Plaquenil and Ear Ringing: What You Should Do
If you develop tinnitus (ear ringing) while taking Plaquenil (hydroxychloroquine), you should report this symptom to your prescribing physician immediately, as tinnitus is a recognized adverse effect listed in the FDA drug label and may indicate ototoxicity. 1
Understanding the Risk
The FDA-approved drug label for Plaquenil explicitly lists tinnitus as a reported adverse reaction under "Ear and labyrinth disorders," along with vertigo, nerve deafness, and deafness 1. While ototoxicity is less commonly discussed than the well-known retinal toxicity of hydroxychloroquine, multiple systematic reviews confirm that both chloroquine and hydroxychloroquine can cause damage to the inner ear structures, resulting in hearing loss, tinnitus, and balance problems 2, 3, 4.
The mechanism appears to involve cochlear damage, including changes in the stria vascularis and lesions in sensory hair cells 2. Importantly, the reversibility of this ototoxicity is debatable—some cases resolve after stopping the medication, while others persist 3, 4, 5.
Immediate Action Steps
You should:
Contact your prescribing physician immediately to report the tinnitus and discuss whether to continue, adjust, or discontinue Plaquenil based on your underlying disease severity
Request a comprehensive audiologic examination that includes:
- Pure tone audiometry to assess for sensorineural hearing loss
- Auditory brainstem response (ABR) testing, which appears to be the most sensitive test for detecting early cochlear injury when still potentially reversible 5
Document the characteristics of your tinnitus:
- Is it unilateral (one ear) or bilateral (both ears)?
- Is it pulsatile (rhythmic with heartbeat) or non-pulsatile (continuous ringing)?
- When did it start relative to beginning Plaquenil?
- What is your current daily dose and total duration of use?
Clinical Decision-Making
The decision to discontinue Plaquenil requires shared decision-making between you, your prescribing physician, and potentially an audiologist or ENT specialist 6. This decision must weigh:
- The severity and activity of your underlying rheumatic or autoimmune disease
- The risk of disease flare if Plaquenil is stopped
- The potential for permanent hearing damage if the drug is continued
- Whether the tinnitus is accompanied by documented hearing loss on audiometry
If audiometric testing confirms sensorineural hearing loss or if tinnitus is severe and bothersome, discontinuation should be strongly considered 3, 4. Some evidence suggests that early discontinuation combined with appropriate therapy (steroids and plasma expanders have been mentioned in the literature) may allow for reversibility 5.
Important Caveats
Do not assume tinnitus is always drug-related: The tinnitus clinical practice guidelines emphasize that clinicians should perform a targeted history and physical examination to identify other potential causes 7. However, given your Plaquenil use, drug-induced ototoxicity must be high on the differential diagnosis.
Imaging is generally not indicated unless your tinnitus is unilateral, pulsatile, or associated with focal neurological abnormalities or asymmetric hearing loss 7
The dose matters: While retinopathy risk is well-established with doses >5.0 mg/kg actual body weight 8, the relationship between dose and ototoxicity is less clearly defined in the literature. However, higher doses and longer durations likely increase risk.
Monitoring Going Forward
If you and your physician decide to continue Plaquenil despite tinnitus:
- Establish baseline audiometry immediately if not already done
- Consider periodic audiologic monitoring, particularly ABR testing
- Remain vigilant for worsening tinnitus or new onset of hearing loss, vertigo, or balance problems
- Ensure your dose is appropriate for your actual body weight and renal function (as renal disease increases drug levels and toxicity risk) 8
The key principle is that ototoxicity, like retinopathy, may not be reversible once established, making early detection and prompt action critical 1, 3, 4.