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Sunday, August 17, 2025

Tinnitus


Introduction

Tinnitus is the perception of sound in the absence of an external source. It is commonly described as ringing, buzzing, hissing, roaring, or humming in the ears. Tinnitus can be constant or intermittent, unilateral or bilateral, and may vary in pitch and intensity. While it is not a disease itself, it is often a symptom of an underlying condition involving the auditory system or systemic health.

Tinnitus affects about 10–15% of the adult population globally, and in some individuals, it can cause significant distress, affecting sleep, concentration, mood, and overall quality of life. Understanding its causes and management is crucial for both patients and clinicians.

Types of Tinnitus

  1. Subjective Tinnitus

    • Most common type.

    • Perceived only by the patient.

    • Associated with hearing loss, noise exposure, or otologic disease.

  2. Objective Tinnitus

    • Rare.

    • Can be heard by an examiner using a stethoscope.

    • Usually caused by vascular or muscular abnormalities in the ear (e.g., pulsatile tinnitus from vascular malformations).

  3. Pulsatile Tinnitus

    • Perception of rhythmic sound in sync with heartbeat.

    • Often vascular in origin and warrants careful investigation.

  4. Somatic (Somatosensory) Tinnitus

    • Related to musculoskeletal problems in the head/neck.

    • Can worsen with jaw or head movement.

Causes of Tinnitus

1. Ear-Related (Otologic) Causes

  • Noise-induced hearing loss (occupational or recreational exposure).

  • Presbycusis (age-related hearing loss).

  • Earwax (cerumen) impaction.

  • Otitis media (middle ear infection).

  • Otosclerosis (abnormal bone growth in middle ear).

  • Ménière’s disease (inner ear disorder with tinnitus, vertigo, hearing loss).

  • Acoustic neuroma (vestibular schwannoma) – benign tumor on auditory nerve.

2. Neurological Causes

  • Multiple sclerosis.

  • Head trauma.

  • Stroke affecting auditory pathways.

3. Vascular Causes (pulsatile tinnitus)

  • Carotid artery stenosis.

  • Arteriovenous malformations.

  • Hypertension.

  • Aneurysm.

4. Systemic Causes

  • Anemia.

  • Thyroid disease (hyperthyroidism, hypothyroidism).

  • Vitamin B12 deficiency.

5. Medication-Induced (Ototoxic Drugs)

  • Aminoglycoside antibiotics (gentamicin, streptomycin).

  • Loop diuretics (furosemide).

  • Salicylates (high-dose aspirin).

  • Chemotherapy agents (cisplatin, carboplatin).

  • NSAIDs (ibuprofen, naproxen).

Clinical Presentation

  • Primary symptom: perception of sound without external source.

  • Associated symptoms: hearing loss, ear fullness, vertigo, headache, insomnia, anxiety, and depression.

  • Pattern recognition:

    • Constant vs intermittent.

    • High-pitched vs low-pitched.

    • Pulsatile vs non-pulsatile.

Diagnostic Evaluation

History

  • Onset, duration, and character of tinnitus.

  • Noise exposure, ototoxic medications, alcohol/caffeine intake.

  • Associated symptoms: vertigo, hearing loss, neurological deficits.

Physical Examination

  • Otoscopy: look for earwax, infection, perforation.

  • Cranial nerve exam: identify neurological deficits.

  • Auscultation: listen over ear and neck for vascular murmurs.

Investigations

  • Audiometry: evaluates hearing loss.

  • Tympanometry: assesses middle ear function.

  • Blood tests: anemia, thyroid dysfunction, B12 deficiency.

  • Imaging:

    • MRI brain/internal auditory canal (for acoustic neuroma).

    • CT/MRA (for vascular causes of pulsatile tinnitus).

Treatment Strategies

1. General Lifestyle Measures

  • Avoid loud noise exposure (use ear protection).

  • Reduce caffeine, nicotine, and alcohol.

  • Stress management and adequate sleep.

  • Background noise (white noise machines, fans, soft music) to mask tinnitus.

2. Treating Underlying Causes

Earwax Impaction

  • Carbamide peroxide drops: 5–10 drops in the affected ear twice daily for up to 4 days.

  • Irrigation or manual removal by clinician.

Ear Infection

  • Amoxicillin: 500 mg orally every 8 hours for 7–10 days (for bacterial otitis media).

  • Ciprofloxacin ear drops (for chronic suppurative otitis media).

Ménière’s Disease

  • Low-salt diet.

  • Betahistine: 16 mg orally three times daily.

  • Diuretics (hydrochlorothiazide 25 mg daily).

Anemia

  • Ferrous sulfate: 325 mg orally once to three times daily.

  • Vitamin B12 (cyanocobalamin): 1000 mcg IM weekly × 4–6 weeks, then monthly.

Thyroid Disease

  • Levothyroxine: starting 25–50 mcg daily, titrated to TSH level.

  • Antithyroid drugs (methimazole or propylthiouracil) for hyperthyroidism.

3. Pharmacological Symptom Relief (Not Curative)

  • Benzodiazepines (short-term use only):

    • Clonazepam: 0.25–0.5 mg orally at night.

  • Tricyclic antidepressants (for severe distress):

    • Amitriptyline: 10–50 mg orally at bedtime.

  • Selective serotonin reuptake inhibitors (SSRIs) for anxiety/depression linked tinnitus:

    • Sertraline: 50 mg orally daily.

4. Non-Drug Therapies

  • Cognitive Behavioral Therapy (CBT): helps reduce distress and improve coping.

  • Tinnitus Retraining Therapy (TRT): combines counseling with sound therapy to habituate perception.

  • Hearing Aids: improve hearing loss and reduce perception of tinnitus.

  • Sound Therapy: white noise devices or music therapy.

5. Emerging Therapies

  • Transcranial Magnetic Stimulation (TMS): neuromodulation technique under study.

  • Cochlear Implants: for patients with severe hearing loss.

  • NMDA antagonists (experimental): research into drugs like memantine for tinnitus modulation.

Prognosis

  • Many cases of tinnitus improve once the underlying cause is treated.

  • Chronic tinnitus may persist but can often be managed with sound therapy and counseling.

  • Severe, persistent tinnitus may affect quality of life and mental health, requiring multidisciplinary care.

Red Flags (Require Urgent Referral)

  • Sudden sensorineural hearing loss with tinnitus.

  • Unilateral tinnitus with progressive hearing loss (possible acoustic neuroma).

  • Pulsatile tinnitus (possible vascular abnormality).

  • Tinnitus with neurological deficits (possible stroke or multiple sclerosis).

Summary of Treatments with Doses

  • Carbamide peroxide ear drops: 5–10 drops twice daily up to 4 days.

  • Amoxicillin: 500 mg PO every 8 hours × 7–10 days.

  • Ciprofloxacin ear drops: 2–3 drops twice daily.

  • Betahistine: 16 mg PO three times daily.

  • Hydrochlorothiazide: 25 mg PO daily.

  • Ferrous sulfate: 325 mg PO 1–3× daily.

  • Cyanocobalamin: 1000 mcg IM weekly × 4–6 weeks, then monthly.

  • Levothyroxine: 25–50 mcg PO daily.

  • Clonazepam: 0.25–0.5 mg PO at night.

  • Amitriptyline: 10–50 mg PO at bedtime.

  • Sertraline: 50 mg PO daily.




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