Tinnitus: The Noise in My Ear!

Tinnitus is perception of an unformulated sound or noise, which does not exist, or a sound that is not normal. In some ways it is similar to vertigo, which is perception of motion that does not exist. It is different from auditory hallucination, which is perception of formulated sound that does not exist, like a musical note, a song, or a conversation. Patients may describe the noise as ringing, hissing, tinkling, whistling, pulsating, or just an unpleasant sound, in one or both ears. Tinnitus is not a disease; it is a symptom that may occur in a number of conditions.

 

How common is tinnitus?

Tinnitus is quite common, probably as common as migraine, but in most cases it is either not that severe or does not last long. About 5% of general population has it severe enough to seek a medical opinion, and about 1% is severely affected. It becomes a problem if it is severe or does not go away. In both cases it affects patient’s quality of life. It may cause anxiety, stress, insomnia, frustration, and depression.

 

What exactly causes tinnitus?

Tinnitus is associated with many ear and systemic conditions, but in most cases, its precise origin or mechanism is unknown. It is generally understood that the cause is either in the cochlear apparatus or the cochlear nerve. The malfunction is at microscopic level, and our technology is not sophisticated enough to provide that level of detail in a living person. MRI of brain may reveal some pathology that can cause tinnitus but in most cases of tinnitus no MRI finding in or around the cochlear system is identified.

 

Are their different types of tinnitus?

Tinnitus may be divided in the following different types:

 

Based upon its perception:

-Subjective: This is when a patient perceives a sound that is not there or not audible otherwise

-Objective: This is when a patient perceives a sound that exists and can otherwise be audible.

 

Based upon its side:

-Unilateral

-Bilateral

 

Based upon the type of noise:

 -Ringing, humming, buzzing or hissing

-Pulsatile tinnitus

-Typewriter tinnitus

-Fluttering tinnitus

 

What are different causes of tinnitus?

Exact cause of tinnitus can be difficult to figure out, and in many cases it is not. One way to understand this is to describe its association, i.e., conditions that are associated with tinnitus. Following is such a list:

 

Tinnitus associated with inner ear conditions:

-Meniere’s disease

-Otosclerosis

-Sudden hearing loss

-Loud noise exposure

-Superior canal dehiscence syndrome

-Autoimmune inner ear disease

 

Tinnitus associated with middle ear conditions:

-Otosclerosis

-Infection or inflammation

-Cholesteatoma

-Eustachian tube malfunction

 

Tinnitus associated with external ear condition:

-Ear wax

-Foreign body, i.e., an insect

 

Tinnitus associated with structures close to ear(s)

-Vestibular schwannoma

-AVM or an arterio-venous malformation

-Palatal myoclonus

-Idiopathic intracranial hypertension

-Glomus jugulare paragangioma

-TMJ syndrome

-Carotid stenosis

-Fibromuscular dysplasia

 

Tinnitus associated with systemic conditions. For example,

-Stress and anxiety

-Pregnancy

-Thyroid dysfunction

-Diabetes mellitus

-Hyperinsulinemia

-Hyper-viscosity syndrome

-Anemia

 

Tinnitus associated with environmental conditions. For example,

-Change in barometric pressure

-Exposure to loud noise

 

Tinnitus associated with drug exposure

 -Furosemide

-Ethyacrynic acid

-Aspirin or similar drugs

-Hydroxychloroquine

-Quinine

-Quinidine

-Methotrexate

-Cisplatin

-Gentamicin

-Azithromycin, clarithromycin

-ACE inhibitors

-Tinnitus of unknown cause

 

How is tinnitus evaluated?

The first consideration is to find its type, subjective or objective, its side, one-sided or bilateral, and the type of noise. Proper history with this information, and examination may help to figure out most likely cause. If needed, further testing is performed to find the underlying cause. Testing usually include an audiogram, imaging with CT or MRI (based upon the suspected cause), tympanometry, or rarely an angiogram. Most patients do not require more than examination and audiogram.

 

How is tinnitus treated?

The treatment is of the cause. If the cause cannot be eliminated, it may become chronic. Currently, there is no effective treatment to alleviate the noise. Mainstay of management is education, counseling, cognitive behavioral therapy, and treatment of anxiety and insomnia. Use of alternate or white noise may be an option to treat associated insomnia.

 

What should I do if I have tinnitus?

Start with talking to your medical doctor. It may just be earwax or common ear infection. If it is not explainable and is not going away, a consultation with an ENT doctor is appropriate. If there is no obvious ear issue, or if the tinnitus is of pulsatile or objective type, consultation with a neurologist may help. Tinnitus can be a source of frustration, both for the patient and the treating physician. It may also require help of an audiologist, therapist and a psychologist. Management of tinnitus is part of neuro-otology, a sub-specialty of neurology. Not all neurologists, and similarly not all ENT doctors, are comfortable managing it. Ask your primary care physician for the right specialist in your area.

 

Where can I get more information about tinnitus?

American Academy of Neurology

American Otolaryngology Society