Ann Otol.

Vol 62, 73-83 (1953) single copy for personal use only
VII

TINNITUS AURIUM IN NORMALLY HEARING PERSONS

MORRIS F. HELLER, M.D.

AND

MOE BERGMAN, Ed.D.

New YORK, N. Y.

As considered here, tinnitus aurium is a medical term describing

sounds of physiological or pathological origin, which may or may not always
be perceived in consciousness.

Kerrison enumerated five general groups of sounds: 1) obstructive, 2)

circulatory-vascular alterations, 3) labyrinthine-cochlear sounds, 4) neurotic -
instability of the auditory nerve, 5) cerebral sounds-involvement of the auditory
centers.

Fowler has divided tinnitus into two categories: 1) vibratory,

mechanical, exogenous-factual sounds within the body, and 2) non-vibratory,
biochemical endogenous-total absence of sound without the body.

Vibratory tinnitus is real sound of a physical source such as muscle

activity, or vascular alteration. Nonvibratory tinnitus is nonfactual sound: an
illusion of sound caused by an irritation of the auditory neural elements. The
points of origin may be anywhere from the tympanic promontory, along the
pathways to the cortex inclusive.

Atkinson also has divided tinnitus into two categories; extrinsic and
intrinsic, which appear to include the two types already mentioned. He
considers intrinsic tinnitus as an auditory paresthesia, a paresthesia of the
auditory nerve, of vascular origin and to be so treated.

From the Audiology Clinic, New York Regional Office, Veterans Administration.
Reviewed in the Veterans Administration and published with the approval of
the Chief Medical Director. The statements and conclusions submitted by the authors
are the result of their own study and do not necessarily reflect the Opinion or policy of
the Veterans Administration.

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74 HELLER-BERGMAN

Wegel recorded: "Tinnitus is a pathologic symptom . . . I am under the

impression that the presence of tinnitus.....generally indicates an active or
progressive lesion and that the cessation of it......is an indication that the
degeneration or atrophy of tissue has been arrested." But then he continued,
"people entirely without tinnitus are extremely rare, if such cases exist at all."

In 1941 Fowler wrote, "It has been found that the presence of tinnitus
is always associated with more or less deafness." In 1944 he altered this view
writing: "It may be, and often is, present in some form in persons who have no
apparent aural or other disease."

Kopetzky stated that tinnitus is a symptom signifying disturbed

sensation, a symptom of aural disease. He continued that tinnitus may appear
before symptomatic deafness.

Lempert suggested on the basis of his observations associated with

middle ear surgery that "tonus impulses originating in the sensory fibers of the
trigeminus, the sympathetic, or glossopharyngeal may enter the tympanic
plexus, but normally [are] not heard." In selected cases, he recommended
tympanosympathectomy.

Fowler further described tinnitus, of which the patient is consciously

aware, as "audible," and tinnitus not ordinarily impinging on the consciousness
as "subaudible." He found tinnitus in 86% of 2000 patients. He indicated that
subaudible tinnitus must be sought for by examination. He also determined
that the loudness of tinnitus was within 5 dB to 10 dB above threshold.
Tinnitus may be measured for frequency, loudness and quality. It may be a
single frequency or multiple frequencies and difficulties may be encountered in
its identification. The exact loudness may also be difficult to determine.
Fowler described techniques for making such measurements.

Audible tinnitus at times appears to interfere with hearing. Patients

often state that were it not for their head noises their hearing would be better,
and that when the head noises are louder the deafness is more severe. It does
not necessarily follow that the tinnitus is always responsible for this. Possibly
with increased deafness the head noises are less easily masked and so appear
louder subjectively. Fowler has described the busy line effect, whereby
receptor cells and neural pathways already preoccupied by an intrinsic stimulus
are not receptive to an external stimulus.

TINNITUS AURIUM 75

Ann Otol, vol 62, p73 - 83

Some conditions in which audible tinnitus have been observed are:

1) Otosclerosis.
2) Meniere's disease.
3) Lermoyez's Syndrome.
4) Pressure or neuritis of the auditory apparatus; brain tumor, eighth
nerve tumor, aneurysm.
5) Otitis media; acute, chronic, suppurative, nonsuppurative.
6) Otitis interna; acute, chronic.
7) Deafness, conductive, perceptive, mixed.
8) Normal hearing with discrete frequency defect.
9) Nasopharyngeal Diseases: Eustachian salpingitis, sinusitis, pharyngitis,
mucosal hypettrophy, hyperplasia, tumor, infection of lymphoid tissue.
10) Dental pathology: malocclusion, malfunction of temporomandibular
joint, impaction, infection.
11) Myositis; cervical, pharyngeal, tympanic.
12) Intoxication-drug; quinine, alcohol, salicylates, caffeine, tobacco,
antiluetic agents, streptomycin, thyroid gland extract.
13) Intoxication-systemic; gastrointestinal, foci of infection.
14) Allergy.
15) Cardiovascular pathology; blood dyscrasias, anemias, hypertension,
hypotension, vascular anomalies, arteriosclerosis, cardiac diseases.
16) Metabolic dysfunction; thyroidism, water balance disturb-
ances.
17) Trauma, acoustic, acute.
18) Trauma, acoustic, chronic.
19) Systemic fatigue.
20) Momentary tinnitus, spontaneous (idiopathic).
21) Impacted cerumen.
22) Cervical constriction.
23) Psychoses.
24) Otic herpes.
25) Bell's palsy.
26) Foreign body trauma to the ear.
27) Head injury, concussion, postconcussion syndrome.
28) Myringitis.
29) Hemorrhage, tympanum or myringa.

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76 HELLER-BERGMAN

The ideal approach to the treatment of audible tinnitus would seem to

be a therapeutic assault on the related etiological factors. At present there is no
sure way to accomplish this. Frequently the etiological agent no longer exists,
however the tinnitus persists. Some of the contemporary measures are:

Medical:
1) Medication; bromides, barbiturates, other sedatives, potassium
Iodide, vitamins, benzyl cinnamate, antiallergic drugs, histamine
therapy, intravenous procaine.
2) Local therapy to disease processes.
3) Elimination of drugs and intoxicants.
4) Elimination of foci of infection.
5) Correction of faulty gastrointestinal function.
6) Correction of metabolic diseases
7) Control of diseases of the vascular system and blood forming organs.
8) Dietary control of fluids, salt , and water balance.
9) Dental rehabilitation.
10) Intratympanic medication.
11) Therapy directed to correct nose and throat pathology, including
roentgen and radium therapy.
12) Politzerization, inflation, message.
13) Removal of cerumen.
14) Psychotherapy.
15) Hearing aid.
16) Electrical therapies, i.e., ultra violet, quartz lamps, galvanism.

Surgical:
1) Otologic
ossiculectomy
mastoidectomy
tympano-sympathectomy
fenestration of the labyrinth
obliteration of the saccus endolymphaticus.
2) Rhinologic.
3) Spinal tap.
4) Cranial surgery for tumor, vascular anomalies section of eight cranial
nerve.
5) Splanchnectomy and similar technics for alleviation of hypertension.

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 TINNITUS AURIUM 77

TABLE I.

REPORT OF SOUND EXPERIENCED BY 80 NORMALLY

HEARING SUBJECTS, IN A SOUND-PROOF ROOM AND
INCIDENCE OF TINNITUS IN 100 PATIENTS WITH DEAFNESS.

NUMBER OF PER CENT OF NUMBER OF PER CENT OF

HARD OF HARD OF NORMAL NORMAL
HEARING HEARING SUBJECTS SUBJECTS
PATIENTS PATIENTS

Sound heard 73 73 75 93.75

(tinnitus)

No Sound (no 27 27 5 6.25

tinnitus)

100 100 80 100

Fowler has emphasized the value of explaining to the patient the nature
of his tinnitus: that it is a symptom and not a disease, and that despite its
annoying and distressing presence, it does not imply a threat to him. An
understanding of the symptom and a recognition of its relative significance in
some instances may reconcile the sufferer to his burden.

From the foregoing it appears that both audible and subaudible tinnitus
have been described as a symptom associated with impaired hearing, or with
systemic diseases, and yet they have been observed in the presence of these
same factors, in persons considered healthy. The implication has been made
that tinnitus may be an early symptom preceding impaired hearing.

It has been noted that healthy persons with normal hearing have
reported tinnitus when the ambient noise level is low. The opportunity
presented itself to us to determine the incidence and character of subaudible
tinnitus by exposing normally hearing persons to an environment in which the
ambient noise level was considerably less than in ordinary living conditions.

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78 HELLER-BERGMAN

Two separate groups of persons were studied: normally hearing,

healthy, adults who experienced tinnitus rarely or not at all, and hard of hearing
adults, veterans of military service.

A sound-proof chamber was used. The ambient noise level was

probably between 15 dB and 18 dB (re: 0.0002 dynes per cm2). Exact
measurements could not be made due to the limitations of the sound level
meters at hand.

In a previous study we investigated the influence of tinnitus of the

doughnut type of receiver worn over both ears. Normlly hearing persons were
placed in the sound proof chamber and the tinnitus experienced with and
without receivers was compared. They were unable to determine any
difference and we concluded that the ambient noise of this chamber was not an
intruding factor.

Eighty adults, apparently normally hearing males and females, from 18

to 60 years of age were included. The selection was predicated on a denial of
past or present aural disease. They reported no deafness or tinnitus, and
considered themselves in good health. They were representative of a sedentary
population, including physicians, dentists, teachers, students, administrators,
clerks and housewives.

Upon entering the sound-proof room the subjects are instructed to make notes
of sounds which might be detected. No suggestion was given that the source
of sound might be within the subject himself. The time of observation was
usually limited to five minutes or less. Written details of their observations
were obtained.

One hundred hard-of-hearing patients, consecutively admitted to the

Clinic, composed a control group. Their histories, otorhinological
examinations and pure-tone audiograms were obtained. A diagnosis of
deafness, its type, and the presence or absence of tinnitus and its description
were recorded. See Table I.

A total of 39 different sounds were described by both groups. Of

these, 27 sounds were named in the impaired group, and 23 sounds were
n~med in the normal group. The sounds described as "buzz," "hum" and "ring"
were enumerated most frequently in both groups, comprising at least 50% of
the responses of each group. Eleven sounds recorded 's were identified in
both groups.

Ann Otol, vol 62, p73 - 83

 TINNITUS AURIUM 79
TABLE II
DIFFEREN T SOUNDS DESCRIBED BY BOTH GROUPS.

NUMBER OF PATIENTS WITH NUMBER OF

IMPAIRED HEARING NORMAL SUBJECTS

1 Bell 3 0
2 Buzz 12 13
3 Drone 1 0
4 Hiss 3 3
5 Hum 10 16
6 Ring 32 11
7 Steam 4 0
8 Roar 5 2
9 Whistle 9 3
10 Click 3 0
11 Tap 1 1
12 Falling water 3 4
13 Heart beat 2 0
14 Truck 1 0
15 Rushing 1 0
16 Airplane 2 1
17 Singing 1 0
18 Insects, crickets 2 6
19 Fog horn 2 0
20 Musical Sounds 1 0
21 Machinery 1 0
22 Rumble 1 0
23 Hollow sound 1 0
24 Squeal 1 0
25 Echo 1 0
26 Surf 0 1
27 Pressure 0 2
28 Vibration 0 1
29 Squeak 0 3
30 Throbing 0 1
31 Rustling leaves 0 1
32 Stuffiness 0 1
33 Tunnels 0 2
34 Pulse 0 7
35 Rubbing Cloth 0 1
36 Watch tick 0 2
37 Thumping pulsation 0 4
38 Zooming-whizzing 1 2
39 Sea shell 2 0

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80 HELLER- BERGMAN

TABLE III.

NUMBER OF SOUNDS REPORTED BY EACH 75 NORMAL

SUBJECTS WITH SUBAUDIBLE TINNITUS AND BY EACH OF 75
HARD OF HEARING PATIENTS WITH AUDIBLE TINNITUS.

NUMBER OF PER CENT OF

NUMBER OF PER CENT NORMAL NORMAL
PATIENTS OF PATIENTS SUBJECTS SUBJECTS

1 sound 48 64 54 72
2 sounds 20 27 15 20
3 sounds 6 8 3 4
4 sounds 1 1 2 2
5 sounds 0 0 1 0.75

The number of different sounds described by the normally hearing

group and by the patients with deafness, in terms of percentage, are in
general agreement. While a majority in both groups reported hearing only
one sound, a substantial number of persons in each group distinguished two
or more sounds.

TABLE IV.
DIAGNOSIS OF DEAFNESS AND INCIDENCE OF TINNITUS
IN 100 PATIENTS.

T INNITUS
PER CENT OF
NUMBER OF 100
DIAGNOSIS PATIENTS PATIENTS

Conductive deafness without otosclerosis

Tinnitus constant 3

Tinnitus inconstant 10 13

No tinnitus 7

Total 20

Otosclerosis (1 case mixed deafness, 7 cases conductive deafness)

Tinnitus constant 4

Tinnitus inconstant 4 8

No tinnitus 0

Total 8

Ann Otol, vol 62, p73 - 83

 TINNITUS AURIUM 81

TINNITUS
PER CENT OF
NUMBER OF 100
DIAGNOSIS PATIENTS PATIENTS

Perceptive deafness

Tinnitus constant 21

Tinnitus inconstant 18 39

No tinnitus 16

Total 55

Mixed deafness

Tinnitus constant 2 7

Tinnitus inconstant 5

No tinnitus 1

Total 8

Mixed deafness of one ear, perceptive deafness of other

Tinnitus constant 3

Tinnitus inconstant 1 4

No tinnitus 1

Total 5

Diagnosis not available

Tinnitus constant 2

Tinnitus inconstant 0 2

No tinnitus 2

Total 4

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82 HELLER - BERGMAN

Of this group, 73% of the patients experienced tinnitus, 27% did not. All
the eight patients in this series with deafness due to otosclerosis had tinnitus.
Of a larger group of otosclerotics in our Clinic, 83 patients, 85% have
tinnitus and 15% are free of it.

COMMENT

Seventy-three per cent of 100 unselected patients with deafness described

tinnitus as a symptom. Twenty-seven per cent experienced
no tinnitus.82

Audible tinnitus was experienced by 94% of the 80 apparently

normally hearing adults when placed in a testing situation having an ambient
noise level no greater than 18 decibels, re: 0.0002 dynes per cm2. It
appears that tinnitus is present constantly but is masked by the ambient
noise which floods our environment. This ambient noise level for ordinary
quiet living conditions usually exceeds 35 dB, and apparently is of sufficient
intensity to mask physiological tinnitus, which remains subaudible.

It would appear, then, that tinnitus will not be eliminated by any

treatment but at best can only become subaudible. This, of course, would
be welcomed both by the patient and the physician.

CONCLUSION

The kinds of head noises described by patients with impaired

hearing as a symptom associated with their deafness and those sounds
described by normally hearing healthy adults, elicited while in a sound-proof
room, appear to be similar.

These head noises seem to occur in about the same order of

frequency.

Tinnitus, which is subaudible, may be a physiological phenomenon

in an intact auditory apparatus.

115 E. 61st ST.

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 TINNITUS AURIUM 83

REFERENCES
1. Atkinson, M., Tinnitus Aurium, Some Considerations
Concerning Its Origin and Treatment, Arch. Otolaryng. 45:68 (Jan.) 1947.
2. Bergman, M., and H~ler, M. F.: Tinnitus in Persons with
Notsnal Hearing (unpublished report).

3. Fowler, E. P., Jr.: Hearing and Deafness, Hallowell Davis, Ed.,

Murray Hill Books Inc., New York, 1947, p. 72.

4. Fowler, E. P.: Tinnitus Aurium in the Light of Recent Ressrch,

Annals of Otology, Rhinology and Laryngology 50:139 (Mar.) 1943.

5. Fowler, E. P.: The Control of Head Noises, the ir Illusion of

Loudness and Timbre, Arch. Otolaryng. 37:391 (Mar.) 1943.

6. Fowler, E. P.: Tinnitus in Normal and Disordered Ears, Arch.

Otolaryng. 39:498 (June) 1944.

7. Fowler, E. P.: Nonvibratory Tinnitus, Factors Underlying

Subaudible and Audible Irritations, The Transactions of the American
Laryngological, Rhinological and Otological Society, Inc., 1947.

8. Fowler, E. P.: Nonvibratory Tinnitus, Factors Underlying

Subaudible and Audible Tinnitus, Arch. Otolaryng. 47:29 (June) 1948.

9. Kerrison, P. D.: Diseases of the Ear, J. P. Lippincott Co.,

1930, p. 136.

10. Kopetzy, S. J.: Deafness, Tinnitus, and Vertigo, Thomas

Nelson and Son, 1948, p. 153.

11. Lempert, J.: Tympano-sympathectomy, a Surgical Technic for

the Relief of Tinnitus, Arch. Otolaryng. 43:199 (Mar.) 1946.

12. Wegel, R. L.: A Study of Tinnitus, Arch. Otolaryng. 14:158

(Aug.) 1931.

Ann Otol, vol 62, p73 - 83