Category Archives: Tinnitus

Hyperacusis: Intolerance to sound

Hyperacusis is a condition characterized by over-sensitivity to everyday environmental sounds which may be unpleasant or painful to the ear as a result of damage sustained to the Auditory system. Hyperacusis can be due to damage to the brain or the neurological system, In these cases, there is processing problem specific to how the brain perceives sound. .

Individuals with hyperacusis have difficulty tolerating normal sounds which are not loud to others such as sound from running water in the kitchen sink, ringing phones, shutting doors, shuffling paper, placing dishes on table, TV sound etc.

40% of patients with tinnitus complain of mild Hyperacusis and around 86% of Hyperacusis sufferers have tinnitus.

Tinnitus is the perception of sound within the human ear such as ringing sensation, when no external sound is present.

Hearing Loss with low tolerance to sound is different term known as recruitment, In Hyperacusis usually hearing is normal.

Hyperacusis may be caused by overexposure to excessively high loudness levels, head injury, stress, and genetic differences or by abnormal responses in the ear muscles, which protects the ear from loud sounds. Other causes may include adverse reactions to medicine or surgeries, chronic ear infections, autoimmune disorders, migraine and some forms of epilepsy.

In cochlear Hyperacusis, the symptoms are ear pain, annoyance and general intolerance to everyday sounds.

In some conditions, wherein the vestibular system is involved is called as Vestibular Hyperacusis. In this condition, the sufferer may experience feelings of dizziness, nausea or a loss of balance when sounds of certain pitches are present at certain level.

AnxietyStress and Phonophobia (fear of loud sounds) may be present in Hyperacusis. Sufferer may result in developing avoidant behavior in order to avoid a stressful sound situation or to avoid embarrassing themselves in a social situation which involves noise. This might lead the sufferer stay away from the society.

Understanding the mechanism of Hyperacusis is often challenging. People who develop Hyperacusis should have a thorough Evaluation by otorhinolaryngologist (Ear, Nose and Throat doctor) and a detail Audiological evaluation to determine the state of the Auditory- Vestibular system.

Although a corrective medical or surgical approach for treating Hyperacusis is not available at this time, there are therapies that can help sufferer to reduce fears and anxieties towards sensitivity of sounds under guidance of an ENT Specialist and supervision by a Clinical Audiologist.

Antidepressant medicines and treating migraine may help.

Retraining Therapy

Retraining therapy consists of counseling and acoustic therapy. The aim is to reduce the patient’s reactions to Hyperacusis. Counseling is designed to help a patient better cope, while acoustic therapy is used to decrease a patient’s sensitivity to sounds and to teach them to view the sound in a positive manner.

Sound Generators

This treatment approach uses the sound of music or broadband noise or music produced via a body-worn system or a small device that looks like a hearing aid, which produces steady and gentle sounds. The theory is that, by listening to a sound at a low level for a certain amount of time each day, the auditory nerves and brain centers will become desensitized and able to tolerate normal environmental sounds again.

Constant use of earplugs/ earmuffs is not recommended because constant or frequent blocking of the ears may further alter the brain’s calibration of loudness which may lead the brain to further restrict its comfort range for sounds.

What to do in hyperacusis ?

1 .Avoid exposure to loud noise

  1. Avoid caffeine, chocolate, smoking , alcohol, MSG
  2. Avoid ototoxic medicines (medicines that might damage ear) such as aspirin, quinine)
  3. Daily exercise
  4. Adequate rest
  5. ENT & Audiological evaluation

Read more about Hyperacusis  http://www.tinnitus.org.uk/hyperacusis

Management of tinnitus (ringing in the ears)

There is no cure and no specific treatment is efficacious for noise/ringing in the ears/head; however person can opt from many options available. In some cases it can be quieted with treatment of underlying cause, thus thorough otologic evaluation and investigation is to be done. In majority of sufferers there is no serious pathology and reassurance is all what is needed.

Most important aspect is patient education regarding nature and prognosis of condition, and general preventive measures.

Medicines-

There is no specific drug designed specifically for tinnitus. There is no active research going on because of high cost and high rate of failure involved in creating a new drug.

Anxiolytics, Carbamazepine, Lidocaine, and intravenous Barbiturates show encouraging results but potentially serious side effects limit usefulness. Relatively low doses may bee effective in tinnitus management.

Patient and clinician together determine right drug considering side effects if it is worth.



Tinnitus Retraining Therapy-

Person can be habituated to sound in the environment, so aim is to train the brain to adapt to sound.

TRT has 2 elements- Direct counseling and sound therapy

Sound therapy: –

Sound therapy is to be combined with other therapies like counseling to improve effectiveness.

Tinnitus is more noticeable and disturbing when environment is quiet. Person with tinnitus thinks that sound is because of or can cause some serious damage to brain or inner ear. This negative emotional response from our subconscious brain (limbic system) travels to conscious brain-cortex, so person reacts.

In sound therapy instead of treating patient surrounding sound is manipulated so that it becomes less noticeable, here are many ways to achieve the goal such as: –

  1. Table top devices-environmental sound machine, water fountain, clocks, fan, radio
  2. CD based system
  3. Hearing aids
  4. Masker
  5. Combination of hearing aid and masker

6.  Cochlear implant/electric stimulation-

Table top devices;

Devices kept on side of bed such as ticking clock, adjusting radio in between two stations, or fan, may divert attention and make tinnitus less noticeable.

Hearing aids;

If a patient has a hearing loss in the frequency range of the tinnitus, hearing aids may be helpful in covering the tinnitus.

Masker;

The use of masking in the treatment of the tinnitus has mixed success, Patient’s perception of the pitch and loudness and the overall intensity of the masking signal should be well understood.

Tinnitus maskers introduce an external pleasant masking sound into affected ear , thereby minimizing or eliminating the perception of the tinnitus.

Cochlear implant;

Cochlear implant may mask tinnitus by ambient sound or may suppress tinnitus by the electrical stimulation sent through the auditory nerve. Some forms of electrical stimulation to the ear can stop tinnitus briefly.
Counseling: –

Effective counseling is most critical aspect of tinnitus management. Tinnitus sufferers are anxious and frightened by the presence of tinnitus and need a careful and clear explanation of the nature of the disorder.

It can be quite disturbing leading to sleep deprivation, depression & decreased work efficiency. Most important aspect of tinnitus is distress, irritation and distraction caused by the noise. Person often feels that such noise is a symptom of brain tumor or stroke. Reassurance should be given by E.N.T. specialist, neurologist and audiologist.

Biofeedback:–

Distress caused by tinnitus is in correlation to degree of attention paid to tinnitus and shifting attention of person to a different signal is bio feedback. It is relaxation technique that teaches to improve coping ability and has 70-90% success rate.

Tinnitus patients have high levels of anxiety, tension, or other symptoms of chronic stress. Biofeedback is quite effective relaxation technique; it teaches person to control certain autonomic body functions such as pulse, muscle tension and skin temperature. Goal is to help person manage stress not by reducing stress but by changing the body reaction to it.

Controversies exist about role of alternate therapies: —

Research results have not conclusively identified these treatments as helpful for tinnitus.

Hypnotherapy

Control of inhalational and food allergy

Bio feedback

Zinc, magnesium and vit-B12

Herbal ginkgo biloba have mixed result

Homeopathic remedies

Acupuncture

Hyperbaric O2

Music- music is soothing to soul, relieves pain and anxiety, and promotes relaxation and positive impulse to limbic system.

But it emphasizes the low frequencies and has little power in high frequency.

Tinnitus patient mostly has less hearing in high frequency and hear better at lower frequency. To correct this mismatch neuromonics are created (creator Dr Paul Davis and Peter Hankey, Australia). Modified music is delivered through high fidelity ear phones that match hearing and tinnitus level.

Research: —

*Research is going on for drugs Acamprosate, Vestipitant+Piroxitine, Neramaxane

*Trans Cranial Magnetic Stimulation-  SHAM stimulation-safe and effective.

*Chronic electrical stimulation of auditory cortex- Rehabilitation by specially trained clinician -daily acoustic neural stimulus customized to audiometric profile is presented to desensitize. Approximately 90% success rate is observed in selected patients with improved life

*Transtympanic perfusion inner ear:

Genta- in menieres disease with intractable vertigo.  Successful and less invasive than surgical procedures such as vestibular nerve section or labirynthectomy.

Dexa- in cochlear meneires may improve hearing, tinnitus, pressure feeling.

General measures and prevention of tinnitus

Previous post- Treatment of underlying cause

Prevention is the best way to ensure no worsening of disease. Certain life style changes are required for tinnitus –

  • Take care of the body by giving it enough rest, sleep and water.
  • Dietary supplements Vitamins A, C, E, and B group and Zinc
  • Micro nutrients to prevent noise induced hearing loss
  • Support and stress management; taking a positive step in controlling the condition and changing response to it
  • Regular exercise
  • Decrease intake of salt
  • Avoid food with high sugar
  • Limit exposure to loud noise, occupational and recreational
  • Avoid aspirin, and NSAIDS
  • Avoid ototoxic medicine
  • Avoid nicotine, alcohol, caffeine
  • Take steps to lower blood pressure and cholesterol
  • Ginkgo Biloba extract is an effective, well tolerated whilst not effective in every single patient, the proven benefits far outweigh any risks.

Next post- management of tinnitus

Treatment of conditions causing tinnitus

( Previous post: – Treatment options for tinnitus)

Person should be assessed and investigated properly by otolaryngologist, audiologist and neurologist if required, to find any treatable condition; management of cause usually take care of tinnitus.

  • Stop medicines causing tinnitus.
  • Wax, foreign bodies can be removed.
  • Treatment of middle ear infections and fluid should be done.
  • Otosclerosis and tinnitus- Surgery and/or hearing aids; surgery may not cure tinnitus and a failed surgery can cause severe tinnitus but correcting conductive deafness (even with poor speech discrimination) allows masking effective.
  • Menieres disease- Tinnitus is difficult to treat in non functioning (dead) ear, so decision for destructive surgery should be taken with care.
  • Abnormal patency of ET- Mostly seen after weight loss, can be corrected by minor surgical correction (25% silver nitrate or diathermy)
  • Surgery for tumor
  • Hearing aids for hearing loss
  • Treatment of blood pressure/thyroid disorder/other medical conditions causing tinnitus.

Next post:

General measures and prevention of tinnitus

Management of tinnitus

Tinnitus Treatment Options

There is no cure and no specific treatment is efficacious for noise/ringing in the ears/head; however you can opt from many options available. In some cases it can be quieted with treatment of cause. In majority of sufferers there is no serious pathology and reassurance is all what is needed.

‘Nothing can be done and you have to live with it’ is to be avoided and patient should be assessed and investigated properly by otolaryngologist, audiologist and neurologist if required, to find any treatable condition.

Most important and essential aspect is educating person with respect to causes and nature of tinnitus, keep in mind treat the patient not the tinnitus…

Treatment protocol should be reviewed, explained to the patient and rational behind the treatment should be clearly understood by the person.

Various treatment options

  • Treat the treatable cause
  • Prevention and General Measures for tinnitus
  • Medicines
  • Tinnitus retraining Therapy- includes sound therapy and counseling.
  • I. Sound Therapy
  1. External sound source
  2. Hearing Aids
  3. Masker
  4. Cochlear electric stimulation/implant
  • II. Counseling
  • Biofeedback (relaxation technique)
  • Alternative therapy (and ginkgo biloba)
  • Music therapy
  • Yoga therapy
  • Transcranial Magnetic stimulation
  • Ultra high frequency vibration therapy
  • Research

Next post: – treatment of  conditions causing tinnitus

Previous post: finding cause for tinnitus

 

Finding Cause for Tinnitus

newatastore1

Tinnitus is not a disease rather an annoying symptom of myriad of conditions, caused by minor changes in the sensitive hearing system (Cochlea and auditory nerve).

 

Patient with tinnitus should undergo thorough otologic and audiological evaluation and if required neurological examination. In most cases tinnitus is not harmful but patient should be investigated properly to find any treatable condition.

Most common cause for tinnitus is hearing loss because of aging, noise, drugs or chemicals.

Possible theory: –

  1. Because cochlea is no longer sending normal signals to brain, confused brain create own noise.
  2. Made worse by anything that makes hearing worse like infection/wax.

Causes: –

I. Related to ear (otologic)-

** Cause may be in the external, middle or inner ear

Subjective causes-

  • Impacted wax
  • Fluid in the middle ear
  • Acute and chronic otitis media
  • Otosclerosis
  • Menieres disease
  • Presbiacusis (age related hearing loss)
  • Head trauma
  • Noise-trauma
  • Ototoxic drugs (such as ACE inhibitors, Antibiotics-ciprofloxacin, erythromycin, streptomycin, and vancomycin, Anti depressant-alprazolam, Anti-malarials-chloroquine and quinine, B-blockers, Diuretics-acetazolamide and amiloride, NSAIDs and Aspirin)
  • Tumor (acoustic neuroma)

Objective causes are less frequent-

  • Aneurism of carotid artery (it is synchronous with pulse)
  • Vascular tumor of middle ear
  • Palatal myoclonus
  • Temporomandibular joint syndrome (misaligned jaw)
  • Tinnitus synchronous with respiration may occur with abnormally patent Eustachian tube (mostly seen after weight loss).

II. Not related to ear-

Disease of CNS, anemia, arteriosclerosis, hypertension, hypotension, hypoglycemia, epilepsy, migraine,

III.  Psychological-

Assessment of tinnitus-

Most important is History and Identification of hearing loss and Clinical Examination of ear by otoscope/operating microscope with detail head and neck examination by specialist.

Investigations:-

  • Pure tone Audiometry, speech audiometry, if required special tests like SISI, ABLB etc.
  • Brain-stem Evoked Response Audiometry If tinnitus is accompanied with other complaints like  headache, vertigo, vomiting,
  • CT scan (especially if tinnitus is asymmetrical, 10% of cases it may be a tumor (Acoustic Neuroma).
  • Blood Investigations to test Anaemia- CBC, Hypothyroidism- TSH, Diabetes-sugar, Syphilis- FTABS and lipid profile.

Comprehensive evaluation of tinnitus and sound tolerance:

  • VAS loudness scale and the quality of life Tinnitus Questionnaire
    Pitch matching
    Loudness matching
    Post masking effect
    Feldman Masking curves
    MCL
    UCL

Most important aspect is educating person with respect to nature of tinnitus,  keep in mind treat the patient not the tinnitus…

Some Latest Research news:-

Hyperactivity of Touch-sensing Nerves in Head, Neck Causes Tinnitus

Scientists Exploring Brain Area Responsible for Tinnitus

Tinnitus-overview

tinnitus-main_full

Tinnitus is not a disease rather an annoying symptom of myriad of conditions, caused by minor changes in the sensitive hearing system (Cochlea and auditory nerve).

Tinnitus (means ringing in Latin) is sound sensation in the ear or head, in the absence of any external source of sound.  Commonest types are hissing, roaring, swishing, rustling, buzzing, humming, or chirping.

(Photo by nathaniel)

Tinnitus varies in pitch and loudness and is more annoying in quiet surroundings, particularly at night.  It can be quite disturbing leading to sleep deprivation, depression & decreased work efficiency. Most important aspect of tinnitus is distress, irritation and distraction caused by the noise. Person often feels that such noise is a symptom of brain tumor or stroke. In most cases tinnitus is not harmful.

Patient with tinnitus should undergo thorough ENT and Audiological evaluation and if required neurological examination. ‘Nothing can be done and you have to live with it’ is to be avoided and patient should be investigated properly to find any treatable condition.

Treatment of the cause should take care of tinnitus but tinnitus may persist even after the disease causing tinnitus has been cured, When a lesion or disease process is not identifiable, then tinnitus management is more difficult.

In majority of cases our system adapts to noise over a period of time and is accepted as a part of normal environment. This process can be helped by proper reassurance and counseling. Relaxation, biofeedback and Yoga help to improve coping with the condition.

Hearing aids are helpful for tinnitus with hearing loss and tinnitus maskers are sometimes recommended. These are similar to hearing aids and generate continuous noise. Their use is based on the fact that the patient is more comfortable in a noisy environment than in a quiet surrounding.

Research shows encouraging result on the effectiveness of pharmacological therapy for tinnitus, such as carbamazepine, lidocaine, and intravenous barbiturates, but potentially serious side effects limit their use.