Tinnitus — Ringing, Buzzing in the Ears: When Is It the Brain and Not the Ear?

Tinnitus — the perception of sound (ringing, buzzing, hissing, clicking) without an external source — affects approximately 15% of adults. Most tinnitus is benign and associated with hearing loss from noise exposure or ageing. But a minority of tinnitus presentations indicate serious underlying pathology — vascular anomalies, acoustic neuroma, or raised intracranial pressure — that require investigation.

Types of Tinnitus

Subjective tinnitus (heard only by the patient): The most common type. Usually related to cochlear or auditory nerve dysfunction. Causes: noise-induced hearing loss (headphones, occupational noise, firecrackers — a major cause in India during Diwali); age-related hearing loss; Menière's disease; ototoxic medications (aminoglycoside antibiotics, high-dose aspirin, certain chemotherapy agents); earwax impaction pressing on the eardrum.

Pulsatile tinnitus (heard as a rhythmic beat synchronised with the heartbeat — sometimes audible to the examiner): This is the type that requires urgent investigation. Causes: glomus tumour (vascular tumour near the ear); arteriovenous malformation; carotid artery stenosis or dissection; idiopathic intracranial hypertension (raised CSF pressure); dural arteriovenous fistula. The beating, pulsing quality is the key distinguishing feature — if tinnitus pulses with the heartbeat, it must be investigated.

When Tinnitus Needs Urgent Neurological Assessment

• Pulsatile tinnitus — especially if new or worsening
• Tinnitus in one ear only, particularly if accompanied by any hearing loss on that side — acoustic neuroma must be excluded
• Tinnitus associated with headache (especially positional), visual disturbance, or double vision — suggests raised intracranial pressure
• Tinnitus following head trauma — may indicate temporal bone fracture or vascular injury
• Rapidly progressive or sudden onset tinnitus with hearing loss — sudden sensorineural hearing loss (requires urgent treatment within 72 hours)

Assessment of Tinnitus

Pure tone audiogram: baseline hearing assessment — essential for all tinnitus patients. MRI brain with gadolinium: for unilateral tinnitus (to exclude acoustic neuroma at the cerebellopontine angle). MRI/MRA for pulsatile tinnitus. Blood tests: thyroid function, anaemia, blood pressure.

Management of Benign Tinnitus

No single treatment cures most tinnitus. Effective management strategies: hearing aids (amplification reduces tinnitus perception in those with hearing loss); sound therapy/white noise (masking reduces tinnitus salience); tinnitus retraining therapy (TRT) — cognitive and acoustic habituation; treating anxiety and depression (strongly associated with tinnitus distress); avoiding silence (tinnitus is worse in quiet environments — background music or white noise at night).

For tinnitus evaluation: Sri Anand CNC, Chanda Nagar, Hyderabad. Call +91 90633 66983.