Tinnitus

hello I'm doctor Ken Lander thanks for watching let's talk about tinnitus tinnitus or tinnitus is a very common condition associated with ringing in the ears actually the word tinnitus comes from the Latin 10 year which means to ring it's common it's frequently a work-related disability according to the Veterans Administration it's one of the most prevalent service-related disabilities there is the definition of the condition well it's a perception of sound that you hear in the head that doesn't arise from any external environmental cause you just hear this noise many individuals may be up to 3/4 of the individuals with tinnitus not unduly troubled by it they don't even seek medical care but about 3 percent of the people are moderately annoyed one and a half percent are severely annoyed and somewhere between a half percent and 1% complained of such severe problems that it negatively impacts their ability to carry on a normal life now tinnitus affects somewhere between about 10 and 15 maybe even up to 20% of the general population seems to occur basically at the same incidence everywhere in the world whether we're talking about the United States or Africa or Asia and that's important when we consider what some of the supposed causes are intermittently it affects probably everybody it's this kind of like you have low back pain for a while you're probably going to have tinnitus for a while in the general population as I mentioned the incidence is somewhere between 10 and 15 or 20% but if we go to an audiology clinic it's probably 85% and people who are completely deaf 75% still note tinnitus more common in men than in women it's frequent in childhood but even though it probably occurs at the same incidence as it does in adults children seem to be less distracted by it prevalence of tinnitus seems to increase increases over time but ages of 40 and 70 and afterward it may well plateau somewhat it can occur abruptly but usually it develops insidiously it can be either intermittent or continuous can improve over time and whether it really improves or whether it's just you're less bothered by it is unknown it can last for years to decades it can be in one year or both ears typically it's located centrally within the head typically it involves both ears or the left ear more than the right ear you perceive in some instances an external location but none can be found traditionally it's always been considered to be an ear problem tinnitus thought to be a forerunner of hearing loss that may well be true but some recent studies suggest that it actually is a brain issue or ends up as a brain issue now the symptoms vary in intensity over time and they increase with stress the description of tinnitus can differ attica Li in the level of annoyance and the sense of an impact on a person's life depending on what else is happening in your life what kind of stresses you have whether you're anxious or depressed most people refer to tinnitus as either a ringing or a buzzing or a hissing maybe a roaring or a clicking or a sizzling whistling cricket light sounds or even rough sounds sometimes the sounds are rhythmical people can experience several different kinds of tinnitus varies over time that can be constant or intermittent and sometimes rarely but sometimes people have more complex sounds complex sounds that are more like music or voices but the perception is that they're indistinct and they don't convey the same meaning the same negative connotation as the auditory hallucinations of schizophrenia they're telling you to do something the tinnitus sounds don't tell you to do anything it can be associated with but it's not necessarily caused by anxiety and depression and insomnia and irritability but if you happen to suffer from any of those chances are your is going to at least when you're suffering from those conditions anxiety or the insomnia the tinnitus is going to be relatively worse it can be so bad sometimes that it leads people to consider suicide now there are many factors that are associated with tinnitus and hearing loss is one of them but the associations not simple and it's not certainly straightforward other possible risk factors include obesity or cigarette smoking or drinking alcohol or previous head injury even high blood pressure or abnormalities of your temporal mandibular joint and in some individuals it seems that there's a genetic predisposition so we can classify tinnitus in a number of different ways vibratory and non vibratory vibratory is a transfer of mechanical vibrations from adjacent structures inside the head into the cochlea non vibratory are just biochemical changes that affect the hearing and affect the brain another classification would be subjective and objective subjective when only you hear the noise you hear the tinnitus you hear the buzzing of the roaring or the clicking by far that's the most common but sometimes people have what are known as objective tinnitus and the objective tinnitus very uncommon but the doctor can actually hear it or somebody else can actually hear the noise that you hear now for the subject of tinnitus common problems have to do with ear related issues so you could have hearing loss you could have conductive hearing loss that means that you can't transfer the sound to the inner ear maybe because of an external ear infection or a cerumen impaction maybe because you've perforated your tympanic membrane have a middle ear in maybe there's some otosclerosis where the bones in your middle ear are fused together or it could be a sensory normal hearing loss it could be a disease or an abnormality of the inner ear maybe the cochlear portion of the eighth cranial nerve may be exposure to loud noise or just getting older what we call presbycusis that's the age-related hearing loss or maybe because you took a medicine that damages your ear and ototoxic medicine maybe you're suffering from Meniere's disease Meniere's disease association of the tinnitus with some hearing loss and some dizziness and some vertigo noise-induced hearing loss that's probably the most common type of acquired hearing loss it's irreversible but it's preventable could be occupational could be recreational you should always use silicone ear plugs if you're going to be around loud noises even short-term loud noise if it's loud enough like a jet engine roaring if you're too close that can cause problems and if you have the hearing loss then that leads to the tinnitus Meniere's disease affects more than 200,000 individuals in the country typically they're over age 40 it's due to an excess of endolymph in the membranous labyrinth of the inner ear that's got three parts got the cochlea that has to do with the hearing the semicircular canals that have to do with your balance and then the vestibule that sits in between usually Meniere's disease is diagnosis of exclusion you have recurrent attacks of episodic vertigo they're severe their unanticipated they can last for minutes two hours the after effects can last for several days you can have severe attacks and then in between the severe attacks you can have relatively milder attacks tends to begin in one ear and then anywhere between about 10 and 40% can involve both ears the tinnitus that's associated with Meniere's disease is due to low frequency hearing loss hearing loss over around the median of 320 Hertz you have a roaring or a buzzing sound hearing loss with time can go from temporary to permanent you can have some fullness in your ear it seems that manures disease the hearing loss as I said is low-frequency affects both the air conduction of bone conduction reduces your ability to hear by somewhere between 15 and 30 decibels you're talking in a 50 or 60 decibel range so half of that can be lost the typical course is fullness in the ear then the tinnitus then the hearing loss then the vertigo maybe you have the tinnitus because you took some odo toxic medicine simple aspirin if you take enough aspirin or if you take enough ibuprofen or Naprosyn you could end up with tinnitus temporary because then you stop the aspirin and then it seems to go away but if you happen to take some other kind of medicines especially the amino glycosides those are antibiotics that are frequently injected well that could permanently damage your hearing same thing can happen if you take some of the risks from ice and tetracycline vancomycin tends to be shorter duration tends not to be permanent like with the aminoglycosides chemotherapy can cause tinnitus chemotherapy like bleomycin or cisplatin or methotrexate Irvan Kristin or even taking a diuretic maybe you have some edema of your legs some swelling of your legs and a doctor gives you some furosemide or lasix or bumex or Etta Crenn I can cause some problems with the hearing and same too if you're exposed relatively high levels of mercury or lead or some other kind of medicines like chloroquine the drugs can affect either the hair cells of the inner ear or the auditory nerve or actually even some of the central nervous system connections then that leads to either hearing loss or vertigo or the tinnitus gotta be especially cautious if you're either very young or you have liver or kidney impairment pregnant yeah the history of hearing loss you're exposed to loud noises you should never take 200 toxic medicines at the same time because then you're just really looking for trouble sometimes the tinnitus is a result of an acoustic neuroma that's a tumor it can destroy the vestibular nerve slowly happened after that does this then you get the dizziness or the vertigo sometimes mild or transient oftentimes the first symptom is the tinnitus tinnitus in the case of acoustic neuroma tends to be unilateral it's less disturbing than the tinnitus of Meniere's disease only after you've had acoustic neuroma for some time does it really interfere with the hearing you can also have instead of the subjective tinnitus you could have objective tinnitus that's where the doctor or somebody else can actually hear the noise that you hear it oftentimes is due to turbulent flow of blood and the carotid artery and the jugular venous system maybe it's due to spontaneous contraction of some muscles in the soft palate or in the middle ear rare cause but sometimes it happens sometimes people develop other kind of tumors Glomus tumor Glomus tumor is a vascular neoplasm and you can sometimes hear the low pulsating tinnitus of this condition or sometimes you have spasm of some of the muscles maybe have eustachian tube dysfunction what we call a patch ulis eustachian tube that's the tube that connects the ear to the back of the throat maybe you have some blowing sounds the Year coincident with your breathing usually after significant weight loss people complain that they're aware of their own voice symptoms seem to disappear when people lie down and have the head in a dependent position or when they perform a valsalva maneuver that's the straining as if you were going to go to the bathroom other issues that can cause some tinnitus or meningioma z' and multiple sclerosis or epilepsy or migraine ur head injury or loss of consciousness metabolic changes like diabetes and hormone changes can be a result of psychogenic factors or maybe some sort of connective tissue disease like rheumatoid arthritis or lupus so if we look at the etiology overall seems that maybe about a quarter of the time it's due to prolonged noise exposure about 20% of the time it's due to some sort of head neck injury maybe whiplash maybe some sort of trauma you fell skull fracture ten percent of the time and infectious disease of some sort 10-15 percent some drug forty percent of the time it's really unknown why you have the condition could be related to anything I mentioned or some hyperthyroidism or hypothyroidism or an emu or vitamin b12 we don't really have a good handle on why people develop tinnitus in the majority of cases generally it's a more severe situation if it's a pulsatile tinnitus that has to do with the blood flow either in the veins or in the arteries or if it's unilateral tends to mean maybe acoustic neuroma maybe it's tinnitus associated with some other kind of ear symptoms well who can perform the examination typically you could see the family doctor the internist the ear nose and throat doctor and neurologist or even a psychiatrist if you're bothered by anxiety or depression routine examination questions about how do you sleep how's your concentration what's the emotional impact what has it got to do with the quality of life and then we have some questionnaires they're limited clinical use them this handicap inventory and the tinnitus functional index and there's the Beck Depression Inventory in the back anxiety inventory those give us a clue as to what's going on in your life we find out about the age you were when the conditions started whether you were exposed to loud noise or head trauma look in the ear make sure there's not cerumen that's impacting it may be a vote itis media find out whether it's episodic like it would be in Meniere's disease or is it a continuous situation do a tuning fork examination to localize the problem holding the tuning fork on the forehead or the nose or the chin and on the mastoid bone and then in front of the ear to see how you hear sometimes blood evaluations may be a thyroid hormone check or a blood count to make sure you're not anemic or check the blood lipids but rarely do you need a full ent evaluation or a cat scan or an MRI audiology examination may be appropriate but usually doesn't really add all that much tympanometry to identify some middle ear problems or changes in the tympanic membrane stiffness might be appropriate pure tone audiometry might give us a little bit of a clue but the problem with the audiometry is that it really measures between 250 and 8000 Hertz when the problem tends to be really due to higher frequency somewhere between 8,000 and 20,000 Hertz and that can't be measured on the routine examinations we're unable to detect the loss up in these ranges and that's where everything starts and then it gradually typically goes down into the higher frequencies that can be tested and we only tested specific frequencies so it's if in between the frequency we're going to miss it then it would appear that a cute loss of auditory input that can lead to some tinnitus can be associated with some apoptosis or some death of the cochlear hair cells but the tinnitus persists even after we cut the auditory nerve so it doesn't have any connection to the ear anymore and people still have the tinnitus so it's thought that maybe actually the central nervous system is the cause of the tinnitus the source of the tinnitus so it might be that it started off with some lack of input from damaged cochlear hair cells in the inner ear or maybe it had to do with some sort of an abnormality of the auditory nerve leading to the central nervous system and this seems to be able to alter the auditory complex the auditory cortex so it's possible that the problem can originate in the cochlea inside the ear but later on over a period of time due to increased excitability and decreased inhibitory action then it can end up self generating in the central nervous system and it can have to do with an abnormality of some neurotransmitters and neuromodulators and all of those things tend to change some of the voltage-gated channels with the sodium and the potassium and the calcium inside the brain and that means that we can have basically the same sort of problem that occurs after an amputation let's say you have your foot amputated if you're unfortunate enough to have that happen well a lot of people still complain of sensations in the foot well there isn't any foot but the sensations are rising in the central nervous system and it's due to the plasticity of the central nervous system and that seems to have a lot to do with the least the generation and the continuation of the tinnitus and it's not only the central nervous system that's related to the hearing not just the auditory complex but then the auditory complex has a broad array of connections to the frontal lobe and the prefrontal emotional centers and the parietal loads in the limbic system and all of those can be changed so what is the origin of tinnitus and the answer is we don't know but it would appear to be about a quarter of the time the inner ear may be a third of the time the acoustic pathways and maybe 40% of the time those brain networks I just talked about so how do we treat it that's the difficult question there is no food and drug administration and there is no European Medicines Agency approved treatment the goal is simply to improve the quality of life not to achieve a cure no treatment at the present time can be guaranteed to work better than an inactive placebo and the treatments that are preferred differ in different countries nobody has a solution to the problem and it remains a clinical and a scientific enigma we explain the situation to individuals we give them some intervention to decrease the distress we try to improve the quality of life we decrease some of the comorbid or associated problems we can treat the anxiety or depression or the insomnia and if a person has some hearing impairment we can improve that too a lot of people say well reduce stress that's easier said than done some people seem to get better if they reduce the caffeine or the nicotine or they treat the allergies but that tends not to be a major issue in 1935 Baron a came out with nasal propane when they saw propane that subsequently been changed to intravenous lidocaine or xylocaine get temporary relief in 40 and 70 percent of the people and it shows that the central auditory system is really involved because it seems to work even after we transect the auditory nerve now it might have some additional effect on the cochlea we just don't know but it seems that the intravenous lidocaine works on those sodium and the calcium and the potassium channels that I mentioned a moment ago now some people take medicines like a cyclic antidepressants nortriptyline it's okay if you're depressed but it property's not going to give you any benefit if you're not and along the way it's going to cause a dry mouth and third vision and it's gonna cause you to have difficulty urinating especially if you're an older man or tends to cause constipation some people use the SSRIs the selective serotonin reuptake inhibitors Prozac and Zoloft and paxil but those drugs might bring forth other kind of issues benzodiazepines and some people like ativan or xanax or clonazepam they help take care of some of the anxiety but they don't really change the tinnitus they're anti-spasmodics and of course people use gabapentin and tegretol and the motor gene for everything including for tinnitus and they don't work for most of the disorders for which they're prescribed well sometimes people use diuretics hydrochlorothiazide or even lasix sometimes an anticoagulant or a vasodilator baby hissing that's very popular especially for Meniere's disease it supposedly has something to do with a cochlea blood flow it's approved in the European Union but it's not approved in the United States and actually there's no support for the treatment it's widely used anyway some people suggest melatonin or vitamin B or zinc or magnesium no that seems to work there proponents of low power lasers or electromagnetic stimulation or acupuncture or herbs or candling or ginkgo cognitive behavioral therapy well that doesn't improve the tinnitus it might assist with some of the anxiety or the depression decreased the annoyance maybe there's relaxation therapy you can combine all of that with sound masking therapy but it still really doesn't work you still have the tinnitus it just may change whether it bothers you as much or doesn't hearing aids well if you have hearing loss that might be a good idea but on the other hand there's no evidence that hearing aids improve tinnitus even though many doctors fit patients with hearing aids it amplifies the high frequency range no benefit actually from the hearing aid and in fact one of the studies was done when they gave some people hearing aids and they put people on a waiting list to get the hearing aid and actually there was no difference between the two groups the people that were waiting to get the hearing aid and the people who already had a hearing aid seem to have about the same level of tinnitus same level of improvement there's sound therapy everybody talks about this masking therapy to make the tinnitus less bothersome well we can provide some low level sound and actually it seems to make some people worse and some of the devices that people use to provide that extra sound the masking sound actually confer their damage the hearing so is there any evidence well it's inconclusive that it's going to be of any benefit brain stimulation with transcranial magnetic stimulation devices how about the tinnitus retraining therapy that's where yet had counseling to the sound generator therapy most people would believe that it's probably hype without substance biofeedback or relation relaxation training it can change the body's reaction to the tinnitus and can train you to cope better it can be associated with fewer negative thoughts and less annoyance but does it change the tinnitus no how about surgery to ablate the cochlear nerve to cut the cochlear nerve from the cochlea does that seem that's going to reduce your hearing it's gonna result in deafness in that side but only 50% of the people going to improve and oftentimes given a while the tinnitus comes back either in the same ear or in the opposite ear well some people believe that surgery especially if you have the object of tinnitus where the blood vessels are passing too close to the auditory nerve and some of the sound is caused by that mmm surgery to cause a buffer between the two conflicting evidence at best cochlear implants they might work in some people but they might cause tinnitus in other people so that's where we currently are with respect to tinnitus or ringing in the ears lots of ideas but we don't have any good solutions and fortunately for most people the extra sounds are not going to be too distressing because our current therapies are kind of like voodoo none of them are regularly shown to be any better than placebo they're just more costly so if you see a practitioner who comes up with an expensive idea or an invasive procedure you ought to get a second or even a third opinion and if you get a prescription make sure that the prescription is not going to be associated with more problems than the tinnitus and if you get a hearing aid make sure that you're able to return it if it doesn't work anyway thanks for watching if you enjoyed the show please tell a friend and consider subscribing so that you'll be notified as we post new videos so always I appreciate your interest I'm dr. ken landau [Music] [Music]

Channel: wellnowdoctor

Views: 5,271

Rating: 4.8881121 out of 5

Keywords: Tinnitus, ringing in the ears, age related hearing loss, noise related hearing loss, meniere's disease, cerumen impaction, middle ear infection, hearing aid, high frequency hearing loss, masking device

Id: JJQi0qZrnIg

Length: 27min 25sec (1645 seconds)

Published: Mon Feb 17 2020