Overview of Tinnitus

INTRODUCTION

The word tinnitus is derived from the Latin word “tinnire” meaning ‘to ring’, and in
English is defined as ‘ringing in the ears’.

Definitions of Tinnitus
 American National Standards Institute (ANSI, 1969) - Tinnitus is defined as “the
sensation of sound without external stimulation”.
 Committee on Hearing, Bioacoustics & Biomechanics (CHABA) – defines
tinnitus as “the conscious experience of sound that originates in the head”.

Tinnitus can been defined as (1) a perception of sound (it must be heard), (2)
involuntary (not produced intentionally), and (3) originating in the head (rather, it is
not an externally produced sound)

There are two types of tinnitus.

 Objective tinnitus
 Subjective tinnitus

Subjective tinnitus refers to an internal sound that is perceived only by the patient,
whereas Objective tinnitus can be heard by the patient and the examiner.

Objective tinnitus is caused by sounds generated in the body and conducted to the
ear. It may be caused by turbulence of blood flow or muscle contractions.

Subjective tinnitus can have many forms: it can be high frequency sounds similar to
the sounds of crickets, like a high- or low-frequency tone, and constant or pulsatile.
Tinnitus can be present at all times or can appear only sometimes.

Tinnitus is classified as either sensory/neural or middle ear (Tyler and Babin, 1986).
Middle-ear tinnitus is typically related to middle-ear vascular or muscular dysfunction.
Sensory/neural tinnitus originates in the cochlear and/or neural auditory pathway.

Tinnitus and auditory hallucinations are perceptions of sounds in the absence of

external noise.

Subjective tinnitus and hallucinations are phantom sounds.

Tinnitus is different from hallucinations and objective tinnitus that is caused by

sounds generated in the body and conducted to the ear. Tinnitus is hearing of
meaningless sounds.

Hallucinations consist of meaningful sounds such as music or speech and occur in

schizophrenia, after intake of certain drugs, and it may occur (rarely) in temporal lobe
disorders.
When someone reports hearing sounds that are like music or voices, it is important
to consider mental illness. Reports of imagined voices or music can occur as part of
psychotic illness such as schizophrenia. If there is no record of such illness, but
there is evidence of depression, anxiety, or unrealistic thoughts or actions, then
these should be addressed with the client and a referral provided to a mental health
professional. In the absence of indications of mental illness, one could treat this as
with other types of tinnitus. Certainly tinnitus can have a central origin.

Reed classifies tinnitus into three broad groups: mild tinnitus, moderate tinnitus, and
severe chronic tinnitus

Mild tinnitus is defined as tinnitus that does not interfere noticeably with everyday
life, moderate tinnitus may cause some annoyance and may be perceived as
unpleasant, and severe chronic tinnitus affects a person’s entire life.

These classifications rely on the individual person’s own description of their tinnitus.

Virtually anything that produces hearing loss can also produce tinnitus. The most
common causes are noise exposure, aging, head injury, and medications.
Sometimes, the causes are unknown.

Some patients with “normal” hearing also report tinnitus. It should be remembered
that “normal” hearing is arbitrary. Someone could have an audiometric “notch” of 20
dB hearing level (HL) at 4,000 Hz with 0-dB HL thresholds elsewhere. This likely
represents an auditory pathology. Additionally, hearing thresholds are traditionally
measured at octave frequencies from 250 to 8,000 Hz, leaving large regions of the
cochlea unexamined, including frequencies above 8,000 Hz
 CAUSE OF TINNITUS

OTOLOGIC NON-OTOLOGIC

Diseases of CNS
SUBJECTIVE Anaemia
Wax OBJECTIVE Arteriosclerosis
Fluid in ME Vascular tumors of ME Hypertension
ASOM,CSOM Aneurysm of carotid artery Hypoglycaemia
EY dysfunction Palatal myoclonus Epilepsy
MD Migraine
Otosclerosis

Presbycusis

Noise trauma

Ototoxic drugs

Tumors VIIIth nerve

NATURE

1. CONTINUOUS-otosclerosis,acoustic neuroma,acute noise trauma

2. INTERMITTENT-Meniere’s disease

3. PULSATILE-glomus tumor

Assessment
The quantification of symptom is fundamental to understanding its mechanisms &
treatments. Measurement of tinnitus will be focused under:

1) Audiological Evaluation
a. Case History
b. Otoscopic Examination
c. Psychoacoustical evaluations.
 d. Physiological evaluations.
2) Medical evaluations.
a. Case History
b. Physical Examination
c. Radiological Examination
d. Laboratory Testing
3) Mental Health Assessment by psychologists
Audiological evaluation

a) Case history & otoscopic examination (discussed in detail in medical

assessment)

b) Hall & Haynes, 2001; recommended the following procedures for Audiological
evaluation in patients with tinnitus / hyperacusis.

i. PTA for octave frequencies from 250 to 10 kHz and inter octave frequencies of
1, 5, 3 & 6 kHz
ii. High frequency audiometry above 10 kHz if thresholds for lower frequency
signals are within normal limits and the results of OAE are also normal.
iii. Word recognition performance at patient most comfortable level
iv. Immittance measurements (tympanometry) but acoustic reflex threshold testing
only with caution – AR measurement in contradicted in patient reporting
hyperacusis especially at levels exceeding the patients loudness discomfort
levels (LDL’s).
v. DPOAE to assess OHC’s integrity and function normal DPOAE findings are
values within an appropriate normative data region.
vi. ABR neurodiagnostic assessment is performed to rule out RCP’
vii. Vestibular test battery (ENG, Fistula test, caloric test, Rotatory chain test and
posterography) to rule out vestibular involvement.
Psychoacoustical Measurement of tinnitus

The pitch, loudness, and amount of noise necessary to mask tinnitus can be
measured to quantify tinnitus, provide assistance for fitting maskers, and monitor
changes in tinnitus perception.

Patients can usually compare the pitch produced by a puretone to the “most
prominent pitch” of their tinnitus (Tyler, 2000). Pitch matching can be highly variable,
and an indication of the variability should be reported in the patient chart.

Although patients do not usually describe their tinnitus as tonal, they are able to
equate the pitch elicited by pure tone with the most prominent pitch of their tinnitus.
Even when the tinnitus is described as a low frequency hum & a high-pitched
screech, most patients can focus on their most prominent tinnitus pitch.

Patients can also adjust the intensity of a tone so that it has the same loudness as
their tinnitus. Sensation level is not a measure of loudness. The results of a tinnitus
loudness match can be reported in dB sensation level (SL), but this level can only be
interpreted over time for a particular patient if the hearing threshold at that frequency
does not change. An alternative approach is to convert the physical intensity of the
sound into the subjective loudness scale based on sones. Sones represent an
nternational standard; 1 sone equals the loudness of a 40-dB sound pressure level
(SPL) 1,000 Hz tone (about 49 dB HL) in a normal listener.

Several things can contribute to the variability of tinnitus measurements. First, one
should be aware that the test stimuli can change the tinnitus. This is probably more
likely to happen for intense stimuli and when stimuli are presented ipsilaterally to the
tinnitus. The ear receiving the stimuli should be reported. Second, in many patients
the perception of tinnitus is not constant but varies throughout the day or from day to
day. The variability of the measurements can be documented by replicating the
measures and recording the results of each trial in the patient’s chart

a) MASKING:

Presentation of a pure tone or noise can mask tinnitus completely. The fact that
tinnitus can be masked suggests that the tinnitus & the response to the acoustic
stimulus share the same neural channels somewhere in the nervous system.

Ipsilateral masking:

Pure tones can be effective in masking tinnitus, even in a patient whose description
of tinnitus is complex. A tinnitus masking pattern can be measured by determining
the tinnitus at several tone frequencies.
Feldmann (1971, 1981, & 1984) proposed masking curves to relate the curve type
to the cause as well as tinnitus to site of lesion.

Procedure:

Establish levels necessary for masking tinnitus for NBN at each frequency tested
on audiogram (250, 500, 1K, 2K, 3K, 4K, 6K, & 8 K) and at frequency of tinnitus
and with BBN.

Give a continuous tone or NBN for approximately 1 to 2 sec duration and ask
whether he hears his own tinnitus in addition to the external sound in the test ear.
Find the minimal for each sound (threshold).

This is completed for all the frequencies, 250 to 8KHz. The resulting curves are
then classified according to Feldman’s system (Goldstein & Shulman, 1997).

There are six types of curves in the Feldman’s system.

Filled circles: Absolute threshold Unfilled circles: Min Masking Level.

 Type 1, convergence, the patient’s threshold curve and masking curve will slope
together from low to high frequencies. They will meet at the frequency of the
tinnitus and all frequencies above that.
 Type 2, divergence, the threshold and masking curves slope further apart from
low to high frequencies.
 Type 3, congruence, the threshold and masking curves almost overlap each
other for all frequencies. This type of tinnitus can be masked by any noise just
above the threshold of the tinnitus.
 Type 4, distance, the masking curve follows the threshold curve, but is at least
20dB above the threshold.
 Type 4a, is the same as type 4,but the tinnitus can only be masked by pure
tones. Finally,
 Type 5, persistence, is found when no sound at any level can mask tinnitus.
This usually happens when the patient has a severe to profound hearing loss,
but occasionally it occurs with those with moderate hearing loss (Goldstein &
Shulman, 1997).
Feldman classified masking curves into 6 patterns and equated them with specific
pathologies.

1. Type I – convergence type – industrial deafness

2. Type II – divergence type – tinnitus of unknown origin
3. Type III – congruence type – partially coincide with a range of 10 dB Meniers
disease
4. Type IV – Distance – well above 20 dB – Presbycusis
5. Type IV A – Dispersion – To mask tinnitus greater intensity for PT’s is require
than for NBN – serous Otitis media
6. Type V – Persistence – tinnitus can’t be masked by any stimulus – cochlear
degeneration

Hyperacusis
Definition
Vernon, 1987 defined hyperacusis as ‘unusual tolerance to ordinary
environmental sounds'

Klein et al., 1990 defined hyperacusis as ‘consistently exaggerated or

inappropriate responses to sounds that are neither threatening nor
uncomfortably loud to a typical person'
Both the definitions underscore the abnormality of behavioural response to sounds
and sounds of low intensity can evoke this experience, and that sounds in general
(ie, everyday sounds) are problematic rather than specific sound

The dictionary definition implies the ability to detect sound at abnormally low
intensities, or, in other words, better than average hearing; this is not how the term is
used in the clinical literature. Subsequent attempts to define hyperacusis have
included “unusual tolerance to ordinary environmental sounds”, “consistently
exaggerated or inappropriate responses that are neither threatening nor
uncomfortably loud to a normal person”, and “abnormal lowered tolerance to sound”.
A more recent definition describes hyperacusis as “abnormal increased sound-
induced activity within the auditory pathways”. As a result, sounds that are
nonintrusive, or unnoticed by the general population, are uncomfortable to people
with hyperacusis. The common thread to all these definitions is that sounds in
general, rather than specific sounds, are unpleasant to individuals with hyperacusis.

Conductive hyperacusis - This is a phenomenon associated with dehiscence of the

superior semicircular canal in which the person may have normal air conduction
thresholds on pure tone audiometry but better-than-normal bone conduction. This
results in an air-bone gap, and the person often complains of hyper-awareness of
sounds

Phonophobia - Phonophobia, literally meaning fear of sound, is a widely used term

in neurology, particularly in association with migraine. Woodhouse and Drummond
reported that at least 50% of migraine attacks are accompanied by increased
sensitivity to sound, and uncomfortable loudness levels are reduced during attacks.
From an audiological point of view, however, phonophobia implies reaction to certain
sounds that have specific emotional associations for that person. Thus, the reduced
sound tolerance seen in migraine might be better described as hyperacusis. True
phonophobia in isolation is unusual.
Misophonia -In 2004, Jastreboff and Hazell describe misophonia as “a negative
reaction to sound results from an enhanced limbic and autonomic response, without
abnormal enhancement of the auditory system.” They suggest that phonophobia is a
subsection of misophonia where fear is the chief component.

Dis-Like of Sounds, finding sound itself aggravating or overwhelming, a feeling of

sensory overload or over-stimulation, this can lead to self-isolation, removal from
noisy environments, using earplugs often, withdrawing from work or social situations,
avoiding sounds or noises.

Recruitment -Recruitment or, to use the full title, loudness recruitment, is a common
finding in individuals with cochlear hearing loss associated with outer hair cell
dysfunction. It is characterized by an abnormally large increase in the perceived
loudness of a sound caused by a slight increase in its intensity. This is not
modulated by mood or levels of anxiety.

This phenomenon may be distinguished from hyperacusis if the individual

experiences sound of moderate intensity as uncomfortably loud (recruitment) or
sound of low intensity as uncomfortably loud (hyperacusis). But the two experiences
are not mutually exclusive.

The boundaries between these definitions can occasionally seem blurred, and it is
also quite possible for a person to have more than one form of reduced sound
tolerance. For example, a person with a cochlear hearing loss may display
recruitment but also have phonophobia.

Types of hyperacusis:
Cochlear versus vestibular hyperacusis
With cochlear hyperacusis, subjects feel ear pain, discomfort, annoyance, and
irritation when certain sounds are heard, including those that are very soft or high-
pitched.

In cochlear hyperacusis, symptoms include ear pain, discomfort, irritation, and

annoyance from any kind of sound whether it be a soft sound or a high-pitched one.
The patient will often have a severe emotional reaction to sound like crying or a
panic attack.
Vestibular hyperacusis is a disturbance of the balance mechanism that occurs in
response to sound exposure. These disturbances have been called various names,
including Tullio’s syndrome and audiogenic seizure disorder.
In vestibular hyperacusis exposure to sound often results in falling or a loss of
balance or postural control and some of the same reactions as with cochlear
hyperacusis can also occur. Other symptoms include sudden severe vertigo or
nausea.
Symptoms associated with Hyperacusis and Phonophobia
Ear pain, irritation, headache, ear fullness , fluttering sensation
 Annoyance from any kind of sound (soft sound /a high-pitched one) with
severe emotional reaction
Fear of sounds, avoid social interactions, lack of self confidence

Table 1 Medical conditions in which hyperacusis has been reported as a symptom (Katznell
and Segal, 2001)
Peripheral Central
Bell’s palsy Migrane
Ramsay Hunt syndrome Head injury
Stapedectomy Williams syndrome
Perilymph fistula Depression
Lyme disease Post-traumatic stress disorder

Hazell (1987) suggested that hyperacusis might be the result of an “abnormal gain
control.” It is as if the brain receives a lack of information after hearing loss and
therefore turns up some hypothetical gain control. Although intriguing, there are
several problems with this suggestion.

First, such a gain control mechanism must not operate on acoustic signals, because
the hearing loss is not corrected.

Second, our clinical experience is that some individuals without any apparent
hearing loss also have hyperacusis. Third, most people with hearing loss do not
report hyperacusis. Whenever emotions are involved, for example, in fear
hyperacusis,other regions of the brain must also be involved.

JOHNSON HYPERACUSIS DYNAMIC RANGE QUOTIENT (JHQ)

It is recommended for normal hearing subjects

Subtract, by frequency, the threshold level measurement from the loudness
tolerance level measurement. This is the hyperacusis dynamic range for that
frequency.

To obtain the Johnson Hyperacusis Quotient, add all the ranges together and divide
by the number of frequencies tested to obtain an average range.