A review of tinnitus symptoms beyond ‘ringing in the ears’: a call to action
From: Curr Med Res Opin. 2011 Jun 23. [Epub ahead of print]
About 10% of the population experiences tinnitus, a common and distressing symptom characterized by the perception of sound in the absence of external stimuli. There is, however, marked heterogeneity in etiology, perception, and extent of distress among those who experience tinnitus. Reactions to tinnitus vary from simple awareness to severe irritation; some people have difficulty in hearing because of the loudness of the noise. Severe tinnitus causes many, often psychological, symptoms (e.g., tension, frustration, impaired concentration, disrupted sleep). For some, tinnitus is temporary, for others it is longstanding. Although many people adjust successfully, others are disabled by tinnitus; approximately 5% experience persistent and severe symptoms affecting their lifestyle and significantly reducing their quality of life. Because tinnitus is poorly understood and no single therapeutic approach is effective for all patients, many patients are told that ”nothing can be done” and they must ”learn to live with it.”
Tinnitus, often referred to as ‘ringing in the ears’, is highly prevalent. However, patients may also present with a number of other symptoms.
To review the broad range of symptoms of tinnitus, to evaluate their impact on patient quality of life and to explore methods of diagnosis and assessment. An electronic literature search was performed in PubMed between September and December 2010.
Accumulating evidence suggests that the symptoms of tinnitus are not confined to the characteristic ‘ringing in the ears’, but instead encompass wide-ranging symptoms that include emotional components such as sleep disturbance, anxiety, depression, irritation, and concentration difficulties.
Patients with tinnitus experience a spectrum of distressing symptoms that impact their quality of life and there is a clear need for action. Clinicians need to recognize and diagnose tinnitus that occurs with other wide-ranging symptoms to ensure that these symptoms are identified and patients receive effective treatment.
Tinnitus, a widespread, often intractable condition, affects millions of people; there is considerable debate about its causes. Tinnitus is distressing and may be severe enough to affect lifestyle and quality of life. Affected patients need considerable support and advice on healthcare options, encouragement to try different treatments and recognition that help and hope are available. Though patients may have to learn to live with tinnitus, the most important thing is that they recognise that help is available.
Recently, in Tinnitus in elderly patients and prognosis of mild-to-moderate congestive heart failure: a cross-sectional study with a long-term extension of the clinical follow-up, BMC Medicine 2011, 9:80,
Tinnitus is the perception of a sound that cannot be attributed to an external source. It is a nonspecific symptom generally referable to a largely unknown dysfunction of the hearing system. A comprehensive definition has been proposed to differentiate normal ear noises from pathological tinnitus defined as a head noise lasting at least five minutes and that occurs more than once per week. A distinction can also be made between subjective and objective tinnitus. The former is more common and refers to an individual sound that is perceived only by the patient. From the epidemiological point of view, tinnitus affects a remarkable number of adults and is frequently associated with a hearing loss of various degrees as expression of a cochlear disorder.
In the United Kingdom approximately 4.7 million of patients are affected by tinnitus and about 5% of them have experienced a severe and persistent disorder that affects their quality of life. The American Tinnitus Association has reported a prevalence of about 19% (37 to 40 million), which increases with age and the degree of hearing impairment. The prevalence of tinnitus has been reported to be higher in men than in women, and this difference might be related to higher hearing thresholds in the male population. Interestingly, only 1% of patients under 45 years of age experience tinnitus, while the prevalence is about 12% in those 60 to 69 years of age and 25 to 30% in those who are >70. Similar data recently have also been reported in a large cross-sectional study carried out with participants in the 1999 to 2004 US National Health and Nutrition Examination Surveys.
Several anatomical regions could contribute to the generation of tinnitus, even if a causative relationship between neurophysiological functions and tinnitus generation has not yet been demonstrated. Moreover, several pathophysiological hypotheses have recently been proposed to explain the genesis of different kinds of tinnitus: from genetic to iatrogenic, from neurological to vascular. However, a final and unique explanation is not actually available. In this complex scenario, tinnitus associated clinical conditions, such as vascular diseases, middle ear diseases, diabetes, hypertension, autoimmune disorders, and degenerative neural disorders with or without concomitant hearing loss, a functional component leading to an impaired regulation of the peripheral vascular tone can be demonstrated.
For that reason, at least partly, tinnitus could be the expression of a circulatory impairment of the microcirculation of the inner ear resulting from a detrimental feedback loop between the control of systemic blood pressure and the reflex activation of the neurohumoral system (for example, sympathetic nervous system and renin-angiotensinaldosterone system. Accordingly, any clinical condition leading to a reduction in systemic and/or regional blood flow at the ear level can trigger the onset of tinnitus or promote its exacerbation in patients already affected by this disorder.
Chronic heart failure could be an ideal biological model to test the vascular disregulatory hypothesis of tinnitus since it is often associated with a reduced cardiac output, as well as with a reflex activation of vasoconstrictive systems, including the sympathetic nervous system and RAAS. The prevalence of chronic heart failure is significantly increased in the elderly population, who also have a higher rate of tinnitus and afford researchers with a reliable clinical setting to investigate the circulatory origin of hearing disorders.
To date, this is the first large, cross-sectional, clinical study supporting an association between tinnitus and chronic heart failure control in elderly patients. Data suggest that the onset of tinnitus might be affected by the degree of decline in LV function and is probably the consequence of an insufficient autoregulatory mechanism at the level of the circulation of the inner ear. These data can have some important clinical implications including the possibility that the onset and/or worsening of tinnitus can antedate the destabilization of chronic heart failure. This would allow for the early identification of patients who deserve a more aggressive management of heart failure or an adjustment of drug treatment, including a cautious administration of NSAIDs. If confirmed by larger prospective studies, this evidence would indirectly contribute to improve the quality of life of patients with chronic heart failure and might reduce the rate of hospitalization, as well as the huge economic burden of the management of chronic heart failure.