Ringing in the ears is common

Q: I have a constant ringing sound in my right ear, which can be annoying, especially when I am in a very quiet room. I am not sure if frequent flying is the cause of it. I am a 60-year-old man and I use a hearing aid in my right ear when I conduct training sessions. What should I do? Is this condition permanent or temporary? I have checked with a doctor and he has found nothing wrong with the ear, but has suggested that I see a specialist.

A: Tinnitus is defined as a perception of phantom sounds. Ringing in the ears or tinnitus is a very common experience. This has been reported to be present in 17 per cent of the general population and increases to 30 per cent in those more than 65 years old. Our cochlear hair cells emit sounds which can be recorded by advanced hearing test equipment. The cochlear is the part of the inner ear which is receptive to sounds.  We generally do not hear these sound energies as our external sound environment will invariably mask them. Tinnitus does not result from a disease process. It is the perception of neural activity. To quote Professor Pawel Jastreboff, the founder of Tinnitus Retraining Therapy: it results from the brain over-compensating for the presence of a small irregularity in the functioning of the cochlea or auditory nerve. Tinnitus is related to many ear conditions. It can result from hearing loss due to impacted wax in the ear canal, a perforated ear membrane, middle ear effusion (build up of fluid) due to nose cancer or infection, middle ear bone scarring due to infection or another condition called otosclerosis (an abnormal bone growth in the middle ear) from a childhood measles infection. It can also be related to inner ear disorders resulting from infection, trauma, loud noise exposure, medications and tumors in the pathway of the auditory nervous system.  More commonly, acute tinnitus is associated with sudden hearing loss that develops over 72 hours. This is seen in a condition call idiopathic sudden sensori-neural hearing loss. There is no known cause. Those with tinnitus complain of a variety of associated symptoms. These can vary and are dependent on the capacity of the person to cope or compensate. Most patients in the acute stage of tinnitus will complain of annoyance, impact on their lifestyles and difficulty coping in quiet environments, especially at night, when the tinnitus sound is magnified due to the absence of ambient noise. Others will experience distress, inability to rest, frustration, problems with concentration, fears, worries and even headaches. Some patients can be affected to the point of developing sleep disturbances coupled with anxiety and depression. About 75 per cent of patients who have acute tinnitus get better with time because of brain plasticity and adaptation. The remainder of patients will still hear the noise but they get used to this, while a minority (5 per cent) will need medical help to cope. There are different types of tinnitus. Simple tinnitus is the most common. In this group of patients, they hear simple, pure tone sounds such as buzzing, cricket noises or high-pitched sounds or a combination of these. Others describe hearing hooting sounds or even the sound of a train engine.  Another group of patients hear repeated tapping noises because of middle ear myoclonus, a condition that results from twitching of the middle ear muscles. Yet others will hear a rhythmic sound, in time with their heartbeat, defined as pulsatile tinnitus. For the majority of these patients with pulsatile tinnitus, the physicians are not able to hear the sound through auscultation of the head and neck with the stethoscope and generally, no cause is found on X-ray imaging. (Auscultation is the method of listening to the sounds of the body during physical examination, usually with a stethoscope.) Another group of patients with audible pulsatile tinnitus (sounds which the physician can hear following auscultation) would require radiographic imaging to exclude small dural arterio-venous fistulas (abnormal connection or passageway between two vessels that normally do not connect) or vascular brain tumors. The patient with audible pulsatile tinnitus needs early management and treatment before further complications set in. A rarer group of patients will hear complex sounds. I have patients who hear continuous chanting sounds or Chinese opera music 24 hours a day. One patient described hearing Singapore’s national anthem Majulah Singapura, while another described hearing cries of “hallelujah”.  These patients have to be distinguished from a more common group of patients who suffer from schizophrenia. The distinguishing factor is that these patients have severe hearing loss in both ears. Treatment of tinnitus depends on the cause. Removing the ear wax will help those who have tinnitus arising from blocked external ear canals. When this is due to sudden hearing loss with no known cause, a trial of steroids, antiviral medications or antioxidant treatments has been reported to improve the hearing and, subsequently, the tinnitus. For many others for whom the cause of the tinnitus is not found on physical examination and even after various investigations, such as magnetic resonance imaging scans to exclude important treatable inner ear conditions, basic counseling, tips on how to avoid silence and the use of enriched environmental sounds can help. For those who are severely affected by tinnitus, we provide Tinnitus Retraining Therapy. It is a directed counseling therapy and utilizes enriched environmental sounds or noise generators to train the brain to adapt to the tinnitus.