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20.07.2014

Tinnitus different sound in each ear, ringing in my right ear for months - Review

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The conscious awareness of sound takes place near the surface of the brain, when a pattern of electrical activity traveling up the nerve of hearing from the ear reaches the auditory cortex.
Each time a pattern from the ears is matched with a pattern in the auditory memory we have the experience of hearing and recognizing a sound. When a sound has special or critical meaning, like the baby waking at night, or the creaking of a floorboard, or the sound of first our name, we respond to it in an automatic manner, even if the volume is very soft. The main difference is that those who find tinnitus troublesome, evaluate and perceive it as a threat, or an annoyance, rather than something of little or no consequence. Unfortunately, these fears may be enhanced by professional advice, or reports from other sufferers, who have had a bad reaction to tinnitus.
Finally, many tinnitus sufferers are angry about the treatment, or lack of treatment, or inappropriate advice that they have received. In some patients, extreme fear of tinnitus results in a phobic state developing, very similar to that of the fear of spiders, frogs, small spaces, flying etc. Wearable sound generators (which look similar to hearing aids), have an important role to play. Tinnitus is the perception of sound heard within the human ear, when there isn’t any outside noise that others can hear.
Tinnitus can occur in one or both ears, constantly or intermittently, be perceived to come from inside or outside of the ear(s), be progressive, pulsing, or vary in intensity and pitch.
Sounds may occur simultaneously, and are described as ringing, hissing, static, crickets, screeching, sirens, whooshing, roaring, pulsing, ocean waves, buzzing, clicking, dial tones and even music.
Most of the individuals that seek help suffer from constant tinnitus, or tinnitus that lasts 24 hours a day, seven days a week. Withdrawal from benzodiazepines and in-ear earphones, whose sound enters directly into the ear canal without any opportunity to be deflected or absorbed elsewhere, are common causes of tinnitus. Feelings of pressure (aural fullness) or pain in or around the ears may accompany tinnitus. Individuals with more severe cases of tinnitus may find it difficult to hear, work, or sleep. Although tinnitus does not cause hearing loss, it can interfere with the ability to communicate. For the most part, tinnitus usually goes away by itself without treatment, but it is permanent in about 25% of all cases. Because tinnitus is usually a symptom of a problem, such as an illness, treating the initial cause should help get rid of, or at least lessen, the sounds. Whether or not this is necessary, will depend on how loud and persistent the sound is, how annoying it is to the person, and if it’s disturbing their daily life. And last, but not least, if you suffer from tinnitus, you join some pretty high profile people throughout history known to have had it too. Thus it can see that there are numerous factors that are weakly correlated with tinnitus, and that hearing impairment is the most strongly associated. Most tinnitus comes from damage to the inner ear, specifically the cochlea (the snail like thing on the right of figure 1, labeled '9').
Patients with Meniere's disease often describe a low pitched tinnitus resembling a hiss or a roar. Tinnitus can also arise from damage to the nerve between the ear and brain (8th nerve, labeled 6, auditory nerve). Tinnitus arises more rarely from injury to the brainstem (Lanska et al, 1987), and extremely rarely, to the brain itself (e.g.
Tinnitus can be associated with Basilar Artery Migraine (BAM), and also tinnitus can be more bothersome when one is having a migraine (Volcy et al, 2005), like sound and light and smells. In our opinion, people are very quick to blame drugs for their tinnitus, but it is rare that this is borne out.
Often people bring in very long lists of medications that have been reported, once or twice, to be associated with tinnitus. As tinnitus is essentially subjective, malingering of tinnitus as well as psychological causes of tinnitus is certainly possible. In malingering, a person claims to have tinnitus (or more tinnitus), in an attempt to gain some benefit (such as more money in a legal case). Schecklmann et al (2014) suggested that tinnitus is associated with alterations in motor cortex excitability, by pooling several studies, and reported that there are differences in intracortical inhibition, intra-cortical facilitation, and cortical silent period.
Cartoon of the middle ear showing muscles that attach to ossicles (ear bones), and ear drum. ABR (ABR) testing may show some subtle abnormalities in otherwise normal persons with tinnitus (Kehrle et al, 2008). We occasionally recommend neuropsychological testing using a simple screening questionnaire -- depression, anxiety, and OCD (obsessive compulsive disorder) are common in persons with tinnitus.
Microvascular compression of the 8th nerve is not a significant cause of tinnitus (Gultekin et al.
Other entities that can sometimes be seen on radiological testing and that can cause pulsatile tinnitus, include AVM's, aneurysms, carotid artery dissection, fibromuscular dysplasia, venous hums from the jugular vein (found in half the normal population), vascular tumors such as glomus, ossifying hemangiomas of the facial nerve, osseous dysplasias such as otosclerosis and Paget's, elevated intracranial pressure. Disrupted sleep is the most significant complaint, and affects between 25-50% of tinnitus patients. The algorithm that we use in our practice to diagnose and treat tinnitus is here (a PDF graphic).
There is a small literature concerning use of intravenous and local anesthesia for tinnitus.
Liu et al (2011) reported use of botox for tinnitus due to tensor tympani myoclonus, by inserting gelfoam with botox through a perforation in the tympanic membrane. Pramipexole was recently reported effective for tinnitus in a study of 40 patients with age related hearing loss in Hungary.
Most of the discussion of devices for tinnitus are discussed, as is proper, under the placebo page.
Cochlear implants, which are used for severe bilateral unaidable hearing loss, usually improve tinnitus (Amoodi et al, 2011). These are devices based on the idea that tinnitus is usually worst when things are very quiet. Occasionally persons with Meniere's disease have relief or reduction of tinnitus from transtympanic gentamicin. Microvascular compression syndrome, in theory, may cause tinnitus, but we have had very little success when the few patients we have seen with this syndrome have undergone surgery.
Tinnitus usually improves in profoundly deaf individuals who undergo cochlear implantion (Olze, 2015).


Avoid exposure to loud noises and sounds, avoid environments that are very quiet (as this makes tinnitus more noticeable).
Tinnitus Retraining Therapy (TRT) is a method of treating tinnitus helpful for some (Wang et al, 2003).
Hoare DJ, Kowalkowski VL, Kang S, Hall DA.Systematic review and meta-analyses of randomized controlled trials examining tinnitus management.
Mahboubi H, Ziai K, Brunworth J, Djalilian HR.Accuracy of tinnitus pitch matching using a web-based protocol. Piccirillo JF, Garcia KS, Nicklaus J, Pierce K, Burton H, Vlassenko AG, Mintun M, Duddy D, Kallogjeri D, Spitznagel EL Jr.Low-frequency repetitive transcranial magnetic stimulation to the temporoparietal junction for tinnitus Arch Otolaryngol Head Neck Surg. Wineland AM, Burton H, Piccirillo J.Functional Connectivity Networks in Nonbothersome Tinnitus. They placed 80 tinnitus free individuals (university members) in a sound proofed room for 5 minutes each, asking them to report on any sounds that might be heard.
Many doctors and other professionals still advise patients that there is nothing that can be done about tinnitus, and that it will go on for ever.
They may feel guilty for having submitted to treatment, which they think, is the cause of their tinnitus.
Once the tinnitus loses its sinister meaning, however loud it has been, or however unpleasant it may seem, it DOES begin to diminish, and in many cases may not be heard for long periods of time. In the subconscious part of the brain concerned with hearing, beyond the inner ear, (but before conscious perception of sound takes place), subconscious filters, or networks of nerve cells (neuronal networks) are programmed to pick up signals on a ‘need to hear’ basis.
With strong reactions, the filters are constantly monitoring tinnitus, but without a reaction, habituation occurs, as it does to every meaningless sound that is constantly present.
Tinnitus masking was at one time thought to be useful in that it simply made tinnitus inaudible. Most tinnitus is first heard at night in a well soundproofed bedroom, or a quiet living room (Heller and Bergman 1953). The Canadian Tinnitus Association estimates that 360,000 Canadians have tinnitus, and approximately 150,000 find that it seriously impairs the quality of their life. It is a condition that can result from a wide range of underlying causes, such as neurological damage (like brain injury or multiple sclerosis), ear infections, oxidative stress, foreign objects in the ear, nasal allergies that prevent (or induce) fluid drain, wax build-up in the ear and exposure to intense percussive and loud sounds. Treatments include identifying and healing an underlying cause, or reducing or masking the noise to make the tinnitus less noticeable. It is estimated that 40% of individuals who suffer from tinnitus experience hyperacusis, but it can occur without tinnitus. For example, Tandon (1987) reported that 1% of those taking imiprimine complained of tinnitus. We doubt that this means that motor cortex excitability causes tinnitus, but rather we suspect that these findings reflect features of brain organization that may predispose certain persons to develop tinnitus over someone else.
Wax should be removed, and the examiner should note whether the ear drum is intact, inflamed, scarred, or whether it is moving.
Because papilloedema is so rare, and tinnitus is so common, it is very unusual to find this dangerous condition.
The stapedius is attached to the stapes (of course -- horseshoe object above), while the tensor tympani is attached to the ear drum. This is not surprising considering how disturbing tinnitus may be to ones life (Holmes and Padgham, 2009). This is because of the very high correlation between anxiety and depression with tinnitus-related annoyance and severity (Pinto et al, 2014).
At that date there were 4 double-blind placebo controlled trials of antidepressants for tinnitus. Stidham et al (2005) injected botox into the area of the ear(above, and 2 places behind), the arm, and compared with placebo.
A recent trial in older people showed that atorvastatin had no effect on the rate of hearing deterioration but there was a trend toward improvement in tinnitus scores over several years.
This is a drug designed for heart disease, that is marketed in Europe for vertigo and tinnitus.
If you have tinnitus associated with a hearing loss, a hearing aid is a reasonable thing to try. For venous tinnitus, possibilities include jugular vein ligation, occlusion of the sigmoid sinus, or closure of a dural fistula.
The effects of unilateral cochlear implantation on the tinnitus handicap inventory and the influence on quality of life.
Medium-term results of combined treatment with transcranial magnetic stimulation and antidepressant drug for chronic tinnitus. Comparison of auditory brainstem response results in normal-hearing patients with and without tinnitus. Maintenance repetitive transcranial magnetic stimulation can inhibit the return of tinnitus. The ability of animals to develop extremely acute hearing, by which they could detect the very small sounds of an attacker a long way off, contributes to the survival of that species. In infancy, new sound experiences are stored in an information hungry, but relatively empty auditory cortex. A universal aversive response occurs with the sound of nails scraping across a piece of glass.
Fear, anger and guilt are very powerful emotions, which are intended to enhance survival-style, conditioned reflex activity, and consequently these emotions greatly increase attention on the tinnitus.
Most importantly, these emotional responses ensure that tinnitus persists, rather than habituates naturally.
In some cases firmly held beliefs are hard to alter, particularly where there is a conviction that tinnitus is only related to ear damage which cannot be fixed. Think again of the way we invariably detect the sound of our own name, or a distant car horn, or a new baby stirring in sleep, whereas we may be unaware of the sound of rain pounding on the roof or surf beating on a sea shore. In fact, this proved to block tinnitus habituation, as it must be audible for habituation to occur. Persistence of tinnitus depends not only on the meaning attached to it, but also to the contrast it creates with the auditory environment. In all cases, sound enrichment should be practiced, using unobtrusive sound sources, to break the silence. For example, some people may prefer to listen to the sounds of the great outdoors – bird calls, falling rain, or waterfalls.
According to Park and Moon (2004), hearing impairment roughly doubles the odds of having tinnitus, and triples the odds of having annoying tinnitus.


Somatic tinnitus means that the tinnitus is coming from something other than the inner ear.
In a double-blind trial of paroxetine for tinnitus, 3% discontinued due to a perceived worsening of tinnitus (Robinson, 2007). Specialists who care for patients with ear disease, usually know very well which drugs are problems (such as those noted above), and which ones are nearly always safe. Of course, tumors are a very rare cause of tinnitus, as tinnitus is at least 100 times more common than tumors of the inner ear area. On the other hand, Hoekstrat et al (2011) suggested that in general these drugs do not work for tinnitus. This study suggested that Botox might improve tinnitus to a small extent (7 improved with active, 2 improved with placebo). Be sure that you try the hearing aid before buying one, as tinnitus is not always helped by an aid. Given that smartphone apps do the same thing as tinnitus maskers, and that most newer hearing aids are blu-tooth capable, we see little reason to pay for a masker-hearing aid when one already owns a cell phone. Surgery seems worth considering only in extreme situations - -the tinnitus is extremely loud, very distressing, and there is a methodology to decide whether or not the tinnitus can be improved with surgery. On the other hand, very few individuals with tinnitus are deaf enough to qualify for cochlear implants.
Later on there is a continuous process of matching familiar memory patterns with those coming from the ear. Tinnitus may be the consequence of a mild age-related hearing impairment, rather than the other way around. In our experience, tinnitus improves when the patient overcomes these feelings and stops dwelling on thoughts of injustice.
Retraining the subconscious auditory system to accept tinnitus as something that occurs naturally, does not spell a lifetime of torture and despair, and is not a threat or a warning signal, can take months and occasionally even years.
Practically, as there is only a tiny proportion of the population with objective tinnitus, this method of categorizing tinnitus is rarely of any help.
In other words, the changes in the brain associated with tinnitus seem to be associated with emotional reaction (e.g. In a large study of tinnitus, avoidance of occupational noise was one of two factors most important in preventing tinnitus (Sindhusake et al. Tinnitus from a clear cut inner ear disorder frequently changes loudness or pitch when one simply touches the area around the ear. The muscles that open the jaw are innervated by the same nerve, the motor branch of 5, that controls the tensor tympani in the ear. There are case reports concerning tinnitus as a withdrawal symptom from Venlafaxine and sertraline (Robinson, 2007).
Nevertheless, this quality of tinnitus probably justifies a trial of oxcarbamazine (a less toxic version of carbamazepine).
TMS seems to be somewhat helpful for depression and migraine, and one would think that a modality that worked for these, would also work to some extent for tinnitus.
If tinnitus is reduced by intratympanic lidocaine injection, it seems reasonable to us that surgical treatment may also be effective (for unilateral tinnitus). Although some areas of the auditory system may be more active than others, every neurone will contribute to some extent to the final perception of tinnitus.
We are in a difficult situation where the classical training of tinnitus being due to inner ear damage is still very dominant. It is important to distinguish between the role of the ear in the EMERGENCE of tinnitus (e.g.
It seems to us that it should be possible to separate out tinnitus into inner ear vs everything else using some of the large array of audiologic testing available today. The exact prevalence of TMJ associated tinnitus is not established, but presumably it is rather high too. In our clinical practice, we have occasionally encountered patients reporting worsening of tinnitus with an antidepressant, generally in the SSRI family.
When this doesn't happen, the treatments that work the best for tinnitus are those that alter ones emotional state -- antidepressants and antianxiety drugs, and ones that allow you to get a full night's sleep.
Robinson reported that tinnitus in depressed patients appears more responsive to antidepressants than in non-depressed patients. This shows that weak patterns of sound, if they are of great significance and meaning, can be detected by subconscious pathways or filters (see above), between ear and brain (auditory cortex), even during sleep. In any event, the threatening qualities of the tinnitus are enhanced by beliefs and negative ideas about tinnitus or associations that have been formed, not any physical changes that may or may not have occurred. For people who also have co-existing or pre-existing anxiety or depression, it can take longer to change their feelings about their tinnitus. We have encountered patients who have excellent responses to cervical epidural steroids, and in persons who have both severe tinnitus and significant cervical nerve root compression, we think this is worth trying as treatment. Having TMJ increases the odds that you have tinnitus too, by about a factor of 1.6 (Park and Moon, 2014). Mechanisms for impovement were suggested to be direct effects of increased serotonin on auditory pathways, or indirect effects of tinnitus on depression or anxiety.
These filters are able to enhance and amplify important sounds, and at the same time, suppress or habituate sounds of no interest. It is often feared that tinnitus will continue to spoil peace and quiet, interfere with concentration at work, quiet recreational activity and the ability to sleep at night. Despite the importance of hearing change (temporary or permanent) in triggering an emergence of tinnitus, a recent study of our tinnitus clinic patients showed there was no significant difference in hearing between the tinnitus group and normal population statistics. The reason for this is not so much because the quality or loudness of the tinnitus is different; in fact we have found that tinnitus is of a very similar type of sound in those who are bothered by it and those who are not. Nature sounds are always the best, as they are already habituated, and usually produce feeling of relaxation, calm and well-being. This makes a more sense than the Wineland result, but of course, they were measuring different things. Remember filters are working 24 hours a day, even when asleep, and so should sound enrichment.
MRI studies related to audition or dizziness must be interpreted with great caution as the magnetic field of the MRI stimulates the inner ear, and because MRI scanners are noisy.



National sleep foundation guidelines
How to stop ringing ears naturally


Comments to “Tinnitus different sound in each ear”

  1. Super_Bass_Pioonera:
    Examination is feasible and should be done difficult to block out mentally, and I could.
  2. ABD_MALIK:
    Even though a lot of remedies are the.