Under normal circumstances, environmental sounds mask this perception. Tinnitus is termed objective when it can be heard by the examiner and subjective when only the patient perceives it (which is far more common).
In the majority of tinnitus cases, no specific cause is identified.
It is frequently associated with hearing loss, but not necessarily.
Types of Tinnitus
1.Non-pulsatile tinnitus (most common ≈ 96 % )
This is typically subjective and represents a false perception of sound heard only by the patient. It is commonly described as buzzing, high-pitched ringing, clicking, or popping.
Possible associations include:
- Noise-induced most common in : Musicians/ DJs, industrial exposure to loud noise, Firearm related in Hunters and military personnel even in the presence of sound protection..
- Onset can start years after exposure
- Presbycusis ( age related hearing loss )
- Ménière’s disease
- Head injury
- Otitis media
- Medication-related causes (e.g., salicylates, NSAIDs, loop diuretics)
2. Pulsatile tinnitus (≈4%)
This form is characterized by a sound synchronous with the patient’s heartbeat and is usually due to turbulent blood flow transmitted to the cochlea. Importantly, it may have an identifiable and treatable cause.
Vascular causes include:
- Atherosclerosis of the internal carotid artery: Progressive stenosis may generate turbulent flow leading to pulsatile tinnitus
- Vascular malformations: Arteriovenous malformations or fistulas represent abnormal arterial–venous communications, either congenital or acquired (e.g., after trauma or venous sinus obstruction)
- Glomus tumours: Rare, highly vascular paragangliomas
- Glomus tympanicum arises from Jacobson’s nerve near the middle ear promontory
- Glomus jugulare originates at the jugular bulb, involving the skull base and possibly extending into the middle ear
Non-vascular causes include:
- Paget’s disease
- Otosclerosis
- Myoclonus of middle ear or palatal muscles (typically produces clicking tinnitus rather than a vascular bruit)
Investigations
Hearing test for all cases: to detect hearing thresholds and possible cause:
Unilateral tinnitus with hearing loss: MRI is indicated to exclude vestibular schwannoma (acoustic neuroma).
Pulsatile tinnitus: MR or CT angiography is recommended.
Suspected carotid stenosis: Carotid duplex ultrasound may be helpful.
Arteriography: Reserved for selected cases due to the small associated risk of cerebrovascular accident.
Treatment
In most cases, reassurance is sufficient, as tinnitus is common and many patients adapt over time.
Symptoms often worsen in quiet environments (e.g., at bedtime), and anxiety about tinnitus may exacerbate perception.
- 1.Treat underlying causes when identified (e.g., hypertension, carotid stenosis, medication effects)
- 2.Behavioural therapy and tinnitus retraining therapy (TRT) provided by audiology specialists can help selected patients develop coping strategies
- 3.Sound generators may be useful for sleep disturbance through masking
- 4. Hearing aids can improve tinnitus in patients with hearing loss via masking effects
- 5. Some Natural supplements are used to improve Tinnitus as Gingko biloba, that improved microcirculation of the inner ear, However it is no consistently proven by high quality studies according to the American academy of Otolaryngology
