Features

Tinnitus: breaking the waves

19 March 2021

It’s a loud and lasting problem for many, and a life-changing issue for a few, writes journalist John Windell. So what is tinnitus and what can be done to restore some peace and quiet?

Tinnitus is defined as a persistent ringing, buzzing, whooshing, hissing or other sound in one or both ears or the head. While most of us will experience unpleasant noise effects at certain times in our lives – for example, after a heavy cold or a loud concert – it usually fades after a few hours or days. The big difference with tinnitus is that it seldom goes away.

Tinnitus affects more than 13% of adults in the UK, which translates to about 7.1 million people (British Tinnitus Association, 2019a). In addition, at least one child in 30 has tinnitus that is ‘clinically significant’ (BTA, 2019b) – that is, it has a real and noticeable effect on daily life. GPs give more than a million tinnitus-related consultations every year (BTA, 2018).

The first thing to understand about tinnitus is that it isn’t a disease or even a ‘condition’ but just a word that describes a wide range of sounds that we might hear. ‘There is no firmly agreed clinical definition of tinnitus,’ says Tony Kay, president of the British Tinnitus Association. ‘In simple terms, tinnitus is the medical term for the sensation of hearing a noise, or noises, in the ear, ears or head that does not have an external source. Tinnitus is a symptom, and has many possible causes and mechanisms.’

Franki Oliver, audiology specialist and spokesperson for the Royal National Institute for Deaf People (RNID), says one line of thinking suggests that tinnitus is caused by some sort of change – ‘a physical change, mental change or emotional change’, she explains. ‘If we look at it within the context of hearing loss, there has been a change in the auditory system. So the sound comes into the ear, is processed by the inner ear and then sent to the brain, which interprets it. But if not all of the sound that normally gets to the brain is getting there, the brain fills in the gaps and starts producing other sounds, which then get interpreted as tinnitus.’

The symptoms

Hearing loss is a common risk factor. ‘One possible cause of tinnitus is changes in the brain in response to the sensory change as a consequence of the hearing loss,’ Tony says. ‘Other risk factors include exposure to loud noise, ear disease, head injury, drugs that are toxic to the ear, anxiety and depression. I’ve seen cases when so-called pranks, such as bursting a balloon by somebody’s ear, has caused tinnitus.’

Its incidence is generally greater among older age groups, and any length of time spent in noisy jobs or pursuing loud hobbies also increases the risk of developing it.

What are the tell-tale symptoms? ‘Hearing a sound in the ears or head that doesn’t originate externally,’ Tony says. ‘Initially, some people think the noise is coming from an outside source, such as the boiler coming on or a car alarm going off.’

The type and severity of symptoms can vary significantly from case to case. ‘Most people who experience tinnitus are not bothered by it, but for some it can have a significant impact on quality of life, and for a minority it may cause suicidal ideation,’ he says. ‘It can interfere with sleep, concentration and mood. For a very small minority it can be devastating and have a severe impact on day-to-day living.’

If the symptoms are driving somebody to crisis point, an immediate referral to audiology or ear, nose and throat (ENT) services is required. Sometimes the more mild cases may also call for specialist attention. ‘If it’s affecting people’s day-to-day lives, if they’re struggling with work or to communicate with people, and it’s stopping them from doing things they would usually enjoy, that would call for a referral,’ Franki says. ‘It can also be associated with more medical reasons, such as a head injury or a change in sensation to the face, numbness or dizziness. If these symptoms come on suddenly, that would require urgent referral.’

While tinnitus is rarely a sign of serious underlying health conditions, it is important that anybody who is bothered by the symptoms should go to their GP for an assessment and ear examination, and then onward referral if appropriate.


Top view: Acoustic neuroma with MRI scan
*Also less commonly, tinnitus can be a symptom of this benign growth.

Tinnitus triggers

Most tinnitus is linked to hearing loss, so it’s important to protect the ears against loud, persistent outside noise that could damage parts of the delicate inner ear. Other causes of tinnitus related to the ear include:

  • Wax build-up
  • Perforated eardrum
  • Ear infections
  • Otosclerosis (abnormal bone growth)
  • Ménière’s disease
  • Neurological disorders

Rarely, it may be triggered by other medical conditions such as:

  • Head or neck injuries
  • High blood pressure
  • Diabetes, thyroid disorders or multiple sclerosis
  • Chemotherapy medicines, antibiotics and aspirin

Stress and anxiety can also trigger tinnitus, which can in turn make people feel even more stressed and anxious.


Can it be treated?

Once somebody is in front of the specialists, what can be done to ease the symptoms? ‘Tinnitus can be treated and cured for some – for example, if it’s down to excessive ear wax, ear infections or hypertension then treating the underlying condition can alleviate it,’ Tony says. ‘For others, the causation is either unknown or not amenable to a cure per se, although effective treatment options are available to help manage the symptoms and impact.’

Cases that are linked to hearing damage are less easily resolved since the damage cannot yet be repaired. In these situations, management techniques are employed. ‘After the initial assessment and diagnostic tests, key management techniques involve treating any underlying condition, information and education about the condition, managing the hearing loss, using sound therapy, talking therapies such as tinnitus counselling and cognitive behavioural therapy, and group and peer support,’ he says. ‘Hearing aids can be effective for many.’

For a lot of people with mild symptoms the goal will be habituation – in other words, a gradual process where they get used to the noise, to the point where the brain begins to pay less attention to it. ‘It’s about setting and readjusting expectations,’ Franki says. ‘So we accept the sound might not go away but we learn to live with it, so it won’t be as intrusive as it might have been initially and it won’t affect our day-to-day life.’

Given that tinnitus is so widespread and yet remains something of a mystery, the BTA and RNID both have research programmes that seek to discover more about the causes of these strange noises and what medical and psychological therapies might quieten them. But as a recent paper (McFerran et al, 2019) concluded, a catch-all cure remains elusive. There are multiple reasons for this: it’s actually unclear how common tinnitus is, a factor compounded by the lack of a certain definition of what it is; the different treatments required by its multiple subtypes; the lack of clarity over its cause, meaning there is little for a drug to target; and a dearth of funding in the necessary multidisciplinary research.

Referring on

For now, any community practitioners encountering a case of tinnitus need to signpost people towards the right services. ‘A child reporting tinnitus should be taken to their GP for an ear examination and be referred for a hearing test,’ Tony says. ‘Most children with tinnitus are not bothered by it, and a simple explanation and reassurance are all that is required.’ Still, a small number of children can be distressed by it; if left untreated, this can cause anxiety and have a significant impact on their educational progress and physical and emotional wellbeing.

Anybody complaining of tinnitus should have an ear examination at their GP to identify and treat any external ear problems. Any further assessments and tests will be referred to ENT and audiology services. ‘Tinnitus is often linked with mood,’ Tony says. ‘If there are concerns about anxiety and depression, an assessment should be carried out by a competent mental health practitioner.’

Franki says that new NICE guidelines on tinnitus, published last year, offer good advice (NICE, 2020). ‘The most important thing is to suggest people go to see their GP. But the guidelines also say that there is good advice practitioners can offer at this point: basically, to reassure people that tinnitus is a common condition and may resolve by itself; that, while it is associated with hearing loss, it’s not normally a sign of an underlying physical problem; and that many people who experience the symptoms do live well with their tinnitus.’


Tinnitus treatments

If the cause of tinnitus is wax build-up or an infection, this can be treated. In the more likely case of hearing loss or stress, treatments include:

  • Hearing aids – to help with hearing loss
  • Sound therapy – devices that distract from the tinnitus or mask it
  • Tinnitus counselling/tinnitus retraining therapy/cognitive behavioural therapy – training people to think differently about their tinnitus
  • Relaxation and mindfulness – to help reduce stress and anxiety levels
  • Exercise and diet – can boost overall wellbeing and reduce stress.

Resources


References

British Tinnitus Association. (2019a) More people living with tinnitus than previously thought. See: tinnitus.org.uk/blog/more-people-living-with-tinnitus-than-previously-thought (accessed 28 January 2021).

British Tinnitus Association. (2019b) Tinnitus: a parent’s guide. See: tinnitus.org.uk/tinnitus-a-parents-guide (accessed 28 January 2021).

British Tinnitus Association. (2018) Number of people living with tinnitus in the UK is set to rise. See: tinnitus.org.uk/blog/number-of-people (accessed 28 January 2021).

McFerran DJ, Stockdale T, Holme R, Large CH, Baguley DM. (2019) Why is there no cure for tinnitus? Frontiers in Neuroscience 13. See: www.frontiersin.org/articles/10.3389/fnins.2019.00802/full (accessed 28 January 2021).

NICE. (2020) Tinnitus: assessment and management. See: nice.org.uk/guidance/ng155 (accessed 28 January 2021).

Image Credit | Shutterstock

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