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Tinnitus: symptoms, causes, diagnosis and treatment


Ringing in the ears and what to do about it

What is tinnitus mean?

• Tinnitus is a symptom, not a disease.

• It is the sensation of sound not brought about by simultaneously externally applied mechanoacoustic or electrical signals—the perception of sound generated involuntarily within the head of an individual.

• Suggests problem between cochlea and auditory cortex.

• Central auditory system plays vital and critical role in experience of tinnitus.

What is the difference between objective and subjective tinnitus?

  • Subjective Tinnitus: perception of sound in the absence of any acoustic or external stimulation; it 's more common than objective tinnitus; typically associated with a high-frequency hearing loss (pitch of tinnitus may correlate with the frequency of hearing loss, most common is 3000–5000 Hz.
  • Objective Tinnitus: The perception of sound caused by an internal sound or vibration of the body can be exacerbated with a CHL.

What are the causes of tinnitus?

The pathophysiology of subjective tinnitus is largely unknown; however, current models focus on the subcortical auditory pathways rather than on cochlear dysfunction; Objective tinnitus is usually caused by an underlying vascular or mechanical disorder.

What percentage of the population has tinnitus?

  • It affects around 1/3 of people over 50; of these, 50% of daily experience.
  • 94% of normal-hearing subjects placed in a soundproof room for up to 5 min have tinnitus like experiences.
  • 10% of adults have experienced tinnitus for >5 min.
  • 4% have tinnitus causing sleep disturbance.
  • 0.5% severely disabled by tinnitus.

What is tinnitus sound like ?

Character of Tinnitus:

Unilateral or bilateral, high-pitched (ringing, hissing) or low (roaring, buzzing), pulsatile or nonpulsatile, clicking, progression and frequency, loudness, pure or multiple tones, level of discomfort (eg, difficulty sleeping).

Is tinnitus serious?

Consider appropriate evaluation for retrocochlear lesions if suspected (vestibular schwannoma may present with unilateral tinnitus).

What are the causes and management of subjective tinnitus?


  • Evaluate medications for known possible causes or contributing factors (eg, Aspirin, NSAIDs and also alcohol may exacerbate subjective tinnitus). 
  • Smoking and caffeine cessation.
  •  relaxation techniques (biofeedback) and improvement of sleep hygiene.
  • Consider referral for habituation/retraining therapy and support groups.
  • Cognitive behavioral therapy (most effective).

What'is a Psychological Model of tinnitus?

  • Humans usually habituate to continuous background stimuli. 
  • Troublesome tinnitus represents a failure of habituation, which is more likely if person is stressed; signal is emotionally meaningful. 
  • Vicious circle of awareness and stress set up.
  • Emotional reaction to tinnitus a major factor in distress.
  • Problems with psychological model: potentially overemphasizes emotion, underemphasizes mechanisms of tinnitus.

What's the cause for pulsatile tinnitus?


● Arterial: Aberrant internal carotid artery, carotid atherosclerosis, persistent stapedial artery, arteriovenous malformations, aneurysm, carotid artery dissection, vascular compression of cranial nerve eight, vascular tumors (glomus). 

● Venous: Jugular bulb abnormalities (high-riding, dehiscence, diverticulum), idiopathic intracranial hypertension, idiopathic pulsatile tinnitus (venous hum).

● Nonvascular: Palatal, stapedial, and tensor tympani myoclonus.

Tinnitus: Ringing in the ears

What is the prevalence of carotid artery dehiscence within the middle ear? 

Approximately 10%, but rarely does it follow an aberrant course placing it at risk during myringotomy.

What constellation of symptoms is commonly associated with patulous eustachian tube?

Tinnitus, aural fullness, autophony, audible respiratory sounds, and vertigo.

What medications  may cause tinnitus?

Aspirin-containing products (most common), other nonsteroidal anti-inflammatory drugs (or NSAIDs), aminoglycosides, proton pump inhibitors (omeprazole, esomeprazole), and certain antidepressants.

What medications  may cause tinnitus?

What device (non medicinal) options are available for patients with subjective non pulsatile idiopathic tinnitus?

Hearing aids, masking devices (deliver constant narrowband white noise to "cover up" ringing), and tinnitus retraining therapy (pitch matched to the patient's tinnitus to theoretically habituate the central auditory system to the noise and eventually neglect it).

Cochlear implants improve tinnitus in some patients, but tinnitus itself is not an indication for implantation.

What is the most effective treatment for tinnitus?


  • Masking devices (white noise generators); change attentional focus.
  • Hearing Aids : 0% will experience total suppression of tinnitus, many experience partial inhibition.
  • Indicated for tinnitus associated with hearing loss. 
  • Reduces tinnitus by amplifying ambient sound to mask the tinnitus. 

  • Simplest method of “direct masking”.
  •  Treating concurrent anxiety/depression reduces impact of tinnitus.
  • White noise generator and HA combined sometimes useful.

Directive counseling, e.g., information and explanation

• Relaxation therapy

Cognitive-behavioural therapy: explanation, relaxation, change of beliefs about tinnitus.

• Sound therapy for hyperacusis.

Transcranial magnetic stimulation under investigation.

British Tinnitus Association's  Information

  • Although the ear is probably the most common source of disorder that generates the abnormal train of neuronal signals that underlie most forms of tinnitus, it is usually unimportant with respect to the “severity” of the tinnitus, i.e., the extent and nature of its adverse eff ects on the patient.
  • Degree of distress depends on the way in which the neuronal signal is processed in the brain, including parts of it outside the auditory system.
  • These processes can be reversed by appropriate counselling to reduce or remove the anxieties and fears caused by tinnitus:
  •  As people come to terms with their tinnitus, lose much of their fear of it, and learn to reduce the attention they give to their tinnitus, so the neuronal pathways and filter settings change, leading to the progressive habituation to tinnitus, which is the general rule
  • Counselling aims to speed up and enhance the habituation process. 
  • Counselling must be encouraged, giving confidence, hope, and expectation of worthwhile improvement at least and possibly even virtual elimination
  • Sound therapy also counteracts the big enemy of the person with tinnitus: quietness.
  • In the quiet, and particularly if there is hearing loss, the central auditory system increases its sensitivity to detect any faint sounds:
  • This increases the apparent loudness of the tinnitus, and also that of external sounds thus causing the oversensitivity to sounds, hyperacusis.
  • If the added sound is loud enough to render the tinnitus sound inaudible, to completely “mask” it, this may, however, delay habituation; you cannot habituate to something you cannot perceive.
  • Nevertheless, some patients fi nd such masking very helpful, and in others it may be all they want.