What Can Be Done About It
Have you ever experienced a strange ringing sound in your ear that sounded as if a mosquito had gone in? Have you ever wondered what causes the ringing sound, and whether it is a manifestation of something more serious? If you suffer from this ringing sound (called tinnitus), then you should continue reading.
In this article, I will explore the common causes of tinnitus, and how you can distinguish the benign causes from the ominous ones.
The ear is a noise-producing factory
The inner ear converts sound energy in the air to electrical energy so that it can be conducted along the hearing nerve to the brain for perception. This process of energy conversion is not totally efficient, and will result in the production of by-products. The main by-product is noise that is usually so soft that it cannot be perceived amidst the noisy din of daily living.
However, if you were to go into a quiet room, you will be able to perceive this by-product noise as a high pitch ringing sound in your ears. In ears that have degenerated with age or injured by excessive exposure to noise, the energy conversion is less efficient. The by-product noise then becomes louder and more perceptible. The tinnitus may become so loud that it can even be heard even as you are walking along a busy street!
How is tinnitus produced?
There are 3 processes that can result in tinnitus:
- Any form of external or middle ear hearing loss that blocks the perception of environmental noise. The inner ear by-product noises will then appear louder and perceptible.
- Any type of inner ear injury that will cause inefficient conversion of acoustic sound energy into bio-electrical energy. The amount of byproduct noise is increased, and can be heard even in the presence of a noisy background environment.
- The tinnitus comes from outside the ear. The noise is produced by anatomical structures that are near the ear, e.g. temporomandibular joint (lying just in front of the ear), arteries and veins near the ear, muscle contractions in the head and neck, and turbulent airflow in the nose and upper airways.
Tinnitus and the outer ear
Anything that obstructs the external ear canal, like wax, foreign body or tumors will impair the passage of sound energy to the inner ear. Because the inner ear hears less of the environment, the by-product noises from the inner ear will appear louder and becomes more perceptible.
A patient of mine, Mr. Lim, visited me in my clinic complaining of right ear tinnitus for 6 months. He had been losing sleep and feeling depressed because of the tinnitus. He also found it difficult to concentrate on his work and to pay attention during night class. He had a habit of drying his ear with a cotton bud after showering.
When I examined him, I found a large piece of cotton wool blocking his ear canal. The piece of cotton wool had been resident in her ear canal for 6 months! The tinnitus disappeared instantaneously when the cotton wool was removed from his ear canal.
Tinnitus, the middle ear and its muscles
If you have lost your hearing because of a broken ear drum or middle ear infection, the by-product noise from the inner ear will appear louder simply because there is less environmental noise to mask it. Middle ear infections can also cause tinnitus through the production of bacterial toxins. These toxins can diffuse into and poison the inner ear. More by-products are then produced and eventually bring about tinnitus.
The 3 parts of the ear:
- External ear
- Middle ear
- Inner ear
There are 2 tiny muscles in the middle ear that will contract when the ear is exposed to loud sounds. The contraction will stiffen up the middle ear bones and ear drum to reduce the loudness of the sounds reaching the inner ear. This contraction of the middle ear muscles protects the inner ear against exposure to loud noises.
The middle ear muscles can sometimes go into spasms and uncoordinated contractions (called myoclonus). When this happens, you will hear a clicking sound in the ear. The clicking sounds can become so loud that another person can hear it with a stethoscope. Tinnitus that can be perceived and verified by another person is described as being “objective”.
Tinnitus and the inner ear
Inner ear function will deteriorate with the ravages of time. Presbyacusis (presby = old, acusis = hear) or hearing loss associated with the degenerative effects of ageing causes inefficient hearing. Sound energy from the environment is being transmitted to the inner ear, but the inner ear is unable to fully convert all the energy into bio-electrical energy that the brain can recognize. This results in hearing loss and tinnitus.
A tympanometer measures the middle ear pressure, ear drum mobility and acoustic reflexes An example of a tympanometry reading which shows:
- Normal ear drum mobility
- Normal ear drum mobility
- Normal middle ear air pressure, which means a normal functioning Eustachian tube
- The volume (V) of the external ear canal is 1.12 ml
- Acoustic reflexes are present
Another common cause of inner ear damage is excessive exposure to loud damaging noise. This causes increased wear and tear of the inner ear – akin to jogging on the road without using proper shoes. Over time, the inner ear gets worn out and hears less efficiently. The extra by-products produced results in tinnitus.
The fragility of the inner ear
The inner ear is affected by a large variety of lifestyle factors – diet, alcohol, tobacco, caffeine, salt, and monosodium glutamate (MSG). Some people are particularly sensitive to salt and MSG. I once treated a patient who would get severe tinnitus whenever she consumed food that contained excessive amounts of salt and MSG. Smoking can lead to tinnitus by causing a narrowing of the blood vessels that supply the inner ear.
Inner ear damage can also occur in SCUBA divers who do not observe the usual health precautions. I once treated a diver who continued to dive even though she had sinusitis and could not clear her Eustachian tubes.
During the dive, she tried to forcefully clear her Eustachian tubes, but to no avail. The increased pressure produced by the Valsalva maneuver was transmitted to the inner ear, causing a round window rupture, and she suffered an acute bout of vertigo, hearing loss and tinnitus.
There are many diseases that affect the body in general and are not specifically related to the ear. Yet they can give rise to disabling tinnitus and even hearing loss.
Conditions like anemia, diabetes, hypertension, abnormal lipid profile, high cholesterol level, kidney failure and liver problems can cause tinnitus by poisoning the inner ear with toxins and depriving it of a healthy blood supply.
Certain drugs like antibiotics, diuretics, and pain-killers can also cause tinnitus by modifying the chemistry within the inner ear.
The acoustic (hearing) nerve and its connections
Tumors can grow and press on the acoustic nerve, giving rise to hearing loss and tinnitus. The most common type of tumor affecting hearing is the acoustic neuroma. This is a benign tumor of the hearing nerve that normally affects only one ear.
Because these tumors are usually unilateral and affect only one ear, tinnitus and hearing loss is therefore more ominous if it affects only one side. A person with one-sided hearing loss should have his inner ears imaged with an MRI (magnetic resonance imaging) in order to exclude or confirm the diagnosis of acoustic neuroma.
This is tinnitus that is audible to another person using a stethoscope. The noises come from a source external to the ear – arteries, veins, joints, muscles, Eustachian tube and airflow in the nose and upper airways.
When tinnitus coincides with the pulse and heartbeat, it is described as “pulsatile”. Pulsatile tinnitus comes from narrowed arteries in the vicinity of the ear. They may also be caused y the presence of a vascular tumor that is richly supplied with blood vessels, e.g. glomus tumor.
During pregnancy, or in people on crash diets (and losing weight rapidly), the Eustachian tube may become wider than usual (patulous Eustachian tube). The noise from the turbulent airflow in the nose and upper airways can then be transmitted easily to the ear. This gives rise to tinnitus that coincides with breathing. The patient can hear himself breathe.
Effects of stress, worry and anxiety
Most types of tinnitus are not serious or life-threatening. However some people may worry excessively about life-threatening causes, take a pessimistic outlook, and are overly concerned about the worst case scenario. When this happens, the tinnitus becomes a bigger problem than it should be.
Although tinnitus does create some inconvenience, its impact is blown out of proportion if the sufferer worries excessively about it. It is important to manage the irrational fears and anxiety that a tinnitus sufferer experiences. Even if the tinnitus cannot be alleviated, at least its impact on life can be minimized and the quality of life enhanced.
Is there a SOLUTION for tinnitus?
Effective treatments are available for tinnitus. The treatment has to be customized for each individual because the causes for tinnitus differ from person to person.
Treatment can only be prescribed after a process of trouble-shooting to understand the specific factors at play in causing tinnitus. The diagnostic phase will include a thorough history taking, physical examination, endoscopic examination of the nose and throat, hearing tests, blood tests and imaging studies like CT scans and MRI.
In some situations, I would direct treatment at the annoyance and irritation that the tinnitus causes rather than the tinnitus itself. Annoyance reduction may be achieved with a combination of cognitive behavior therapy, medications and exercises. Many times, the loudness of the tinnitus decreases when the annoyance caused by the tinnitus is treated.
Drugs, vitamins and herbs for tinnitus
Drugs relieve tinnitus through the following mechanisms:
- Improve the circulation, oxygenation and nutrition to the inner ear and brain, e.g. betahistine, niacin and carbogen (a mixture of 5% carbon dioxide and 95% oxygen).
- Reduce the swelling of the inner ear that causes recurrent vertigo, hearing loss and tinnitus (Meniere’s disease), e.g. steroids and diuretics.
- Stabilize the connecktions between the inner ear hair cells and the hearing nerves, e.g. caroverine. Caroverine works on a specific type of tinnitus called cochlear-synaptic tinnitus.
- Alleviate the stress and anxiety that comes with each attack of tinnitus, and the worry that it may be a manifestation of a more serious condition, e.g. sedatives, benzodiazepines, tranquilizers, and SSRIs (selective serotonin reuptake inhibitors).
- Supplement vitamins or minerals that are deficient in the diet, e.g. vitamin B complex, folate, zinc, and magnesium.
Chinese physicians have used gingko biloba leaves for centuries to treat asthma and bronchitis. Gingko has been shown to increase circulation in the body and brain. Most studies showed that 30% to 70% of subjects had reduced symptoms over a 6 to 12 week period. No serious side effects were observed. There were a few minor side effects that were not statistically significant compared to subjects treated only with placebo.
Remedies that reduce stress
Certain techniques, like biofeedback, acupuncture, massage and aromatherapy, may help to alleviate tinnitus by reducing stress and allowing the tense body and mind to relax. Many people report that their tinnitus worsens when they are tired and stressed out from a hard day’s work. Getting a good night’s sleep and avoiding unneckessary bad stress will help to improve tinnitus.
Having some soothing background music while sleeping at night will help the mind relax as well as provide background noise to mask out the tinnitus.
How to mask the perception of tinnitus
People with tinnitus may benefit from hearing aids to enhance the perception of environmental sounds. The background noise will then suppress and block out the tinnitus. Masking is the technique of using external sounds to mask the tinnitus and to make it less disturbing. Masking machines look like hearing aids and come in both in-the-ear and portable models.
Many people also find relief from tuning a regular FM radio to an empty frequency station and listening to static. This static is the product of low frequency remnant sounds arising from the cosmic background microwave radiation, a relic from the birth of the universe during the Big Bang.
So next time if you cannot sleep because of tinnitus, you should consider listening to the birth of the universe!
Another popular method is to run a slightly noisy old electric fan, or to sleep with the bedroom windows open to let the sounds of traffic in. If you have an audio CD player, consider putting on a CD with the sounds of nature (ocean, jungle, waterfall, seaside, etc) or light music before going to bed.
Can tinnitus be prevented?
The most common cause of tinnitus is over-exposure to excessively loud noise. As exposure to loud noise is usually avoidable, most cases of tinnitus are therefore preventable.
Avoid these noisy situations, or use hearing protection to reduce its damaging effects. Rock concerts, movie theatres, nightclubs, construction sites, guns, power tools, stereo headphones and loud musical instruments are just some of the things that can be hazardous to your ears.
If you experience temporary ringing sounds in your ears after being exposed to loud noise, you are at risk of suffering from hearing loss and tinnitus. If the tinnitus is causing you to worry that you might be suffering from a brain tumor, get your doctor to evaluate the problem for you.
If the tinnitus is affecting our quality of life and ability to perform and concentrate, your doctor may design a treatment strategy to reduce the impact of the tinnitus. No matter what the cause of tinnitus is, many tools are available that will help you manage and cope with the problem.
The TEN Steps to Tinnitus Relief
Here are some techniques that will help you gain control of your tinnitus problem:
- Get enough sleep and rest. Avoid sleep deprivation and excessive fatigue.
- Avoid the use of nerve and brain stimulants, e.g. coffee (caffeine) and smoking (nicotine).
- Accept the tinnitus as an annoying reality, and learn to ignore it as much as possible.
- Know that the tinnitus will not cause you to go deaf, lose your mind, or cause death. Banish all catastrophic and terrifying thoughts from your mind.
- Tinnitus is more disturbing at bedtime in quiet surroundings. Any noise in the room, such as the nearby sounds of traffic, or a CD of soothing music, will mask and cover up the irritating tinnitus and make them less annoying.
- If you have significant hearing loss, a hearing aid can reduce your tinnitus by amplifying environmental sounds and masking the tinnitus.
- A masking device may help reduce tinnitus by introducing external sounds. Many patients obtain relief only when the device is worn, while others find that tinnitus is reduced for hours even after the device has been removed.
- Some patients become depressed when they are unable to cope with their tinnitus. These patients will benefit from tinnitus retraining therapy, tinnitus habituation, cognitive behavior therapy, physical exercise, and anti-tinnitus medication.
- Stress and anxiety can amplify the perception of tinnitus, and increase the distress and annoyance caused by tinnitus. Patients can benefit from biofeedback, acupuncture, massage, aromatherapy, and stress management training.
- Tinnitus is worsened by jaw (temporomandibular) or neck musculoskeletal disorders. In these cases, dental treatment or physical therapy may be helpful.