Doctor, What is That Ringing in My Ear?
Tinnitus is the awareness of a sound that is not coming from the external environment. It may be a buzzing, humming, whistling, shushing or even the sound of an engine or machine. People who hear words or music are usually suffering from a central nervous system ailment. The sound may be perceived to originate in one or both ears or even somewhere inside the head.

We classify tinnitus as objective or subjective. Objective tinnitus can be heard by another person. This can be due to the sounds caused by muscular contraction (as in palatal myoclonus, TMJ syndromes and arthritis), turbulent flow through blood vessels (medical term: bruits), or even the opening and closing of the Eustachian tube of the ear. Subjective tinnitus cannot be perceived by anyone other than the sufferer. It is subjective tinnitus that is the more difficult to treat. Subjective tinnitus can be due to a malfunction of any portion of the hearing pathway: the external ear (external auditory canal), middle ear (tympanic membrane and small bones that transmit its vibrations), the inner ear (fluid filled chambers in which sensory cells detect vibrations transmitted to the fluid from the middle ear) and the more central structures (auditory or eighth cranial nerve that connects the inner ear to the brain and the hearing pathway within the brain itself.

External Ear: This tubular structure from the outside leads to the outer surface of the tympanic membrane (abbreviated TM, the “drum head” of the middle ear). Wax, hair or foreign material in the canal (beads, sand, water, etc.) can cause tinnitus, especially if there is contact with the TM. The cure is to remove the offending material.

Middle Ear: This air containing space is supplied with air through the Eustachian tube, a passage way from the back of the nose to the middle ear. The tube is closed except during yawning or swallowing. You can hear it open when you swallow (listen for the click that it makes). Sometimes the muscle that opens the tube (tensor veli palatine) goes into a rapid spasm and causes a humming sound that may be audible to others. There are two tiny muscles in the middle ear that can also cause humming. These spasms can be induced by caffeine or anxiety. When the Eustachian tube does not work well, the air of the middle ear can be replaced by fluid (mucus) which causes hearing loss and tinnitus. Eustachian tube malfunction from a cold or allergies is self limited and can be helped by decongestant medicines and allergy medications. Rarely, tumors of the middle ear (glomus tumor) can cause a pulsating tinnitus due to their high number of blood vessels.

Inner Ear: This is usually the site of most cases of persistent tinnitus. The delicate nerve endings (hair cells) that detect the vibrations of sound in the fluid of the inner ear are readily injured or destroyed by insults such as loud noise, blows to the hear, certain viral infections, certain medicines, such as aspirin) and once they are lost they are not replaced. Over a person’s lifetime, the gradual destruction of these fragile cells leads to a progressive hearing loss with age (presbycusis) that is frequently accompanied by tinnitus. It seems that the decreased input from the sensory cell allows the nerve activity to be unregulated, and the brain interprets this as a sound. This is the tinnitus that the patient perceives. It is the inner ear tinnitus that is so hard to treat because we cannot restore the missing hair cells. The only way this will be fully cured is to regenerate these cells with stem cell treatment.

Nevertheless, anything and everything has been tried, but there is NO treatment that is truly successful. Lidocaine might temporarily reduce tinnitus though its reduction of nerve activity, but it has to be given intravenously. Lipoflavinoids have been touted as helpful, but are scientifically unproven. Melatonin has also been touted as being helpful. The main problem with tinnitus is that its constant presence emotionally upsets the patient and forces the sufferer to concentrate on the sound itself, thus making it seem louder and louder. This is the same thing that happens with pain, and tinnitus can be rightfully considered a kind of pain. Methods of reducing the brain’s focus on the sound are therefore helpful: biofeedback, anxiety reducing drugs, yoga and meditation. While they don’t eliminate the tinnitus, these techniques make it less bothersome so that the suffering is reduced. Another helpful treatment is to give an external sound in the ear to “mask” the tinnitus. This can be in the form of a noise machine, the “white noise” static from a radio, or even a fan. There are tinnitus maskers available as well that are placed in the ear and look like a hearing aid. Tinnitus Retraining Centers have also appeared in various areas and rely on retraining the patients' brains so they treat tinnitus similar to the way they treat the sound of a refrigerator in their kitchen, which they are normally not aware of, and when they do hear the sound, it is not bothersome. The method retrains reflexes involving connections of the auditory with the limbic and autonomic nervous systems, and retrains the subconscious part of the auditory pathway to block the tinnitus signal. TRT always consists of two components: intensive one-on-one directive counseling, and sound therapy, most frequently with the use of sound generators (which emit low level of broad-band noise), following a specific habituation protocol. Tinnitus should never be masked in TRT, because one can never habituate signal one cannot detect.