Tinnitus is the perception of noise in the absence of any corresponding sound source. Physicians and patients tend to immediately assume that this disorder is mainly localized at the level of the auditory system. In the case of idiopathic tinnitus, patients are told that there is no treatment and they just need to “learn to live with it.” The aim of this article is to show that tinnitus is secondary to an aberrant brain-ear circuitry affected by disorders such as mood, anxiety, and alcohol and substance abuse as well as executive dysfunction, migraine, sleep and stress. By treating these comorbidities, tinnitus tends to improve.
A 55-year old man (MR) presents with bilateral tinnitus and high-frequency sensorineural hearing loss. MR has a complex developmental history including global developmental delay, traumatic brain injury at the age of 5, and dyslexia diagnosed at age 16. MR works part-time as a train operator and is exposed to high levels of acoustic trauma. His brain MRI scan reveals an incidental finding of volume loss within the bilateral parietal lobes. He denies any significant decline in cognitive functioning. However, in the context of a language-based learning disability, he continues to struggle with several aspects of language, including problems with articulation, reading, writing, and spelling, consistent with his baseline.
MR reports no difficulty carrying out his job responsibilities and is fully independent for all activities of daily living. His mental status is consistent with expectations for an individual with a language-based learning disability, including deficits across several aspects of language. He also exhibits select weakness in aspects of the executive domain that overlap heavily with language functions, including sequencing, word generation, and retrieval of unstructured verbal information.
The causes of his difficulties, although likely neurodevelopmental, were exacerbated by additional salient factors, such as tinnitus that in turn is directly related to and worsening a lack of restorative sleep due to sleep apnea and a split shift work schedule, as well as a history of alcohol use. The goal of the evaluation and management of this patient was to treat his comorbid conditions, decreasing his perception of tinnitus. It was recommended that he use ear protection, wear sound cancellation devices, and taper off alcohol. He receives mindfulness training and cognitive behavioral therapy for dyslexia and attentional difficulties. A low dose of sertraline is started for anxiety and melatonin and continuous positive airway pressure (CPAP) for sleep regulation.
Dr Chemali is Director, Neuropsychiatry Clinics; Director, Behavioral Neurology-Neuropsychiatry Fellowship; Director, Global Implementation Program in Neuropsychiatry, Behavioral and Social Sciences; Associate Professor, Harvard Medical School, Massachusetts General Hospital, Boston, MA. Dr Nehme is Psychiatry Fellow, Consult-Liaison Psychiatry, Cambridge Health Alliance, Cambridge, MA. The authors report no conflicts of interest concerning the subject matter of this article.
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