Symptoms - Tinnitus

Discover the world of tinnitus, its symptoms, impacts, causes, and treatments, in this easy-to-understand review.

Understanding Tinnitus

* In this review, the term tinnitus will specifically refer to "non-pulsatile tinnitus." For information on "pulsatile tinnitus," please refer to this article.

Tinnitus is the perception of sound without any external source. This constant noise can take on many forms, including ringing, buzzing, humming, hissing or even a high-pitched tone. It affects millions of people worldwide, and while it can be a temporary or mild inconvenience for some, it can be a persistent, disruptive condition for others. This type of tinnitus can affect people of all ages and often occurs without any apparent external trigger.The severity and type of sound can vary widely among individuals.

There are different types of tinnitus. This article will focus specifically on "non-pulsatile tinnitus", which refers to a continuous, unchanging noise that isn't linked to the flow of blood or the heartbeat. People with non-pulsatile tinnitus often describe it as hearing a persistent sound that seems to come from inside the ear, even in quiet environments. It can affect one or both ears, and the intensity and frequency of the sound can vary greatly between individuals. Unlike environmental sounds, non-pulsatile tinnitus is not audible to others and is often described as an "invisible" sound.

Tinnitus Definitions

Tinnitus: The perception of sound without an external source.

Primary Tinnitus: Tinnitus that is idiopathic (no identifiable cause) and may or may not be associated with sensorineural hearing loss. This is the most common form of tinnitus.

Secondary Tinnitus: Tinnitus associated with a specific underlying cause (other than sensorineural hearing loss) such as otosclerosis, wax build-up, Ménière's disease, etc.) or an identifiable organic condition (see below).

Recent Onset Tinnitus: Tinnitus lasting less than 6 months.

Persistent Tinnitus: Tinnitus lasting 6 months or longer.

Bothersome Tinnitus: Tinnitus that distresses the patient, affects quality of life and/or functional health status. The patient seeks active therapy and management strategies.

Nonbothersome Tinnitus: Tinnitus that doesn't significantly affect quality of life but may cause curiosity about its cause or concern about its progression.

Recognizing the Signs and Symptoms

Beyond the constant ringing, buzzing, clicking, or hissing noise in the ears, tinnitus can be accompanied by a variety of symptoms depending on its cause. Some of the most common signs include:

• Hearing Loss: Tinnitus often occurs alongside hearing loss, especially in older adults or those with noise-induced hearing damage. People may notice that they struggle to hear in noisy environments or that certain sounds seem muffled.
• Ear Fullness: Some people experience a sensation of pressure or fullness in their ears, which may fluctuate with the intensity of the tinnitus.
• Hyperacusis: This is an increased sensitivity to everyday sounds. Patients with hyperacusis may find normal sounds uncomfortably loud, making social environments difficult to tolerate.
• Difficulty Concentrating: The constant noise can make it hard to focus, especially in quiet environments, which can affect work, school, or reading.
• Headache or Dizziness: In some cases, tinnitus is associated with other symptoms like headaches or dizziness, which can complicate the diagnosis.

While tinnitus itself is not typically life-threatening, it can have a significant impact on quality of life, particularly if these other symptoms are present. 

The Mental Health and Quality of Life Impact of Tinnitus

Tinnitus can take a toll on mental health, especially when the noise becomes constant or intrusive. The brain’s constant awareness of the sound can lead to anxiety, stress, and even depression. The emotional distress is often linked to a feeling of loss of control; people feel they can't escape the noise, which can lead to frustration or helplessness. In severe cases, the constant sound can create a heightened emotional response, known as "catastrophizing," where the individual fixates on the tinnitus and perceives it as unbearable.

This mental strain can become a vicious cycle: stress and anxiety can exacerbate tinnitus, while tinnitus intensifies these emotions, making it difficult for the brain to "tune out" the noise. Studies show that people with chronic tinnitus are more likely to develop anxiety disorders or depression. Managing this mental health burden is critical, and counseling or therapy is often a key component of treatment.

Cognitive Impact
Many individuals with tinnitus report difficulties with concentration and memory. The persistent noise can interfere with cognitive processes, making it challenging to focus on tasks or retain information.

Communication Difficulties
Tinnitus can make it challenging to hear and understand speech, especially in noisy environments. This can lead to social isolation as individuals may avoid social situations or struggle to participate in conversations.

Work Performance
The combination of sleep disturbances, cognitive difficulties, and emotional stress can negatively impact work performance and productivity.

How Tinnitus Affects Sleep
One of the most common complaints from people with tinnitus is that it disrupts their sleep. During the day, ambient sounds, social interactions, and other distractions can help mask the ringing in the ears. However, at night when it's quiet, the brain becomes more aware of the tinnitus, making it harder to fall asleep. For some, the noise remains disruptive throughout the night, causing frequent awakenings and resulting in poor quality sleep. Sleep deprivation can, in turn, worsen tinnitus symptoms. Lack of rest heightens the brain's sensitivity to sound, increasing the perception of tinnitus and leading to fatigue, irritability, and difficulty concentrating during the day. Establishing good sleep hygiene and, in some cases, using sound machines to mask the tinnitus can help break this cycle.

Tinnitus Handicap Inventory

The Tinnitus Handicap Inventory (THI) is a widely used questionnaire designed to assess the impact of tinnitus on a person's quality of life. It consists of 25 questions that evaluate the emotional, functional, and catastrophic effects of tinnitus. The questions explore how tinnitus affects everyday activities, emotional well-being, concentration, and sleep, as well as any associated anxiety or depression. Each question is answered with "Yes," "No," or "Sometimes," and the total score reflects the severity of the tinnitus handicap. A higher score indicates a more significant impact on the individual’s daily life. his test helps doctors understand how severe your tinnitus is and helps track if it gets better or worse with treatment. It’s a useful tool to help find the best way to manage tinnitus.

The THI is a valuable tool for healthcare providers to understand how much tinnitus is affecting a patient's life and to track changes in symptoms over time, particularly before and after treatment interventions. This helps in tailoring personalized treatment plans and monitoring progress.

Potential Causes of Tinnitus

* It is important to understand that we unfortunately often do not find a cause for tinnitus. In such cases, we would consider the tinnitus as idiopathic.

The causes of non-pulsatile tinnitus are varied and can involve different systems in the body. Some of the most common causes include:

Auditory (otologic) causes:

• The most common cause of tinnitus is sensorineural hearing loss, particularly age-related hearing loss (presbycusis) or hearing damage from exposure to loud noise.
• Conductive hearing loss such as otosclerosis, ear infections and earwax buildup can also cause tinnitus.
• Ménière's disease would cause episodes of tinnitus but with vertigo and hearing loss.
• Rarely, a tumor on the hearing nerve (such as vestibular schwannoma) could cause tinnitus that would be affecting one ear only, and usually presents with hearing loss in that same ear.

Medical Causes:

• A common medical cause is excessive caffeine intake, which is a known neuro-stimulant.
• Head traumas, concussions and neck whiplash injuries are also common.
• Hormonal imbalances (such as hypo- or hyperthyroidism), less common
• Electrolyte or vitamine imbalances, less common
• Neurologic diseases (multiple sclerosis),
• uncontrolled hypertension,
• depression and anxiety.

Medication-related causes:

• High doses of aspirin can cause tinnitus, but it would usually be reversible.
• Chemotherapy drugs can be ototoxic and permanently damage the auditory system, leading to tinnitus.
• There are other ototoxic medications, see here. 

Proprioceptive (Somatosensory) Causes: Tinnitus can also result from problems with the muscles, nerves, or joints around the head and neck. In my practice, I've observed that this is a far more prevalent cause than people realize. This is especially common in young healthy individuals with tinnitus and a normal hearing test, and in older individuals who begin to develop neck and jaw arthritis. It is unfortunately often overlooked and under-treated.

• Temporomandibular joint (TMJ) disorders can cause or worsen tinnitus due to the close proximity of the jaw joint to the ear.
• Muscle tension or inflammation in the neck or upper spine can alter nerve signals, leading to tinnitus.

Psychogenic Causes: Psychological factors, such as stress, anxiety, or depression, can contribute to the onset or worsening of tinnitus. In some cases, the brain's perception of sound can be altered by emotional states, making tinnitus more noticeable or distressing.

Effects of Alcohol on Tinnitus

Temporary Worsening
Alcohol consumption can temporarily worsen tinnitus symptoms in some individuals. This effect is often noticed during or shortly after drinking.

Dehydration
Alcohol is a diuretic, which can lead to dehydration. Dehydration can affect the balance of fluids in the inner ear, potentially intensifying tinnitus symptoms.

It's important to note that the relationship between alcohol and tinnitus can vary significantly among individuals. While some people may experience worsened tinnitus symptoms after drinking alcohol, others may not notice any change or may even report temporary relief. For those who experience tinnitus, it may be beneficial to monitor how alcohol consumption affects their symptoms and consult with a healthcare professional for personalized advice.