WHEN BELLS ARE RINGING (BUT THERE AREN'T ANY BELLS)
by Vern Modeland
It happens. You awaken in the night, then lie reviewing the sounds around
you. Breathing. Curtains rustling in a breeze. The rattle of cans while a
cat does a garbage inventory. A radio playing somewhere. A jet far
overhead. Then, for some of us, there's that other sound in the quiet of
the
night. Some describe it as the noise a cicada makes, an ocean's roar, a
sizzle, or like a transformer's hum. For others it's more like the ringing
of bells, and that's where the name for this condition comes. This "other"
sound is called tinnitus, from the Latin tinnire, which means to ring or
tinkle like a bell.
Tinnitus, pronounced tin -i-tus or tin- night -us, rings continually in
the
minds of millions of people. It may be in one ear, both, or be perceived
as
somewhere else in the head or, rarely, as an outside sound.
A sound outside the ears, one that can sometimes also be heard by an
examiner
with a stethoscope, is described clinically as "objective" tinnitus.
Objective tinnitus is usually found to be caused by the movement of joints
in
the jaws, clogged Eustachian tubes in the middle ear, or repetitive muscle
contractions. Sometimes, in a quiet room, someone with objective tinnitus
might be hearing the pulse of his or her blood in the carotid artery in
the
neck, the hum of normal flow of blood through the jugular vein, or
movement
of bones in the neck.
Ringing, buzzing, blowing, roaring, clanging, popping, or nonrhythmic
beating
noise that ranges from a small nuisance for most people to a cacophony for
others that can dominate life and make it hard to sleep, understand
conversations, or concentrate on work is called "subjective" tinnitus. For
a
few, its torment can be so severe they seek psychiatric help, describing
their private sound as like an internal siren. And, more than 200 years
after the word made its way into the English language, medical experts
have
no great insight to report as to the likelihood of breakthroughs in
treating
tinnitus. For now, they say, no one can guarantee you that there's a cure
for this type of sound that is in your head only.
Researchers estimate that 36 million Americans have tinnitus, and the
condition is severe enough in 7.2 million that they have sought medical
help. Some medical professionals who treat tinnitus say even those figures
might be low. Robert Dobie, M.D., a professor in the Department of
Otolaryngology at the University of Washington Medical Center in Seattle,
estimates 14 percent to 17 percent of Americans have frequent or constant
tinnitus. He says that for 1 percent to 2 percent of them, tinnitus is
severe enough to affect their everyday life. The American Tinnitus
Association (P.O. Box 5, Portland, Ore. 97207) says its studies indicate
that as much as 5.3 percent of the population suffers from severe
tinnitus.
The percentage of the total population reporting tinnitus is about the
same
in England, and probably in any other industrialized nation, according to
Jack Vernon, now in his 22nd year as director of the Hearing Research
Center
at The Oregon Health Sciences University in Portland.
Three men have tinnitus for every two women who do--probably because more
men than women work in construction, manufacturing, and other very noisy
locations, says Vernon.
Sam Hopmeier, a St. Louis audiologist with extensive experience in
treating
tinnitus, says subjective tinnitus is most frequently related to hearing
impairment. But, even if you don't work in overly noisy surroundings and
have never experienced tinnitus, there's a good chance it still may
someday
ring for you. By middle age, the symptom can appear with no particular
cause. Dobie says accumulated exposure to noise and age-related changes in
the body are principal reasons.
Another physician, Max A. Goldstein, once
wrote of certain types of tinnitus that "the patient is literally
listening
to old age sneaking up on him."
Tinnitus is by definition a symptom of something and not itself a disease.
A
symptom of what? It's been linked to hearing loss and its opposite, hyperacusis (extremely sensitive hearing); hypertension (high blood
pressure); hyperglycemia (high blood sugar); arthritis, especially in the
neck; tumors; injuries to the head, neck or ears, including whiplash;
drugs,
including aspirin and other over-the-counter painkillers, alcohol,
nicotine,
and some antibiotics; Meniere's disease of the inner ear, which also has
as
its symptoms dizziness, nausea, and progressive hearing loss; and
otosclerosis, a disease in which bones in the ear are immobilized by new
bone
growth. Treatment of any one of these generally results in relief from
accompanying tinnitus.
Infection or wax in the ears also has been found to start tinnitus ringing
as
a signal of the need for treatment.
Tinnitus in younger people most frequently follows injuries to the head or
ears, including hearing damage caused by loud music. Loud noise, according
to Vernon, is the most prevalent cause of tinnitus and one of the most
preventable causes of hearing impairment. A crusader against abuses to our
hearing, Vernon promoted an unsuccessful bill in the Oregon legislature
that
would have required warning signs at the doors of night clubs where loud
music is played, to caution those who enter about the risk from the din
inside.
Damage to the ear caused by excessive exposure to loud noises has been
documented. Our ears contain microscopic hairs as a fringe on the ends of
auditory cells in the inner ear. When healthy, these hairs move in
response
to the pressure of sounds that vibrate the eardrum.
The movement leads to
chemical changes that in turn produce small electrical signals. The
electrical signals excite nerve cells in each of some 30,000 fibers that
spiral away from the cochlea, a snail-shaped and fluid-filled compartment
in
the inner ear. This spiral of fibers comes together to form the auditory
nerve and carries stimulation from the ear to the brain. Continued or
repeated exposure to loud noises can damage the tiny hairs in the inner
ear,
sometimes leaving them with the appearance of rows of trees bent or broken
before a hurricane's wind. Where there are no healthy hairs, erect and
swaying to each sound that reaches the ear, there will be no stimulus to
the
brain from that particular nerve and nothing more to be heard--from the
outside, anyway.
At present, there are no drugs approved by FDA specifically to treat
tinnitus and, to date, no major controlled clinical drug studies.
Major discoveries of drugs or devices that seemed to have an effect on
tinnitus have frequently been serendipitous. In the mid 1930s, a physician
injected Novocain (procaine hydrochloride, a nerve-blocking anesthetic of
short duration) into a surgical patient's nose. The patient also had
tinnitus and remarked that the tinnitus cleared temporarily after the
injection. A New Zealand pain clinic, in early tests of another local
anesthetic, lidocaine hydrochloride, found that drug also temporarily
stopped
tinnitus. In a controlled study at the Oregon Hearing Research Center, 23
of
26 people tested said lidocaine either put their tinnitus into remission
or
turned it off completely. But lidocaine had serious side effects, and its
impact on tinnitus only lasted for a half hour or so, Vernon says.
Paul Guth, a pharmacologist who researches hearing and balance mechanisms
at
the Tulane Medical School, New Orleans, says side effects of lidocaine in
tests to treat tinnitus included amnesia, slurred speech, and fainting.
Guth's research has been into medications that target the hearing system.
One such drug, aminooxyacetic acid (AOAA), had reached clinical trials in
controlling epileptic seizures and seemed to be safe in humans. A former
student, Richard Bobbin, reported to Guth he found AOAA also had a
measurable effect on endocochlear potential, an electrical voltage output
essential to the function of the inner ear. A reduction in the
endocochlear
potential reduces activity in the auditory nerve, studies showed. Bobbin
reported AOAA lowered endocochlear voltage potential in laboratory
animals,
so Guth tested it on 70 people with tinnitus.
Fourteen patients reported
some relief, he found. However, 10 of those who were helped also reported
side effects that led Guth to search for other drugs that also could
reduce
endocochlear potential.
Furosemide, a potent diuretic prescribed for people who have very severe
kidney damage, also was tried on tinnitus patients. Reported side effects
for kidney patients included tinnitus and transitory hearing impairment,
but
Guth found that when furosemide was given in reduced dosages intravenously
to 37 volunteers with tinnitus, half of them reported they believed it
helped, so Guth continued testing furosemide in oral doses on nine
patients.
Seven of the nine volunteered to continue taking the medication, an
indicator
that they must be getting some relief, he said.
Alprazolam (trade name Xanax), a central nervous system depressant
prescribed
for anxiety disorders, has been reported to have helped a small number of
tinnitus patients. And it introduced another line of questioning. What is
the relationship between depression and tinnitus? Is tinnitus a cause or
result? Dobie's research indicates that antidepressant medications,
particularly tricyclic antidepressants, have helped convert people who are
suffering from tinnitus into people who are dealing with it. Dobie adds
that
other patients referred to him have benefited from relaxation techniques,
biofeedback (conscious effort to control involuntary body functions such
as
breathing and heartbeat), and other forms of therapy that show them how
better to live with tinnitus. Hypnotism has been tried for relief of the
mental stress caused by tinnitus, but no positive results are documented.
Technology also may have some answers for tinnitus sufferers. Directing a
small charge of electricity into the auditory nerve has shown some promise
in
silencing tinnitus. Of 20 persons tested with electrical nerve stimulation
at the Washington Medical Center in Seattle, only one was helped, but that
person was helped dramatically, according to Dobie.
If electrical nerve stimulation continues to show promise, surgically
implanted stimulators may become a technology for the future in tinnitus
treatment. Meantime, a more elementary electronic device is already
helping
some. It's the tinnitus masker. Using an external noise source to mask the
rush, the ringing, or the roar of tinnitus has been effective for about 70
percent of the 500 people that St. Louis audiologist Hopmeier has treated
for tinnitus during the past 10 years.
The principle in masking is much the same as when you realize you are no
longer bothered by routine office noises, ventilator fans, or traffic
sounds.
Masking is based on the mind's ability to ignore external noises
that become familiar or monotonous. It's easier to ignore an external
sound
than an internal one, Hopmeier points out.
Vernon became interested in masking in 1977 after the chance discovery by
a
patient that he could not hear his tinnitus when he stood near a
waterfall,
and that the water's sound was an acceptable and welcomed substitute for
tinnitus. But the best masking sound is not the "white noise" of a
waterfall, according to audiologist Hopmeier. That would interfere with
the
wearer's ability to understand speech, he says. So, following a hearing
and
perception test that Hopmeier describes as his way to determine a
"sensation level," to indicate the amount of stress the person is
experiencing due to his or her tinnitus, a masking device is customized
that
is most pleasing and helpful for the wearer.
More than 90 percent of people who come to Hopmeier with tinnitus also
have
some impairment to hearing that they either had not recognized or did not
think was significant. Their concern had become focused on their tinnitus,
he explains. Sixty percent of the tinnitus masking devices he has fitted
have been combined with a hearing aid, and for some people the devices are
fitted in both ears, depending on the amount of hearing loss and the
patient's perception of the tinnitus' location. Dual-purpose hearing and
masking devices have separate volume and on-off controls. Hopmeier says
most
users eventually become less dependent on the masking and more on the
hearing
aid, which offers a natural masking effect. The hearing aid's own
amplification of voices and other sounds in the environment draws the
user's
attention away from his or her tinnitus, Hopmeier explains.
Some of the relief that masking gives tinnitus patients may be
psychological,
according to Dobie. For some tinnitus sufferers, just knowing they have
their masking device available to use if they want seems to provide
reassurance and relief. Dobie, Vernon and Hopmeier agree that the lack of
control over this unwanted noise in their heads is the distressing aspect
of
tinnitus that leads most people to seek help.
Masking devices require FDA approval because they present a potential for
risk of injury to the ears or long-term hearing impairment due to
overstimulation from the continuous and sometimes loud masking noise. Five
brands and nine models of tinnitus masking devices have approval for
marketing from FDA.
James L. Parkin, a Salt Lake City otolaryngologist, observes that
"tinnitus
is an irritating symptom for both the patient and the physician. The
patient
is annoyed most by the problem during times of fatigue or anxiety. He is
concerned that it indicates serious mental or physical illness. The
physician is annoyed because his diagnostic efforts may not reveal a
well-defined cause for the complaint."
Tinnitus. It . . . happens.
This article was published in FDA Consumer magazine several years ago. Click Here for Original Article
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