Tinnitus

What is tinnitus?

Tinnitus is a perception of sounds in your ears or head that is not caused by an external sound source.  Many people describe tinnitus as ringing in their ears; however, the quality of the sound can vary. Some people report experiencing buzzing, crickets, roaring, hissing, or clicking sounds. Most cases of tinnitus are subjective, meaning only the patient can hear it.  However, there are rare cases of objective, pulsatile tinnitus that may sound like a pulsing or whooshing sound that occurs in rhythm with the heart beat. Additionally, spasms of the muscles in the middle ear can cause objective tinnitus. In those cases, it may be possible for the doctor to hear the tinnitus during the physical examination.

Tinnitus may be present all the time or it may be intermittent. For some people, tinnitus can be bothersome and negatively impact their daily lives. For example, it may interfere with the ability to concentrate or sleep. Other people may not be bothered by the presence of tinnitus.

What causes tinnitus?

Tinnitus is a symptom of a problem in the auditory system, rather than a disease in its own right. There are many possible causes of tinnitus. It is typically caused by an underlying condition but sometimes a specific cause cannot be identified.

Hearing loss is a common cause of tinnitus. Sensorineural hearing loss is due to damage to the cochlea and/or the auditory nerve. Most subjective tinnitus is caused by damage to the sensory hair cells in the cochlea. In such cases, the damaged hair cells may send irregular electrical stimulation to the brain, causing the brain to perceive tinnitus.

Exposure to loud noises is known to cause damage to the sensory hair cells which can result in hearing loss and tinnitus. Tinnitus may develop prior to the onset of permanent noise-induced hearing loss. Tinnitus and hearing loss due to noise exposure is preventable. Therefore, it is important to use hearing protection and avoid exposure to hazardous noise levels.

Impacted ear wax can result in pressure in the ear canal and affect the vibration of the ear  eardrum, causing tinnitus.

Medications may cause tinnitus or make it worse. Several types of medications have tinnitus as a possible side effect. Some medications that are commonly associated with tinnitus include the following: nonsteroidal anti-inflammatory drugs (NSAIDs), diuretics, antimalarial drugs, antidepressants, cancer drugs, some antibiotics (e.g., clarithromycin, ciprofloxacin, tetracycline), cardiac medications, and anticonvulsants. Inform your medical provider if you experience an onset or worsening of tinnitus as a result of your medication.

Other possible medical causes of tinnitus:

• Middle ear infection
• Stiffening of the bones in the middle ear (ossicles)
• Hormonal changes
• Thyroid abnormalities
• Tumors of the auditory nerve or brain
• Temporomandibular joint disorders
• Head or neck injuries
• Blood vessel disorders
• High or low blood pressure
• Diabetes
• Muscle spasms in the middle ear

Tinnitus and COVID-19

Studies have shown that tinnitus can be caused by COVID-19 (Viola et al., 2020; Jafari et al., 2021; Chirakkal et al., 2021). Tinnitus associated with COVID-19 may occur due to an infection of the central nervous system or vascular damage as a result of the virus (Viola et al., 2020). In addition to the impact on the auditory system, tinnitus may also be secondary to increased mental and emotional stress resulting from the COVID-19 pandemic (Jafari et al., 2021).

Presently, none of the available COVID-19 vaccines list tinnitus as a side effect. The incidence of tinnitus following COVID-19 vaccinations is low; however, more research is being done to better understand the frequency of vaccine-associated tinnitus.

Is tinnitus permanent?

The cause of tinnitus will determine whether it is permanent. If tinnitus occurs as a result of a condition that can be treated medically (e.g., impacted ear wax, middle ear infection), the tinnitus will likely subside when the condition resolves following intervention. If tinnitus is due to damage to the inner ear or another long-standing, permanent condition, then it will likely be permanent. However, there are treatment options available to help reduce the negative impact of tinnitus. Sometimes tinnitus may seem to come and go. Various factors, such as stress, fatigue, and environmental noise (i.e., how quiet it is) can contribute to the perception of intermittent tinnitus.

How is tinnitus diagnosed?

A tinnitus evaluation will include a thorough case history, questionnaires to determine the impact of the tinnitus on quality of life, and a hearing evaluation. Testing may also include an assessment of the subjective loudness and pitch of the tinnitus. The audiologist or physician may diagnose tinnitus based solely on reported symptoms. In some cases, such as with unilateral and/or pulsatile tinnitus or tinnitus that occurs in conjunction with asymmetrical hearing loss, imaging may be necessary to ascertain the underlying cause and best course of intervention.

Treatment for tinnitus

If tinnitus is bothersome and negatively impacts your quality of life and/or if it is accompanied by hearing loss, it is recommended that you seek an evaluation by an otolaryngologist (ear, nose, and throat physician) or audiologist. Additionally, if you experience pulsatile tinnitus or asymmetrical tinnitus, a medical evaluation is recommended. While there is no cure for tinnitus, there are many treatment options that can help patients manage tinnitus and reduce its negative emotional and cognitive effects. Some treatment options include the following:

Hearing Aids are recommended for people who experience tinnitus in conjunction with hearing loss. Amplification can often alleviate or reduce tinnitus symptoms. Cochlear implants may be recommended for individuals who have tinnitus and severe to profound hearing loss.

Maskers are ear-level devices that look like hearing aids. There are also some hearing aids that provide amplification as well as tinnitus masking. They produce noise to “mask” or cover up the tinnitus. The audiologist will likely use the maskers as part of a comprehensive therapeutic program designed to reduce attention to tinnitus and the associated negative emotions. Eventually, the goal is to reduce the patient’s reliance on masking.

Tinnitus Retraining Therapy (TRT) is a treatment program designed to reduce the negative effects of tinnitus. TRT is typically administered by an audiologist and includes management of ear-level devices (i.e., hearing aids and/or maskers) along with counseling to address emotional and quality of life concerns. It also includes an educational component that addresses what happens in the brain and auditory system to cause tinnitus.

Sound Machines that generate white noise or environmental, nature sounds (e.g., rainfall, forest sounds, ocean sounds) may help mask tinnitus and make it less noticeable. There are tabletop machines as well as sound pillows, which can be helpful at night when tinnitus may impact sleep. There are also many apps and websites that offer a variety of sound options for free or low cost. Additionally, the noise from a fan or air conditioner can help make tinnitus less noticeable.

Cognitive Behavioral Therapy (CBT) and other forms of counseling with a licensed mental health professional can help address stress, anxiety, and depression that may be linked to tinnitus. Counseling may involve hypnosis and relaxation strategies.

Medications such as antidepressants and antianxiety drugs may be prescribed to address mental health concerns related to tinnitus. However, it is important to note that tinnitus generally cannot be cured by medication. Prescription medications are not recommended for tinnitus treatment unless there is an underlying medical condition (e.g., depression, anxiety) that would benefit from such intervention.

Group therapy and/or support groups may be beneficial because they allow patients to share their experiences and management strategies with other people who have tinnitus. Choosing a group that is facilitated by a qualified professional (e.g., physician, audiologist, mental health clinician) can help ensure that the information and recommendations shared are accurate and productive.

Treatment for underlying medical conditions (e.g., blood vessel disorders, thyroid abnormalities, etc.) may alleviate or reduce associated tinnitus symptoms.

A Note on Unproven Treatments

Dietary supplements such as ginkgo biloba, melatonin, zinc, and Lipoflavonoid are often advertised for tinnitus treatment; however, there is no evidence to suggest that they are effective treatments for tinnitus. Acupuncture is another modality that does not have sufficient evidence to support recommendation for tinnitus treatment. Researchers are working on new tinnitus treatments such as transcranial magnetic stimulation and hyperactivity and deep brain stimulation; however, there is not yet sufficient data to recommend them at this time.