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Sunday, August 10, 2025

Tinnitus


 Definition

Tinnitus is the perception of sound in the absence of an external acoustic stimulus. It is often described as ringing, buzzing, hissing, humming, or pulsating in one or both ears and may be continuous or intermittent.

Types

  • Subjective tinnitus – perception of sound only heard by the patient; most common type, linked to auditory system abnormalities

  • Objective tinnitus – sound generated within the body that can be heard by an examiner (e.g., vascular bruits, muscle spasms); rare

Causes

Ear-related (otologic)

  • Sensorineural hearing loss (age-related, noise-induced)

  • Ménière’s disease

  • Acoustic neuroma (vestibular schwannoma)

  • Otosclerosis

  • Earwax impaction

  • Chronic otitis media

Vascular

  • Arteriovenous malformations

  • Carotid artery stenosis or dissection

  • Hypertension

  • Benign intracranial hypertension (pseudotumor cerebri)

Neurological

  • Multiple sclerosis

  • Head injury

Drug-induced (ototoxicity)

  • Aminoglycosides

  • Loop diuretics

  • Cisplatin

  • Aspirin (high doses)

  • NSAIDs

Other

  • Jaw/neck muscle tension (temporomandibular joint dysfunction)

  • Anxiety, depression

Risk Factors

  • Prolonged noise exposure

  • Age >60 years

  • Male sex (slightly higher risk)

  • Smoking

  • Cardiovascular disease

Clinical Features

  • Perception of sound (ringing, buzzing, clicking, pulsating)

  • May be unilateral or bilateral

  • Associated symptoms: hearing loss, dizziness, ear fullness, headache, balance problems (depending on cause)

Diagnosis

  • Detailed history (onset, duration, laterality, associated hearing loss, vertigo, pulsatility, noise exposure, medications)

  • Otoscopic examination

  • Pure tone audiometry (hearing test)

  • Tympanometry

  • MRI (if unilateral tinnitus with asymmetric hearing loss to exclude acoustic neuroma)

  • MRA/CT angiography (if pulsatile tinnitus to assess vascular causes)

Treatment

General approach

  • Identify and treat underlying cause (e.g., remove impacted wax, treat infection, manage hypertension)

  • Stop or replace ototoxic medications when possible

Non-pharmacological management

  • Hearing aids (if associated with hearing loss)

  • Sound therapy (masking devices, white noise machines)

  • Cognitive behavioural therapy (CBT) for coping strategies

  • Tinnitus retraining therapy (TRT)

  • Stress management and sleep hygiene

Pharmacological options (limited efficacy, used selectively)

  • Antidepressants (amitriptyline, nortriptyline) if significant anxiety/depression

  • Melatonin for sleep disturbances

  • No strong evidence for routine use of benzodiazepines, anticonvulsants, or herbal remedies (e.g., Ginkgo biloba)

Surgical/interventional

  • Reserved for treatable structural/vascular causes (e.g., acoustic neuroma removal, AVM repair)

Prognosis

  • Tinnitus can be persistent; management focuses on cause correction and symptom control

  • Many patients adapt over time with supportive measures




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