Tinnitus

Disease Description (Causes and Symptoms)

Disease name: Tinnitus (Tinnitus)

• Definition: A symptom in which a sound is perceived in the ear or inside the head despite there being no external sound source; only the patient can perceive it.
• Main causes and pathophysiology
  • Auditory tinnitus (approximately 85%): Damage to or dysfunction of the inner ear or auditory nerve (presbycusis, noise-induced hearing loss, sensorineural hearing loss, Ménière’s disease, sudden sensorineural hearing loss, etc.) → abnormal peripheral signals are perceived as tinnitus in the central auditory system.
  • Non-auditory (somatic) tinnitus: Caused by vascular conditions (hypertension, atherosclerosis, vascular malformations, vascular tumors, etc.), muscular conditions (spasms of muscles around the ear or in the neck or jaw), systemic diseases (anemia, thyroid disease, diabetes), or temporomandibular joint and cervical spine abnormalities, and transmitted through the auditory pathways.
• Symptom characteristics
  • Sound patterns: High-pitched metallic sounds, buzzing, hissing, insect sounds, or the sound of wind or flowing water, etc. A simple tone is common (approximately 3/4 of cases), but complex sounds are also possible.
  • Usually worsens when the surroundings are quiet or when the person is tired, sleep-deprived, stressed, or nervous.
  • Depending on the cause, hearing loss or dizziness (such as in Ménière’s disease) may occur.
• Findings suggesting an emergency (requiring emergency evaluation)
  • Sudden unilateral hearing loss, pulsatile tinnitus (synchronized with the heartbeat), or progressive neurological deficits (such as sensory or motor abnormalities in the limbs).

Treatment Methods

• Initial evaluation and treatment of the cause
  • Otolaryngology examination (assessment of the external and middle ear), pure-tone audiometry, and tinnitus testing (subjective tinnitus assessment).
  • If necessary, ABR (auditory brainstem response), temporal bone CT or MRI (particularly when accompanied by unilateral or progressive hearing loss or when a tumor or vascular lesion is suspected), blood tests (for thyroid disease, anemia, etc.), and blood pressure measurement may be performed.
  • If an underlying disease (chronic otitis media, Ménière’s disease, thyroid disease, hypertension, etc.) is identified, treat that condition.
• Core non-pharmacological treatments
  • Tinnitus retraining therapy (TRT): Combines counseling and education with sound exposure (such as white noise) to promote habituation to tinnitus — the behavioral therapy with the strongest supporting evidence.
  • Cognitive behavioral therapy (CBT): Helps improve anxiety, depression, and sleep disorders caused by tinnitus.
  • Sound therapy: Provides environmental sounds through hearing aids (when hearing loss is present) or sound generators (maskers) to relieve symptoms.
• Adjunctive and pharmacological treatments
  • Medication: There is no specific medication that directly cures tinnitus. When anxiety, sleep disorders, or depression are present, antidepressants, anxiolytics, or sleeping pills may be prescribed short-term to relieve symptoms. (Evidence of efficacy is limited.)
  • Some supplements (e.g., Ginkgo biloba) have limited supporting evidence.
  • If a medication (an ototoxic drug) is suspected to be the acute cause, discontinuation or replacement of that medication may be considered (consult a doctor).
• Procedures/surgery
  • In cases of structural lesions (vestibular schwannoma, vascular malformation, etc.), treatment appropriate to the lesion, such as surgery or radiation therapy, is performed after imaging studies.
• Lifestyle management and precautions
  • Avoid exposure to loud noise (using earplugs, etc.), limit excessive caffeine, nicotine, and alcohol consumption, get sufficient sleep, manage stress, and avoid overwork.
  • Ototoxic drugs (aminoglycoside antibiotics, high-dose diuretics, anticancer drugs, some anti-inflammatory drugs, etc.) should be adjusted after consultation with the attending physician.
  • Excessive anxiety caused by tinnitus may worsen symptoms, so early counseling and psychotherapy are recommended.

Checklist Before an Outpatient Visit (Including Example Questions)

Items and records to prepare

• List of currently used medications (including prescription drugs, over-the-counter drugs, and supplements)
• When the symptoms began and how they have progressed (when they first started, and whether the onset was sudden or gradual)
• Record of tinnitus characteristics: unilateral/bilateral, type of sound (buzzing, piercing, pulsatile, etc.), persistence (constant/intermittent), and situations that worsen it (quiet surroundings, stress, etc.)
• Accompanying symptoms: hearing loss, blocked-ear sensation, ear fullness, dizziness, headache, visual disturbances, or neurological symptoms
• History of noise exposure (military service, concerts, occupational noise, etc.) and whether there has been recent ear trauma, ear infection, or head trauma
• Results of previous hearing or imaging tests (if available, bring photographs or reports)
• Sleep patterns, caffeine, alcohol, and smoking habits, and stress level

Example questions during the medical history interview (items that are useful for the patient to write down)

• When did the tinnitus first start? Did it begin suddenly?
• Is the sound heard in only one ear, or in both ears?
• Are there specific situations in which the tinnitus worsens or improves? (Position, chewing, moving the neck, etc.)
• Have you recently started any new medication among the medicines you have taken?
• How much does it affect daily life (sleep, concentration, and work)?

General Example Questions to Ask the Doctor

• How extensively should the cause of my tinnitus be investigated? Which tests do you recommend?
• Based on my test results, what is the prognosis? Can it be cured?
• Which lifestyle factors must I avoid?
• What are the side effects and duration of use of my current medications (or the medications I may be prescribed)?
• If regular follow-up tests (hearing tests/imaging) are needed, at what intervals should they be performed?

Examples of Disease-Specific Questions

• (When accompanied by unilateral or progressive hearing loss) "I have tinnitus in only one ear, along with hearing loss. Should vestibular schwannoma (acoustic neuroma) be ruled out with MRI (or ABR)?"
• (For pulsatile tinnitus) "My tinnitus is synchronized with my pulse. Which imaging tests (ultrasound, CT angiography, or MR angiography) do you recommend to check for a vascular lesion (such as stenosis of the neck or inner ear artery, or a venous varix)?"

When an urgent hospital visit is needed: If sudden unilateral hearing loss, pulsatile tinnitus, severe dizziness and vomiting, or progressive neurological abnormalities occur, seek emergency care or specialist evaluation immediately.