Sunday, 19 January 2014
For whom the bell tolls - Tinnitus
If you know anyone with tinnitus, or ringing in the ears, you might know that it can be a real problem. Some people don't notice the pinging, ticking, buzzing or bells. Others are devastated by it. And you almost certainly do know someone with tinnitus since it affects 1 in 5 people (Mayo). Thing is, people with tinnitus usually don't like to talk about it. Let's learn why.
Tinnitus is a noise or ringing in the ears. It can affect both ears or just one. The noise can be subtle or screamingly overt. The sound can be a gentle hissing (like a tap running in another room), a ticking or clicking (like a watch held to the ear), or a loud buzzing, ringing, or high pitched whine (like an air raid siren from London 1944).
Tinnitus can start right out of the blue and quite often scares the heck out of people. It can be temporary. It often isn't. But the brain adapts so it appears to recede or go away. I will explain that in greater detail in a minute.
Tinnitus is a symptom that has a number of different potential causes. The absolute most common cause of tinnitus is hearing loss. Hearing loss can come with ageing (known as presbycusis), or from exposure to loud noise (heavy equipment, loud music, firearms), or from a structural problem with sound conduction (ear wax or ear bone changes like otosclerosis).
Other causes of tinnitus are not as common but your NP or Physician will want to exclude these conditions. Meniere's disease, TMJ disorders, head injuries, metabolic disorders (diabetes, thyroid disease), atherosclerosis (clogging of the arteries) or vascular/capillary abnormalities, high blood pressure, and head and neck tumours can all cause ringing in the ears. Acoustic neuromas (tumours on the cranial nerve responsible for hearing) will do it but only in one ear.
Some specialists will want to rule out neurological conditions like multiple sclerosis and infections like syphilis. Medications can cause or worsen tinnitus usually when they are given at higher doses. These include some antibiotics, cancer medications, quinine, aspirin, diuretics and some psychiatric drugs like antidepressants.
The process of eliminating all of these horrible conditions can be quite terrifying. Some things are simple to rule out with a carotid artery ultrasound or simple physical exam. Other conditions require an MRI scan of your noggin which for some people is about as much fun as doing your taxes. At minimum if you experience tinnitus you should be having a hearing test, blood pressure readings, basic blood tests, and a physical examination by your health care provider.
In truth for all the years that I have been providing primary health care almost all of the patients with tinnitus have it from hearing loss. I have patients who are in their late 30's with tinnitus and others who don't notice it until they are in their 80's.
Regardless of the cause constant ringing in the ears can cause a multitude of problems. It's true that many of my patients really don't notice it much. Others are considerably more distressed, particularly when it first starts, and they may experience insomnia, fatigue, severe stress, memory and concentration problems, anxiety and depression. Often people with tinnitus have difficulty hearing quiet or high pitched sounds. Some people become isolated when they avoid social situations because they are distressed or cannot hear. Many people don't like to talk about tinnitus because it makes them focus on the ringing which is then perceived to be louder. Tinnitus is often compared with chronic pain in that it is constant, subjective, and can be traumatizing if we feel that we have no control over it (Canadian Academy of Audiology).
So when does this story get better? Well in fact it does. Because we can gain control over tinnitus with a number of different strategies and tools. Sometimes patients are told by their health care provider that "tinnitus can't be cured". Or to "go home and get used to it". This is NOT helpful and really isn't accurate. It's true that we don't "cure" tinnitus. But we can decrease our sensation of it - just like we do with pain.
The brain is a truly amazing thing and what happens is that it adapts to the tinnitus and ultimately blocks it out. In most cases of tinnitus we stop hearing part of the hearing range. The brain "fills in" that part of the range. But it isn't able to make it sound exactly like the ambient noise around us which is always changing. So what we hear is a ringing or whining sound. But over time our brain then adapts to the new sound and starts to block it out. When the ringing first starts it can be perceived as extremely loud - almost like a buzzer. But over time this recedes into the background until you go days and days without noticing it.
Adaptation takes weeks to months so it is important that patients remember two things - one is that it will fade into the background - the other is that there are a lot of strategies and management techniques that can be employed in the meantime. Often the person with the tinnitus will not think of these things so we need to help them out. I cannot stress enough how important it is that if someone in your life has tinnitus please make sure they are getting all the help and support that they need.
First of all there are a number of distracters/masking devices/noise machines. What these do is provide an external noise for your brain to focus on so that it doesn't hear the tinnitus. These can be immensely helpful for getting to sleep but some people like to have them on in the background during the day. You can buy a number of devices on-line and now there are a selection of mobile phone applications that you can download (most are free). There are some things you may already have in your house that are often effective - a fan, a bubbling fish tank, air humidifiers, air filters, and decorative water features.
Medications should definitely be reviewed. Any medication that is a known cause of tinnitus (e.g. aspirin) should be reduced. And there are medications you might start that can have a very positive impact on life quality - such as anti-depressants and sleeping tablets. You may not need these medications forever but until your brain adapts and you start to block out the ringing it can be very important to take these medications in consultation with your provider.
If tinnitus is caused by hearing loss it can be extremely helpful to see a hearing specialist and try hearing aids. Some people will get tinnitus before hearing loss registers on their test - the canary in the coal mine so to speak. Other people will show advanced hearing loss. Either way hearing aids can be very effective.
Counselling and cognitive behavioural therapy is also helpful to a lot of people. Most social workers can provide this type of care. There are also specialized centres that focus on tinnitus management and retraining therapy. Some of these centres provide care at their centres as well as counselling and management programs on-line.
Anyone who has potentially acquired tinnitus from noise damage and hearing loss at work should consider a WSIB claim. In any place where there is identified hearing loss risk (factory workers, mine workers, working with heavy equipment, military personnel) financial support for hearing aids and management aids and programs are often provided.
Best of all is to reduce the risk of tinnitus in the first place. If you are told to wear hearing protection at work - use it! And make sure that it is working properly and doing the job. Pay attention to your general and cardiovascular health - don't smoke, exercise often, eat a healthy whole foods diet, and keep your screening tests current (if you know the words here - sing along).
And most importantly - reduce your noise exposure. I first developed tinnitus when I was 41 years old. It came on during a pertussis infection (and antibiotics) that I contracted at work. I will never know if it was caused by the infection, the drugs, or the eventual hearing loss picked up on my hearing tests. But if I could, I think I would take back the miles and miles of marathon and triathlon training with the music at full blast on my earphones. Or standing by the larger-than-life speakers at the many concerts - Midnight Oil, Violent Femmes, The Clash, The Stones, Sting, Bowie, Genesis, Peter Gabriel, Blue Rodeo, Indigo Girls, Sarah McLaughlin, Bob Seger, Joe Jackson, Dave Brubeck, Elton John, Eurythmics, Blur, The Hip, Spirit of the West, Jan Arden, The Waltons, Great Big Sea, and so many more. I might even have missed all of the Bruce Springsteen concerts if it meant I could have skipped that MRI scan.
Thanks for reading Getting Healthy with NP Sam. Comments welcome - please click the pencil icon below.
Basics of Tinnitus (Mayo Clinic)
Tinnitus (Canadian Academy of Audiology)
Tinnitus Retraining Therapy (Canadian Tinnitus & Hyperacusis Centre)
Tips for Managing Tinnitus (Canadian Tinnitus Foundation)
Deborah Lain, BA, MSc Psychology Services for people with Tinnitus
Tinnitus Management Modules (Deborah Lain - Hope for Tinnitus)
Sound Devices for Tinnitus (Sound Oasis)