Tinnitus - The Ring In Your Ears

Tinnitus - An overview

Often referred to as “ringing in the ears” by patients, tinnitus is a common presenting complaint by patients and can affect to as many as 20% of the population.

Tinnitus is not a disease. It is not a pathological entity. It is a symptom of underlying conditions such as age-related hearing loss, ear injuries or other systemic diseases like hypertension.


Tinnitus - Symptoms

Symptoms include:

• Ringing in the ear
• Buzzing in the ear

These symptoms can vary in pitch and may be heard in one or both ears. In some instances, it can be so loud so as to cause patients to become distracted in entirety. The symptoms last for a varying period of time, may be cyclical or persistent.

Broadly speaking, tinnitus can be divided into:

• Tinnitus that is only heard by the patient. Ie Subjective tinnitus. Commonly, this kind of tinnitus is caused by problems with either the auditory nerves or nervous pathways involved with hearing.
• Tinnitus that is audible to the physical examiner. Ie the doctor. This type of tinnitus is extremely rare and can be caused by issues with the blood supply, middle ear issues or abnormal musculature.

Tinnitus - Time to see the Doctor?

Bottom line - if it bothers you, please seek a medical consult. Especially if:

• Tinnitus develops and is persistent after a recent upper respiratory infection such as the flu and does not resolve after a week or so.
• Tinnitus occurs out of the blue with no obvious reasons or cause that you can identify
• You experience hearing loss or dizziness and giddiness when experiencing tinnitus 

Tinnitus - Causes

While many conditions can cause tinnitus, sometimes the cause can remain elusive.

From first principles - Tinnitus is caused by abnormal nerve impulses being transmitted from the inner ear, an organ that is lined with microscopic and highly sensitive hairs that move in relation to sound waves. Abnormal nervous transmissions from these hairs causes the brain to interpret these signals as “sound”, thereby resulting in a “ringing” sensation.

Hence, any condition involving the ear or inbuilt physiology of hearing can and will cause tinnitus.


Tinnitus - Common causes

• Age-related hearing loss - Medically termed as “presbycusis”, tinnitus as a result of age-related hearing loss is common and often begins around age 60 or so. 

• Noise Pollution - Noise pollution secondary to industrial and or recreational activities can cause tinnitus. The banging of heavy equipment in factories, the whine of the chainsaw, the boom of the rifle, the roar of rock music played directly into the ear via headphones etc all cause loud noises that impact heavily on the eardrum. This in turn causes tinnitus. Short term exposure to noise pollution usually goes away after some time but chronic exposure can lead to permanent ear damage and hearing loss. 

• Ear Wax - Excessive amounts of ear wax can result in hearing loss and or irritation to the eardrum simply because of physical contact when accumulated in sufficient quantities. This in turn can cause tinnitus. 

•  Otosclerosis - Hardening of bones in the middle ear can affect hearing and cause tinnitus. There is a genetic link for patients suffering from this condition. 

Tinnitus - Less common causes

• Meniere's disease - This is an inner ear disorder caused by abnormal inner ear fluid pressure. It is harmless but can cause severe vertiginous giddiness in associated with tinnitus and can be psychologically traumatizing to patients experiencing their first attack. 

• Disorders with the Temporo-Mandibular Joint (TMJ) - Patients with abnormal TMJ joints can experience tinnitus as a side effect of their problem with the jaw. 

• Head and neck Trauma - Trauma involving this portion of the body can and will affect the inner ear, auditory nerves and brain function. Depending on the site of injury, tinnitus experienced by these patients is usually one sided in relation to their injury. 

• Acoustic Neuromas - This is a benign tumour of one of the cranial nerves that controls balance and hearing. Again, it generally causes tinnitus in only one ear. 

Tinnitus - Rare causes

These are usually related to the blood supply.

• Atherosclerosis. Loss of elasticity in the major blood vessels supplying the middle and inner ear with age due to the buildup of cholesterol causes blood flow within the vessels to be more forceful, causing each “flow” to be heard within the ears. 

• Cancers involving the Head and Neck Region. Any tumour causing compression on blood supply can cause tinnitus as one of the presenting symptoms. 

• Hypertension (“High Blood Pressure”) - Hypertension and any factors that trigger a sudden rise in blood pressure can cause tinnitus simply because of the increased pressure in blood flow to the ears. 

• Turbulent Blood Flow. Any physical cause of narrowing or kinking in the arteries supplying the neck can cause tinnitus due to disruption of blood supply. This is usually seen with either damage or compression to the carotids.

• Congenital Arteriovenous Malformations (AVMs) -  AVMs are congenital and basically refer to direct but abnormal connections between arteries and veins without intervening capillaries. These malformations all for diversion of blood flow and pressure and can cause tinnitus. If present, tinnitus caused by this condition is often one sided.

Medications that can potentially cause tinnitus

• Antibiotics - eg Polymyxin B, erythromycin, vancomycin and neomycin
• Chemotherapy agents - eg mechlorethamine and vincristine
• Diuretics - eg frusemide
• Drugs used for Prophylaxis - eg Quinines 
• Antidepressants 
• Aspirin at high doses

Tinnitus - Risk Factors

• Noise Pollution, especially to loud noises - Extended periods of exposure to high amplitude sound waves damage the microscopic hair cells within the ear, thereby triggering tinnitus in turn. Patients working in noisy environments like industrial complexes, the army or even musicians are more prone to this effect. 
• Advance Age. Tinnitus can develop with advancement of age as the bony structures within the ear harden. 
• Gender - Men are more prone to developing tinnitus compared to women. 
• Smoking -  Likely the secondary effect of cigarette smoke advancing up the eustachian tube irritating the inner ear.
• Cardiovascular problems - As explained above, because changes in blood flow can trigger tinnitus, any condition affecting the cardiovascular system can potentially trigger tinnitus. 

Tinnitus - Complications

While tinnitus is most often simply irritating, in severe cases it can disturb rest and sleep and cause a host of other problems including:

• Memory loss
• Stress
• Fatigue
• Insomnia
• Depression
• Concentration loss
• Anxiety and irritability

Tinnitus - Diagnosis of Underlying Problems

Tinnitus is a symptom rather than a standing diagnosis by itself. To diagnose the underlying problems, the following tests may be used:

• Audiology - Sounds at specific pitch and frequency will be played to the patient in a soundproof room. The patient will be asked to indicate whenever they hear a sound. This test will differentiate between sounds that are played and heard, sounds that are played and not heard, and sounds that are heard but not played (tinnitus) 
• Bedside examination - Doctors might ask the patient to move in certain specified manners to help identify underlying disorders presenting as tinnitus. 
• Imaging - CT and MRI scans of the ear and brain can and will assist with the diagnosis for finding the underlying cause of tinnitus. 

Pitch and tone type of sounds experienced by patients can give a clue to the underlying cause for tinnitus. These include:

• Clicking - Often this is due to spasmic muscle contractions in and around the ear. 
• Rushing or Humming - This may be vascular in origin, especially if variations are noted with change of posture. 
• Rhythmic - Rhythmic pulsations and regular beats of tinnitus can be caused by abnormalities with the blood vessels or cardiovascular system. Eg aneurysms, tumours, or hypertension.
• Low-pitched ringing - eg Minere’s Disease, often associated with vertiginous giddiness and dizziness.
• High-pitched ringing - Often associated with prolonged exposure to noise pollution. Special care needs to be taken if the tinnitus is experienced only on one side. 
• Others - Foreign Bodies, ear wax or loose hair irritating the eardrum can all produce awkward and unpredictable sounds in the ear. 

Note: The underlying cause of tinnitus is often difficult to identify and in many cases, the cause may never be found. However, tinnitus can be managed well in many cases in collaboration with your primary physician.


Tinnitus - Management and Prevention

• Hearing Protectors - Use of hearing protectors reduces damage if exposed to loud sounds over prolonged periods of time. 
• Maintaining Good Cardiovascular Health - Preventing cardiovascular diseases reduces tinnitus. 
• Stop Smoking - Cessation of Smoking will reduce tinnitus. 

Remember - Management of Tinnitus involves treating the underlying cause if identifiable, or managing the symptoms thereof if not.

About The Author

Dr Lau Tzun Hon is a resident housecall doctor at CMY Medical. He received his MBBS (Hons) from Sydney University in 2001 and has served in the both private and government restructured hospitals prior to commencing his practice in Home Care.

While in the Government Restructured Hospitals, Dr Lau served primarily in the Department of Accident & Emergency Medicine and Anaesthesia. Upon entering the Private sector, Dr Lau worked in both public and private A&E departments before venturing into Home Care.

Over the years, he has developed a strong passion to maintain and  enhance the quality of life for patients under his care.  A strong believer that healthcare does not need to be financially straining, Dr Lau often delivers more value beyond expectations.