Tinnitus: What Causes Ringing in the Ears
04 April 2019
Tinnitus and hearing loss
Tinnitus, often described as ringing in the ears, is very common among my patients. It may manifest as an intermittent or continuous sound in one or both ears. Its pitch can go from a low roar to a high squeal or whine. Prior to any treatment, it is important to undergo a thorough examination and evaluation by your otolaryngologist and audiologist. An essential part of the treatment will be your understanding of tinnitus and its causes.
What causes tinnitus?
Tinnitus is commonly defined as the subjective perception of sound, like a persistent ringing, by an individual, even in the absence of external sounds. Tinnitus is not a disease in itself but a common symptom. Various parts of the hearing system, including the inner ear, are often responsible for this symptom. At times, it is relatively easy to associate the symptom of tinnitus with specific problems affecting the hearing system; at other times, the connection is less clear.
Tinnitus may be caused by different parts of the hearing system. At times, for instance, it may be caused by excessive earwax, especially if the wax touches the eardrum, causing pressure and changing how the ear drum vibrates. Other times, loose hair from the ear canal may come in contact with the ear drum and cause tinnitus.
Middle ear problems can also cause tinnitus, such as a middle ear infection or the build up of new bony tissue around one of the middle ear bones which stiffens the middle ear transmission system (otosclerosis). Another cause of tinnitus from the middle ear may be muscle spasms of one of the two tiny muscles attached to middle ear bones. In this case, the tinnitus can be intermittent and at times, the examiner can also hear the patient’s sounds.
Most commonly, tinnitus originates in the inner ear. Damage and loss of the tiny sensory hair cells in the inner ear (that can be caused by different factors) may be commonly associated with the presence of tinnitus. This may be cause by viral infection and present as a common cold and followed by a sudden onset of tinnitus. Diabetes and neuropathies may cause hearing loss with tinnitus. It is interesting to note that the pitch of the tinnitus often coincides with the area of the maximal hearing loss.
One of the preventable causes of tinnitus, often described as a persistent ringing in the ears, is excessive noise exposure. In some instances of noise exposure, tinnitus is the first symptom before hearing loss develops, so it should be considered a warning sign and an indication of the need for hearing protection in noisy environments. As we age, the incidence of tinnitus increases. Hearing loss associated with ageing (also known as presbycusis) typically involves loss of and damage to the hair cells.
Conditions that affect the hearing nerve can also cause tinnitus, the most common being benign tumours, typically originating from one of the balance nerves in close proximity to the hearing nerve. These are commonly referred to as acoustic neuroma or vestibular schwannoma. Tinnitus caused by an acoustic neuroma is usually unilateral and may or may not be accompanied initially by a hearing loss.
Tinnitus may also originate from lesions on or in the vicinity of the hearing portion of the brain, called the auditory cortex. These can be traumatic injuries with or without skull fracture, as well as whiplash-type injuries common in automobile accidents. Benign tumours known as meningiomas that originate from the tissue that protects the brain may also be a cause for tinnitus that originates from the brain.
There are a number of non-auditory conditions that can cause tinnitus, as well as lifestyle factors. Hypertension or high blood pressure, thyroid problems, and chronic brain syndromes can all cause tinnitus without any specific auditory problems. Often these causes cause bilateral tinnitus. Stress and fatigue may cause tinnitus, or can contribute to an exacerbation of an existing case. Poor diet and lack of exercise that may cause blood vessel and heart problems may also either cause it or exacerbate an existing condition.
How is tinnitus treated?
An otolaryngologist finds a specific cause for your tinnitus, then he or she may be able to offer specific treatment to eliminate the noise. This determination may require testing, including imaging studies, audiological tests, tests of balance function, and other laboratory work. However, most of the time, other than linking the presence of tinnitus to sensory hearing loss, specific causes are very difficult to identify.
Fortunately, most often sensori neural hearing loss is seen in cases of unilateral tinnitus. Adequate and prompt treatment will reverse the hearing loss and following the hearing improvement, the tinnitus often resolves.
Treatment of sudden sensori neural hearing loss
An initial audiometry assessment allows us to quantify the degree of hearing loss. The more severe the hearing loss, the more disability it causes and the less likely it would recovers. The risk factors are identify and corrected when possible.
The most consistent results are achievable with high dose steroids. In the past, oral steroids are often given. This may results in some adverse effects that are associated with oral steroid therapy. Currently, injectable steroids are often given directly into the cochlear via the round window. This is performed with a special fine needle through the eardrum. Intra tympanic delivery gives better results as compares to oral steroid intake. Intra tympanic steroid also minimize the complication that may occurs with high dose oral steroid intake. For patient with diabetes, this would be the method of choice.
When high dose oral steroid is given, the patient is closely monitored for its side effects. The common adverse effects are, dyspepsia, gastritis, headache, blurring of vision, glaucoma, and excessive tiredness and hunger.
Early treatment within the first week gives much better outcome as compare to delayed treatment. Occasionally, the patient is seen 2 to 3 months after the onset of tinnitus. If hearing loss is present, complete recovery in these cases are less likely. However, most patient will adapt to the tinnitus by this time.
Adequate rest and vitamin B12 are often given together with the steroid therapy.
Can children be at risk for tinnitus?
It is relatively rare but not unheard of for patients under 18 years old to have tinnitus as a primary complaint. However, it is possible that tinnitus in children is significantly under-reported, in part because young children may not be able to express this complaint. In pre-teens and teens, the highest risk for developing tinnitus is associated with exposure to high intensity sounds, specifically listening to music. In particular, virtually all teenagers use personal MP3 devices and nearly all hand-held electronic games are equipped with ear buds. It is difficult for a parent to monitor the level of sound children are exposed to. Therefore, the best and most effective mode of prevention of tinnitus in children is proper education relative to excessive sound exposure, as well as monitoring by parents or other caregivers.
Tips to lessen the severity of tinnitus when medication fails
• Avoid exposure to loud sounds and noises.
• Get your blood pressure checked. If it is high, get your doctor’s help to control it.
• Decrease your intake of salt. Salt impairs blood circulation.
• Avoid stimulants such as coffee, tea, cola, and tobacco.
• Exercise daily to improve your circulation.
• Get adequate rest and avoid fatigue.
• Stop worrying about the noise. Recognize your head noise as an annoyance and learn to ignore it as much as possible. It is part of you.
What can help me cope?
Concentration and relaxation exercises can help to control muscle groups and circulation throughout the body. The increased relaxation and circulation achieved by these exercises can reduce the intensity of tinnitus in some patients.
Tinnitus, or the condition of ringing in the ears, is usually more bothersome in quiet surroundings.
Masking tinnitus with a competing sound at a constant low level, such as a ticking clock or radio static (white noise), may make it less noticeable.
Hearing aids may reduce head noise while you are wearing them and sometimes cause the noise to go away temporarily. If you have a hearing loss, it is important not to set the hearing aid at excessively loud levels, as this can worsen the tinnitus in some cases. However, a thorough trial before purchase of a hearing aid is advisable if your primary purpose is the relief of tinnitus.
Tinnitus maskers can be combined within hearing aids. They emit a competitive but pleasant sound that can distract you from head noise. Some people find that a tinnitus masker may even suppress the head noise for several hours after it is used, but this is not true for all users.
This article was adopted from the America Academy of Otolaryngologist.
