Understanding Tinnitus: Causes, Diagnosis, and Treatment

Tinnitus is a condition that manifests as bothersome ringing in the ears and affects between 10-20% of the U.S. population annually.

Common Symptoms

Tinnitus is the perception of sound when no actual external source is present. Phantom sounds may be intermittent or continuous, and can come across as buzzing, humming, hissing, roaring, high-pitched tones, crickets, clicking, or whooshing. Although typically benign, symptoms of tinnitus can lead to stress, anxiety, depression, insomnia, poor sleep, and difficulty concentrating. 

There are three primary kinds of tinnitus that account for about 80% of all cases. The first and most common is hearing loss-related tinnitus. The second is somatic tinnitus, and refers to symptoms caused by musculoskeletal issues in the jaw or neck region. Lastly is stress-related tinnitus, which is brought on by high levels of anxiety or stress that trigger ringing in the ear. Occasionally, some people may also experience a fourth type of tinnitus that causes sounds to be heard in time with their heartbeat, a form of the condition called pulsatile tinnitus. It’s important to seek medical consultation if this condition reflects your own experience with tinnitus symptoms, as it may be tied to other cardiovascular concerns. 

Understanding Tinnitus: What Are The Main Causes?

There are many possible causes of and contributing factors to tinnitus, but research suggests that tinnitus is ultimately caused by abnormal activity in the part of the brain that processes sound. As mentioned above, stress is a common contributor to tinnitus, and it may be that stress affects the way the brain processes tinnitus. While tinnitus itself is not harmful, it can be a symptom of a number of underlying diseases and conditions. Here we will discuss  a few common conditions that can cause tinnitus. 

#1 Hearing loss

While not everyone with hearing loss has tinnitus, many people with tinnitus have hearing loss. In fact, it is the leading cause of tinnitus, with an estimated nine in ten tinnitus patients also experiencing some degree of hearing loss. The reason hearing loss and tinnitus are so closely tied is because damage to the inner ear cells and auditory nerve leads to decreased sensitivity to external sounds, which, in turn, causes internal neural activity to be interpreted as tinnitus.

If you have tinnitus related to hearing loss, you may be a candidate for treatment with Treble Health. Answer a few brief questions to see if we can help you manage your tinnitus.

Age Related Hearing Loss

While age related hearing loss is normal, tinnitus doesn’t necessarily worsen with age. In fact, it may improve as the brain learns to adapt to the sounds – a process known as habituation. Much like people’s ability to tune out the sound of their own breathing or chewing, the brain can also habituate to the ringing to the point where tinnitus is longer bothersome.

Auditory Trauma/Noise Induced Hearing Loss

While hearing loss may be progressive and age-related, it can also be caused by auditory trauma from loud noises or sudden sounds, and can be either temporary or permanent. Repeated and/or prolonged periods of loud noise exposure can cause damage to cells in the inner ear and nerves in the auditory system. This can lead to tinnitus even before hearing loss becomes apparent or measurable. If you are regulars around loud noises, ear plugs are a great form of hearing protection, as there are so many different options in multiple price ranges.

Viral Infections

Hearing loss can also be the outcome of a virus, causing a condition known as labyrinthitis – inflammation of the labyrinth (or inner ear). These ear-related conditions may clear up along with the underlying virus or infection. 

Medical Conditions

There are rarer medical conditions that also affect the auditory system and can lead to tinnitus. Among these is Meniere’s Disease, a disorder of the inner ear, which generally involves episodes of vertigo in addition to tinnitus and loss of hearing. An acoustic neuroma, also called a vestibular schwannoma, is a growth on either the auditory nerve or vestibular nerve that can affect functioning of the nerve fibers and the blood supply to the inner ear, often resulting in loss of hearing, tinnitus, and dizziness. Although an acoustic neuroma (a tumor on a nerve connecting the brain and ear) is usually benign, it can affect hearing and balance. Otosclerosis, is another condition that can result in loss of hearing and tinnitus, which is a condition that causes abnormal bone growth in the middle ear, resulting in poor transmission of sound. 

Other Conditions

Other ear conditions that may cause hearing loss and tinnitus include build-up of ear wax or excess middle ear fluids, often due to an ear infection. If these conditions cause blockage of sound to the ear, this can lead to tinnitus that is generally resolved when the blockage resolves. Allergies and congestion can also play a role, temporarily interfering with sound traveling into the ear, and thus making tinnitus more apparent for the duration of the blockage. 

#2 Jaw or Neck Issues

Disorders of the temporomandibular joint (TMJ) and neck can also cause tinnitus. TMJ dysfunction originates from misalignment or malocclusion of the jaw or grinding your teeth, causing inflammation and irritation of muscles around the joint of your jaw. This often leads to or exacerbates tinnitus, and people with TMJ disorders are known to be at higher risk for tinnitus. While there’s little consensus on how these disorders cause tinnitus, it’s clear that jaw issues and neck strain or pain – which can also cause inflammation and irritation – can trigger tinnitus. Medical and dental treatment have been shown to ease tinnitus symptoms. 

#3 Head Injuries

Various head traumas have been reported in up to 10% of patients seeking tinnitus treatment, and those whose tinnitus was related to trauma tended to have a higher rating of distress from their tinnitus. Moreover, about half of all traumatic brain injury cases report injury-related tinnitus. TBIs tend to be most common for people over 75 years of age, as well as those in the military and in especially high impact sports. 

#4 Chronic Health Conditions

For other medical maladies that may result in tinnitus, there are at least 200 linked to the condition – from common diseases such as diabetes and cardiovascular diseases to auto-immune disorders such as rheumatoid arthritis or lupus that cause inflammation (while causality isn’t proven, correlation is clear).

Diabetes

Diabetes is correlated to loss of hearing, and elevated blood sugar, which is a symptom of diabetes, causes damage to blood vessels that eventually affect the inner ear.

Cardiovascular Diseases

Cardiovascular diseases similarly can affect the blood supply to the inner ear resulting in damage to delicate structures of hearing and leading to tinnitus. Another issue with cardiovascular diseases is that in some cases, like with high blood pressure, forceful pressure of blood through vessels can cause an audible sound, which is known as “pulsatile” tinnitus.

#5 Stress

Significant stress is a risk factor for developing tinnitus. Stress may occur in the months leading up to the onset of tinnitus. The central nervous system is a part of the body that regulates emotional stress. Some examples of stressful periods in life include emotional problems, financial changes, moving to a new home, changing jobs, or a death in the family.

#6 Medications 

Many medications are considered “ototoxic,” meaning they can cause damage to the inner ear at certain dosages, and if you look at the side effect list of most medications, tinnitus is commonly listed as a potential side effect. In cases like these, it is important to pay attention to whether tinnitus is listed as a common or a rare side effect, as this potential damage may then result in tinnitus or even hearing loss. Fortunately, most individuals taking medications will not experience an onset of new tinnitus or a change to existing tinnitus. Ototoxic medications include certain antibiotics such as gentamicin and tobramycin (often given intravenously), chemotherapy agents (such as cisplatin and carboplatin), loop diuretics such as furosemide, and anti-malarial drugs such as quinine and hydroxychloroquine. Nonsteroidal anti-inflammatory drugs (NSAIDs) may also cause or make tinnitus worse in high dosages (like aspirin, naproxen, and ibuprofen).

Tinnitus usually resolves when stopping NSAIDs or non-ototoxic medications, but in some cases, the symptoms may be more long-term even after ceasing use. If you are concerned about the impact of these medications on your tinnitus, hearing loss, or vestibular function, it is important to consult with your health care provider to decide what the best path forward is. While medications are not always avoidable, your provider may sometimes be able to provide alternative treatment methods. In situations where medication is the only option, you can also consider having your hearing and balance monitored regularly to catch any early signs of ototoxicity.

Finding The Cause Of Tinnitus

Diagnosis

So, how is tinnitus diagnosed? For most patients, tinnitus comes on gradually. Some patients will occasionally report cases of sudden onset. In either case, it’s extremely important to see a medical professional when you experience symptoms for the first time. While tinnitus is likely benign (albeit frustrating), it’s occasionally tied to deeper issues that are wise to rule out. 

During your initial diagnostic exam – usually by an ENT or audiologist – clinicians will help determine underlying issues, if any, and make appropriate referrals for ongoing support. This first visit involves taking your medical and tinnitus-related history, and undergoing a physical exam. You’ll then be given a battery of auditory tests to evaluate your hearing, and you may even have an MRI or other imaging scans to take a closer look between your ears. 

How Do I Know Which Doctor To See First?

Audiologists, ENTs, and PCPs all play a valuable role in managing tinnitus, and it can be difficult to know which specialist should be seen first.

ENT Doctors

ENT (Ear, Nose, and Throat) Doctors diagnose, assess, and treat underlying medical issues related to the condition. This can be something as straightforward as an  ear infection, or a medical issue that may be much more serious. However, if the root cause of the tinnitus is due to a medical condition, an ENT will be crucial in the management of tinnitus.

Audiologists

Audiological evaluations are often a part of the ENT assessment. This is where they will identify whether there is any accompanying hearing loss, and if so, to what degree and if it affects one or both ears.  Audiologists are involved in the monitoring of hearing status and the non-medical management of tinnitus. In some cases, audiologists will work closely with ENT when monitoring the hearing status of someone experiencing tinnitus due to an underlying medical condition – as a change in hearing and/or tinnitus status can impact the course of treatment. In other cases, where there is not necessarily an underlying medical condition, audiologists will monitor the patients’ hearing for the purpose of management – such as programming a hearing aid. 

Tinnitus Treatments 

While the above article discusses underlying causes of tinnitus, you may find that there are certain things that exacerbate your tinnitus in daily life. For example, stress, diet, and quiet are all things that may make your tinnitus more prominent. And while the underlying condition leading to tinnitus may need evaluation and management by a medical professional, there are many tools available to you that help you learn how to mitigate the effects of exacerbating factors on your tinnitus.

There are numerous evidence-based modalities to treat tinnitus. What’s most critical amid all the advice, however, is to ensure that you co-create a plan of care with your health team that fits your unique needs and conditions. Patient care is unique to you, so it’s worth thinking about what works for your lifestyle and accounts for any “comorbidities” (that is, health concerns you may experience in addition to tinnitus). One specific treatment option is called Tinnitus Retraining Therapy (TRT) – a type of therapy that uses a combination of counseling and tinnitus maskers (also known as ear level sound generators).

Just know that whatever treatment plan you pursue, there are many options to mitigate the malaise. Sound therapy, counseling, stress-reduction, mindfulness, hearing aids, masking, and so much more. Treble Health audiologists specialize in helping patients find personalized ways to manage tinnitus, so be sure to speak to a professional to develop and monitor solutions that work for you. 

Seeking Medical Counsel 

Lastly, it’s worth noting a few occasions when it’s important to seek medical help immediately.

• If your tinnitus starts suddenly and is persistent.
• If you notice any sudden hearing loss, dizziness, or pain with your tinnitus.
• If your tinnitus is pulsating or whooshing in time with your heartbeat.
• If you have any symptoms of stroke or neurological issues, including slurred speech, difficulty walking, or weakness and numbness in your face or limbs.