MS (Multiple Sclerosis) and Tinnitus

Hi Dr Nagler,

Thank you for taking time to help with the forum questions. I was diagnosed with MS 15 years ago. At that time I also had what they assumed was a relapse that caused hyperacusis. Orignally bilateral it is now right ear only and I manage it, rarely needing earplugs. Certain noises will always be an issue for me.

Along with that I've had tinnitus off/on but it's never been unbearable or loud enough to hear all the time. Recently my right ear has become quite loud. My regular GP has no idea what to do, and my neuro says it isn't MS (to be fair, she is not a specialist and I'm not in a good area for medical care or MS expertise). I live in Mississippi (southern) and can't find any specialists within a few hours range. I did called an audiologist who is listed on the ATA but she doesn't work with tinnitus unless it relates to hearing loss. I am setting up an appointment with my ENT but suspect he won't find anything.

Of the various treatments (TRT, sound therapy, supplements. medication etc) I'm wondering which direction you would consider given that I have MS so it's likely nerve damage causing it. I would appreciate any thoughts you have. I truly wish I was closer to a center that worked with tinnitus so I could see experts. My previous audiologist in CT was excellent, she worked with Dr Natan Baumann who I know has been quite involved in research. I did try to reach out to her by email but have not had a response.

Thank you in advance for your thoughts!

Barri

 

And thank you, Barri, for your interesting question.

I tend to look at this sort of thing from a very pragmatic standpoint. To you, the question of the possible relationship between your tinnitus and your MS is an important one. I totally get that. But strictly from a pragmatic standpoint, it is not. And here's why. Either your tinnitus is or is not related to your MS. If it is, there is no known MS treatment that will predictably ablate or diminish your tinnitus to any appreciable degree. And if it is not, there is no known MS treatment that will predictably ablate or diminish your tinnitus to any appreciable degree. So again strictly from a pragmatic standpoint, there's no difference. That being the case, I would look at your tinnitus and your MS as two totally independent entities.

Regarding your MS, I presume you are being regularly monitored by your GP or your neurologist.

Now, regarding your tinnitus ...

According to your post, you are about to see your ENT with a chief complaint of tinnitus. You say that likely he "won't find anything," but it's still a very important step. When an ENT sees a patient with tinnitus, he or she is looking at two things. First, is your tinnitus caused by any of the handful of causes of tinnitus that can be fixed and in-so-doing fix the tinnitus? And second, is your tinnitus caused by any of the very rare causes of tinnitus that represent a threat to health or life? The answer to the first question is likely going to be no - but on the chance that the cause of your tinnitus can actually be fixed and moreover that doing so will result in resolution of your tinnitus, we are obviously done here. Regarding the second question, your MS is certainly a significant medical problem, but using the reasoning in the above paragraph, we are taking your MS out of the equation. What other things will the ENT look for? Well, since your tinnitus is markedly asymmetrical, to be thorough he will likely want to order an MRI to rule out a benign tumor along your auditory nerve called an acoustic neuroma - but as I noted earlier, that sort of thing is quite rare. (By the way, if you have not already done so, you should also see your GP for a routine physical exam with lab work.)

OK, Your ENT has completed his evaluation, and (as is the case the vast majority of the time) you have learned that (1) whatever is causing your tinnitus it is not something that can be fixed and (2) it is not something previously undiagnosed that is a threat to your health or life. Given that this is the case, now your tinnitus is - for lack of a better term - a nuisance. It can be an INCREDIBLY HUGE NUISANCE or it can be a tiny little nuisance or it can be anything in between, but what you do about it from this point on depends on how much of a nuisance it is rather than the fact that it is present. Yes, you can have very loud tinnitus that is not a nuisance, you can have very soft tinnitus that turns your life upside down, you can have every imaginable combination and permutation - but no matter what the situation, your decision regarding whether or not to do anything further should be dictated only by how much of a nuisance it is.

Now here there are numerous options. I'll tell you how I would start. First, I would consider doing nothing. Even if it is very bothersome, you might just give it some time. The tinnitus in your right ear only recently got louder; there is a good chance that it will settle back down on its own. And even if it does not settle back down, there is a good chance that over time it will begin to bother you less and less (i.e., become less of a nuisance) through a natural process called "habituation."

One simple thing you might consider would be tinnitus masking to see if you can override your internal tinnitus sound with a pleasant external sound. Masking has recently gotten a "bum rap" because some feel that it interferes with habituation. But whether or not that is indeed the case, if your tinnitus is bothersome and masking provides you with satisfactory relief, then what do you care? All you want if your tinnitus cannot be cured is for it to be less bothersome!

Here are two other things I would consider trying early on if your tinnitus is bothering you and you want to "do something." Since as noted earlier habituation is a natural process, it should proceed on its own unless there are significant barriers along the way. So you might work on identifying your own barriers to habituation and do your best to reduce or eliminate them. I wrote a piece about just that sort of thing a while back. (See: https://www.tinnitustalk.com/threads/overcoming-obstacles-to-habituation.6886/) You might also try some self cognitive behavioral therapy as described in my "Letter to a Tinnitus Sufferer" that I have attached to the bottom of this post.

You asked about supplements, but I am unaware of any controlled studies showing that supplements are of any value in tinnitus. Moreover the supplement industry is not subject to FDA regulations, so regardless of what they tell you, you have no assurance that what is on the label is actually in the bottle. And then there is the issue of impurities. So I would stay away from vitamins and supplements unless you have a clearly documented deficiency. And while on the subject I would stay away from ginkgo and similar preparations. In my opinion it's like throwing your money down the drain.

You also asked about medications. Unfortunately, there are no medications I am aware of that will predictably ablate or diminish tinnitus. There are lots of things people "try," but nothing has been shown to be effective in properly conducted studies. Medications for co-morbid conditions like anxiety or depression may be considered if the situation truly demands, but should only be prescribed by a physician very familiar with their use since they can represent a two-edged sword in tinnitus.

Finally you asked about TRT. In my opinion TRT, NTT, TAT, PTM, and indeed all the alphabet soup of tinnitus may be considered in select cases - but for you at this stage of the game those approaches are far on down the line. Hopefully your condition will become less and less bothersome on its own. You mentioned Natan Bauman in your inquiry. If you contact him, he will likely suggest something he calls CHATT - more alphabet soup as I see it. Hold off. I presume that the Connecticut audiologist you saw was Janice Howard. If she does not respond to your e-mail, you might try to reach her in her office at 800-432-7481. I agree with you; she is excellent. And sometimes just hearing the caring voice of somebody you know who is knowledgeable can make a huge difference!

I hope you find this information to be helpful.

All the best -

stephen nagler