What can cause tinnitus (ringing in the ears) without dizziness and hearing loss?

Causes of Tinnitus Without Dizziness and Hearing Loss

Tinnitus without associated dizziness and hearing loss is most commonly caused by temporomandibular joint (TMJ) disorders, somatic tinnitus, vestibular migraine, or vascular abnormalities. 1

Common Causes

1. Temporomandibular Joint (TMJ) Disorders

• Characterized by tinnitus that can be modulated by jaw or neck movements 2
• More common in:
  • Younger patients
  • Female patients
  • Patients with better hearing function
• May present with jaw pain, clicking, or limited jaw movement
• TMJ-related tinnitus patients typically have lower subjectively perceived tinnitus loudness 2

2. Somatic Tinnitus

• Caused by somatosensory system dysfunction in the head and neck 3
• Key characteristics:
  • Can be modulated by specific movements of the jaw, neck, or limbs
  • May be associated with neck pain or tension
  • Often unilateral
• Clinical examination may reveal:
  • Craniocervical muscle trigger points
  • Dental wear patterns suggesting bruxism
  • Tinnitus modulation with "somatic testing" (specific head/neck movements) 3

3. Vestibular Migraine

• Can present with tinnitus without significant hearing loss 1
• Distinguishing features:
  • History of migraine headaches
  • Light sensitivity
  • Motion intolerance
  • Visual auras before, during, or after attacks
  • Mild or absent hearing loss that remains stable over time 1

4. Vascular Abnormalities (Pulsatile Tinnitus)

• Characterized by rhythmic sound synchronous with heartbeat 1
• Common causes include:
  • Aberrant arterial or venous anatomy
  • Vascular malformations
  • Atherosclerotic carotid artery disease
  • Jugular bulb abnormalities
  • Abnormal condylar and mastoid emissary veins 1

5. Other Causes

• Medication side effects 1
• Anxiety or panic disorders 1
• Dental implant complications (rare) 4
• Idiopathic (primary) tinnitus 1

Diagnostic Algorithm

1. Characterize the tinnitus:

   • Pulsatile vs. nonpulsatile
   • Unilateral vs. bilateral
   • Constant vs. intermittent
   • Modifiable by position or movement

2. For pulsatile tinnitus:

   • Consider vascular causes
   • Evaluate for objective tinnitus (audible to examiner)
   • Consider imaging (CTA or MRA) if persistent 1

3. For nonpulsatile tinnitus:

   • Evaluate for TMJ dysfunction:
     • Jaw pain or clicking
     • Limited jaw movement
     • Ability to modulate tinnitus with jaw movement
   • Assess for migraine features:
     • History of headaches
     • Light sensitivity
     • Visual disturbances
     • Family history of migraine

4. For somatic tinnitus:

   • Test for modulation with:
     • Neck movements
     • Jaw movements
     • Pressure on trigger points
   • Evaluate craniocervical musculature for tenderness

Clinical Pearls and Pitfalls

Pearls:

• The ability to modulate tinnitus with jaw or neck movements strongly suggests somatic or TMJ-related tinnitus 2, 3
• TMJ disorders are more common in younger female patients with tinnitus 2
• Vestibular migraine can present with tinnitus without significant hearing loss or vertigo 1

Pitfalls:

• Failing to distinguish between pulsatile and nonpulsatile tinnitus, which have different etiologies and management approaches 1
• Missing TMJ disorders as a cause of tinnitus, especially in patients without obvious jaw symptoms
• Overlooking vestibular migraine in patients without classic headache symptoms
• Not evaluating for medication side effects as a potential cause

When to Consider Imaging

Imaging is generally not recommended for nonpulsatile tinnitus without associated symptoms, but should be considered in:

• Pulsatile tinnitus
• Unilateral persistent tinnitus
• Tinnitus associated with focal neurological abnormalities
• Tinnitus with asymmetric hearing loss 1, 5

When indicated, appropriate imaging may include:

• CT angiography for suspected vascular causes
• MRI with internal auditory canal protocol for suspected vestibular schwannoma or other structural abnormalities 1

Remember that identifying the underlying cause of tinnitus is crucial for directing appropriate treatment and improving quality of life for patients with this often distressing symptom.