Tinnitus: Causes, Symptoms, and Treatment Options - Otolaryngology

Dr. Ye Dawei reply Otolaryngology

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Xiao Xun, your tinnitus issue is not significantly related to hepatitis B or sleeping on your side.
Here is the information for your reference:
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【"Local Surrounding the Central" – Correct Concepts for Treating Tinnitus】
Mr.
Chang Junhong from the Democratic Progressive Party wrote a small book years ago titled "The Path to Governance – The Theory and Practice of 'Local Surrounding the Central'." In it, he discussed how the opposition party could first gain local governance through elections in various counties and cities in Taiwan, and then push towards the central government and even the presidential election.
This strategy of surrounding the central government from the local level can also be applied to the diagnosis and treatment of the bothersome condition known as tinnitus.
Tinnitus is a very subjective experience.
After a basic local examination by an otolaryngologist, which rules out earwax or otitis media, the doctor often arranges for a hearing test.
If hearing loss is present and is of a neurological nature, the doctor can only advise oral medications to prevent further deterioration of hearing, but there are no specific remedies for tinnitus treatment.
If the hearing test shows normal results, it is often considered purely a psychological issue.
The concept of "local surrounding the central" suggests that tinnitus is rarely a singular event; patients often have other underlying conditions alongside their tinnitus, and it is very likely that tinnitus is merely one clinical manifestation of these diseases.
If treatment can be approached from the perspective of other clinical symptoms, and if these objective symptoms (like "local") improve, leading to the subjective tinnitus (like "central") disappearing, we can consider the treatment successful.
With the prosperity of the economy, there has been a corresponding increase in patients with hypertension and hyperlipidemia.
Changes in entertainment among younger populations, such as KTV, concerts, and personal music devices, are also major causes of noise-induced tinnitus.
The intense competition in industrial society has led to vascular spasms in the cochlea, and the aging population has resulted in more cases of age-related vascular tinnitus.
These are all factors that an otolaryngologist must consider when treating tinnitus.
Below is an introduction to diseases related to tinnitus.
● Classification of Tinnitus
"Tinnitus is the gradual onset of deafness," and "if tinnitus persists, it will lead to deafness." These ancient phrases highlight the serious potential of tinnitus to cause significant hearing loss.
The English term for tinnitus comes from the Latin word meaning "to ring." Scholars typically classify tinnitus based on its causes as follows:
○ Cochlear Tinnitus
Cochlear tinnitus, as the name suggests, is tinnitus caused by inner ear disorders.
The most well-known conditions include Meniere's disease and the increasingly common sudden sensorineural hearing loss.
I have previously discussed this in "A Discussion on Dizziness," and I will reiterate it here.
1.
Meniere's Disease
When the general public thinks of dizziness, they often think of "Meniere's," and even general practitioners may diagnose it as such.
However, there are not as many cases of Meniere's disease as one might think; many patients who complain of dizziness are often overdiagnosed by physicians.
If the number of Meniere's cases is disproportionately high among patients in a neurotology clinic, the physician's competence may be called into question.
In simple terms, if a patient presents with dizziness, tinnitus, and hearing loss, the physician will consider this disease.
The renowned Japanese physician Ichiro Kitabatake even described it as a "7 points disease" due to the following characteristics:
1) Severe dizziness: It feels as if the world is spinning and can last for several hours, with the first episode being the most intense.
2) Spontaneous dizziness: It occurs without any apparent trigger and can happen suddenly.
3) Recurrent dizziness: Patients with Meniere's disease often experience repeated episodes, rarely just a single occurrence.
4) Reversible dizziness: There are periods of complete normalcy between episodes; dizziness does not persist for days.
5) Dizziness accompanied by cochlear nerve symptoms: Patients often experience fluctuating hearing, severe tinnitus during acute episodes, and sometimes perceive sounds at different frequencies.
6) Hearing loss is often more pronounced at low frequencies.
7) There is a "reverberation phenomenon," where patients often complain of discomfort in noisy environments like markets or stations.
To date, no laboratory tests can definitively diagnose Meniere's disease, making a detailed medical history and basic physical examination crucial.
Patients often experience unforgettable episodes of severe dizziness accompanied by tinnitus, a feeling of ear fullness, and hearing loss.
These episodes do not occur daily and last longer than the brief episodes seen in benign paroxysmal positional vertigo, nor do they last as long as vestibular neuritis.
Most patients experience dizziness for about 3 to 4 hours before gradually improving, but episodes may recur weeks later.
Many elderly patients report having experienced recurrent dizziness since their youth, with gradual hearing loss and persistent tinnitus over time.
This condition typically occurs between the ages of 20 and 40 and has a maternal inheritance pattern.
The cause is believed to be endolymphatic hydrops in the inner ear, leading to a sensation of ear fullness.
Treatment primarily involves medical management, including neurotropic agents, vasodilators, and mild sedatives.
If episodes occur once a month, treatment should last at least four months; if they occur every two months, treatment should last at least five months, which is the interval between episodes plus three months.
If medication is ineffective or the patient cannot tolerate long-term medication, endolymphatic sac decompression surgery may be considered.
2.
Sudden Sensorineural Hearing Loss
"Sudden" means that the patient can clearly indicate a specific day or even a moment when they suddenly lost hearing or experienced severe ringing.
This is considered an otolaryngological emergency, and patients are generally advised to seek immediate hospitalization.
Some patients may also experience dizziness and vomiting, necessitating a differential diagnosis from Meniere's disease.
Typically, there is only one episode of dizziness, lasting a day or several days, after which it does not recur, but hearing loss and tinnitus persist.
In contrast, Meniere's disease involves recurrent dizziness, but hearing often recovers more quickly after an episode.
A small number of acoustic neuroma cases may present with sudden sensorineural hearing loss, requiring a CT scan for differential diagnosis.
The causes are widely accepted to include inner ear circulatory disturbances, viral infections, and autoimmune diseases, with treatment now focusing on specific potential causes rather than a "shotgun" approach.
1) Inner ear circulatory disturbances: These occur due to obstruction or spasm of the blood vessels supplying the inner ear, leading to hypoxia and hearing impairment.
This is more common in patients with systemic vascular diseases such as diabetes, hypertension, or hyperlipidemia.
Therefore, treatment primarily involves plasma expanders (Dextran), which is a glucose polymer with a molecular weight of 40,000 that reduces blood viscosity and prevents thrombosis.
2) Viral infections: Many viruses can infect the inner ear, such as the rubella virus and cytomegalovirus, which can cause congenital deafness in fetuses; mumps virus, measles virus, varicella-zoster virus, and recently prevalent influenza viruses can cause acquired hearing loss.
Treatment involves administering corticosteroids, starting with 60 mg per day for six days, then tapering over two weeks.
3) Autoimmune diseases: Patients often have systemic autoimmune diseases such as systemic lupus erythematosus or rheumatoid arthritis, and typically experience bilateral hearing loss.
Diagnosis is initially based on medical history, physical examination, and electronystagmography (ENG) to differentiate between central and peripheral causes.
Patients are generally advised to be hospitalized for at least a week; if hearing does not improve, they may be discharged, but if there is improvement, they may stay for another week.
During hospitalization, daily hearing tests and eye movement changes are recorded, and follow-up every two weeks after discharge is recommended for three months.
Prognostic indicators include: 1) earlier treatment leads to better outcomes; 2) high-frequency loss has a poorer prognosis; 3) those with dizziness have a worse prognosis, while those with tinnitus still have cochlear nerve function, indicating a better prognosis; 4) older age correlates with a poorer prognosis.
○ Noise-Induced Tinnitus
Generally, noise-induced tinnitus can be divided into chronic noise exposure and acute trauma-induced tinnitus.
The former results from long-term exposure to noisy environments, while the latter can occur from events such as explosions, gunfire, fireworks, or the popular rock concerts and personal music devices among today's youth.
1.
Chronic Noise-Induced Hearing Loss
The modern industrialized society has brought prosperity but also created a noisy environment.
Many work environments can lead to this occupational hazard, such as railways, factories, airports, auto repair shops, DJs, video game store employees, and stockbrokers.
Noise levels below 80 decibels are less likely to cause hearing damage, but exposure to noise levels exceeding 100 decibels for over 8 hours can easily lead to temporary threshold shifts.
If one avoids noisy environments quickly, hearing can recover.
However, if permanent threshold shifts occur, hearing loss is irreversible.
Pathologically, one can observe degeneration of outer hair cells and fusion or loss of stereocilia in the inner ear, which is an irreversible tissue injury.
Labor safety regulations have established permissible exposure limits to continuous or intermittent noise to protect workers' hearing, which can be referenced for daily life and work.
In principle, the maximum allowable industrial noise level is 90 decibels, and exposure should not exceed 8 hours per day.
2.
Acute Trauma-Induced Hearing Loss
Acute trauma-induced hearing loss refers to inner ear damage caused by intense external sound stimuli over a short period.
This is a direct physical injury from mechanical waves.
Young people often frequent rock concerts, karaoke, and pubs, and may experience tinnitus, hearing loss, and a feeling of ear fullness the following day, which can be termed "disco deafness," "karaoke deafness," or "personal music device deafness." After the presidential election, several patients presented in the clinic with symptoms of ear fullness, ear pain, and tinnitus after exposure to loudspeakers at campaign headquarters, which could also be termed "election deafness." Additionally, the high-pressure shock waves from the recent explosion in Wall Street lasted more than 1.5 milliseconds, while the shock waves from gunfire typically last less than 1.5 milliseconds.
Unlike irreversible hearing loss from long-term noise exposure, these acute cases are due to transient auditory trauma, and medication treatment is very effective.
It is strongly recommended to seek prompt treatment to restore hearing.
However, if noise levels exceed 130 decibels and exposure is prolonged (such as continuous firecrackers during celebrations), it can also lead to decreased auditory fatigue, similar to the irreversible damage caused by chronic noise exposure.
○ Metabolic Tinnitus
The most common cause of metabolic tinnitus among the population is hyperlipidemia, which has surged due to the economic prosperity of modern society, leading to widespread nutritional excess.
In neurotology clinics, as many as 10% of patients may suffer from this condition.
Patients with hyperlipidemia often complain of persistent "dizziness, brain fog, and tinnitus," experiencing an indescribable discomfort.
The mechanisms causing tinnitus include: 1.
The blood vessels in the inner ear are very delicate and lack collateral circulation, making it easy for lipids to deposit in the cochlea.
2.
Increased blood viscosity can lead to poor circulation and embolism in the inner ear vessels.
Patients with hyperlipidemia seen in internal medicine often have other conditions such as hypertension, diabetes, atherosclerosis, or heart disease, requiring several months of medication before seeing effects.
In contrast, patients with hyperlipidemia seen in neurotology clinics often present with tinnitus and dizziness as their initial symptoms, without accompanying internal diseases.
Typically, they feel significantly better after just one week of medication.
Among all symptoms, dizziness responds best to treatment, followed by tinnitus, while hearing loss shows no improvement.
If blood lipid levels normalize after stopping medication, patients are likely to relapse if they do not pay attention to their diet.
However, once they resume medication, they immediately feel relieved.
Subsequent blood tests show that lipid levels have returned to normal, supporting our hypothesis.
○ Vascular Tinnitus
The vertebral artery supplies blood to the brain and inner ear, merging with the basilar artery and branching into the anterior inferior cerebellar artery, posterior inferior cerebellar artery, and superior cerebellar artery.
If the arteries supplying the inner ear become obstructed or spasmodic, it can easily lead to ischemia in the inner ear, causing abnormal discharges in the auditory nerve, clinically presenting as tinnitus.
Patients often experience dizziness, nausea, vomiting, and hearing loss, and may also have systemic symptoms such as occipital headaches, neck and shoulder pain, and numbness in the limbs due to insufficient blood supply to the posterior cranial fossa.
Most patients are elderly and often have comorbidities such as hypertension, diabetes, heart disease, and hyperlipidemia.
For vascular tinnitus, which arises from poor blood circulation, traditional treatment often involves vasodilators to achieve therapeutic effects.
However, for vascular narrowing caused by atherosclerosis, vasodilators cause systemic vasodilation and cannot selectively dilate only the inner ear vessels.
It is now widely accepted that treatment should focus on improving hemodynamics, increasing the deformability of red blood cells, and reducing blood viscosity to ensure that the inner ear receives adequate oxygen and nutrients.
"Vasoactive agents," which are medications targeting this concept, can be derived from natural ginkgo biloba extracts or synthesized artificially.
Red blood cells have a diameter of about 7 micrometers, while the true diameter of capillaries is only 3 to 4 micrometers.
These medications can enhance the deformability of red blood cells, allowing them to pass more easily through narrowed vessels; they can also act on blood vessels to reduce spasms and prevent platelet aggregation, thus promoting smooth blood flow.
○ Tumor-Related Tinnitus
In otolaryngology, unilateral tinnitus should raise suspicion for two types of tumors: nasopharyngeal carcinoma and acoustic neuroma.
This disease has also been discussed in "A Discussion on Dizziness," and I will post it again.
◎ Acoustic Neuroma
The auditory nerve runs from the inner ear to the brainstem, with tumors most commonly occurring at the opening of the internal auditory canal, specifically at the cerebellopontine angle (CP angle).
Initially, patients may only experience gradual unilateral hearing loss or tinnitus.
This tumor grows very slowly, so even if it compresses the vestibular nerve, central compensation may prevent dizziness.
As the tumor enlarges and compresses blood vessels, it can lead to sudden hearing loss or dizziness, and symptoms can become very diverse as the disease progresses.
If an acoustic neuroma is confined to the internal auditory canal and is less than 1 cm, it may be difficult to detect on a CT scan.
Some have attempted to perform a lumbar puncture to introduce air into the cerebral ventricles, allowing the patient to lie on their side to see if air can fill the internal auditory canal; if an acoustic neuroma is present, the air will not fill the canal, known as "air CT." Its drawback is that patients may experience continuous headaches for about a week due to the air in the skull.
With the advent of magnetic resonance imaging (MRI), tumors smaller than 1 cm can now be easily diagnosed.
If the tumor grows larger and extends towards the cerebellum or brainstem, it can pose a life-threatening risk.
Clinically, patients may present with normal hearing and no dizziness, but auditory brainstem responses may show no reaction, necessitating consideration of this condition.
● Prevention is Better than Treatment
After classifying the causes of tinnitus, we learn that many of the factors leading to tinnitus can be prevented in advance.
Patients with Meniere's disease should pay attention to their diet and avoid excessive salt intake.
The increase in cases of sudden sensorineural hearing loss may be related to the development of civilization and life stress.
Occupational noise damage is often untreatable, so it is crucial to monitor noise levels in the work environment.
Acute trauma-induced hearing loss responds well to early treatment, making it even more important to avoid potentially harmful environments.
For metabolic tinnitus, in addition to managing internal diseases, appropriate exercise and avoiding fatty foods can help maintain normal cholesterol levels.
● Self-Questioning for Tinnitus
Through some carefully designed questions, we can often identify the potential causes of a patient's tinnitus.
Here are some simple questions:
1.
Is the tinnitus accompanied by dizziness? Does it become louder during dizziness? Tinnitus associated with dizziness should consider the possibility of "cochlear tinnitus." Meniere's disease, sudden sensorineural hearing loss, and anterior inferior cerebellar artery disturbances are often unilateral; vertebrobasilar insufficiency tends to be bilateral.
In Meniere's disease, tinnitus often becomes louder during dizziness.
2.
Is the work environment noisy? Have you worked in a high-noise environment for an extended period? Have you experienced gunfire or injury from fireworks? As mentioned earlier, the human ear can tolerate noise levels up to 90 decibels, and exposure should not exceed 8 hours per day.
If tinnitus occurs, it is essential to leave the noisy environment to prevent irreversible damage to the cochlear hair cells.
Standard ear protection can only block 30 to 40 decibels of noise and is ineffective against high-decibel noises from sources like airplane engines, trains, or lathes.
3.
Have you had blood tests for cholesterol levels? Do you have anemia, high or low blood pressure, thyroid disease, diabetes, or atherosclerosis? Tinnitus caused by systemic vascular diseases is often bilateral, so it is essential to rule out these internal diseases in tinnitus patients.
4.
Are you taking any long-term medications? Have you received antibiotic injections? Some medications, such as aspirin, quinine, contraceptives, antihypertensives, and antipsychotics, can sometimes cause bilateral tinnitus, which resolves upon discontinuation.
Older physicians sometimes administered streptomycin, kanamycin, or gentamicin, which can also lead to tinnitus over time.
Therefore, if tinnitus occurs after an injection, it is crucial to stop the injection to prevent irreversible damage.
5.
Is the tinnitus high-pitched or low-pitched? Is it unilateral or bilateral? Auditory nerve lesions typically present as high-pitched tinnitus, while Meniere's disease or middle ear disorders often present as low-pitched tinnitus.
Cochlear tinnitus is usually unilateral, while central vascular tinnitus is often bilateral.
6.
Is the tinnitus synchronized with your heartbeat? If tinnitus coincides with your heartbeat or pulse, consider the possibility of a vascular malformation or venous anomaly.
If turning your neck towards the affected side alleviates the tinnitus, it may indicate excessive pulsation in the neck vessels.
7.
Is the tinnitus related to breathing? Common respiratory infections or Eustachian tube obstruction from flying can cause tinnitus.
Overactive Eustachian tubes can also lead to tinnitus, often accompanied by a sensation of ear vibration during breathing.
If bending down to tie your shoes causes immediate relief due to increased blood flow to the brain, this may also alleviate symptoms.

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Reply Date: 2004/02/11