Tinnitus, often described as a “storm in the ear” – a phrase dating back 2,000 years in Egypt – is a condition that significantly impacts quality of life and is frequently linked to underlying psychiatric conditions. The condition affects a substantial portion of the population, with prevalence increasing with age. Approximately 13.7% of individuals between 45 and 64 years old experience tinnitus, rising to one in four people over the age of 64. This increase is attributed to both psychosocial factors associated with aging and the progressive, age-related decline in hearing.
Tinnitus is categorized as either acute or chronic, with the transition occurring after three months. The vast majority of cases – around 95% – are subjective, meaning the sound is perceived only by the individual. Subjective tinnitus can stem from a variety of causes, including noise exposure, age-related hearing loss (presbyakusis), inflammation of the middle ear (otitis media), sudden hearing loss, Menière’s disease, and otosclerosis. Less common is objective tinnitus, which is audible to an examiner and can be pulsatile (synchronized with the heartbeat) or muscular in origin. Conditions like tubal dysfunction, retrocochlear masses, and temporomandibular joint pathologies can also contribute to objective tinnitus.
A crucial step in evaluating tinnitus is ruling out dangerous underlying causes, particularly in cases of pulsatile tinnitus. Vascular malformations, such as arteriovenous malformations (AV malformations) or glomus tumors, and atherosclerotic narrowing of arteries, like carotid stenosis, require careful investigation. The severity of tinnitus and its impact on a patient’s life can be assessed using tools like the Tinnitus Handicap Inventory, which evaluates emotional distress, social interaction difficulties, cognitive impairment, and behavioral changes, including sleep disturbances and difficulty coping with daily life.
Distinguishing between compensated and uncompensated tinnitus is also important. Uncompensated tinnitus has a more substantial negative impact on quality of life and can be associated with anxiety, sleep disorders, and even suicidal ideation. Initial evaluation involves checking blood pressure and pulse to rule out hypertensive disorders, and auscultation of the neck to identify any pulse-synchronous flow murmurs. Further investigations, such as Doppler ultrasound of the brain’s arteries, may be necessary if an AV fistula or glomus tumor is suspected. Assessment of the temporomandibular joint, looking for pain or bruxism (teeth grinding), may also be warranted.
If tinnitus occurs alongside hearing loss, an otolaryngological (ENT) consultation is essential. Ear microscopy can help identify chronic inflammation, such as a cholesteatoma. Transnasal fiber endoscopy can visualize the internal ear canal and assess Eustachian tube function. A comprehensive hearing test, including reintonaudiometry, tinnitus matching (to determine the pitch and loudness of the perceived sound), speech audiometry, tympanometry, stapedius reflex testing, and otoacoustic emissions, provides a detailed assessment of auditory function.
Additional diagnostic tests may include brainstem audiometry, vestibular testing (if dizziness is present), MRI of the cerebellopontine angle (particularly in cases of asymmetrical hearing loss to rule out a vestibular schwannoma), and angio-MRI or angio-CT scans for pulsatile tinnitus. Once dangerous causes have been excluded, the focus shifts to explaining the condition to the patient and reassuring them that the diagnosis is not life-threatening.
Treatment for tinnitus is highly individualized, based on severity, level of distress, patient expectations, co-existing conditions, and the underlying cause. A key component of management is developing coping strategies. For patients with hearing loss, hearing rehabilitation – including hearing aids or, in some cases, cochlear implants – can help restore auditory input and reduce the perception of tinnitus. Devices that generate background noise to mask tinnitus have not been shown to be consistently effective.
Current guidelines, such as the S3 guideline on chronic tinnitus, generally advise against the use of medication specifically to treat tinnitus due to a lack of robust evidence. Corticosteroids are an exception only in the acute stage when tinnitus is associated with sudden hearing loss. Research on Ginkgo biloba has yielded inconclusive results, although it may be considered, particularly in patients with dementia and tinnitus. Melatonin may be helpful in addressing sleep disturbances often associated with tinnitus, while betahistine, cannabinoids, and dietary supplements are not recommended due to insufficient evidence.
Cognitive behavioral therapy (CBT) is the most well-studied and effective treatment for tinnitus. Studies have demonstrated its positive effects not only on the perceived loudness of tinnitus but also on depressive symptoms and overall quality of life. Tinnitus apps can also assist patients in developing habituation strategies, though they are generally less effective than formal CBT. Finally, it’s crucial to recognize and address any co-existing psychiatric conditions, such as anxiety, adjustment disorders, sleep disorders, and depression. In severe cases, a six-week inpatient tinnitus program offering a range of therapies – including acupuncture, breathing exercises, relaxation techniques, physiotherapy, psychotherapy, and hearing aid support – may be considered.
