Red flag symptoms: Tinnitus

Provide reassurance but watch out for serious underlying causes.

Hearing aids can 'mask' tinnitus
Hearing aids can 'mask' tinnitus

Tinnitus (from the Latin for ringing) is a common ear complaint which can affect people of all ages.

At least 15 per cent of the UK population experience it at some stage, and for a few patients it can lead to a significant and permanent impairment of their subjective well-being.

Tinnitus is defined as perceived noise in one or both ears in the absence of an external stimulus. Patients describe whistling, hissing, humming or clicking noises, or a mixture of sounds.

We all have a degree of noise in our ears, probably caused by baseline electrical activity and natural blood flow within the ear. However, these sounds do not normally reach our consciousness.

The possible causes for tinnitus are manifold: noise exposure and hearing loss are the most common causes, but ear wax, head injuries, infections and certain medications may also lead to tinnitus, although frequently there is no apparent single cause.

Medications that have been implicated as causes of tinnitus include aspirin, diuretics and certain antibiotics.

A triad of rotational vertigo, hearing loss and tinnitus suggests Meniere's disease. This is, however, a rare condition.

Pulsatile tinnitus may indicate a vascular malformation, obstruction (typically in the carotid artery) or a glomus tumour.

Occasionally tinnitus is accompanied by hyperacusis, an exaggerated perception of certain sounds or frequencies. This indicates cochlear damage.

When to refer
Patients should be referred to the ENT clinic if tinnitus is unilateral, has appeared suddenly, or is causing significant physical or psychological distress, or additional symptoms, such as vertigo or neurological deficits are present. Pulsatile tinnitus will also require a much more detailed assessment.

Management
Tinnitus is naturally masked by background noise, which is why hearing loss often makes the condition worse. Increasing background noise can therefore improve tinnitus, and hearing aids, maskers and sound therapy are effective treatments.

Surgical approaches, such as ablation of the auditory nerve, can cause permanent hearing loss and exacerbate tinnitus, so should be avoided in most cases.

Acoustic neuromas, which typically cause unilateral tinnitus, are unlikely to be operated on as they tend to grow extremely slowly, if at all.

Reassurance
Patients often worry that brain tumours or significant cardiovascular events are the cause for their tinnitus.

They need to be reassured that such malignant causes are atypical, especially in the absence of any other symptoms.

Many patients notice that stress, anxiety and fatigue worsen tinnitus, and relaxation techniques and antidepressants may be useful to some.

Providing reassurance and information can prevent a patient from becoming chronically unwell or from trying unproven and possibly expensive alternative treatments, such as Ginkgo biloba.

While some patients may find tinnitus self-help groups helpful and supportive, for some they may reinforce the illness and exacerbate frustration with the lack of effective medical treatment.

Patients with long-standing tinnitus and dysfunctional coping strategies can have a poor prognosis, although some specialist clinics might be able to offer successful retraining therapy combined with appropriate psychological support.

  • Dr Jacobi is a salaried GP in York
Possible causes
  • Hearing loss
  • Noise
  • Obstruction of ear canal (wax)
  • Infections
  • Medication side-effects
  • Idiopathic
  • Meniere's disease
  • Tumours (acoustic neuroma, glomus tumour)
  • Unilateral
  • Sudden onset vertigo
  • Neurological symptoms
  • Pulsatile
  • Severe functional or psychological distress.

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