Tinnitus: easing the distress when the noise won't go away

1. Before you begin

It is eleven o'clock at night. The dishwasher stops, the street falls quiet, and there it is: that high-pitched whistle, like a television left on in an empty room. You strain your ears to find out whether it is louder than yesterday. Perhaps it is. You switch the radio on, turn it down, switch it off, switch it on again. At two in the morning, you type "tinnitus cure" into your phone and come across a personal story that chills you. The next day, at the office, you hear it between two of your colleague's sentences.

Perhaps you have been told that you have to "live with it". The sentence is right in substance. Yet it sounds like being abandoned, because nobody has explained to you how.

Three things, straight away.

The sound is real, and the distress can come down even if the sound stays. It is produced by your auditory system: it is neither imaginary nor "all in your head" in the sense people often mean. But the suffering it causes does not depend only on its loudness. It depends on the attention it captures, on what it makes you fear, on your nights and on your mood, and those levers can move.

An examination of the ears first, once, and properly. Tinnitus most often goes with some hearing loss, sometimes slight, and more rarely it signals a disease that can be treated. Certain signs mean you should seek medical advice quickly, and section 2 describes them. Once this assessment has been done, repeated examinations add nothing more, unless something changes.

What helps most is neither a medicine nor a miracle device. No medicine has been shown to silence tinnitus. Cognitive behavioural therapy, or CBT, a structured psychotherapy that works on what you do and on what you tell yourself, reduces the distress in a real way, although modestly. It is the psychological approach whose effectiveness is best established in this field, and this guide describes its principles, step by step.

2. The doctor or the ENT specialist first

Why start there

The British guideline on tinnitus, published by the National Institute for Health and Care Excellence, the public body that writes medical guidelines in the United Kingdom, asks for people to be reassured from the outset: tinnitus is common, it can go away by itself, and although it often goes with hearing loss, it is rarely linked to another physical problem. It can, however, reveal a disease that can be treated, sometimes urgently, and that is why the examination comes before everything else.

The signs that cannot wait

These pointers come from the British guideline, from the French guideline, published by the Haute Autorité de santé, the public body that sets standards of good medical practice in France, and from the Assurance Maladie, France's public health insurance, which informs the public on its website. They are there to help you know when to seek advice, not to diagnose yourself.

• A sudden drop in hearing, developing over a few hours or over two or three days, in one ear or both, is an emergency, even if it does not hurt. The British guideline asks for the person to be seen within twenty-four hours, the Haute Autorité de santé for treatment to be started without delay, and the Assurance Maladie for people to seek medical advice immediately. In practice, get examined the same day, by an ENT specialist, or at the emergency department if you cannot see one quickly. Only this examination can tell an ear that is simply blocked, by earwax for example, from damage to the inner ear that needs treatment.
• If you only notice this drop after a few days, still seek advice without waiting: the British guideline still asks for an examination within twenty-four hours when the drop began less than a month ago. An American guideline from 2019, published by the American academy of ENT doctors, points out that prompt treatment can improve the recovery of hearing.
• Violent vertigo that does not settle, weakness or paralysis of the face, difficulty speaking or weakness on one side of the body can signal a stroke, that is, a sudden interruption of the blood flow to part of the brain. In that case, call the emergency services in your country without waiting.
• Tinnitus that beats in time with the heart and that appeared suddenly, or that is changing quickly, calls for immediate medical advice, according to the Assurance Maladie.
• Tinnitus that appeared after a blow to the head, or that appeared less than ten days ago together with a sudden, severe and unusual headache, also calls for immediate medical advice, the same day.
• Tinnitus that appeared suddenly with fever and chills, nausea or vomiting, or impaired consciousness, is the same kind of emergency, according to the Assurance Maladie.
• Tinnitus that has been beating in time with the heart for some time, or that affects only one ear, calls for an appointment with an ENT specialist in the coming weeks, without letting it drag on. It often justifies imaging, that is, an examination that shows the inside of the head, such as the one described below.
• Vertigo that keeps coming back, hearing that is gradually declining, ear pain or an ear that stays blocked deserve an appointment with your doctor, who will refer you to an ENT specialist.

The sound that beats in time with the heart, called pulsatile tinnitus, is often due, according to the Assurance Maladie, to an abnormality of a blood vessel in the neck or head, and its cause can then often be treated.

The usual assessment

The ENT specialist examines the ears and carries out audiometry, that is, a measurement of hearing in a soundproof booth, which the French guidelines ask to be done. Other examinations, such as an MRI, a magnetic resonance imaging scan that shows the brain and the inner ear, are requested depending on what the examination and the audiometry show, particularly when the tinnitus is on one side only or pulsatile. Conversely, for tinnitus heard in the same way on both sides, which does not beat in time with the heart and comes with no other sign, the British and French guidelines advise against imaging: it would teach nothing useful.

Once, and properly

Wanting to be sure is legitimate. The trap comes afterwards, when you have another examination every time the sound varies, or change ENT specialist every six months. These checks bring relief for a few days, then the doubt comes back, a little stronger. A change in the nature of the sound, such as a sound that starts to beat, a change of side or hearing that drops, is something to show the doctor. A variation in your usual sound, after a noisy evening or a cold, is something to get through with the plan in section 17. If the fear of a serious illness spreads to other sensations in your body, The fear of being ill: health anxiety explains how to get out of this circle.

Finally, tell every doctor and your pharmacist about your tinnitus before any new treatment, as the Assurance Maladie recommends: some medicines are toxic to the ear.

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