Sixty-five-year-old Simon* was looking forward to retirement, and finally that day has arrived. He lives alone in his own house and enjoys his independence. His physical health is good except for an occasional “buzzing” in the ears. It worsens at night and even disturbs his sleep. Because of increasingly frequent sleepless nights, Simon feels tired during the day. He has been taking aspirin 81 mg daily as recommended by his primary care provider five years ago for stroke prevention because of a transient ischemic attack in the past.

Simon is one of many elders with a complaint of noise in one or both ears (tinnitus). It’s not an illness, but a symptom that in many cases can be very disturbing. As with Simon, it causes sleep disturbances and an inability to concentrate. If it persists, it can affect a person’s mood, leading to general psychological distress and often depression.¹ In some cases, tinnitus becomes so annoying that a person can even become suicidal.²

Tinnitus is a perception of sound that is heard by a person but that doesn’t have an external source. Patients often describe the sound as ringing, buzzing, roaring, or whistling. Heard as a single sound, or a combination of sounds, it can be perceived as coming from inside or outside the ear.³

Tinnitus is most common in older people. An estimated 15% of people over 45 and 25% of people over 65 are affected.⁴ The percentage peaks between 65 and 74, and the severity of tinnitus increases with age.⁵ Among hearing-impaired people, an estimated 75% to 80% experience tinnitus. But it can also occur in people with normal hearing.

Tinnitus can be characterized as subjective or objective. Subjective tinnitus is a sound heard only by the affected person. Objective tinnitus is a sound that the healthcare examiner can hear through a stethoscope placed near the patient’s ear. Etiology and treatment of the two types are different. The objective type, usually caused by vascular abnormalities or neurologic disorders, is less common;3 this module will focus on the subjective type.

As the elderly population grows, tinnitus is expected to pose an increasing health challenge. Nurses must be able to address this common problem by identifying causes and aggravating factors and by educating patients about preventive measures to improve their quality of life.

How we hear

To understand the pathophysiology of subjective tinnitus, it’s helpful to review the auditory system. The auricle, part of the external ear, helps collect sound waves. The sound waves go through the external auditory canal to the tympanic membrane (eardrum), which separates the external ear canal from the middle ear. The sound vibrates the eardrum. That vibration travels to the middle ear, which consists of three small bones joined together: the malleus, incus, and stapes. The sound travels along these bones, and the stapes transmits it into the inner ear.

The inner ear consists of a snail-shaped tube called the cochlea, which contains the sensory receptors for hearing, called the organ of Corti. Stimulated by the sound vibration, these receptors produce electrical impulses that are carried by the auditory nerve to the brain. The brain interprets these impulses, forming the perception of sound.¹

With advanced age, hearing declines because of changes in the auditory system. The most pronounced changes often occur in the inner ear; the cochlea and organ of Corti atrophy. The number of hair cells (sensory cells) in the organ of Corti diminishes with age, as does the number of auditory cranial nerve fibers. The stria vascularis, which supplies blood to the inner ear, can also atrophy. Furthermore, the number and activity of ceruminal glands, which produce cerumen (ear wax), decrease, and the cerumen produced tends to become drier, eventually blocking the external auditory canal. The tympanic membrane becomes thicker and wider. Scarring, which can worsen tinnitus, often develops from multiple infections or injuries.⁵

Many other factors can be responsible for tinnitus, including otologic disorders, medications, neurologic or metabolic diseases, and lifestyle, nutritional, and physiological age-related changes in the auditory system. Tinnitus can be a primary or secondary symptom of an underlying condition. Noise exposure is also a significant factor in tinnitus in all ages, including the elderly. But in half of all the cases, the etiology is not known.^6,7

The mechanism of tinnitus in elderly patients with hearing deterioration has been hypothesized as follows: The cells in the brain that process sound become disinhibited when injured and become very active even without receiving enough input from the ear and the auditory nerves. This increased activity produces the sounds of tinnitus. Some clinicians have compared this process to phantom limb pain, when patients with limb amputation experience sensations that they perceive as originating in the missing limb.⁵

Crossing the gap

Another hypothesis involves the sections of myelin loss along the auditory nerve. Signals have to cross from one nerve fiber to another across the demyelinated areas of the auditory nerve before reaching the brain, and this crossing generates sound.3 Another theory considers that when hearing acuity changes with age, the responsible part of the brain has to work harder to hear. Straining to hear, the brain creates the extra perception of noise.⁸

Medical disorders affecting any part of the auditory pathway can trigger tinnitus, including tympanic membrane perforation, ear infection, and inner ear fluid accumulation as occurs in Meniere’s disease. Sometimes, tinnitus is the first symptom of serious underlying conditions, such as a cerebral aneurysm or an acoustic neuroma, a benign tumor involving the branch of the eighth cranial nerve (the auditory nerve). Trauma to the acoustic area may dislocate the ossicles, resulting in tinnitus. Tinnitus can also arise from prolonged exposure to extreme noise — or even a severe single exposure.⁷

Other conditions that can induce or aggravate tinnitus include an increase in blood volume as in polycythemia⁹ or a decrease in blood volume as in anemia, severe hypertension,10 an underactive thyroid, and hypoglycemia. Tinnitus can be one of the symptoms of MS.^2,7

In some cases, diseases that affect the musculoskeletal system, such as cervical spondylosis (vertebral degenerative disease), may be responsible for tinnitus as the result of osteophytic growths pressuring the vertebral arteries.¹⁰ Progressive hearing deterioration due to advancing age or an excessive exposure to noise induces tinnitus. Other causes include obstruction of the ear canal by a foreign object or an excessive accumulation of dry cerumen.⁵

All these conditions produce subjective tinnitus. But vascular disorders, such as atherosclerosis of the carotid artery or malformation in intracranial arteries or veins, can produce objective tinnitus. In palatal myoclonus, palate muscles contract, causing a continuous or intermittent clicking sound in the ear, which constitutes vibratory tinnitus.^7,10

More than 500 medications have tinnitus as a potential adverse effect.⁸ One of the most common medications causing tinnitus is aspirin when used for a prolonged time.5 It can injure hair cells in the cochlea and the auditory cranial nerve.

Other common medications can have a similar effect, including other salicylates; some diuretics (for example, furosemide [Lasix]) or bumetanide [Bumex]); aminoglycoside antibiotics, such as streptomycin, vancomycin (Vancocin), or neomycin (Neobiotic); and chemotherapeutic agents, such as cisplatin (Platinol). Other medications that can provoke tinnitus include quinine (Quinamm, Formula Q) and bone resorption inhibitors, such as risedronate (Actonel).^5,6 Many antidepressants also have tinnitus as an adverse effect. In some cases, tinnitus is dose related (as, for example, with high doses of salicylates) and can be reversible.¹¹

With advancing age, common nutritional deficiencies in zinc, iron, magnesium, or cyanocobalamin (vitamin B12) can be responsible for tinnitus. In some cases, food additives, such as MSG, can contribute. Alcohol, stress, and fatigue can exacerbate tinnitus. Vasoconstriction from caffeine and tobacco can also lead to tinnitus.^3,5,8

Tinnitus is often associated with hearing deterioration. In this case, the condition is not life-threatening. But in many other cases, tinnitus can be a first symptom of more serious conditions; therefore, a thorough exam is essential. The nurse can help discover the contributing causes and, in some cases, potentially life-threatening conditions and then identify ways to alleviate tinnitus to improve quality of life.

Essential questions

After obtaining a detailed description of the complaint from the patient, the nurse should conduct a thorough history that answers the following questions about the mode of onset, location, character, aggravating or ameliorating factors, and exposure to ototoxic medications.

• Did any events coincide with the onset of tinnitus? Exposure to loud noises, recently or in the past, can damage the hearing pathway and trigger tinnitus. After even a short exposure to severe noise, transient tinnitus can occur.⁷ Also consider aggravating factors, such as stress, muscle tension in the jaw and neck, sinus disease, dental problems, and fatigue.7,5 Head or ear trauma may dislocate the ossicles, causing tinnitus.⁸

• Was the onset gradual or sudden? Unilateral or bilateral? For example, a sudden onset with pain or vertigo and a feeling of fullness in the ear might be due to tympanic membrane perforation. Sudden, acute, unilateral tinnitus can be a first symptom of sensorineural hearing loss, possibly due to an acoustic neuroma and requiring prompt medical attention. A bilateral, high pitch may be a symptom of high blood pressure.^3,7,12

• Have any similar episodes occurred in the past and what was their severity?

• Does the tinnitus have a significant effect on daily life?

• How long does the tinnitus last? Intermittent, mild, high-pitched tinnitus with short duration can occur in people with normal hearing.^12,13 Constant tinnitus with the perception of many different sounds can be caused by otosclerosis, which can progress into hearing loss. Intermittent, muffled, low-pitched sounds, which patients often describe as a hollow sound of their own voice, could be due simply to cerumen or a foreign object obstructing the ear canal. Tinnitus attacks lasting 10 minutes up to several hours — or even continuing days or weeks with remission — with intermittent hearing loss and a feeling of fullness in the ears can be a symptom of Meniere’s disease.¹⁴ Constant tinnitus with unsteadiness on the feet when rising from bed or standing up can be due to atherosclerosis of the carotid artery.⁵

• What is the character of the symptom? For example, a pulsation described as hearing one’s own heartbeat can be due to cerebral aneurysm, carotid vaso-oclusive disorder, or arteriovenous malformation. Fast, popping, staccato clicking noises lasting just a second — or up to a few minutes — can be caused by a muscle spasm in a surrounding area.¹³ A roaring in the head is usually due to vascular or neurological problems.⁷

• Are there concomitant symptoms, such as tongue or facial numbness or pain, new headache, dizziness, or vertigo? Such symptoms need immediate attention by a medical care provider; they may be symptoms of stroke or other serious problems. Blurred vision, headache, or nausea can be the symptoms of extremely high blood pressure.^7,14

• Is the patient using OTC or prescribed medications or herbal remedies? How about in the past? Be aware of drug-drug interaction. Numerous drugs have a negative effect or are ototoxic, possibly leading to tinnitus.

• Does the patient take vitamin and mineral supplements? Vitamin and mineral deficiencies, particularly B12 or zinc, can cause or aggravate tinnitus. Does the patient have a history of hypertension, anemia, atherosclerosis, temporomandibular joint complaints, hypothyroidism, MS, disorders of cervical vertebrae, cardiovascular diseases, anxiety, or depression? High prevalence of tinnitus has been found in people with depression and anxiety disorders. Depression can enhance the perception of tinnitus.^3,7

Keep it simple

A number of simple strategies help guide the physical exam:

• Observe the patient’s general appearance, noticing any anxious behavior or depressed mood. Observe the skin and mucous membrane because dehydration, common in the elderly, can precipitate or aggravate tinnitus. Pale skin may imply anemia as a possible cause.^1,3 Check vital signs to rule out hypertension. Perform an otoscopic exam to exclude perforated tympanic membrane, ear infection, or simple canal obstruction due to a foreign body or dry cerumen.

• Check hearing by whispering randomly chosen letters 1 to 2 feet from each ear, while the untested ear is occluded.¹⁶ If a hearing problem is indicated, refer the patient to an audiologist.^15,16

• Inspect the nasopharynx for masses that might obstruct the eustachian tube. Rule out atherosclerosis of the carotid artery by palpating and auscultating it to detect a weak pulse or bruits. If caused by atherosclerosis of the carotid artery, constant tinnitus can be interrupted by applying pressure over the artery.^14,16

• A few simple tests are useful for checking neurological function. For example, finger-to-nose movements can detect abnormality of the cerebellar function. Ask patients to touch their nose with the left and right index fingers with the eyes open and then with the eyes closed. Observe accuracy in targeting the nose.

• Check the motor function of the seventh cranial nerve (facial nerve), looking for asymmetry of movements when the patient is smiling or talking.

Silencing tinnitus

After identifying a medical cause of tinnitus, the physician or NP can inform the patient about care options. For example, by treating systemic diseases, such as hypothyroidism or anemia, and assuring the patient that ringing in the ears is not caused by life-threatening conditions, the provider can reduce anxiety and, in many cases, the perception of tinnitus severity.^7,9

Even if medical causes are ruled out, nurses play an important role in managing tinnitus in elders. If mild tinnitus has no effect on daily living, reassurance and counseling may be sufficient. For example, the nurse can advise a smoker or someone with high intake of caffeinated drinks to cut back and then observe any improvement over time. Because older people are often mineral- and electrolyte-deficient, counseling on diet and hydration can be helpful.³ Hearing aids will help correct hearing acuity and at the same time relieve tinnitus in about 50% of cases.³

Counseling on reducing alcohol consumption, or the use of illicit drugs if relevant, can be beneficial. Nurses can advise patients to avoid extremely loud noises and to use hearing plugs. In some cases, tinnitus is alleviated when medications are changed, stopped, or reduced in dose.^3,4

Although there is no FDA-approved medication specifically to treat severe tinnitus, some medications have had a positive outcome for some patients. (In other words, these medications are used off-label for tinnitus.) For example, oral antidepressants, usually tricyclic antidepressants, at bedtime seem to be very helpful for depressed patients.^1,3 (The incidence of depression often correlates with severe tinnitus.³) In some cases, tinnitus that disturbs sleep is alleviated by medications used as sleeping aids, such as benzodiazepines, but these medications can also have adverse effects, such as dizziness, confusion, and sedation. If used over time, they can lead to dependence, and patients must be warned.^3,8 If tinnitus causes sleepless nights, alprazolam (Xanax) is the most often recommended benzodiazepine because it is less sedative than other drugs in its class.³ Herb supplements, such as ginkgo biloba, have shown mixed results in reducing tinnitus. Some antioxidants, such as L-glutathione, N-L-acetylcysteine, acetyl-L-carnitine, D-methionine, magnesium, and zinc, have been recommended for “good ear health.”^3,8

Patients with severe psychological problems in addition to tinnitus, such as depression, panic attacks, anxiety, or phobias, benefit from management by a multidisciplinary team. In many cases, a referral to an otolaryngologist, audiologist, and, some cases, psychiatrist is necessary.^3,8

In extreme situations, cochlear implants are an option. In some cases, patients recovered completely after cochlear implant, but results are inconsistent and depend on the cause of tinnitus.^7,8,17

Nonpharmaceutical management of mild tinnitus includes sound therapy. During sound therapy, the patient listens to a soothing sound via earphones, for example. Sound therapy masks tinnitus and is especially effective during sleep time or in quiet surroundings.^3,7,18

Hearing aids often reduce additional strain of the brain to hear, allowing more sound from the environment to reach the brain, and so the perception of tinnitus volume is lowered.⁸ Some patients with good hearing receive relief from a tinnitus masker device, which looks like a hearing aid and delivers soothing sounds that take attention away from the tinnitus.³

In many other cases, cognitive-behavioral therapy has been successful in retraining the brain to interpret tinnitus as neutral. A successful outcome was reported even after a brief meeting with a psychologist who counseled behavioral changes and cognitive restructuring.¹⁹

One novel approach is a cognitive-behavioral self-help program using a computer. In one study, a patient accessed a program on the Internet that involved relaxing, focusing on positive images, shifting focus from tinnitus to other stimuli, controlling breathing, and increasing physical activity to manage stress. After three months, the patient showed significant improvement.²⁰

Tinnitus occurs at all ages, but it is more common in elders. It can lead to an inability to concentrate and can interfere with sleep. Although tinnitus can arise from the physiological changes of aging, it can indicate other, more serious medical problems. Many interrelated factors may contribute to tinnitus. Through systematic assessment, the identification of the cause, and assistance for elders in developing ways to cope, nurses will help ensure patients’ quality of life.

And Simon?

Simon mentioned the ringing in his ears to the nurse practitioner who visits his senior center every month. She conducted a thorough history, noting that Simon was on aspirin therapy. She reassured Simon that although his tinnitus needed further evaluation, it most likely was not a symptom of a more serious condition. The next step: referral to an audiologist, and afterward, follow-up by the nurse practitioner.