OVERVIEW
• Tinnitus is a sensation of sound within the ear or head that not due to external noise.
• The sound generally has a ringing, buzzing, or humming quality but can be of any nature
• It may be unilateral or bilateral.
• It may come and go. It may or be persistent
• There may or may not be associated hearing loss.
• It can occur at any age, but is more common among the elderly
• Around 10-15% of the population suffer from tinnitus. In most cases, it is mild and does not cause any disturbance, but for approximately 1% of people, it may disrupt concentration, work and sleep, leading to considerable stress.
• Tinnitus isn’t a disease per se — it’s a symptom of an underlying condition, such as ear injury, age-related hearing loss or a circulatory system disorder.
• Identifying and treating any underlying cause sometimes helps. Usually, treatment measures include reduction or masking the noise, to make the tinnitus less bothersome.

TYPES OF TINNITUS
There are two types of tinnitus
• Subjective tinnitus is tinnitus only audible to the patient. This is the most common type. It can be caused by ear problems, problems with the hearing (auditory) nerves or the part of the brain that interprets sound.

• Objective tinnitus is tinnitus the doctor hears when he or she does an examination. This rare type can be caused by a blood vessel disorder, a middle ear bone condition or muscle spasms in the inner ear

RISK FACTORS OF TINNITUS
• Increasing age
• Male gender
• Smoking
• Prolonged noise exposure
• Underlying cardiovascular disease

TINNITUS CAUSES
EAR PROBLEMS CAUSING TINNITUS
• Age associated hearing loss
• Prolonged exposure to loud noise – eg portable music devices, gunshot etc
• Earwax accumulation in the ear canal
• Otosclerosis (bony changes in the ear ossicles)
• Meniere’s disease (inner ear condition due to abnormal inner ear fluid pressure)
• Disorders of the temporomandibular joint (TMJ)
• Acoustic neuroma (benign tumor of the VIIIth cranial nerve, unilateral tinnitus)
• Eustachian tube dysfunction due to radiation, pregnancy, sudden significant weight loss
• Muscle spasms in inner ear

CIRCULATORY DISORDERS CAUSING TINNITUS
• Hypertension
• Arteriovenous malformations (unilateral tinnitus)
• Atherosclerosis
• Head and neck tumors
• Turbulent blood flow

DRUGS CAUSING TINNITUS
• Anti-cancer drugs – methotrexate, cisplatin
• Diuretics – bumetanide, furosemide, ethacrynic acid
• Antibiotics – erythromycin, vancomycin, polymyxin B, neomycin
• Quinine preparations
• Antidepressants
• High doses of aspirin
• Caffeine and nicotine
• Certain herbal supplements

SYMPTOMS OF TINNITUS
As previously stated, tinnitus is an abnormal noise (or noises) heard by the patient that doesn’t come from external sources. The types of noises that people hear include

• Ringing
• Buzzing
• Whistling
• Humming
• Roaring
• Clicking
• Hissing

COMPLICATIONS OF TINNITUS
• Fatigue
• Anxiety and irritability
• Stress
• Sleep issues
• Difficulty concentrating
• Memory issues
• Depression

Treating these associated problems may not cure the tinnitus, but may help improve the quality of life.

DIAGNOSIS OF TINNITUS
Physical examination – An ENT specialist will perform a detailed physical examination to rule out any ear conditions that may be causing the tinnitus.

Movement – The patient will be asked to move his eyes and neck, clench the jaw, or move the arms and legs to check if the tinnitus worsens. This may signify an underlying disorder that needs treatment

Audiology test – The patient sits in a soundproof room wearing earphones that will relay specific sounds into one ear at a time. The patient indicates when they hear the sound, and the results are compared with results normal for the patient’s age and sex. This helps to identify or rule out possible causes of tinnitus.

Imaging tests – Imaging tests such as CT or MRI scans may show tumors or other possible causes of tinnitus.

Unfortunately, in many cases, the cause of tinnitus is never found. The doctor may then discuss possible steps to take to reduce the severity of the tinnitus and cope with the noise better

TREATMENT OF TINNITUS
While medication may be used for tinnitus, especially to treat associated factors such as anxiety and depression, there is no drug approved specifically for the treatment of tinnitus. Treatment focuses mainly on providing methods to cope with the tinnitus better.

TREATING ANY UNDERLYING CAUSE
• Earwax removal can decrease tinnitus symptoms.
• Underlying vascular conditions may require medication, surgery or other forms of treatment
• If a medication appears to be the cause of tinnitus, the doctor may advise stopping or reducing the drug, or switching to a different drug.

NOISE SUPPRESSION
• White noise machines produce simulated environmental sounds such as ocean waves or falling rain or ocean waves, to reduce tinnitus symptoms. A white noise machine with pillow speakers can help with sleep. Fans, air conditioners or humidifiers in the bedroom also may help cover the internal noise at night.
• Hearing aids can be especially helpful if there are associated hearing problems with the tinnitus.
• Masking devices similar to hearing aids, produce a continuous, low-level white noise that reduces symptoms of tinnitus.
• Tinnitus retraining – A wearable device delivers individually programmed tonal music to mask the specific frequencies of the tinnitus the patient may experience. This therapy may accustom the patient to the tinnitus, and to avoid focusing on it. Counseling is an important component of tinnitus retraining.

MISCELLANEOUS MEASURES TO REDUCE TINNITUS
• Avoid total silence as it can enhance symptoms of tinnitus
• Avoid loud and noisy situations
• Manage and avoid stress where possible
• Get sufficient sleep and rest
• Avoid watching TV or reading in bed
• Avoid stimulants at night
• Exercise regularly
• Identify triggers and avoid them
• Practise relaxation techniques such as yoga and deep breathing