Mechanisms of subjective tinnitus

The inner ear contains many thousand minute hairs which vibrate in response to sound waves. Receptor cells (hair cells) in turn send signals to the brain which are interpreted as sound. Although receptor cells can be regenerated from the adjacent supporting Deiters cells after injury in birds, reptiles, and amphibians, in mammals it is believed that they can be produced only during embryogenesis. Although mammalian Deiters cells reproduce and position themselves appropriately for regeneration, they have not been observed to transdifferentiate into receptor cells except in tissue culture experiments.Therefore, if these hairs become damaged, through prolonged exposure to excessive volume, for instance, then deafness to certain frequencies occurs. In tinnitus, they may falsely relay information at a certain frequency that an externally audible sound is present, when it is not.

The mechanisms of subjective tinnitus are often obscure. While it's not surprising that direct trauma to the inner ear can cause tinnitus, other apparent causes (e.g., TMJ and dental disorders) are difficult to explain. Recent research has proposed that there are two distinct categories of subjective tinnitus, otic tinnitus caused by disorders of the inner ear or the acoustic nerve, and somatic tinnitus caused by disorders outside the ear and nerve, but still within the head or neck. It is further hypothesized that somatic tinnitus may be due to "central crosstalk" within the brain, as certain head and neck nerves enter the brain near regions known to be involved in hearing.

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Pulsatile Tinnitus

In this form of tinnitus the sufferer hears something resembling their heartbeat in their ear. The cause for pulsatile tinnitus usually involves vascular, tumor or muscular causes. A blood vessel may be close to the eardrum, a vascular tumor such as a "glomus" may fill the middle ear, or a vein similar to a varicose vein may make enough noise to be heard. Other pulsatile tinnitus possibilities include dehiscence of the jugular bulb, and an abberently located carotid artery. An enlarged jugular bulb on the involved side is common in persons with venous type pulsatile tinintus.

In persons with pulsatile tinnitus, additional tests may be proposed to study the blood vessels and to check the pressure inside the head. Gentle pressure on the neck can be performed to block the jugular vein but not the carotid artery. The Valsalva maneuver reduces venous return by increasing intrathoracic pressure. If there is a venous hum, this usually abates or improves markedly. If the pulsatile tinnitus pulsation is arterial, these tests have no effects. MRI/MRA or CT is often suggested in younger patients with unilateral pulsatile tinnitus.

In older patients, pulsatile tinnitus is often due to atherosclerotic disease and it is less important to get an MRI/MRA. In some cases of pulsatile tinnitus a lumbar puncture may be considered if there is a possibility of benign intracranial hypertension. More invasive pulsatile tinnitus testing includes the "balloon occlusion test", where a balloon is blown up in the internal jugular vein to see if it eliminates pulsatile tinnitus.

It is strongly recommended that all individuals with pulsatile tinnitus locate an excellent physician with interest in the circulatory system and complete a thorough examination. Based on research, which included reviewing 7 otolaryngology textbooks and over 250 research studies, data appears to support the underlying cause for detecting a pulsatile tinnitus as physiologic in nature. That said, there are many, many cases of pulsatile tinnitus that defy diagnosis and identification of the causative agent.

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Tinnitus Management

Tinnitus ("TIN-a-tus" or "Tin-EYE-tus"), more commonly spoken of as "ringing in the ears" or "head noise," has been experienced by almost everyone at one time or another. It is defined as the perception of sound in the head when no external sound is present.

In addition to "ringing," head noises have been described as hissing, roaring, pulsing, whooshing, chirping, whistling and clicking. Ringing and head noises can occur in one ear or both ears, and can be perceived to be occurring inside or outside the ear. It can accompany hearing loss. It can exist independent of a hearing loss.
What should I do?

Since tinnitus is a symptom of a problem, the first thing you should do is to try to find out the underlying cause. You should have a medical examination with special attention given to checking factors associated with tinnitus such as blood pressure, kidney function, medications/drug intake, diet and allergies, emotional stress, noise exposure, and diseases involving the auditory system. Tinnitus can be associated with conditions that occur at all levels of the auditory system.

Some of these conditions are impacted wax (external ear); ear infection, middle ear tumors, otosclerosis, vascular problems (middle ear); Menieres disease, ototoxic medications, circulation disorders, noise-induced hearing loss (inner ear); and, at the central level, 8 th nerve and other tumors, migraine, and epilepsy.

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Tinnitus on the rise due to increase in noise levels

It is no wonder that tinnitus is on the increase, especially amongst younger people. Our ears are assailed daily by noise levels that they were not designed to cope with. It is often said that we have a stone-age body in a 21st Century world. Our ears are capable of picking up tiny sounds that were important for survival in the natural world, for example awareness of prey or predators some distance away.

But if you look at the chart below you can see that many every-day noises such as busy city-centre traffic or even a lawnmower can produce noise levels which, if you are exposed to for too long, can cause hearing damage or even tinnitus. If we take more extreme examples such as a rock concert or nightclub then you can see that hearing damage can occur very quickly. It will come as no surprise then to discover that many performers and disc jockeys suffer from hearing loss and tinnitus.

The chart shows noise levels measured in decibels (abbreviated dB) so here is a brief explanation for anyone unfamiliar with the terminology. The term actually comes from the name of the inventor of the telephone, Alexander Graham Bell, and the measurement has to take account of the huge variation in intensity of the range of sounds we can hear. So if we take a really quiet sound like a watch ticking or leaves rustling and compare with a loud jet like Concorde at takeoff, then the difference in the power of the sounds is about 1,000,000,000,000 times!

So on the decibel chart, 0dB is near total silence but 10dB is ten times more powerful and 20dB is 100 times more powerful, 30dB is 1000 times more powerful, and so on. A hairdryer at 80dB is one hundred times as loud as normal conversation at 60dB. A rock concert of 120dB is a million times as loud as normal conversation.

Any noise above 80dB can cause hearing loss and the loss is related to the power of the sound and the length of time you are exposed. It is no accident then that from February 2006, the new noise regulations lower threshold for the workplace, when ear protectors must be made available, is reduced from 85dB to 80dB. However, legislation will not apply to the music and entertainment industries until 2008 so avoid excessive noise if you are off to a rock concert and take earplugs with you. This particularly applies to existing tinnitus sufferers. Earplugs can improve the clarity of the sound in these conditions and make conversation easier.
Any exposure to noise above 140dB will cause immediate hearing damage.

Despite the risks, it is amazing what lengths some people will go to in order to create deafening sounds. The current fashion is to install stereo systems in cars with more amplification power than the Rolling Stones used to use to fill a stadium. The stereo is probably worth more than the car but we can predict with certainty that the owners will have hearing problems later in their lives.

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Varying success for medications to relieve Tinnitus

Many medications have been tried to relieve tinnitus with varying degrees of success. Tricyclic antidepressants, such as amitriptyline and nortriptyline, have been used with some success, but these medications have troublesome side effects, such as dry mouth, blurred vision and constipation.


Two recent clinical trials found that the migraine medications gabapentin (Neurontin) and acamprosate (Campral), a drug used to treat alcoholism, are effective in relieving tinnitus for some people.

Treatments with limited results

Some other treatments that have been tried, but which have had inconsistent results, are:

• Acupuncture
• Hypnosis
• The herb ginkgo
• Cochlear implant, an electronic hearing device
• Electrical stimulation
• Medications, such as benzodiazepines (nervous system depressants) and baclofen (a muscle relaxant)
• Hyperbaric oxygen chamber, a therapy to get a high level of oxygen in your blood
• Zinc

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Prevention of Tinnitus

Because tinnitus and hearing loss can be permanent conditions, precautionary measures are advisable. If a ringing in the ears is audible after exposure to a loud environment such as a concert or work place, it means that damage is being done. Prolonged exposure to noise levels as low as 70 dB can result in damage to hearing . If it is not possible to limit exposure, wearing earplugs or ear defenders can be advantageous. For musicians and DJs, special musicians' earplugs can lower the volume of the music without distorting the sound and can prevent tinnitus developing in later years.

It is also important to check medications for potential ototoxicity. Ototoxicity can be cumulative between medications, or can greatly increase the damage done by noise. If ototoxic medications must be administered, close attention by the physician to prescription details such as dose and dosage interval can reduce the damage done.

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Masking For Symptomatic Relief

A sound with higher decibel can mask the low decibel sound of tinnitus. This can be illustrated below:
Sound from surrounding Environment: A TV programme running in the background is often helpful when the tinnitus is disturbing.

Some examples of masking due to environmental sounds are:

Playing with friends, surfing on a beach, festival and other celebrations.

A "Walkman" or “Ipod” can be used with plug-in-ear earphones; which can be switched on when resting.

Modern hearing aids incorporating latest technological advancement are very effective at submitting the usual soft environmental sounds around you, and helping to get tinnitus mask. Older aids were not useful for this purpose. They can be programmed to amplify the whisper like sound around you without amplifying loud decibel sounds (thus avoiding noise induced hearing loss), and thus mask the annoying unwanted irritating tinnitus sound.




Tinnitus maskers : They are not hearing aids in true sense but generate some pleasing sounds in the ears which are not disturbing. They in no way can be used for people with hearing loss. But its use for masking is very limited as most of tinnitus affected age group are of old age with hearing loss and so hearing aid is a better option..

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