oise-Induc nnnitus Frank P. LaMarte, MD; and Richard S. Tyler, PhD INTRODUCTION Tinnitus is the perception of sound that has its origin within the body. It may be either intermittent or continuous. It is commonly reported by the victim of noise- induced hearing loss (NIHL) but may rep- resent the first symptom of a variety of disease processes. Tinnitus is directly related to noise exposure. There is a 70% increased risk of developing tinnitus with a positive history of occupational noise exposure when compared to those without a history of noise exposure (Coles, 1984b). Tinnitus of short duration (up to 15 min- utes) has been reported following only a few minutes exposure to acoustic stimuli great enough to produce auditory fatigue (Atherley, Hempstock, & Noble, 1968). Occupational noise exposure and recrea- tional noise exposure probably cause more new cases of tinnitus than all other etiologies combined (Miller & Jakimetz, 1984). It is not always possible to une- quivocally determine the etiology of the noise exposure associated with the individ- ual's tinnitus. The potential sources of non-work related noise exposure are numerous, and may include exposure while attending rock concerts, listening to uereos, participation in sports such as hunting and hobbies such as model air- plane flying. Another potential source of annitus is noise exposure during active nilitary duty. Some patients suffer more from their Innitus than from their hearing loss (Tyler XL Baker, 1983). Tinnitus associated with !HHL is usually high pitched (Axelsson & 1985), and in general, the greater the NIHL the more chance there is of developing tinnitus. Man and Naggan (1981) investigated 102 cases of NIHL (in the age group of18 to 35 years) and found a clear correlation between the maximum hearing loss and the severity of tinnitus. However, Lindberg, Lyttkens, Melin, and Scott (1984) questioned 1091 patients with tinnitus (those with nonspecific diagnoses) and failed to reveal a correlation between the severity of tinnitus and the reported amount of hearing loss. Reed (1960) stud- ied 200 patients and found no relationship between the objectively determined loud- ness of a patient's tinnitus, type of deafness or hearing loss. Some victims of tinnitus appear to toler- ate their symptoms with little difficulty. Yet others suffer from a wide variety of difficulties including emotional problems, altered lifestyles, general health problems, hearing problems (Coles, 1984a; Tyler & Baker, 1983), work-related problems (Jakes, Hallam, Chambers, & Hinchcliffe, 1985), difficulties with speech understand- ing, concentration and insomnia (Axels- son & Sandh, 1985). The combined impact of these problems in the work place is neither well appreciated nor well under- stood. Noise-induced tinnitus is covered only briefly in most occupational medical texts MOHN JOURNAL, SEPTEMBER 1987, VOL. 35, NO.9 403
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Noise-Induced Tinnitusoise-Induc nnnitus Frank P. LaMarte, MD; and Richard S. Tyler, PhD
INTRODUCTION Tinnitus is the perception of sound that
has its origin within the body. It may be either intermittent or continuous. It is commonly reported by the victim of noise induced hearing loss (NIHL) but may rep resent the first symptom of a variety of disease processes. Tinnitus is directly related to noise exposure. There is a 70% increased risk of developing tinnitus with a positive history of occupational noise exposure when compared to those without a history of noise exposure (Coles, 1984b). Tinnitus of short duration (up to 15 min utes) has been reported following only a few minutes exposure to acoustic stimuli great enough to produce auditory fatigue (Atherley, Hempstock, & Noble, 1968). Occupational noise exposure and recrea tional noise exposure probably cause more new cases of tinnitus than all other etiologies combined (Miller & Jakimetz, 1984). It is not always possible to une quivocally determine the etiology of the noise exposure associated with the individ ual 's tinnitus. The potential sources of non-work related noise exposure are numerous, and may include exposure while attending rock concerts, listening to uereos, participation in sports such as hunting and hobbies such as model air plane flying. Another potential source of annitus is noise exposure during active nilitary duty.
Some patients suffer more from their Innitus than from their hearing loss (Tyler XL Baker, 1983). Tinnitus associated with !HHL is usually high pitched (Axelsson & ~andh, 1985), and in general, the greater
the NIHL the more chance there is of developing tinnitus. Man and Naggan (1981) investigated 102 cases of NIHL (in the age group of18 to 35 years) and found a clear correlation between the maximum hearing loss and the severity of tinnitus. However, Lindberg, Lyttkens, Melin, and Scott (1984) questioned 1091 patients with tinnitus (those with nonspecific diagnoses) and failed to reveal a correlation between the severity of tinnitus and the reported amount of hearing loss. Reed (1960) stud ied 200 patients and found no relationship between the objectively determined loud ness of a patient's tinnitus, type of deafness or hearing loss.
Some victims of tinnitus appear to toler ate their symptoms with little difficulty. Yet others suffer from a wide variety of difficulties including emotional problems, altered lifestyles, general health problems, hearing problems (Coles, 1984a; Tyler & Baker, 1983), work-related problems (Jakes, Hallam, Chambers, & Hinchcliffe, 1985),difficulties with speech understand ing, concentration and insomnia (Axels son & Sandh, 1985). The combined impact of these problems in the work place is neither well appreciated nor well under stood.
Noise-induced tinnitus is covered only briefly in most occupational medical texts
MOHN JOURNAL, SEPTEMBER 1987, VOL. 35, NO.9 403
and there are relatively few researchers investigating tinnitus secondary to NIHL.
The potential problems associated with tinnitus in the work place include increased absenteeism, difficulty under standing telephone conversations, in creased risk of accidents, difficuity witn concentration, frustration, depression, tiredness, irritability, and many other fac tors which may decrease productivity. In addition, the employer may be liable for acquired tinnitus associated with work. Tinnitus is frequently caused by NIHL and can easily be prevented by developing and following a hearing conservation program and by educating workers to report any early episodes of tinnitus or hearing loss so that they may be provided with hearing protectors or changed to a less noisy job.
CATEGORIES AND CAUSES There are two major categories of tin
nitus (Tyler & Babin, 1986). The first is middle-ear tinnitus, which is generated by the para-auditory structures and is either mechanical or vascular in origin. The most common mechanical cause is palatomyo clonus, but it also includes tensor tympani myoclonus and stapedial myoclonus (Schleuning, 1982). Tinnitus of vascular origin is nearly always pulsatile and is syn chronous with the cardiac beat. It is usu ally due to a vascular lesion or vascular anomaly.
The other major category is sensori neural tinnitus and is generated by the sen sorineural auditory system. This is the most common type of tinnitus and the least well understood. It may be caused by cochlear and retrocochlear lesions, ototoxic drugs, cardiovascular problems, metabolic disorders, neurologic problems, other systemic disorders and noise. Its etiology can range from hair-cell destruc tion to a brain tumor. The differential diag nosis must include, but not be limited to, metabolic disorders, such as hyper thyroidism and hypothyroidism; cardio vascular disease such as hypertension; neurotoxic drugs such as aminoglyco sides, loop diuretics, salicylates, tricyclic antidepressants, cochlear and retro cochlear lesions; Bell's Palsy and many other central nervous system lesions.
The traditional separation of tinnitus into objective and subjective, that respec tively heard or not heard by the examiner, is of limited value. While in most cases objective tinnitus parallels middle-ear tin nitus, in other cases the same disease might result in a tinnitus which is subjec tive in one patient and objective in another (Tyler & Babin, 1986). Tinnitus must also
Occupational and recreational noise exposure probably cause more cases
of tinnitus than allother etiologies combined.
be differentiated from auditory hallucina tions, for example, voices or music, which may suggest psychologic disturbances, tumors or other central nervous system lesions.
Noise-induced tinnitus is sensorineural in type and most likely results from a cochlear lesion secondary to noise exposure.
PREVALENCE Thirty-two percent of the adult popula
tion in the United States report having had tinnitus at some time (National Center for Health Statistics, 1980). Over 90% of patients reporting tinnitus have some type of otologic problem and approximately 50% of these have a noise-induced hearing loss (Schleuning, 1982). Chuden (1981) reported that the frequency of tinnitus in noise-induced hearing loss is 35%. The prevalence of tinnitus increases with age in both noise exposed and non-noise exposed populations (Coles, 1984b) up to the age of 70 (Reed, 1960).
EVALUATION A complete history and physical exam
ination must be performed to rule out the presence of other more life-threatening diseases, such as acoustic neurinomas, meningiomas, and other central nervous system lesions. The history should include information regarding associated hearing loss, vertigo, aural fullness, head trauma, time of onset, mode of progression, his tory of noise exposure and family his tory-all are essential in the evaluation. Patients should also be asked about cardio-
vascular disorders such as hypertension (Schleuning, 1982); metabolic disorders including hyperthyroidism and hypothy roidism; history of anemia; neurotoxic drugs such as aminoglycosides, loop diuretics, salicylates and tricyclic anti depressants. This is followed by a com plete medical examination with blood pressure and consultation witn an otolaryngologist for neurotologic exam ination. The audiometric assessment gen erally plays a substantial part in the evalua tion. Laboratory tests may include a complete blood count, thyroid profile, serologic test for syphilis and a blood glucose level. If a retrocochlear lesion is suspected, auditory brainstem evoked response testing and/or computerized axial tomography may be indicated.
Many patients have great concern regarding the medical significance of their tinnitus (Shulman, 1984). They often sus pect the worst possible diagnosis, such asa brain tumor. Reassurance may be a signifi cant part of the treatment.
In summary, the evaluation must be complete enough to rule out other diseases that may cause tinnitus. The evaluation should distinguish sensorineural from middle ear tinnitus, particularly because the latter can be treated with surgery or medicine (Tyler & Babin, 1986).
TREATMENT In general, treatment is directed toward
the cause of the symptom. This article will focus on the treatment of tinnitus associ ated with NIHL. To begin with, there is no universally accepted cure for tinnitus. Many treatment modalities exist and have proven helpful to some tinnitus sufferers.
Medication Several groups of drugs have shown
some potential for the treatment of tin nitus, but no set protocol for drug treat ment is currently available. Drugs cur rently under investigation include anes thetics, antidepressants and vasodilators (Bentler & Tyler, 1987).
Antidepressants. These drugs are used to help the patient tolerate the symptom when their tinnitus is severe. Amitriptyline is one of the antidepressants used to relieve patient's stress, which often results in exacerbation of their tinnitus (Hatangdi, Boas, & Richards, 1976; Melding & Goodey, 1979).
Anesthetics. Anesthetics have bot] peripheral and central sensorineural block- ing action. Martin and Coleman (1980\ noted an improvement in approximately two thirds of their patients following th.
404 AAOHN JOURNAL, SEPTEMBER 1987, VOL. 35, NO.
intravenous administration of lidocaine. However, other investigators have reported an increase in the severity of tinnitus in nearly one third of their patients following treatment (Duckert & Rees, 1981). Lido caine is also of limited value because the relief lasts for only moments to hours. Tocainide hydrochloride, an oral analog of lidocaine, can be taken orally and has a longer duration of action. Emmett and Shea (1980) found relief of tinnitus in four out of six patients treated with this drug while Blayney, Phillips, Guy, and Colman (1985) reported relief in only three out of 32 patients.
Vasodilators. The rationale for the use of these drugs is that tinnitus is associated with cochlear ischemia (Atkinson, 1947) and the vasodilators increase blood flow to the cochlea. Nicotinic acid (Vitamin B6) , a peripheral vasodilator, has been used but has not always been found to help.
The results of these studies vary greatly and many lack good controls.
Hearing Aids and Tinnitus Maskers External noise can diminish tinnitus.
Hearing aids may amplify background noise and mask the patient's tinnitus, or the circuit noise in the hearing aid may act to mask the tinnitus (Tyler & Bentler, 1987). Tinnitus maskers generate noise and the user can control its level. Some hearing aids have tinnitus maskers built into them. The patient should be informed that this is lot a cure and the tinnitus does not gener ally go away just by using the masker. Tinnitus maskers have helped some tin nitus sufferers, but the number of patients lhat have been helped is controversial [Mcfadden, 1982; Roeser & Price, 1980). Regardless of the exact percentage it is still a viable treatment for some.
Biofeedback The patient learns to relax by using bio
feedback techniques. This helps to relieve stress which may lessen the severity of iheir tinnitus. The training program is Jesigned to develop the patient's ability to «ontrol his autonomic (involuntary) nerv dus system. House (1978, 1984) studied crnly patients with severe tinnitus who did •ot gain relief by other treatment modalities. Eighty percent reported improvement following biofeedback treat lIlent.
Counseling Many patients may not be helped by any
., the treatment modalities discussed. lounseling may play an important role in ~lping these patients cope with their tin-
The potential problems associated with tinnitus in
the workplace include increased absenteeism, frustration, depression, tiredness, and irritabilit}'.
nitus. The patient needs to know that his complaint is a common one. Informing them after appropriate workup that they do not have a life-threatening condition may relieve much of their anxiety. They need to know that there is no one universal cure, but treatment does exist. Addressing these initial problems and making appropriate referrals when needed should prove advan tageous for all concerned.
CONCLUSIONS A correspondence between tinnitus and
noise-induced hearing loss has been estab lished. The impact this symptom has on the individual's life varies enormously. Some patients suffer more from the tin nitus than the associated .hearing loss. While tinnitus has recently been the target of much investigation, little is known about this distressing symptom or its total impact on lifestyle and work productivity. Tinnitus due to noise exposure can be pre vented by a properly designed and man aged hearing conservation program (Kryter, 1985) and by educating the gen eral population regarding the conse quences of recreational noise exposure. It may be treated to a limited degree by the use of medications, tinnitus maskers, bio feedback and counseling. Although the mainstem of treatment is prevention, reas surance and discussion regarding treat ment options and their limitations are essential. Objective tests to measure the presence or absence of tinnitus and analy sis of the relationship between the degree
of hearing loss and the severity of tinnitus are needed. It would be useful to know patients who are at high risk of developing tinnitus so that hearing protectors could be provided or the employee removed from noisy environments. The problems of the tinnitus sufferer must be better understood and will be with continued research.
REFERENCES Atherley, G.R.C., Hempstock, T.I., & Noble, W.G.
(1968). Study of tinnitus induced temporarily by noise. Journal of the Acoustical Society ofAmer ica, 44, 1503-1506.
Atkinson, M. (1947). Tinnitus aurium. Some consid erations concerning its origin and treatment. Archives cfOtolaryngologica, 45. 68-76.
Axelsson, A., & Sandh, A. (1985). Tinnitus in noise induced hearing loss. Journal ofAudiology, 19, 271-276.
Bentler, R.A., & Tyler, R.S. (1987). Tinnitus man agement. Asha, May, 27-32.
Blayney, A.W., Phillips, M.S., Guy, A.M., & Col man, B.H. (1985). A sequential double-blind crossover trial of tocainide hydrochloride in tin nitus. Clinical Otolaryngology. 10, 97-101.
Chuden, H.G. (1981). Diagnostische massnahmen bei tinnitus. Hals Nase Ohrenarzt, 29, 418.
Coles, R.R.A. (l984a). Epidemiology of tinnitus: (I) Prevalence. Journal ofLaryngology and Otology 9, (Suppl) 7-15.
Coles, R.R.A. (l984b). Epidemiology of tinnitus: (2) Demographic and clinical features. Journal of Laryngology and Otology 9, (Suppl) 195-203.
Duckert, L.G., & Rees, T.S. (1981). Treatment of tinnitus with intravenous lidocaine: A double blind randomized trial. Otolaryngology Head and Neck Surgery. 91. 550-555.
Emmett, 1.R., & Shea, 1.1. (1980). Treatment of tin nitus with tocainide hydrochloride. Otolaryngol ogy Head and Neck Surgery. 88, 442-446.
Hatangdi, V.S., Boas, R.A., & Richards, E.G. (1976). Post herpetic neuralgia management with antiepileptic and tricyclic drugs. In 1.1. Bonica, D. Albe-Fessaro (Eds.), Advances in Pain Research and Therapy (pp. 583-587). New York: Raven Press.
House, 1.W. (1978). Treatment of severe tinnitus with bio-feedback training. Laryngoscope, 88. 406-412.
House, 1.W. (1984). Tinnitus: Evaluation and treat ment. American Journal ofOtology, 5, 472-475.
Jakes, S.C., Hallam, R.S., Chambers, C., & Hinchcliffe, R. (1985). A factor analytical study of tinnitus complaint behaviour. Audiology, 24, 195-206.
Kryter, K.D. (1985).The Effects ofNoise on Man (pp. 619-655). New York: Academic Press, Inc.
Lindberg, P., Lyttkens, L., Melin, L., & Scott, B. (1984). Tinnitus-Incidence and handicap. Scan dinavian Audiology. 13, 287-291.
Man, A., & Naggan, L. (1981). Characteristics of tinnitus in acoustic trauma. Audiology, 20, 72-78 .
Martin, EW., & Coleman, B.H. (1980). Tinnitus: A double-blind crossover controlled trial to evaluate the use of lidocaine. Clinical Otolaryngology. 5, 3-11.
McFadden, D. (1982). Tinnitus: Facts, Theories and Treatments (pp. 89-101). Washington, D.C.: National Academy Press.
Melding, P.S., & Goodey, R.1. (1979). The treatment of tinnitus with oral anticonvulsants. Journal of Laryngology and Otology, 93. 111-122.
Miller, M.H., & Jakimetz, J.R. (1984). Noise
AOHN JOURNAL, SEPTEMBER 1987, VOL. 35, NO.9 405
exposure, hearing loss, speech discrimination and tinnitus. Journal of Laryngology and Otology. (Suppl) 9,74-76.
National Center for Health Statistics. (1980). Basic data on hearing levels of adults 25-74 years. United States 1971-1975. Vital and Health Statis tics Publication, Series II, Number 215.
Reed, G.F. (1960). An audiometric study of two hun dred cases of subjective tinnitus. Archives of Otolaryngologica. 71. 84-94.
Roeser, R.J., & Price, D.A. (1980). Clinical experi ence with tinnitus maskers. Ear and Hearing. 1. (2),69-70.
Schleuning, A.J. (1982). Tinnitus. In G. Gates (Ed.), Current Therapy in Otolaryngology-Head and Neck Surgery (pp. 42-44). New York: BC Decker
Inc. Shulman, A. (1984). The tinnitus sufferer: The
responsibility of the professional. Journal of Laryngology and Otology. (Suppl) 9, 3-5.
Tyler, R.S., & Babin, R.W. (1986). Tinnitus. In c.w. Cummings, J.M. Fredrickson, L. Harker, C.J. Krause, D.E. Schuller (Eds.), Otolaryngology Head and Neck Surgery (pp. 3201-3217). SI. Louis: c.v. Mosby, Co.
Tyler, R.S., & Baker, L.J. (1983). Difficulties experi enced by tinnitus sufferers. Journal ofSpeech and Hearing Disorders. 48, 150-154.
Tyler, R.S., & Bentler, R.A. (1987). Tinnitus mask ing and hearing aids for tinnitus. In R. Sweetow (Ed.). Seminars in Hearing. 8(1), 49-61. New York: Thieme Medical Publishers.
ABOUT THE AUTHORS: Dr. LaMarte is j
Resident, Occupational Medicine, Institute 0. Agricultural and Occupational Medicine Department of Preventive Medicine atu Environmental Health. He is presently a Internal Medicine Associates, Section o.J
Occupational Medicine, Omaha, Nebraska; Dr. Tyler is Associate Professor and Directm of Audiology, Department of OtolaryngoloK} Head and Neck Surgery, Department oJ Speech Pathology and Audiology, University of Iowa, Iowa City, Iowa.
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3NI
INTRODUCTION Tinnitus is the perception of sound that
has its origin within the body. It may be either intermittent or continuous. It is commonly reported by the victim of noise induced hearing loss (NIHL) but may rep resent the first symptom of a variety of disease processes. Tinnitus is directly related to noise exposure. There is a 70% increased risk of developing tinnitus with a positive history of occupational noise exposure when compared to those without a history of noise exposure (Coles, 1984b). Tinnitus of short duration (up to 15 min utes) has been reported following only a few minutes exposure to acoustic stimuli great enough to produce auditory fatigue (Atherley, Hempstock, & Noble, 1968). Occupational noise exposure and recrea tional noise exposure probably cause more new cases of tinnitus than all other etiologies combined (Miller & Jakimetz, 1984). It is not always possible to une quivocally determine the etiology of the noise exposure associated with the individ ual 's tinnitus. The potential sources of non-work related noise exposure are numerous, and may include exposure while attending rock concerts, listening to uereos, participation in sports such as hunting and hobbies such as model air plane flying. Another potential source of annitus is noise exposure during active nilitary duty.
Some patients suffer more from their Innitus than from their hearing loss (Tyler XL Baker, 1983). Tinnitus associated with !HHL is usually high pitched (Axelsson & ~andh, 1985), and in general, the greater
the NIHL the more chance there is of developing tinnitus. Man and Naggan (1981) investigated 102 cases of NIHL (in the age group of18 to 35 years) and found a clear correlation between the maximum hearing loss and the severity of tinnitus. However, Lindberg, Lyttkens, Melin, and Scott (1984) questioned 1091 patients with tinnitus (those with nonspecific diagnoses) and failed to reveal a correlation between the severity of tinnitus and the reported amount of hearing loss. Reed (1960) stud ied 200 patients and found no relationship between the objectively determined loud ness of a patient's tinnitus, type of deafness or hearing loss.
Some victims of tinnitus appear to toler ate their symptoms with little difficulty. Yet others suffer from a wide variety of difficulties including emotional problems, altered lifestyles, general health problems, hearing problems (Coles, 1984a; Tyler & Baker, 1983), work-related problems (Jakes, Hallam, Chambers, & Hinchcliffe, 1985),difficulties with speech understand ing, concentration and insomnia (Axels son & Sandh, 1985). The combined impact of these problems in the work place is neither well appreciated nor well under stood.
Noise-induced tinnitus is covered only briefly in most occupational medical texts
MOHN JOURNAL, SEPTEMBER 1987, VOL. 35, NO.9 403
and there are relatively few researchers investigating tinnitus secondary to NIHL.
The potential problems associated with tinnitus in the work place include increased absenteeism, difficulty under standing telephone conversations, in creased risk of accidents, difficuity witn concentration, frustration, depression, tiredness, irritability, and many other fac tors which may decrease productivity. In addition, the employer may be liable for acquired tinnitus associated with work. Tinnitus is frequently caused by NIHL and can easily be prevented by developing and following a hearing conservation program and by educating workers to report any early episodes of tinnitus or hearing loss so that they may be provided with hearing protectors or changed to a less noisy job.
CATEGORIES AND CAUSES There are two major categories of tin
nitus (Tyler & Babin, 1986). The first is middle-ear tinnitus, which is generated by the para-auditory structures and is either mechanical or vascular in origin. The most common mechanical cause is palatomyo clonus, but it also includes tensor tympani myoclonus and stapedial myoclonus (Schleuning, 1982). Tinnitus of vascular origin is nearly always pulsatile and is syn chronous with the cardiac beat. It is usu ally due to a vascular lesion or vascular anomaly.
The other major category is sensori neural tinnitus and is generated by the sen sorineural auditory system. This is the most common type of tinnitus and the least well understood. It may be caused by cochlear and retrocochlear lesions, ototoxic drugs, cardiovascular problems, metabolic disorders, neurologic problems, other systemic disorders and noise. Its etiology can range from hair-cell destruc tion to a brain tumor. The differential diag nosis must include, but not be limited to, metabolic disorders, such as hyper thyroidism and hypothyroidism; cardio vascular disease such as hypertension; neurotoxic drugs such as aminoglyco sides, loop diuretics, salicylates, tricyclic antidepressants, cochlear and retro cochlear lesions; Bell's Palsy and many other central nervous system lesions.
The traditional separation of tinnitus into objective and subjective, that respec tively heard or not heard by the examiner, is of limited value. While in most cases objective tinnitus parallels middle-ear tin nitus, in other cases the same disease might result in a tinnitus which is subjec tive in one patient and objective in another (Tyler & Babin, 1986). Tinnitus must also
Occupational and recreational noise exposure probably cause more cases
of tinnitus than allother etiologies combined.
be differentiated from auditory hallucina tions, for example, voices or music, which may suggest psychologic disturbances, tumors or other central nervous system lesions.
Noise-induced tinnitus is sensorineural in type and most likely results from a cochlear lesion secondary to noise exposure.
PREVALENCE Thirty-two percent of the adult popula
tion in the United States report having had tinnitus at some time (National Center for Health Statistics, 1980). Over 90% of patients reporting tinnitus have some type of otologic problem and approximately 50% of these have a noise-induced hearing loss (Schleuning, 1982). Chuden (1981) reported that the frequency of tinnitus in noise-induced hearing loss is 35%. The prevalence of tinnitus increases with age in both noise exposed and non-noise exposed populations (Coles, 1984b) up to the age of 70 (Reed, 1960).
EVALUATION A complete history and physical exam
ination must be performed to rule out the presence of other more life-threatening diseases, such as acoustic neurinomas, meningiomas, and other central nervous system lesions. The history should include information regarding associated hearing loss, vertigo, aural fullness, head trauma, time of onset, mode of progression, his tory of noise exposure and family his tory-all are essential in the evaluation. Patients should also be asked about cardio-
vascular disorders such as hypertension (Schleuning, 1982); metabolic disorders including hyperthyroidism and hypothy roidism; history of anemia; neurotoxic drugs such as aminoglycosides, loop diuretics, salicylates and tricyclic anti depressants. This is followed by a com plete medical examination with blood pressure and consultation witn an otolaryngologist for neurotologic exam ination. The audiometric assessment gen erally plays a substantial part in the evalua tion. Laboratory tests may include a complete blood count, thyroid profile, serologic test for syphilis and a blood glucose level. If a retrocochlear lesion is suspected, auditory brainstem evoked response testing and/or computerized axial tomography may be indicated.
Many patients have great concern regarding the medical significance of their tinnitus (Shulman, 1984). They often sus pect the worst possible diagnosis, such asa brain tumor. Reassurance may be a signifi cant part of the treatment.
In summary, the evaluation must be complete enough to rule out other diseases that may cause tinnitus. The evaluation should distinguish sensorineural from middle ear tinnitus, particularly because the latter can be treated with surgery or medicine (Tyler & Babin, 1986).
TREATMENT In general, treatment is directed toward
the cause of the symptom. This article will focus on the treatment of tinnitus associ ated with NIHL. To begin with, there is no universally accepted cure for tinnitus. Many treatment modalities exist and have proven helpful to some tinnitus sufferers.
Medication Several groups of drugs have shown
some potential for the treatment of tin nitus, but no set protocol for drug treat ment is currently available. Drugs cur rently under investigation include anes thetics, antidepressants and vasodilators (Bentler & Tyler, 1987).
Antidepressants. These drugs are used to help the patient tolerate the symptom when their tinnitus is severe. Amitriptyline is one of the antidepressants used to relieve patient's stress, which often results in exacerbation of their tinnitus (Hatangdi, Boas, & Richards, 1976; Melding & Goodey, 1979).
Anesthetics. Anesthetics have bot] peripheral and central sensorineural block- ing action. Martin and Coleman (1980\ noted an improvement in approximately two thirds of their patients following th.
404 AAOHN JOURNAL, SEPTEMBER 1987, VOL. 35, NO.
intravenous administration of lidocaine. However, other investigators have reported an increase in the severity of tinnitus in nearly one third of their patients following treatment (Duckert & Rees, 1981). Lido caine is also of limited value because the relief lasts for only moments to hours. Tocainide hydrochloride, an oral analog of lidocaine, can be taken orally and has a longer duration of action. Emmett and Shea (1980) found relief of tinnitus in four out of six patients treated with this drug while Blayney, Phillips, Guy, and Colman (1985) reported relief in only three out of 32 patients.
Vasodilators. The rationale for the use of these drugs is that tinnitus is associated with cochlear ischemia (Atkinson, 1947) and the vasodilators increase blood flow to the cochlea. Nicotinic acid (Vitamin B6) , a peripheral vasodilator, has been used but has not always been found to help.
The results of these studies vary greatly and many lack good controls.
Hearing Aids and Tinnitus Maskers External noise can diminish tinnitus.
Hearing aids may amplify background noise and mask the patient's tinnitus, or the circuit noise in the hearing aid may act to mask the tinnitus (Tyler & Bentler, 1987). Tinnitus maskers generate noise and the user can control its level. Some hearing aids have tinnitus maskers built into them. The patient should be informed that this is lot a cure and the tinnitus does not gener ally go away just by using the masker. Tinnitus maskers have helped some tin nitus sufferers, but the number of patients lhat have been helped is controversial [Mcfadden, 1982; Roeser & Price, 1980). Regardless of the exact percentage it is still a viable treatment for some.
Biofeedback The patient learns to relax by using bio
feedback techniques. This helps to relieve stress which may lessen the severity of iheir tinnitus. The training program is Jesigned to develop the patient's ability to «ontrol his autonomic (involuntary) nerv dus system. House (1978, 1984) studied crnly patients with severe tinnitus who did •ot gain relief by other treatment modalities. Eighty percent reported improvement following biofeedback treat lIlent.
Counseling Many patients may not be helped by any
., the treatment modalities discussed. lounseling may play an important role in ~lping these patients cope with their tin-
The potential problems associated with tinnitus in
the workplace include increased absenteeism, frustration, depression, tiredness, and irritabilit}'.
nitus. The patient needs to know that his complaint is a common one. Informing them after appropriate workup that they do not have a life-threatening condition may relieve much of their anxiety. They need to know that there is no one universal cure, but treatment does exist. Addressing these initial problems and making appropriate referrals when needed should prove advan tageous for all concerned.
CONCLUSIONS A correspondence between tinnitus and
noise-induced hearing loss has been estab lished. The impact this symptom has on the individual's life varies enormously. Some patients suffer more from the tin nitus than the associated .hearing loss. While tinnitus has recently been the target of much investigation, little is known about this distressing symptom or its total impact on lifestyle and work productivity. Tinnitus due to noise exposure can be pre vented by a properly designed and man aged hearing conservation program (Kryter, 1985) and by educating the gen eral population regarding the conse quences of recreational noise exposure. It may be treated to a limited degree by the use of medications, tinnitus maskers, bio feedback and counseling. Although the mainstem of treatment is prevention, reas surance and discussion regarding treat ment options and their limitations are essential. Objective tests to measure the presence or absence of tinnitus and analy sis of the relationship between the degree
of hearing loss and the severity of tinnitus are needed. It would be useful to know patients who are at high risk of developing tinnitus so that hearing protectors could be provided or the employee removed from noisy environments. The problems of the tinnitus sufferer must be better understood and will be with continued research.
REFERENCES Atherley, G.R.C., Hempstock, T.I., & Noble, W.G.
(1968). Study of tinnitus induced temporarily by noise. Journal of the Acoustical Society ofAmer ica, 44, 1503-1506.
Atkinson, M. (1947). Tinnitus aurium. Some consid erations concerning its origin and treatment. Archives cfOtolaryngologica, 45. 68-76.
Axelsson, A., & Sandh, A. (1985). Tinnitus in noise induced hearing loss. Journal ofAudiology, 19, 271-276.
Bentler, R.A., & Tyler, R.S. (1987). Tinnitus man agement. Asha, May, 27-32.
Blayney, A.W., Phillips, M.S., Guy, A.M., & Col man, B.H. (1985). A sequential double-blind crossover trial of tocainide hydrochloride in tin nitus. Clinical Otolaryngology. 10, 97-101.
Chuden, H.G. (1981). Diagnostische massnahmen bei tinnitus. Hals Nase Ohrenarzt, 29, 418.
Coles, R.R.A. (l984a). Epidemiology of tinnitus: (I) Prevalence. Journal ofLaryngology and Otology 9, (Suppl) 7-15.
Coles, R.R.A. (l984b). Epidemiology of tinnitus: (2) Demographic and clinical features. Journal of Laryngology and Otology 9, (Suppl) 195-203.
Duckert, L.G., & Rees, T.S. (1981). Treatment of tinnitus with intravenous lidocaine: A double blind randomized trial. Otolaryngology Head and Neck Surgery. 91. 550-555.
Emmett, 1.R., & Shea, 1.1. (1980). Treatment of tin nitus with tocainide hydrochloride. Otolaryngol ogy Head and Neck Surgery. 88, 442-446.
Hatangdi, V.S., Boas, R.A., & Richards, E.G. (1976). Post herpetic neuralgia management with antiepileptic and tricyclic drugs. In 1.1. Bonica, D. Albe-Fessaro (Eds.), Advances in Pain Research and Therapy (pp. 583-587). New York: Raven Press.
House, 1.W. (1978). Treatment of severe tinnitus with bio-feedback training. Laryngoscope, 88. 406-412.
House, 1.W. (1984). Tinnitus: Evaluation and treat ment. American Journal ofOtology, 5, 472-475.
Jakes, S.C., Hallam, R.S., Chambers, C., & Hinchcliffe, R. (1985). A factor analytical study of tinnitus complaint behaviour. Audiology, 24, 195-206.
Kryter, K.D. (1985).The Effects ofNoise on Man (pp. 619-655). New York: Academic Press, Inc.
Lindberg, P., Lyttkens, L., Melin, L., & Scott, B. (1984). Tinnitus-Incidence and handicap. Scan dinavian Audiology. 13, 287-291.
Man, A., & Naggan, L. (1981). Characteristics of tinnitus in acoustic trauma. Audiology, 20, 72-78 .
Martin, EW., & Coleman, B.H. (1980). Tinnitus: A double-blind crossover controlled trial to evaluate the use of lidocaine. Clinical Otolaryngology. 5, 3-11.
McFadden, D. (1982). Tinnitus: Facts, Theories and Treatments (pp. 89-101). Washington, D.C.: National Academy Press.
Melding, P.S., & Goodey, R.1. (1979). The treatment of tinnitus with oral anticonvulsants. Journal of Laryngology and Otology, 93. 111-122.
Miller, M.H., & Jakimetz, J.R. (1984). Noise
AOHN JOURNAL, SEPTEMBER 1987, VOL. 35, NO.9 405
exposure, hearing loss, speech discrimination and tinnitus. Journal of Laryngology and Otology. (Suppl) 9,74-76.
National Center for Health Statistics. (1980). Basic data on hearing levels of adults 25-74 years. United States 1971-1975. Vital and Health Statis tics Publication, Series II, Number 215.
Reed, G.F. (1960). An audiometric study of two hun dred cases of subjective tinnitus. Archives of Otolaryngologica. 71. 84-94.
Roeser, R.J., & Price, D.A. (1980). Clinical experi ence with tinnitus maskers. Ear and Hearing. 1. (2),69-70.
Schleuning, A.J. (1982). Tinnitus. In G. Gates (Ed.), Current Therapy in Otolaryngology-Head and Neck Surgery (pp. 42-44). New York: BC Decker
Inc. Shulman, A. (1984). The tinnitus sufferer: The
responsibility of the professional. Journal of Laryngology and Otology. (Suppl) 9, 3-5.
Tyler, R.S., & Babin, R.W. (1986). Tinnitus. In c.w. Cummings, J.M. Fredrickson, L. Harker, C.J. Krause, D.E. Schuller (Eds.), Otolaryngology Head and Neck Surgery (pp. 3201-3217). SI. Louis: c.v. Mosby, Co.
Tyler, R.S., & Baker, L.J. (1983). Difficulties experi enced by tinnitus sufferers. Journal ofSpeech and Hearing Disorders. 48, 150-154.
Tyler, R.S., & Bentler, R.A. (1987). Tinnitus mask ing and hearing aids for tinnitus. In R. Sweetow (Ed.). Seminars in Hearing. 8(1), 49-61. New York: Thieme Medical Publishers.
ABOUT THE AUTHORS: Dr. LaMarte is j
Resident, Occupational Medicine, Institute 0. Agricultural and Occupational Medicine Department of Preventive Medicine atu Environmental Health. He is presently a Internal Medicine Associates, Section o.J
Occupational Medicine, Omaha, Nebraska; Dr. Tyler is Associate Professor and Directm of Audiology, Department of OtolaryngoloK} Head and Neck Surgery, Department oJ Speech Pathology and Audiology, University of Iowa, Iowa City, Iowa.
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