Tinnitus (Ringing, Clicking, in the Ears)

• Tinnitus is a ringing, buzzing, swishing, clicking, or other type of noise that seems to originate in the ear or head rather than from an external source.
• Tinnitus is not an illness itself but a symptom of other conditions, such as:
  • Hearing loss
  • Ear infection
  • Ear wax buildup
  • Loud noise exposure
  • Ear trauma
  • Certain medications
  • Meniere's disease
  • Brain tumors or other tumors near the ear
  • Blood flow problems
  • Pregnancy
  • Anemia
  • Overactive thyroid
• An increase in pressure of the fluid surrounding the brain, and temporomandibular joint (TMJ) disorder
• The main symptom of tinnitus is hearing sound in your ears not due to an external source that no one around you can hear. The noise is often described as ringing, buzzing, clicking, or rushing. Hearing loss and dizziness may occur if the tinnitus is due to Meniere's disease.
• Because tinnitus is due to other health conditions that may require medical treatment, it should be evaluated by a doctor, especially if the tinnitus is only on one side, is sudden, or is associated with hearing loss.
• Treatment of tinnitus depends upon the cause and may include medications, stress reduction techniques, biofeedback, lifestyle changes, tinnitus retraining therapy (TRT), masking devices, and cognitive behavioral therapy (CBT).
• Home remedies are generally not recommended for tinnitus because they may not address the underlying cause.
• The best way to prevent some cases of tinnitus is to avoid damage to your hearing, such as loud noise exposure. For many other causes there may be no way to prevent the accompanying tinnitus symptoms.
• There is currently no cure for most cases of tinnitus.
• Symptoms of tinnitus may come and go over time, and if you have had tinnitus it's likely it will recur. While it may be annoying, most people can learn to cope with it. Stress, diet, and noise exposure may worsen symptoms.

Tinnitus is pronounced tih-NIGHT-us or TIN-ih-tus.

Tinnitus is a ringing, buzzing, hissing, swishing, clicking, or other type of noise that seems to originate in the ear or head. Most of us will experience tinnitus or sounds in the ears at some time or another. According to the National Institute on Deafness and Other Communication Disorders (NIDCD), about 10% of adults in the U.S. - nearly 25 million Americans - have experienced tinnitus lasting at least five minutes in the past year. Tinnitus is identified more frequently in white individuals, and the prevalence of tinnitus in the U.S. is almost twice as frequent in the South as in the Northeast.

Tinnitus can be extremely disturbing to people who have it. In many cases it is not a serious health problem, but rather a nuisance that may go away. However, some people with tinnitus may require medical or surgical treatment. Sixteen million Americans seek medical treatment each year for tinnitus, and about one-quarter of those experience it so severely it interferes with their daily activities.

Tinnitus can arise in any of the four sections of the hearing system. They include the:

1. Outer ear
2. Middle ear
3. Inner ear
4. Brain

Some tinnitus or "head noise" is normal. A number of techniques and treatments may be of help, depending on the cause.

Picture of the structures of the outer, middle, and inner ear

• Subjective tinnitus: This is the most common type of tinnitus because you hear a sound, but no one else can hear it.
• Clicking or pulsatile tinnitus: The noise it produces usually is a buzzing or ringing type sound, but it may be a clicking or rushing sound that goes along with your heartbeat.
• Objective tinnitus: This is a much more uncommon sort of tinnitus. With this type your doctor may sometimes actually hear a sound when he or she is carefully listening for it.

Tinnitus is not a disease in itself but rather a reflection of something else going on in the hearing system or brain.

Hearing loss: Probably the most common cause for tinnitus is hearing loss. As we age, or because of trauma to the ear (through noise, drugs, or chemicals), the portion of the ear that allows us to hear, the cochlea, becomes damaged. Current theories suggest that because the cochlea is no longer sending the normal signals to the brain, the brain becomes confused and essentially develops its own noise to make up for the lack of normal sound signals. This then is interpreted as a sound, tinnitus. This tinnitus can be made worse by anything that makes our hearing worse, such as ear infections or excess wax in the ear.

Trauma: If tinnitus is caused by trauma to the ear it usually is noticed in both ears, because both ears generally are exposed to the same noises, drugs, and other influences.

Exposure to loud noise: Loud noise exposure is a very common cause of tinnitus today, and it often damages hearing as well. Unfortunately, many people are unconcerned about the harmful effects of excessively loud noise from firearms, high intensity music, or other sources. Twenty-six million American adults have suffered noise-induced hearing loss, according to the NIDCD.

Medications: Drugs such as aspirin (if overused), aminoglycoside antibiotics (a powerful form of infection-fighting drug), and quinine. More than 200 different drugs are known to have tinnitus as a side effect.

Meniere's disease: Symptoms include dizziness, tinnitus, and fullness in the ear or hearing loss that can last for hours, but then goes away. This disease is actually caused by a problem in the ear itself. The tinnitus is merely a symptom.

Acoustic neuroma: This is a rare subjective cause of tinnitus, and includes a certain type of brain tumor known as an acoustic neuroma. The tumors grow on the nerve that supplies hearing and can cause tinnitus. This type of the condition usually are only noticed in one ear, unlike the more common sort caused by hearing loss usually seen in both ears. Causes of objective tinnitus are usually easier to find.

Pulsatile tinnitus: This problem usually is related to blood flow, either through normal or abnormal blood vessels near the ear. Causes of pulsatile tinnitus include pregnancy, anemia (lack of blood cells), overactive thyroid, or tumors involving blood vessels near the ear. Pulsatile tinnitus also can be caused by a condition known as benign intracranial hypertension (an increase in the pressure of the fluid surrounding the brain).

Clicking types of objective tinnitus can be caused by TMJ misalignment problems, or "twitching" of muscles of the ear or throat.

Most newly noticed tinnitus should be evaluated by a doctor or other health care professional. Because tinnitus usually is a symptom of something else, if it begins suddenly, see your doctor. This is particularly important if the tinnitus is only heard on one side.

Although the majority of cases of tinnitus are not caused by any acute medical problems, certain symptoms and signs need to be evaluated to determine whether or not a more serious medical condition is causing the symptoms.

If you begin having any of these issues call your doctor or other health care professional for evaluation.

• Any time tinnitus or ringing in the ears comes on suddenly, particularly in one ear, or is associated with hearing loss. Sudden hearing loss is often accompanied by tinnitus, and there are medications that may help to restore hearing. Also certain types of tumors can cause sudden hearing.
• Tinnitus that is pulsatile (in rhythm with your heartbeat) and comes on suddenly should also be checked relatively rapidly. In very rare instances, this sort of tinnitus can develop because of an aneurysm (a bulging of the wall of a blood vessel) near the ear or because of the sudden onset of very high blood pressure.
• Any time the problem is noticed in association with changes in personality, difficulty speaking or walking, or with any other movement problem, you should be evaluated for the possibility of a stroke.
• If you have constant ringing in the ears and it's affecting your daily life, see a doctor or other health care professional.

The initial diagnosis of tinnitus may be made by a general practitioner or internist. You may be referred to an otolaryngologist (an ear, nose, and throat specialist, or ENT).

Depending on the underlying cause of the tinnitus you also may see other medical professionals to treat the condition such as a:

• Dentist for temporomandibular joint (TMJ) disorder (TMJ) or other dental problems
• Cardiologist (heart specialist) for heart disease
• Oncologist (cancer specialist) for a brain tumor or other cancer
• Gynecologist for hormonal changes in women
• Endocrinologist (specialist in disorders of the endocrine system) for thyroid conditions
• Neurologist (specialist in the brain and nervous system) for neck or cervical disorders
• Audiologist (specialist in auditory and balance systems) to help with therapy
• Physical therapist to treat problems due to injury or strain
• Psychologist to counsel you in dealing with the issue

• The initial medical evaluation for tinnitus will include a complete health history and physical examination of the head and neck including the various nerves in the area.
• A complete hearing test (audiogram) will also be performed. Depending on the type of tinnitus, either a special audiogram known as an auditory brainstem response (ABR) or a brain scan such as a computerized tomography (CT) scan or magnetic resonance imaging (MRI) may also be required.
• In some cases, your blood pressure and possibly some blood tests to evaluate thyroid gland function may be taken.
• In very rare instances, a spinal tap may be performed to measure the fluid pressure in the skull and spinal cord.

If you having ringing in your ears, you should be evaluated by a doctor or another health care professional. Treatment of tinnitus depends upon the cause.

Examples of ways to treat the symptoms of the problem include:

• Medications (including antidepressants and antianxiety drugs)
• Decreasing emotional stress via stress management techniques
• Biofeedback
• Hearing aids
• Counseling
• Wearable or tabletop sound generators
• Acoustic neural stimulation
• Cochlear implants
• Osteopathy
• Physical therapy
• Chiropractic
• Surgery (neurectomy or microvascular decompression)
• Bite implants for patients with TMJ
• Lifestyle changes

It is important to follow the doctor's directions in obtaining further evaluations and tests for your tinnitus. You may need an appointment with an ear, nose, and throat specialist (otolaryngologist) or an audiologist for further testing. It is important to follow up on these recommendations when they are made to confirm that your tinnitus is not caused by another illness.

Most cases of tinnitus should be evaluated by an ear, nose, and throat doctor before home treatment begins to be sure that the tinnitus is not caused by another treatable problem.

Herbal home remedies (ginkgo biloba, melatonin), and the vitamin zinc are not recommended by the American Academy of Otolaryngology. Lipo-flavonoid is a supplement being marketed as a way to relieve tinnitus, but there is no current evidence it is effective for most cases of the condition; however, it may be helpful for symptoms of Meniere's disease. Check with your doctor or other health care professional before taking any herbal or over-the-counter (OTC) natural remedies.

Treatment for tinnitus depends on the underlying cause of the problem. In the majority of cases, it's caused by damage to the hearing organ. In these cases, there is normally no need for treatment other than reassurance that the sounds are not being caused by another treatable illness.

In the very rare instance where tinnitus is extremely bothersome, there are a number of treatment options.

• Some of the most helpful include anti-anxiety or antidepressant medication and sometimes maskers-small devices like hearing aids that help to block out the sound of the tinnitus with "white noise."
• "Sound therapy" uses external noises to help change a patient's perception of, or reaction to, tinnitus. These external sounds may mask the tinnitus, or help distract from it.
• For people who are bothered by tinnitus only when trying to sleep, the sound of a fan, radio, or white noise machine is usually all that is required to relieve the problem.
• Wearable sound generators that fit into the ear use a soft sound such as random tones, music, or a "shhhhhh" sound, to help mask the tinnitus.
• Most people with tinnitus find that their symptoms are worse when under stress, so relaxation techniques can be helpful.
• Avoid caffeine because it may worsen symptoms.
• Biofeedback may help or diminish tinnitus in some patients.
• Tinnitus retraining therapy (TRT) trains you to accept the sounds from tinnitus as normal, helping you to be less aware of it. Masking devices resemble hearing aids and produce low-level sounds that can help reduce awareness of the sounds.
• Similar to TRT, cognitive behavioral therapy (CBT) may help retrain you to feel less distressed with the noise.
• Psychological counseling may help people learn to cope by giving them tools to change the way they think about and react to their symptoms.
• Avoid aspirin or aspirin products in large quantities.
• Hearing loss worsens the effect of the issue, so wear hearing protection and avoid loud noises are very important in preventing the sounds and symptoms from worsening.
• Hearing aids may help people when hearing loss accompanies their tinnitus. Hearing aids can be adjusted and make it easier to hear, making it less likely to notice it.
• If severe hearing loss accompanies tinnitus, cochlear implants may be used. Like a hearing aid, these devices can help patients hear outside noises better, which can help mask the sounds.
• For people whose tinnitus is very loud or persistent, a new technique called acoustic neural stimulation helps change the neural circuits in the brain helping desensitize you to the sounds and other signs.
• If it's caused by TMJ bite realignment or other dental treatments may help relieve symptoms.
• Osteopathy, physical therapy, or chiropractic may help ease symptoms.
• In extreme cases, surgeries such as neurectomy (removal of the cochlear nerve) or microvascular decompression (decompressing the cochlear nerve) may be performed to relieve symptoms.
• In cases where the tinnitus is caused by one of the other rare problems (such as a tumor or aneurysm), treatment involves fixing the main issue. Although this does not always resolve the issue, some people note relief of their symptoms. Only a very few cases of tinnitus are caused by identifiable, repairable medical conditions.
• Transcranial magnetic stimulation, antidepressants, and anticonvulsants treatments are not recommended by the American Academy of Otolaryngology.

The only real prevention for tinnitus is to avoid damaging your hearing. Most causes other than hearing loss do not have prevention strategies.

According to the American Tinnitus Association, there are several things you can do to protect yourself from excessive noise-related tinnitus:

• Protect your hearing at work. Your work place should follow Occupational Safety & Health Administration (OSHA) regulations. Wear ear plugs or earmuffs and follow hearing conservation guidelines set by your employer.
• When around any noise that bothers your ears (a concert, sporting event, hunting) wear hearing protection or reduce noise levels.
• Even everyday noises such as blow drying your hair or using a lawnmower can require protection. Keep ear plugs or earmuffs handy for these activities.

Currently there is no cure for most cases of tinnitus. Depending on the type of tinnitus, symptoms will tend to come and go over time. Stress level, diet, and exposure to noise can worsen tinnitus. Many people find their tinnitus annoying but can learn to adapt without difficulty. It is likely that if you have had tinnitus, you will have it again in the future.