Ringing in the ears or ‘tinnitus’ (pronounced with the accent on the ‘tin’) is one of the most prevalent and bothersome of symptoms related to diving. Tinnitus may be caused by damage or disease, anywhere along the path of the auditory system.
Tinnitus is the perception of sound when no external sound is present; and is often referred to as “ringing in the ears.” It can also take the form of hissing, roaring, whistling, chirping or clicking. The noise can be intermittent or constant, with single or multiple tones; it can be subtle or at a life-shattering level. It can strike people of all ages and, for most, it is difficult to treat.
It is estimated that over 50 million Americans are affected by tinnitus to some degree. Of these, about 12 million suffer severely enough to seek medical attention. And, about one million sufferers are so seriously debilitated that they cannot function on a “normal,” day-to-day basis. In diving, it is a symptom of serious changes that have occurred because of the effects of pressure, either barotrauma, excessive attempts to equalize or to a decompression accident.
In divers, it also can be related to TM joint pressure from clamping down on the mouthpiece, wax buildup in the ear canal with tympanic membrane irritation, barotrauma to the middle and inner ear, decompression illness involving the inner ear, or rupture of the round window with perilymph fistula. With the latter, it most often found in association with vertigo and there is usually some deafness.
It may also be caused by physical trauma, infections of the ears, long standing exposure to very noisy environments, scarring and rigidity of the small bones in the middle ear (otosclerosis), toxic damage by medications (e.g. Streptomycin), and tumors of the brain or the auditory (hearing) nerve.
Tinnitus is still a phenomenon about which we know little and which has few effective treatments. During the last two decades, hyperbaric oxygenation therapy (HBO) has been used in the treatment of sudden deafness and chronic distressing tinnitus, with mixed results. Other therapies include non specific prescription medicines, non-traditional medical treatments, such as acupuncture, stress reduction and relaxation therapy, hearing aids and biofeedback therapy.
It should be emphasized that the newer methods of treatment are still under evaluation and that at this time there is no universal, symptomatic or specific treatment for tinnitus.
Things that divers can do:
1. Get a good examination by a diving oriented ENT doctor. The tinnitus may not be from diving at all!
2. Check out your regulator mouthpiece for fit. Consciously avoid clamping down on the mouthpiece. (Try this yourself–clamp down on your teeth and hear the high-pitched whine!)
3. Avoid the use of nerve stimulants, i.e, excessive amounts of coffee (caffeine) and smoking (nicotine).
4. Learn as quickly as possible to accept the existence of the head noise as an annoying reality and them promptly and completely ignore it as much as possible.
5. Tinnitus is usually more marked at bedtime, when one’s surroundings become quiet. Use any kind of masking sound-maker.
How to Treat Tinnitus: There is not a cure for tinnitus. However, a variety of treatment options exist that offer varying levels of relief to many sufferers. Treatment options include:
• hearing aids
• Tinnitus Retraining Therapy
• TMJ treatment
Objective Tinnitus (Actually audible or observable )
The rarer form, consists of head noises audible to other people in addition to the sufferer. The noises are usually caused by vascular anomalies, repetitive muscle contractions, or inner ear structural defects. The sounds are heard by the sufferer and are generally external to the auditory system. This form of tinnitus means that an examiner can hear the sound heard by the sufferer by using a stethoscope. Benign causes, such as noise from TMJ, openings of the eustachian tubes, or repetitive muscle contractions may be the cause of objective tinnitus. The sufferer might hear the pulsatile flow of the carotid artery or the continuous hum of normal venous outflow through the jugular vein when in a quiet setting. It can also be an early sign of increased intracranial pressure and is often overshadowed by other neurologic abnormalities. The sounds may arise from a turbulant flow through compressed venous structures at the base of the brain.
Subjective Tinnitus(Inaudible to an observer)
This form of tinnitus may occur anywhere in the auditory system and is much less understood, with the causes being many and open to debate. Anything from the ear canal to the brain may be involved. The sounds can range from a metallic ringing, buzzing, blowing, roaring, or sometimes similar to a clanging, popping, or nonrhythmic beating. It can be accompanied by audiometric evidence of deafness which occurs in association with both conductive and sensorineural hearing loss. Other conditions and syndromes which may have tinnitus in conjunction with the condition or syndrome, are otosclerosis, Meniere’s syndrome, and cochlear or auditory neve lesions.
Hearing loss, hyperacusis (excessive loudness), recruitment, and balance problems may or may not be present in conjunction with tinnitus.
Many sufferers report that their tinnitus sounds like the high-pitched background squeal emitted by some computer monitors or television sets. Others report noises like hissing steam, rushing water, chirping crickets, bells, breaking glass, or even chainsaws. Some report that their tinnitus temporarily spikes in volume with sudden head motions during aerobic exercise, or with each footfall while jogging.
Objective tinnitus sufferers may hear a rhythmic rushing noise caused by their own pulse. This form is known as pulsatile tinnitus.
In a database of 1544 tinnitus patients, 79% characterized the sound as “tonal” with an average loudness of 7.5 (on a subjective scale of 1-10). The other 21% characterized the sound as “noise” with an average loudness of 5.5. When compared to an externally generated noise source, the average loudness was 7.5dB above threshold. 68% of patients were able to have their tinnitus masked by sounds 14dB or less above threshold. The internal origination of the tinnitus sounds was perceived by 56% of the patients to be in both ears, 24% from somewhere inside the head, 11% from the left ear, and 9% from the right ear.
In aother database of 1687 tinnitus patients, no known cause was identified for 43% of the cases, and noise exposure was the cause for 24% of the cases.
Diving Causes of Tinnitus
- TMJ syndrome (Clenching of teeth on the regulator)
- Middle ear barotrauma (Due to pressure/volume changes)
- Inner ear barotrauma. (Due to pressure/volume changes)
- Round window rupture (Due to elevated pressure blowing this window out into the middle ear0
- Inner ear decompression accident (Due to bubbles damaging the inner ear tissues)
Finally, advice from an otolaryngologist familiar with the damage that can occur from diving should be obtained. Self -diagnosis and treatment has no place in the management of tinnitus from diving injuries.
Scand Audiol 1999;28(2):91-6
Long-term effect of hyperbaric oxygenation treatment on
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