Tinnitus: The Ringing Ear

“Doc, I have this ringing sensation in my ears…..” is a common ear related complaint that patients present with in my clinic. This ringing sensation is called “tinnitus”.

Tinnitus is defined as the “perception of sound that is not generated outside the body”. Some define it as a sensation of sound that does not exist.  It may vary in its form and intensity. It is often described as ringing, humming buzzing or chirping. About 10-35% of the population may suffer from tinnitus at some point or the other. In fact it has been shown that if you place someone in a sound proof room for more than 20 minutes there is a 65% chance that person will experience tinnitus like sounds. Though its incidence may seem to be high but only about 10% of those having tinnitus are really troubled by it. That is still a significant number.

As there are several causes for tinnitus, the goals of the physician or the ENT doctor is to establish a diagnosis when possible and identify the treatable problems. Where the cause cannot be determined, it is important to assess the severity and determine if treatment is necessary.

A detailed history will include the duration, pattern, quality and severity of the tinnitus. Also included in the history is any significant medial history, associated symptoms related to the ears, and psychological issues and medication history. Aspirin is one medication that can cause tinnitus.

Examination will include an examination of the ears with the microscope and complete head and neck examination. A nasal endoscopy is done to rule out any pathology in the nose, sinuses and the nasopharynx. Tinnitus can be a presenting symptom of nasopharyngeal cancer.

An audiologic evaluation is essential to look for any associated hearing loss or middle ear pathology.

Imaging studies may include a computed tomography (CAT scan) of the temporal bone. CAT scan is excellent to study the bony anatomy of the ear. To look at the soft tissue anatomy a Magnetic Resonance is done. This is indicated particularly when the symptoms or the hearing loss are asymmetrical.  If the patient has pulsatile tinnitus a Magnetic resonance angiogram or CT angiogram may be indicated. An arteriogram may be done when there is high index of suspicion of a vascular lesion.

Special Considerations:

  1. Clicking tinnitus may be due to Temporo-mandibular Joint dysfunction or stapedial myoclonus. Stapedial myoclonus is a condition that affects a small muscle in the middle ear.
  2. Pulsatile tinnitus: there are major vessels like the internal carotid artery, the internal jugular vein and the sigmoid sinus that come in close relationship with the ear. Increased vascular flow or lesions affecting these structures, such as glomus tumours, may cause pulsatile tinnitus. High intracranial pressure may also cause pulsatile tinnitus.
  3. Superior Canal Dehiscence: In this condition the bone overlying one of the semi-circular canals is weak or absent. It is usually associated with conductive hearing loss and vertigo
  4. Other conditions that can cause pulsatile tinnitus include dural AV fistulas and sigmoid sinus diverticulum.
  5. Acoustic Neuroma: this is a benign tumour arising from the 8th cranial nerve. Patients usually present with unilateral tinnitus, asymmetrical hearing loss, atypical vertigo and sudden hearing loss.

For cases where there is no obvious cause for the tinnitus and the patient is very troubled by the symptoms treatment for tinnitus include, hearing aids, tinnitus maskers, tinnitus habituation therapy and music based therapies. Medications may be helpful for some.