What are the causes and treatments of tinnitus (ringing in the ears)?

Tinnitus: Etiology and Management

Tinnitus is primarily caused by hearing loss, noise exposure, and otologic conditions, and should be managed with a combination of audiologic evaluation, sound therapy, and cognitive behavioral therapy for optimal outcomes in reducing morbidity and improving quality of life. 1

Etiology of Tinnitus

Tinnitus can be classified into two main types:

Subjective Tinnitus (Most Common)

• Hearing-related causes:

  • Noise-induced hearing loss
  • Age-related hearing loss (presbycusis)
  • Cerumen impaction 1

• Otologic conditions:

  • Otitis media
  • Meniere's disease
  • Otosclerosis 2

• Neurologic causes:

  • Vestibular schwannoma (acoustic neuroma)
  • Intracranial hypertension 1, 3

• Medication-induced:

  • Ototoxic medications (certain antibiotics, NSAIDs, chemotherapy agents) 4

Objective Tinnitus (Less Common)

• Vascular abnormalities:

  • Arteriovenous malformations (AVMs)
  • Arteriovenous fistulae (AVFs)
  • Carotid artery stenosis
  • Glomus tumors 1, 2

• Other causes:

  • Temporomandibular joint disorders
  • Middle ear muscle spasms 3

Diagnostic Approach

Initial Evaluation

1. Targeted history:

   • Characteristics: onset, duration, pitch, loudness, pulsatile vs. non-pulsatile
   • Associated symptoms: hearing loss, vertigo, headache
   • Aggravating/alleviating factors
   • Medication history
   • Noise exposure history
   • Impact on quality of life and sleep 1

2. Physical examination:

   • Otoscopic examination to identify cerumen impaction, tympanic membrane perforation, or middle ear fluid
   • Neurologic examination to identify focal deficits 1

3. Audiologic testing:

   • Recommended for all patients with:
     • Unilateral tinnitus
     • Persistent tinnitus (≥6 months)
     • Tinnitus associated with hearing difficulties
     • Even in patients without perceived hearing loss 1

Imaging (Not Routine)

• Indicated for specific presentations:
  • Pulsatile tinnitus → CT angiography or MR angiography
  • Unilateral tinnitus with asymmetric hearing loss → MRI with contrast of internal auditory canals
  • Focal neurological findings → MRI brain with contrast 1

Management Approach

First-Line Treatments

1. Education and counseling:

   • Explain natural history
   • Provide coping strategies
   • Reassurance when appropriate 1

2. Hearing aids:

   • Recommended for patients with hearing loss and persistent tinnitus
   • Improves tinnitus by amplifying external sounds and reducing auditory deprivation 1

3. Sound therapy:

   • White noise machines
   • Smartphone apps
   • Tinnitus masking devices 1, 5

4. Cognitive Behavioral Therapy (CBT):

   • The only treatment shown to improve quality of life in tinnitus patients
   • Should be considered for all patients with bothersome tinnitus 1, 6, 3

Additional Treatments

• Tinnitus Retraining Therapy:

  • Combination of sound therapy and counseling
  • Supportive but not conclusive evidence 1, 5

• Management of underlying conditions:

  • Treatment of carotid artery atherosclerosis
  • Management of skull base tumors
  • Treatment of intracranial hypertension 2

Common Pitfalls to Avoid

• Failing to remove cerumen before assessment 1
• Overlooking non-otologic causes of tinnitus 1
• Not performing comprehensive audiologic evaluation for unilateral or persistent tinnitus 1
• Using unproven medications or supplements without evidence 1
• Ordering unnecessary imaging for non-concerning tinnitus presentations 1
• Dismissing patient concerns with statements like "there is nothing that can be done" 2
• Missing pulsatile tinnitus which can indicate serious vascular pathology requiring urgent evaluation 1

Special Considerations

• Pulsatile tinnitus requires prompt evaluation as it may indicate vascular abnormalities that could be life-threatening 1
• Unilateral tinnitus with asymmetric hearing loss requires imaging to rule out vestibular schwannoma 1, 3
• Tinnitus with sudden hearing loss requires urgent evaluation and treatment 3
• Noise exposure prevention is important to prevent development or progression of tinnitus 3