitus: Pathophysiology and management. Tokyo: IGAKU_SHOIN Ltd.
Kuk, F., Tyler, R., Russell, D. & Jordan, H.Y. (1990). The psychometric properties of tinnitus handicap questionnaire. Ear and Hearing, 11, 434-445.
McFadden, D. (1982). Tinnitus: Facts, theories and treatments. Washington D.C.: National Academy Press.
Newman, C. (1999). Audiologic management of tinnitus: Issues and options. The Hearing Journal, 52, 10-18.
Newman, C., Wharton, J. & Jacobson, G. (1997). Self-focused and somatic attention in patients with tinnitus. Journal of the American Academy of Audiology, 8, 143-149.
Paparella, M.M. & Meyerhoff, W.L. (Ed.). (1981). Sensorineural hearing loss, vertigo and tinnitus. Baltimore, MD: The Williams & Wilkeins Company.
Penner, M. (1983). The annoyance of tinnitus and the noise required to mask it. Journal of Speech and Hearing Research, 26, 73-76.
Shulman, A. (1991). Medical audiological tinnitus patient protocol. Tinnitus Diagnosis/Treatment, 319-321.
Silman, S. & Silverman, C.A. (1991). Auditory diagnosis: Principles and applications.
San Diego, CA: Academic Press.
Sweetow, R. (1986). Cognitive aspects of tinnitus patient management. Ear and Hearing, 7, 390-396.
Sweetow, R. & Levy, M. (1990). Tinnitus severity scaling for diagnostic and therapeutic usage. Hearing Instruments, 41, 20-21, 46.
Tyler, R. (1993). Tinnitus disability and handicap questionnaires. Seminars in Hearing, 14, 377-383.
Tyler, R. & Conrad-Armes, D. (1983). The determination of tinnitus loudness considering the effects of recruitment. Journal of Speech and Hearing Research, 26, 59-72.
Wilson, P., Henry, J., Bowen, M. & Haralambous, G. (1991). Tinnitus reaction questionnaire: psychometric properties of a measure of distress associated with tinnitus. Journal of Speech and Hearing Disorders, 34, 197-201.
Wynne, M. (1999). Clinical application of self-assessment inventories for tinnitus patients. [Poster Session]. American Academy of Audiology Conference. Miami, FL.
Yost, W.A. (1994). Fundamentals of hearing: An introduction. San Diego, CA: Academic Press.
Zeigler, M. (1999). Tinnitus in college-a comparison of the incidence of tinnitus in college music major, and non-music majors. Tinnitus Today, 24, 20-21.

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