Patient education: Tinnitus (ringing in the ears) (Beyond the Basics)

TINNITUS OVERVIEW — Tinnitus is the perception of a ringing, buzzing, hissing, or roaring sound in one or both ears. It may be continuous or intermittent (occasional), can be pulsing or steady, and can range in severity from a soft buzz to a loud ring.

It is estimated that as many as 50 million people in the United States suffer from chronic tinnitus (lasting longer than six months) [1]; about a quarter of those have tinnitus that is severe enough to interfere with daily activities. Tinnitus is more common in men than women, and it becomes more common with aging [2,3].

Although tinnitus can be annoying, it is not usually a sign of a serious problem. There are ways to mask and adapt to the symptoms to minimize the impact of tinnitus on daily life.

TINNITUS CAUSES — Tinnitus is often caused by damage to the tiny hairs on auditory cells within the inner ear (figure 1). When the cells are damaged or stressed, they change the signal they send to the brain. Sometimes this produces a noise heard only by the patient. Damage to the hair cells can be a result of normal aging, or it can occur after exposure to very loud noise, certain medications, injury, or disease. Sometimes the damage is temporary but the noise is permanent.

Occasionally tinnitus can be a result of problems not related to the hearing system. Disorders of the jaw joint (called the temporomandibular joint), severe anxiety, and neck injuries can cause tinnitus.

Age-related hearing loss — Normal hearing loss often occurs with advancing age and is frequently accompanied by tinnitus.

Noise-induced hearing loss — Prolonged exposure to excessively loud noise (eg, from chainsaws, gunfire, or even loud music) may lead to temporary or permanent hearing loss and tinnitus. A short blast of loud noise also can cause severe to profound hearing loss, pain, or hyperacusis (abnormal sensitivity to noise).

Other causes of auditory system dysfunction — There are many auditory problems that can lead to hearing loss and tinnitus. These include use of certain medications, stiffening of the bones in the middle ear (otosclerosis), tumors within the auditory system, blood vessels or neurologic disorders, and genetic or inherited inner ear disorders.

TINNITUS SYMPTOMS — A high-pitched steady tone (ringing) is the most common form of tinnitus. Other symptoms can include a pulsation that is rushing or humming and varies in intensity with exercise or changing of body position. A clicking sound may indicates a nerve or muscle abnormality.

TINNITUS DIAGNOSIS — It is important for anyone with tinnitus to be evaluated to ensure that there is not another, more serious problem. In addition, anyone with severe or worsening and continuous ringing, buzzing, or other noises in the ear should be evaluated. Other specialized tests may be recommended.

Hearing tests can help provide more information about the potential cause of tinnitus. Other tests, such as brain imaging with magnetic resonance imaging (MRI) or computed tomography (CT) scans may be needed, depending upon the results of the medical history and physical examination.

TINNITUS MANAGEMENT — The management of tinnitus involves treating any underlying disorders or abnormalities (see 'Tinnitus causes' above) as well as addressing the tinnitus itself. Although there is no cure for most cases of chronic tinnitus, there are ways to manage the condition.

Treatment of underlying problems

Hearing loss — Hearing aids may improve tinnitus symptoms in people with age-related hearing loss. Hearing aids work by making outside sounds clearer and louder, which may cause the tinnitus noise to be less noticeable. People with other causes of hearing loss may benefit from surgery to the outer or middle ear.

Cochlear implants are devices that are implanted in the inner ear and use electrical stimulation to help improve hearing. They may be recommended for adults or children with severe to profound hearing loss who do not benefit from hearing aids. These implants may help relieve tinnitus in some cases; however, they are only available in selected cases and a full evaluation is required before consideration.

In patients with auditory system damage due to use of medication, stopping the medication may improve tinnitus and prevent hearing loss from worsening. Patients should consult with a health care provider before starting or stopping any medications.

Depression — Depression is common in people with tinnitus. Safe and effective treatments for depression are available and antidepressant medications may improve the symptoms of tinnitus in some people. Antidepressants can also improve a person's ability to cope with the problem. (See "Patient education: Depression in adults (Beyond the Basics)" and "Patient education: Depression treatment options for adults (Beyond the Basics)".)

Insomnia — People who have difficulty sleeping as a result of tinnitus may be treated with medications and/or behavior changes to improve sleep. (See "Patient education: Insomnia treatments (Beyond the Basics)".)

Behavioral therapies — A number of behavioral therapies can help a person to live with chronic tinnitus.

Tinnitus retraining therapy — Tinnitus retraining therapy (TRT) involves retraining the subconscious part of the auditory system to accept the sounds associated with tinnitus as normal, natural sounds rather than annoying sounds [4]. The goal is for the person to become unaware of their tinnitus unless they consciously choose to focus on it.

TRT is performed by experts in a tinnitus center; it includes counseling as well as the use of a wearable device that emits low-level noise and environmental sounds. Although TRT has demonstrated short-term success in many tinnitus sufferers, it requires a commitment to the program; the noise-generating device may need to be worn for one to two years. Studies show up to 80 percent of patients find some relief of their tinnitus with TRT.

Masking — Masking devices resemble hearing aids and produce low-level sounds, which help to reduce or eliminate the tinnitus noise in some patients [5]. Masking does not relieve tinnitus in all patients. Some people report a worsening of their tinnitus with masking. Those who do experience relief typically find that tinnitus returns after the masking device is removed.

Patients can also achieve a lesser degree of masking by listening to quiet music or creating low background noise with a radio on low volume, a fan, a white noise machine, or pillow speakers. This may be especially helpful for people with tinnitus that is bothersome in quiet environments.

Biofeedback and stress reduction — Biofeedback is a relaxation technique that teaches a person to control certain body functions, such as heart and breathing rate. Biofeedback may help people to manage tinnitus-related distress by changing their reaction to it. Some people experience relief of tinnitus symptoms once they are able to stop thinking of their tinnitus as bothersome or stressful [6].

Cognitive behavioral therapy — The goal of cognitive behavioral therapy (CBT) is to teach patients to manage their psychological responses to tinnitus. It involves using coping strategies, distraction skills, and relaxation techniques.

Other therapies — A number of other types of treatments for tinnitus have been studied, although none have been found to reliably be more effective than placebo. Nevertheless, many tinnitus support groups have members who are helped by these treatments. Individual patients who respond may be experiencing a true benefit.

●Electrical stimulation – Electrical stimulation of certain parts of the inner ear can be accomplished by placing electrodes on the skin or using acupuncture needles (see below). There are different modes of delivering electrical stimulation, depending on the patient's situation and other factors such as whether hearing loss is present.

●Acupuncture – Acupuncture involves inserting hair-thin metal needles into the skin at specific points on the body. It causes little to no pain. Acupuncture may be used alone or in combination with electric stimulation.

●Repetitive transcranial magnetic stimulation – During repetitive transcranial magnetic stimulation (rTMS), a powerful magnetic field is used to stimulate the brain. This treatment shows promise for some tinnitus sufferers but is still experimental.

●Herbal remedies – Combinations of herbs (also called botanicals) are often promoted as treatments for medical problems. Herbal medicines may come in the form of a powder, liquid, or pill. Ginkgo biloba and melatonin have both been studied for use in treating tinnitus. While some patients report benefit from these types of treatment, there are no studies with high rates of improvement in tinnitus from herbal remedies.

●Vitamins and minerals – Vitamins and minerals that have been studied for treatment of tinnitus and inner-ear health include niacin (a B vitamin), zinc, and copper. While some patients report benefit from these types of treatment, there are no studies with high rates of improvement in tinnitus from vitamin or mineral remedies.

PROGNOSIS — The impact of tinnitus on everyday life varies, often depending upon the severity of the tinnitus noise. About 25 percent of sufferers report an increase in tinnitus severity over time [7]. Long-term tinnitus is unlikely to go away completely. However, it often becomes less bothersome over time, especially when hearing loss is also present.

WHERE TO GET MORE INFORMATION — Your healthcare provider is the best source of information for questions and concerns related to your medical problem.

This article will be updated as needed on our web site (www.uptodate.com/patients). Related topics for patients, as well as selected articles written for healthcare professionals, are also available. Some of the most relevant are listed below.

Patient level information — UpToDate offers two types of patient education materials.

The Basics — The Basics patient education pieces answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials.

Patient education: Tinnitus (ringing in the ears) (The Basics)
Patient education: Age-related hearing loss (presbycusis) (The Basics)
Patient education: Ear wax impaction (The Basics)
Patient education: Labyrinthitis (The Basics)
Patient education: Meniere disease (The Basics)
Patient education: Vestibular schwannoma (acoustic neuroma) (The Basics)

Beyond the Basics — Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are best for patients who want in-depth information and are comfortable with some medical jargon.

Patient education: Depression in adults (Beyond the Basics)
Patient education: Depression treatment options for adults (Beyond the Basics)
Patient education: Insomnia treatments (Beyond the Basics)

Professional level information — Professional level articles are designed to keep doctors and other health professionals up-to-date on the latest medical findings. These articles are thorough, long, and complex, and they contain multiple references to the research on which they are based. Professional level articles are best for people who are comfortable with a lot of medical terminology and who want to read the same materials their doctors are reading.

Etiology and diagnosis of tinnitus
Etiology of hearing loss in adults
Evaluation of hearing loss in adults
Hearing amplification in adults
Treatment of tinnitus

The following organizations also provide reliable health information.

●National Library of Medicine

(www.nlm.nih.gov/medlineplus/healthtopics.html)

●National Institute on Deafness and Other Communication Disorders (NIDCD)

(https://www.nidcd.nih.gov/health/tinnitus)

●American Academy of Otolaryngology - Head and Neck Surgery (AAOHNS)

(https://www.enthealth.org/conditions/tinnitus/)

●American Tinnitus Association

(www.ata.org)

●The American Speech-Language-Hearing Association (ASHA)

(www.asha.org/public/hearing/disorders/Tinnitus.htm)

●The International Tinnitus Journal

(www.tinnitusjournal.com)