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The aim of our study was to outline the prevalence of hyperlipidemia in patients who had high-frequency hearing loss and tinnitus due to noise exposure. Cochlear hair cells and neural and central auditory pathways are involved in the generation of subjective tinnitus [1]. Decrease in internal diameter of the vascular bed resulting from hyperlipidemia compromises the oxygen transportation capability of the blood to the cochlea, and chronic hypoxia is likely to occur by the reduction in oxygen supply of the inner ear, which in turn would lead to insufficient adjustment of the cochlear metabolism. This may result in the overproduction and accumulation of free radicals, which disturb the microcirculation of the cochlea and play an important role in ischemiainduced cochlear injury [7].
The reasons for the susceptibility to noise-induced hearing loss of patients who have been exposed to a noisy environment have been the subject of various studies. Previous data indicate that the cochlea and the central auditory system age faster and earlier in patients with hyperlipidemia and that the risk of noise-induced hearing loss is much higher [5,11].
The aim of this study was to outline the prevalence of hyperlipidemia in patients who had high-frequency hearing loss and tinnitus due to chronic noise exposure and to evaluate the risk of developing sensory hearing loss in those patients as compared to risk in control subjects.
We conducted this prospective study in 120 consecutive patients with complaints of chronic subjective tinnitus of varying degrees of severity and hearing loss due to noise exposure. The patients were examined otoscopically and were reviewed by an audiometric test battery including puretone audiometer (AC-30, IAC, Copenhagen, Denmark), stapes reflex, and tympanometry (Amplaid 775, Milan, Italy).
Antilipid treatment with statin derivatives was planned once-daily oral dosing for up to 1-2 years (minimum, 12.4 months).
We then compared tinnitus scores and hearing levels in patients with no response to antihyperlipidemic therapy and in patients who had a normal blood cholesterol level after the treatment. The duration of tinnitus in patients with noise exposure varied from 2 months to 12 years (mean, 5.5 years). Of 22 patients in the unresponsive group, 6 had high cholesterol and triglyceride, 9 had high triglyceride, and 7 had high cholesterol only before the antilipidemic therapy. Of 20 patients in the responsive group, 7 had high cholesterol or triglyceride, 10 had high triglyceride, and 3 had high cholesterol only before the antilipidemic therapy. The difference between the pitch-match frequencies before and after therapy was not significant.
Epidemiological investigations emphasizing the relationship between hearing loss and the risk factors for coronary artery disease date back to the 1960s [18].
Spencer [19] found that 42.3% of 300 patients with different symptoms of inner-ear pathology had clearly defined hyperlipoproteinemia. The effect of hyperlipidemia on auditory perception has been studied clinically and experimentally.
The exact pathological mechanism for the hyperlipidemia-induced hearing loss remains obscure. In his study of 64 rats, Pillsbury [37] exposed half to loud noise and fed half of each subgroup a fat diet and found elevated auditory brainstem response thresholds in the hyperlipidemic animals. Studies investigating the restorative possibility of a low-cholesterol diet and antihyperlipidemic therapy on hearing loss and tinnitus are very few.
LDL apheresis has been reported to be much more effective as compared with standard prednisolone, dextran, and pentoxifylline therapy in patients with sudden hearing loss [9].
In our study, changes in tinnitus scores before and after therapy in the responsive group were significant as compared with those in the unresponsive group. Tinnitus and hearing loss are frequently encountered after an acute acoustic and blast trauma or chronic noise exposure. Tinnitus is a condition in which noise comes from inside the ear rather than the environment. NB: We use cookies to help personalise your web experience and comply with Irish healthcare law. This site contains information, news and advice for healthcare professionals.You have informed us that you are not a healthcare professional and therefore we are unable to provide you with access to this site. Tinnitus is defined as perception of auditory sensation in the absence of any external stimulation. Tinnitus can occur in one or both ears, range from very low to very high pitch, and may be continuous or intermittent.
The causes of objective tinnitus are vascular (vascular tumours; arteriovenous malformation) and neurologic (idiopathic stapedial muscle spasm, patulous Eustachian tube). A normal cochlea emits sounds all the time, but they are not heard because outside noise masks them. A full medical and audiological assessment should be done in order to provide the best management of tinnitus. It is very important to conduct an audiological evaluation on the patient with tinnitus and this should be carried out by a qualified audiologist.
Since tinnitus can be associated with a number of conditions that may occur at any level of the auditory system, the audiological evaluation can demonstrate information regarding the cause and options for treatment. It should begin by taking a thorough case history, which would include onset, duration, laterality, severity, pattern and associated symptoms. The acoustic stapedial reflexes and reflex decay and ABR will distinguish between cochlear and retro-cochlear auditory dysfunction. Some patients with tinnitus will have dyssynchrony in all or part of the ABR waveform (Shulman, 1997). There are other audiological measurements for tinnitus that provide information about its pitch and loudness. There are various different treatment options available for tinnitus, with varying degrees of statistical reliability and satisfaction. However, unfortunately, in many cases the cause of tinnitus cannot be identified and hence, it becomes difficult to treat medically or surgically.
The electrode array inserted into the cochlea sends an electrical signal to the auditory cortex and it is theorised that these frequency signals of the electrical stimulation mask the tinnitus. However, these implants are advised only to certain group of patients, as electrode implantation destroys whatever healthy hair cells were left inside the cochlea. There are various drugs or medications used to relieve tinnitus, but there are none that have been designed specifically to treat the condition. However, the studies show that the drug therapy reduces associated symptoms of tinnitus such as annoyance, frustration and depression.
Biofeedback is a relaxation technique that is designed to teach the patient to control certain autonomic body functions, such as pulse, muscle tension and skin temperature.
By managing the patient’s emotional reaction to the tinnitus, they are helped to learn coping strategies that often help him or her to deal with it. Sound therapy includes wearing hearing aid-like devices and also non-wearable devices like table-top sound machines.
This is the reason it becomes highly important to discuss each individual’s tinnitus situation with a qualified health professional.
BSH, MD(AM), MSC(ASc), MISA is an Audiological Scientist at the Audiology Clinic, 40 Lower Leeson Street, Dublin 2.

Low-Cholesterol Diet and Antilipid Therapy in Managing Tinnitus and Hearing Loss in Patients with Noise-Induced Hearing Loss and Hyperlipidemia.
We investigated the role of a low-cholesterol diet and antihyperlipidemic therapy to alleviate the severity of tinnitus and possibly promote hearing gain after therapy in patients with acoustic trauma. Analysis of the epidemiological data indicates that exposure to noise is widespread and is one of the most common causes of tinnitus, which leads to various somatic and psychological disorders and interferes with the quality of life [2]. Auditory perception in such cochleas is very sensitive to reduction of the oxygenation in the inner ear [6].
Platelet aggregation and blood viscosity due to high lipid levels will intensify inner-ear damage owing to slowing of microcirculation and will contribute to the development of both progressive and sudden hearing loss [8,9]. Gratton and Wright [10] demonstrated the accumulation of lipid in the stria vascularis and outer hair cells in chinchillas after experimentally induced hypercholesterolemia, which might intensify the detrimental effect of ototoxic drugs or noise. We instituted a low-cholesterol diet and antihyperlipidemic therapy to investigate whether any benefit accrued in terms of hearing gain and tinnitus relief.
The project was approved by the local medical research ethical committee, and we obtained informed consent from each patient. Audiometric tests included air- and boneconduction thresholds for pure tones of 125-8,000 Hz, tests of speech reception and speech discrimination, contralateral and ipsilateral reflex measurements, and tympanometry.
Measurement of loudness of the tinnitus was based on subjective assessment by the patients.
Daily dosage ranged from 10 to 40 mg for simvastatin (Zocor) and from 10 to 80 mg for atorvastatin calcium (Lipitor). Average ages of patients in the unresponsive and the responsive groups were 39 and 42 years, respectively. Wilcoxon and Mann-Whitney U tests were used to compare the pretreatment data with the posttreatment results and to compare the results of responders and nonresponders.
None of these patients demonstrated any drop to normal ranges in cholesterol or triglyceride values after the treatment. When those patients were asked to qualify the severity of their tinnitus, seven rated their tinnitus as the same (35%), two rated it as increased (10%), seven rated it as decreased (35%), and four had no tinnitus (20%). The correlation between serum lipids and auditory dysfunction has been investigated before, and it has been reported that sensorineural hearing loss is more prominent in those with high levels of cholesterol, triglyceride, and lowLDL and in patients with low HDL concentration [18-23]. Increased blood viscosity and atherosclerosis of the cochlear vessels reduce the blood perfusion of the cochlea and promote hearing impairment [6,8,19,20,23,24].
When patients were required to qualify the severity of their tinnitus, 35% of the patients in the responsive group rated their tinnitus as decreased, and 20% of patients reported no tinnitus. Even though other factors making the patients susceptible to noise-induced hearing loss should be considered, on the basis of present results it can be concluded that the incidence of hyperlipidemia is high among patients with noise-induced hearing loss and that significant improvement in lowered intensity of tinnitus and in average hearing thresholds at higher frequencies can be achieved after lowering patients' serum lipid level [43]. The auditory sensation could be ringing, for example, or other head noises that are not produced by an external source. One classification system outlines vibratory and non-vibratory types, while another group classifies subjective and objective types of tinnitus. It can arise in the outer ear, the middle ear, the inner ear or any abnormality in the auditory cortex. Since there are many factors that can cause tinnitus, it is difficult to pinpoint the pathophysiology behind it. If one goes into a sound-proof room, where normal external noise is diminished, then these sounds emitted from the ear can be heard. Audiological assessment includes basic audiometric testing, speech audiometry, tympanogram, acoustic reflexes and decays, oto-acoustic emissions (OAEs) and auditory brainstem response (ABR). These cases can then be pursued by an audiologist for treatment of tinnitus through different therapeutic techniques. However, this author is not aware of any studies that show extraordinary improvement in tinnitus. The drugs that have been studied to relieve tinnitus include anti-depressants, anti-anxiety drugs and anti-convulsants. It has been reported that tinnitus is worse in patients who experience great amounts of stress and depression. It is often seen that the patient with severe tinnitus is described as having an additional emotional problem such as depression or anxiety. The aim of cognitive therapy is not to treat tinnitus, but to help the patient to cope better with the problem.
These electronic devices produce an external sound that is designed to override patient’s tinnitus. However, it is important to note that these options do not work for everyone; neither do they work at the same degree for each individual patient. Fortytwo hyperlipidemic patients with subjective tinnitus and hearing loss due to noise exposure were enrolled for the study.
It has been reported that high-plasma cholesterol and triglyceride levels are one of the major risk factors for the development of occupational hearing loss [3-5].
It seems that noise and other metabolic disturbances have a synergistic effect on the development of tinnitus and hearing loss [5]. A diagnosis of acoustic trauma was verified by an ear, nose, and throat physician according to a clinical history of chronic noise exposure in patients who sought medical help for complaints of tinnitus and high-frequency hearing loss.
Patients who had chronic otitis media or middle-ear effusion, those with an abnormal ear drum (perforation, retraction, etc.) or auditory canal, and those who had abnormal tympanometry (other than type A) were excluded. In the study, from 120 patients we chose 42 male patients (35%) with elevated cholesterol or triglyceride or both (age range, 19-60 years; mean age, 45 years). The patients were separated into two groups: the "unresponsive" group, made up of 22 patients who had no response to either of the therapies and still had hyperlipidemia, and the "responsive" group, consisting of 20 patients who had lower cholesterol or triglyceride levels. The results of the blood lipid profiles were withheld from the individual to prevent a placebo effect with the tinnitus therapy. The significance of the difference in patient's comments on their tinnitus after the treatment ("same," "decreased," "increased," and "disappeared") was analyzed using McNemar and chi-square tests. However, the incidence of hyperlipidemia among a selected group of patients with neurosensory hearing loss varies. They selected a group of subjects aged between 20 and 50 years and compared auditory thresholds at high frequencies and serum lipid levels. Noise and metabolic disturbances have a synergistic effect on the development of tinnitus and hearing loss. Effects of experimental cochlear thrombosis on oxygenation: Auditory function of the inner ear.
Direct effects of intraperilymphatic reactive oxygen species generation on cochlear function. Clinical utility of LDL-apheresis in the treatment of sudden hearing loss: A prospective, randomized study. The relation of hearing in the elderly to the presence of cardiovascular disease and cardiovascular risk factors.

Appearance of free radicals in the guinea pig inner ear after noise-induced acoustic trauma. Progressive sensorineural hearing loss, subjective tinnitus and vertigo caused by elevated blood lipids.
A comparison of auditory brainstem evoked potentials in hyperlipidemic and normolipidemic subjects. Exploration of the early auditory effects of hyperlipoproteinemia and diabetes mellitus using otoacoustic emissions. Hypertension, hyperlipoproteinemia, chronic noise exposure: Is there a synergism in cochlear pathology? Effects of noise exposure and hypercholesterolemia on auditory function in the New Zealand white rabbit. Hearing improvement after therapy for hyperlipidemia in patients with chronic-phase sudden deafness. A prospective case-controlled study of 197 men, 50-60 years old, selected at random from a population at risk from hyperlipidemia to examine the relationship between hyperlipidemia and sensorineural hearing loss. This disorder is not uncommon in the paediatric population, however children generally do not complain instinctively of having tinnitus.
The most common causes for subjective tinnitus are otologic disorders or some conditions that cause hearing loss. The possible causes for resulting objective tinnitus are blood flowing through the jugular vein (Vernon, 1998) or middle-ear muscle spasm (Schleuning, 1998). Medical examination should be carried out, with special attention given to identify factors associated with tinnitus such as disease involving the auditory system, noise exposure, drug intake, mental or emotional stress, allergies, blood pressure et cetera.
Each of these tests can possibly help the audiologist to identify the nature and cause of tinnitus and may indicate a site of lesion. These measurements are pitch matching, loudness matching, minimal masking level and residual inhibition.
If the tinnitus is symptom of a treatable medical condition, then treating the condition will eliminate tinnitus. Some studies show that half of tinnitus sufferers were relieved from tinnitus after the cochlear implant. Cognitive therapy is a psychotherapeutic approach that aims to treat the emotional reaction to tinnitus by changing the patient’s thought process. All patients who were required to complete the questionnaire and who were subjected to clinical examination were military personnel. A pure-tone signal was presented continuously at 50-Hz intervals at between 10- and 20-dB levels.
We placed all these patients on a low-cholesterol diet or antihyperlipidemic therapy (Table 2). When patients were asked to qualify the severity of their tinnitus, 10 rated their tinnitus as the same (47%), 9 rated it as increased (42%), 2 rated it as decreased (9%), and 1 patient had no tinnitus (2%). Lowry and Isaacson [12] reported 20% hyperlipoproteinemia among 100 patients with bilateral hearing loss. Lipidosis of the inner ear has been postulated by Nguyen and Brownell [33] as an alternate mechanism. Insufficient perfusion of the cochlea due to increased blood viscosity and microthrombosis related to hyperlipidemia has been claimed to cause susceptibility to noiseinduced hearing loss [35]. We found in our study that the incidence of hyperlipidemia among patients with noiseinduced tinnitus and hearing loss was 35%. Characteristics of tinnitus and etiology of associated hearing loss: A study of 123 patients.
The exact mechanism for this tinnitus is still not clearly understood; however many possible causes have been proposed. This causes different neurons to get activated, which activate the auditory cortex and give the perception of sound. We excluded on the basis of their response to the questionnaire or clinical examination subjects who had a history of familial hearing loss, head trauma, collagen disease, neurological or hormonal disturbance, addiction to alcohol, or ototoxic drug therapy. The main criteria for response to the antihyperlipidemic therapy was defined as a return to normal cholesterol or triglyceride levels after therapy or at least a 40% drop from either of the initial blood cholesterol or triglyceride levels if the values were slightly above the normal limits.
The latter authors showed that the lateral wall of outer hair cells from guinea pig cochlea incorporates water-soluble cholesterol. Axelsson and Lindgren [34] matched 78 men at age 50 years with high serum cholesterol levels to 75 randomly selected 50-year-old men and found significant correlation between noise exposure and high cholesterol level. Although there are no over-the-counter therapies that relieve tinnitus, many people manage it by learning to control how they respond to it or by using hearing aids. Another possibility is that the hearing aid makes communication easier and thus reduces stress, which as a result may ease tinnitus. The difference between tinnitus scores in the unresponsive and responsive groups and the change in tinnitus scores before and after therapy in the responsive group were significant.
None of the patients had cerebrovascular disease, hypertension, electrolyte imbalance, cranial nerve deficit, or clinical signs of peripheral neuropathy. Then, the pitch-match frequency threshold of the tinnitus was measured as the tinnitus loudness match of the pure-tone stimulus presented with a 1-dB increase of tinnitus frequency. Morizono and Paparella [30], using cholesterolfed rabbits, showed increased auditory dysfunction with time at all frequencies. This uptake of cholesterol is accompanied by an increased stiffness of the cells, which may impair the cells' electromotile response. Enhancement of cochlear action potentials and auditory brainstem responses has been demonstrated after limited intake of cholesterol. However, patients were at the chronic phase, more than 1 month from the onset of the hearing loss. It seems that the order of destruction and the high-frequency nature of the auditory dysfunction are correlated not only with the frequency and severity of the noise exposure but with the presence of the secondary pathology, as the formation of vasoactive lipid peroxidation products after intense noise is similar to the condition seen in metabolic damage to the organ of Corti [7,14-17].
In a survey of 44 patients with cochlear-type hearing loss, Booth [26] found hyperlipidemia in 28% of the men and 10% of the women. These authors observed hearing improvement of more than 10 dB in 9 of the 12 patients after antihyperlipidemic therapy.
In this manner, preventive measures may provide restorative support to the injured cochlea. We required all patients to rate their tinnitus from 1 to 10, with 10 being loudest (Table 1).
Each level was defined by short explanations to simplify the patients' grading of their tinnitus.

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