Tinnitus: current understanding and contemporary management

Michael D. Seidmana, Robert T. Standringa and John L. Dornhofferb

a

Henry Ford Health System, Director Division

Otologic/Neurotologic Surgery, Medical Director
Center for Integrative Medicine, Detroit, Michigan and
b
University of Arkansas for Medical Sciences,
Professor of Otolaryngology, Samuel D McGill Chair in
Otolaryngology Research, Little Rock, Arkansas, USA
Correspondence to Dr Michael Seidman, Henry Ford
Health System, Director Division Otologic/
Neurotologic Surgery, Medical Director Center for
Integrative Medicine, Detroit, MI 48202, USA
Tel: +1 248 661 7211; e-mail: mseidma1@hfhs.org
Current Opinion in Otolaryngology & Head and
Neck Surgery 2010, 18:363368

Purpose of review
Tinnitus is a debilitating condition that affects a broad range of patients. Despite
thorough and extensive research, the cause of tinnitus has yet to be determined. Also,
there has never been a single intervention identified that can consistently eliminate the
symptoms of tinnitus. However, despite our inability to cure tinnitus, there are many
medical and behavioral strategies that may result in symptomatic relief. The purpose of
this article is to review some of the previous information on tinnitus and to examine the
recent research on the etiology and management of this condition.
Recent findings
Recent research into the etiology of tinnitus has demonstrated that genetics plays less
of a role than previously thought. Although many medications can cause some relief of
tinnitus, a number of well designed studies have failed to identify a single cure. For
patients with severe tinnitus who have failed other treatments, such as dietary
modification, herbs and nutrients, sound therapies (tinnitus retraining, Neuromonics,
masking, and others), or centrally acting medications, transcranial magnetic stimulation
has emerged as a viable treatment option.
Summary
Tinnitus is a common medical complaint and debilitating problem for some patients. It
has a broad range of etiologies and even more potential treatments. This review is meant
to inform the reader on the current options available to treat this condition.
Keywords
clinical evaluation, etiology, otology, tinnitus, treatment
Curr Opin Otolaryngol Head Neck Surg 18:363368
2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
1068-9508

Introduction
Tinnitus is generally defined as a perception of sound
in the absence of an external acoustic stimulus. It is a
common medical complaint that has multiple causes and
can be divided into two main types. Subjective tinnitus
differs from objective tinnitus in that patients with
objective tinnitus are hearing sounds stemming from
vibrations of turbulent blood flow, myoclonus, or muscle
contractions, to name a few. This occurs in a very small
proportion of patients who complain of tinnitus and will
not be reviewed in this article [1,2]. Subjective tinnitus,
referred to as tinnitus for the remainder of this paper,
affects approximately 50 million Americans and more
than 600 million individuals worldwide [3,4]. It has a
prevalence of roughly 1215% in the adult population
[5,6,7]. Many of those affected have concurrent hearing
loss, and it is thought to be age-related, as demonstrated
by the data that nearly 12% of men aged 6574 years are
affected [5]. The majority of people who have tinnitus
tend to fall in the age range of 4070 years [8]. Men tend
to have tinnitus more often than women. Tinnitus may
have a genetic component in that more Caucasians are
1068-9508 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

affected than AfricanAmericans in the United States;

however, there are conflicting thoughts on this point,
which will be discussed later. There may also be an
environmental component in that people in the southern
United States are twice as likely to complain of tinnitus as
those who live in the northeast [5]. The purpose of this
article is to offer a review of the current theories of
etiology, evaluation, and management of tinnitus.

Etiology
There have been multiple hypotheses proposed as to the
etiology of tinnitus, yet a common mechanism of tinnitus
remains to be fully elucidated. The production of sound
without an external stimulus is thought to arise from
aberrant neural activity from any point along the auditory
pathway, from the cochlear apparatus to the auditory
cortex [9]. Possible theories regarding the production
of tinnitus include damaged hair cells with unregulated
discharge and over-stimulated auditory nerves, hyperactive auditory nerve fibers, or lack of suppression of
activity in the auditory cortex on peripheral auditory
nerve activity [10,11].
DOI:10.1097/MOO.0b013e32833c718d

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364 Otology and neuro-otology

Otologic pathology is the most common cause of tinnitus

[8]. Tinnitus has been correlated with noise exposure,
noise-induced hearing loss, presbycusis, otosclerosis,
otitis, cerumen impaction, Menieres disease, and sensorineural hearing loss [12]. Neurologic causes include
vestibular schwannomas, multiple sclerosis, and head
injuries [10,12]. Tinnitus was noticed by 57% of patients
with acoustic schwannomas before the radiographic diagnosis was made. This was the third most prominent
presenting symptom behind unilateral hearing loss and
unsteadiness [13]. Infectious causes of tinnitus include
otitis media, meningitis, syphilis, and other auditory
inflammatory processes [12]. Iatrogenic causes can occur
from otologic surgery or may present as side effects
of many medications, including salicylates, NSAIDs,
aminoglycoside antibiotics, loop diuretics, some chemotherapy drugs, opioids, and others [12,14]. Metabolic
disorders that may be associated with tinnitus include
vitamin B12 deficiency, zinc deficiency, hyper/hypothyroidism, and anemia. Other causes also include temporomandibular joint dysfunction and craniomandibular
disorders [12]. Psychogenic disorders, including depression, anxiety, and fibromyalgia, are also thought to have
an association with tinnitus [10,15]. Folmer et al. [15]
reported a correlation between depression and tinnitus.
In a review of 436 patients with tinnitus, 151 (34%) also
had a history of depression. On the basis of a tinnitus
severity questionnaire, depression was correlated significantly with tinnitus severity, but not with reported loudness, indicating a possible psychological component of
the disease. To further investigate the role of psychiatric
pathology, Deniz et al. [16] looked for a serotonergic
cause of tinnitus and found that a serotonin transporter
gene may play a role in tinnitus.
Early hypotheses on the etiology of tinnitus suggested
that it arose with hearing loss or cochlear damage [1720].
This idea seems plausible based on the observation that
many patients with chronic tinnitus also have hearing
impairment. An interesting paper published by Barnea
et al. [21] demonstrated that tinnitus did not reflect
concurrent damage in the cochlea or brainstem auditory
pathways based on extended high-frequency audiometry and auditory brainstem responses in nonhearingimpaired individuals. Other data demonstrate that the
perception of tinnitus and the frequency range of hearing
loss are related. When the tinnitus pitch of individuals is
matched to a pure tone, most of the matches occur at a
frequency at which hearing is impaired [22]. A study by
Ochi et al. [23] analyzed the relationship between tinnitus and hearing impairment in patients with unilateral
tinnitus. They found a threshold difference between the
tinnitus-affected ear and the unaffected ear near the
frequency of the perceived tinnitus pitch, suggesting
that tinnitus may be related to hearing loss at the same
frequency. These data, along with other data attempting

to match hearing loss thresholds to tinnitus pitch, may be

skewed, however, based on the fact that many audiograms do not test for hearing impairments outside the
pitch frequency range of 125 Hz8 kHz [23].
There has been some thought that tinnitus may have a
genetic preponderance as it has been shown to have a
significant familial aggregation [5,24]. In a recent large
Norwegian population study by Kvestad et al. [7], tinnitus was found to have a heritability of 0.11, demonstrating
a low importance of genetic factors. This study found a
lower hereditability estimate than previous twin studies
with smaller sample sizes [25].

Evaluation of the patient with tinnitus

A thorough history and physical is crucial in the evaluation of the patient with tinnitus. A standard approach to
history taking will help to differentiate between subjective and objective tinnitus as well as to diagnose easily
treatable causes, such as medication side effects. Along
with a detailed description of the characteristics of the
sound, the history should include symptom onset and
timing, location, pitch and loudness, pattern, associated
symptoms, exposures, and exacerbating/alleviating
symptoms. The patients past medical/surgical history
should focus on identifying contributing causes, such
as hyperlipidemia, thyroid disorders, anemia, metabolic
deficiencies, and otologic surgeries [10]. The history
should include a description of the patients symptoms.
Patients may complain of bilateral or unilateral symptoms. Tinnitus is often described as ringing, buzzing,
cricket-like, hissing, or as a humming sound [1].
It is important to inquire how tinnitus is affecting the
patients quality of life, as this typically dictates the level
of management required. Questions to assess this should
include: Do the symptoms affect your activities of
daily living? Do the symptoms interfere with your sleep?
On a scale of 1 to 10, how much is your life affected by
tinnitus? A response of 12 would indicate that the
tinnitus is mild, but the patient wants to be sure everything is okay. A response of 910, on the contrary, would
imply that the tinnitus is so severe the patient cannot
work and is disabled by the sound. Many practitioners
supply their patients with surveys to rate the subjective
lifestyle disruption caused by their tinnitus. Two
validated tools include the Tinnitus Severity Index
(TSI) and the Tinnitus Handicap Inventory (THI)
[15,26]. The TSI includes 12 questions on how tinnitus
affects activities of daily living, overall quality of life, and
related psychological disorders [15]. The THI includes
25 items grouped into functional, emotional, and catastrophic subscales. These scales demonstrated excellent
reliability in quantifying the impact of tinnitus on daily
living [26].

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Tinnitus Seidman et al.

The physical examination should focus on the head and

neck, with specific attention paid to the external ear
canal, tympanic membrane, oral cavity, and temporomandibular joint. The cranial nerves, especially the fifth,
seventh, and eighth, should be thoroughly tested.
Auscultation of the carotid arteries, mastoid, and periaural areas should be performed to rule out any objective
tinnitus etiology. Tinnitus that originates from a venous
source can be suppressed by compression of the ispilateral jugular vein [10].
Following the physical examination, comprehensive
audiologic testing should be performed. This should
include pure-tone thresholds with air and bone conduction, acoustic impedance measurements with tympanometry and acoustic-reflex thresholds, speech audiometry,
and maskability tests [12]. Additional testing should
be performed for those patients with results suspicious
for vestibular schwanommas, including unilateral highfrequency hearing loss combined with poor speech
discrimination [12]. These findings require further neuroimaging to obtain a definitive diagnosis. There are several
other noninvasive neuroimaging techniques that can be
employed including positron emission tomography (PET),
single photon emission computed tomography (SPECT),
and functional magnetic resonance imaging (fMRI). More
recently we have been using magnetoencephalography
(MEG), which allows detection of cortical neuronal
activity and may thus be useful in the diagnosis and
mapping of tinnitus [27].

Management
There is no single cure for tinnitus, and, currently,
there is no single US Food and Drug Administration
or European Medicines Agency-approved drug on the
market to treat tinnitus. In addition, in a review of 69
randomized clinical trials, Dobie [28] found that no
treatment provided superior, long-term alleviation of
tinnitus symptoms compared with placebo. However,
many treatment modalities have been shown to improve
the symptoms of tinnitus [29], and an open discussion
with the patient should make him or her aware of the fact
that, although there is no cure, there are interventions
that may be of some benefit.
The treatment algorithm for tinnitus usually starts with
lifestyle modification and is followed by supplements or
medications. Over four million prescriptions are written
each year in the United States and Europe for the
treatment of tinnitus [30]. If these fail, then tinnitus
retraining therapy, Neuromonics, hearing aids, and masking devices may be attempted. An emerging therapy for
tinnitus is repetitive transcranial magnetic stimulation,
but it is currently undergoing testing in clinical trials and
is not universally available.

365

If all of these modalities fail, as is not uncommon with

severely affected patients, psychotherapy and alternative
therapies, such as acupuncture, may be offered. In the
1800s a German physician named Grappengeiser (as cited
by Feldmann) provided evidence that electrical stimulation of the ear can alleviate tinnitus in some patients
[31,32,33]. There are on-going studies to assess how
electrodes near the round window or short-array cochlear
implants (10 mm or less) can positively affect tinnitus
[34]. It is well known that deaf patients who have undergone cochlear implantation often report improvement in
their tinnitus. Seidman et al. [35] have also attempted
intracranial electrical stimulation on six patients with
electrodes implanted into the auditory cortex or the
prefrontal gyrus. Thus far, four of the six patients have
had some improvement.
Diet and lifestyle modifications

This initial management of tinnitus includes counseling

the patient on eliminating intake of certain substances,
such as salt, caffeine, alcohol, simple sugars, aspartame,
MSG, NutraSweet, and food coloring/dye. Although this
may help patients with mild symptoms, it is unlikely to
improve those who are severely affected.
Medications and supplements

Many medications have shown some benefit for alleviating tinnitus symptoms. Benzodiazepines, antidepressants, anticonvulsants, and antiglutamatergic agents have
been among those prescribed. Some trials with benzodiazepines have shown a benefit in treating tinnitus
symptoms, whereas others did not show a difference
[36]. In a trial using alprazolam, a 65% reduction in the
loudness of tinnitus was achieved among the treated
patients, compared with 5% in the control group [37].
In another large trial using clonazepam, a 32% improvement in tinnitus symptoms was demonstrated [38].
Various classes of antidepressants have been able to
decrease tinnitus symptoms. Amytriptyline, in the older
class of tricyclics, has been shown to cause a decrease in
symptom complaints compared with placebo after a
6-week course [39]. Other trials with second-generation
antidepressants, such as selective serotonin reuptake
inhibitors (SSRIs), have not had as favorable results
compared with placebo [40]. Other studies have demonstrated that sertraline had no effect on annoyance, but it
reduced tinnitus loudness [41]. This benefit may be due
to the antidepressive effects of the medication alleviating
the psychological comorbidity often attributed to tinnitus
rather than alleviation of the tinnitus itself [42].
Anticonvulsants have been tried in the past, but the
majority of the data demonstrate no benefit. Carbamazepine has been shown to have no difference compared
with placebo in controlled studies [43,44]. Gabapentin

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366 Otology and neuro-otology

has also failed to show a benefit over placebo in treating

tinnitus [45,46]. Antiglutamatergic agents, such as memantine, have been attempted in the treatment of tinnitus.
These NMDA receptor antagonists, approved for the
treatment of Alzheimers disease, have failed to show a
reduction of tinnitus symptoms in a large randomized,
double-blind study [47]. Despite these negative reports
the lead author has treated some patients with success
using GABA-related medications.
The use of supplements has also been attempted to treat
tinnitus symptoms. Many studies have investigated
Ginkgo biloba, but results are controversial with regard
to its efficacy. A review by Holstein evaluated 19 controlled trials, five comparing G. biloba with a placebo and
three with other medications. In total, 11 of the trials
found a positive benefit of Ginkgo for tinnitus [48]. In
another review, Ernst and Stevinson [49] showed significant improvement of Ginkgo over placebo. Despite this
positive evidence, a Cochrane review demonstrated that
there is no difference in treatment with Ginkgo compared
with placebo [50,51].
Other supplements that may improve the symptoms of
tinnitus are the B-complex vitamins. Deficiency in many
of these nutrients has been implicated in tinnitus [52,53].
Although no randomized controlled trials have shown
vitamin B12 to be effective in decreasing tinnitus symptoms, there is some thought that it may help patients who
are deficient in the supplement who also have comorbid
tinnitus [54].
Retraining and masking therapies

The concept of tinnitus retraining therapy (TRT) is

based on neurophysiological evidence demonstrating
that people can habituate to acoustic stimuli in their
environment. This therapy involves directive counseling
and sound therapy in the form of white noise devices set
at a low decibel level so as not to interfere with hearing.
The data published on this therapy demonstrated an
improvement in 80% of patients with tinnitus [55].
Tinnitus masking is another modality that has shown
some benefit in treating tinnitus. This uses a patientadjusted low-level sound to mask the subjective tinnitus
sounds [56]. In an interesting head-to-head comparison
between the two, Henry et al. [57] found that tinnitus
masking was better for short-term results (3 months)
and TRT showed greater symptomatic relief at 12 and
18 months.
The Neuromonics tinnitus treatment is a 6-month
program that uses a binaurally correlated acoustic signal
that intermittently covers up the patients tinnitus
perception. This was shown to provide a significant
improvement in symptom disturbance over a 12-month
period [58].

Repetitive transcranial magnetic stimulation

Transcranial magnetic stimulation (TMS) has recently

emerged as a potential treatment option for tinnitus
[5964]. TMS induces electrical stimulation of cortical
neurons by creating a brief, focused magnetic field over
the surface of the brain [65]. When magnetic pulses are
delivered repetitively and rhythmically, the process is
called repetitive TMS (rTMS). The magnetic field
induced by rTMS is brief (microseconds), relatively weak
(except directly under the coil) [66], and declines rapidly
with distance away from the coil (falling off sharply after
2 cm) [65,67]. Pulse trains can be delivered at low (1 Hz)
or high (>1 Hz) frequencies, which tend to decrease or
increase neural activity beneath the coil, respectively.
Studies of the motor cortex indicate that low-frequency
stimulation produces a temporary inhibitory effect [68],
whereas high-frequency stimulation (>5 Hz) produces an
excitatory effect [69,70]. Standard TMS coils are only
able to directly stimulate the superficial cortex, but
deeper brain structures and structures in the opposite
cerebral hemisphere may be affected by TMS via connecting neural pathways [71,72].
Most studies using rTMS for treatment of tinnitus have
utilized low-frequency magnetic pulses applied to one
temporal lobe for 30 min, once daily, for 310 consecutive days. Some have used functional imaging with
neuronavigation to select the treatment site based on
asymmetrical cortical activation, whereas others have
targeted the left superior temporal lobe in all cases or
the side opposite the loudest tinnitus. Regardless of
targeting technique, beneficial results are obtained in
about 50% of patients who receive active treatment.
Although treatment effect may last 6 months in some
cases [60], most studies have not demonstrated longlasting tinnitus suppression, with effects lasting only a
few hours to a few days [61,63,64]. In order for rTMS to
serve as a tinnitus therapy, certain parameters, such as
frequency, duration, and number of treatment sessions;
targeting strategies; delivery; and patient factors need to
be better understood. These are currently under investigation in several clinical trials.
There are many other treatments that have been used
for tinnitus that have not been reviewed in this article.
These include intravenous lidocaine, intratympanic
steroids, psychotherapy, neuromuscular treatment, and
acupuncture, to name a few. The reader is directed to
the following references for more information [3,4,10
12,26,29].

Conclusion
Tinnitus is an extremely common medical complaint that
affects millions of people worldwide. Some patients who
present with tinnitus symptoms may be debilitated by

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Tinnitus Seidman et al.

their disorder. Although there is currently no cure for

tinnitus, a number of viable treatment options have
proven successful in some patients. The treatment algorithm described in this article should provide a reasonable
strategy for helping the patient with tinnitus. However, it
is evident that continued research needs to be performed
to obtain a better understanding of the disorder and
ensure reliable and longer lasting treatments.

References and recommended reading

Papers of particular interest, published within the annual period of review, have
been highlighted as:

of special interest
 of outstanding interest
Additional references related to this topic can also be found in the Current
World Literature section in this issue (p. 467).
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