Is It Tinnitus?
By Murray Grossan, MD
Editor: People with hearing loss routinely talk about their tinnitus.
But is what a particular person has really tinnitus? You may be surprised
by the answer, and you'll learn something about objective tinnitus,
subjective tinnitus, and false tinnitus along the way. Thanks to bhNEWS
for this article, which originally appeared in "Advance for Audiologists".
Although tinnitus is defined as a subjective sensation of a sound heard
by the patient but which cannot be recorded or otherwise detected by any
means, sometimes there are underlying physical causes that cause the
sound. When these causes can be perceived by another person, the tinnitus
is termed "objective;" when only the patient can hear the sound and no
underlying causes can be identified, the tinnitus is termed "subjective."
Diagnosis requires careful evaluation because other conditions can
cause symptoms that mimic tinnitus, and patients often mistake and
mislabel other conditions as tinnitus.
Objective tinnitus occurs when certain blood vessels become noisy. This
can be due to an aneurism near the ear, hardening of a blood vessel,
pressure on a vessel caused by a shunt or other implanted device, or
enlargement of a vein or artery near the ear. The most common
characteristic of objective tinnitus is that it sounds like a beat or
throb and matches the pulse. It can be detected in OAE testing. Objective
tinnitus can occur suddenly and may be temporary because it can accompany
elevated blood pressure; when the blood pressure is reduced, the tinnitus
may stop as suddenly as it started. If a patient complains of a sudden
onset of tinnitus, ask about their blood pressure history.
In theory, with all our modern techniques for visualizing blood vessels
and circulation to the brain, identifying the offending vessel should be
possible, and then the problem can be corrected. In practice, however,
identification has proven to be difficult in many cases.
Another cause of objective tinnitus is a glomus jugulare tumor, which
involves the jugular vein as it courses beneath the middle ear. When the
vein fills into the floor of the middle ear, the patient hears a sound
that matches the pulse, and hearing is also affected. In looking at the
tympanic membrane, often you can see a bluish dome that represents the
dilated vein of this lesion.
If a patient claims to have tinnitus, describing, "When I yawn or eat
it gets worse," perhaps the patient actually has temporomandibular joint
disorder (TMJ). Look at the jaw when the patient opens the mouth. Does it
open midline, or zigzag or jut severely to one side? Place your index
fingers into both joints and ask the patient to chew. You may be able to
feel and hear crepitation; heard by the patient, this sound often can be
mistaken for tinnitus. Your finger pressure may also reveal that one of
the joints is painful. Understanding TMJ is important to the audiologist
for other reasons because it also can cause patients to complain of pain
when using a hearing aid.
A patent eustachian tube can cause false tinnitus symptoms. Here the
eustachian tube is wide open, causing a distressing alteration of sound
that can be aggravated by nasal breathing. Don't blame the patient for
mislabeling this condition as tinnitus-it is actually hard to describe.
Unfortunately, it is hard to correct as well. One method is to inject a
filler to partially close the opening.
Hyperacusis is often mistaken for tinnitus. In this condition, ordinary
loud sounds are "too loud" and feel painful and upsetting, but the
"tinnitus" goes away in quiet. Subjective tinnitus differs in that it is
louder in quiet.
Where English is a second language, it is more difficult to understand
a complaint of tinnitus. Patients can mistake headache, drug reaction,
fatigue, hypertension, flu, and even depression as tinnitus.
The audiologist is in the best position to help patients with tinnitus
symptoms understand those symptoms and relieve the anxiety that may
accompany them. But practitioners must first answer the question, "Is it
Tinnitus Case Study
Mrs. C, age 49, was mildly overweight and hypertensive, but not
diabetic. She awoke at 3 a.m. with very loud tinnitus in her right ear.
She thought it might be an alarm or siren. When it persisted, she thought
it might be an insect in the ear and asked her husband to look with a
flashlight. He didn't see anything. By 4 a.m. she couldn't stand it any
more, and her husband drove her to the emergency room. There, the doctor
was concerned about stroke. Mrs. C was hypertensive and taking medication,
but her blood pressure was 145/95. Fearing a stroke, the ER doctor sedated
Mrs. C, brought the blood pressure down and put her to sleep. By 11 a.m.,
an MRI of the brain had been done, but it showed no abnormalities. The ER
doctor recommended carotid artery visualization, but the patient, after an
explanation of what would be involved, opted to forgo the procedure and
instead seek further treatment on her own.
She consulted a local ENT, who reviewed Mrs. C's history and examined
her. Her ears were normal; an audiogram showed a mild high tone drop off
but was symmetrical. He carefully checked for nystagmus and watched her
walk, but there were no signs of dizziness. Mrs. C also exhibited no signs
of facial nerve weakness. She did show a slight crepitation in both
temporomandibular joints, but reported no pain. The doctor prescribed one
of the heavily advertised herbal medications and asked Mrs. C to return in
When she returned, there was little improvement. The doctor reviewed
her medications and checked her blood pressure, which had dropped to
129/86. Mrs. C. stated that the tinnitus was a little bit better than at
its onset but was still so distressing that she was unable to do her work
as an accountant.
A week later, Mrs. C consulted another ENT doctor. He repeated the ENT
and neurologic exams and performed another audiogram. There was no change
in the audiogram. The doctor asked if there was a sensation of fullness in
the right ear; Mrs. C said there was not. The practice's audiologist then
performed a tinnitus match; it was matched at 6,000 Hz at 15 decibels
below the 25 db hearing level of 6,000 Hz. The doctor diagnosed cochlear
hydrops, to be treated with a carbonic anhydrase inhibitor-Methazolamide-and
a low-salt diet to include distilled water.
In a week, Mrs. C was significantly improved. A repeat audiogram showed
no improvement in the audiogram but a significant reduction in the volume
of tinnitus. The doctor continued her on the above regimen.
Meniere's disease is cochlear hydrops that reoccurs. Both conditions
are characterized by fullness of the ear, hearing loss, dizziness and
tinnitus. The patient may be awakened by any one or more of these
symptoms. Since Mrs. C had no prior episodes, she couldn't have Meniere's.
How could the diagnosis of hydrops be made with only one symptom? In
this case it was possible because the tinnitus awakened her out of a sound
sleep, it persisted and other etiologies of stroke-increased cerebrospinal
pressure and hypertension-had been ruled out. Her response to the
treatment confirmed the diagnosis.
The elevated blood pressure in the emergency room had been caused by
anxiety and was not a causal factor of her symptoms. Salt, however, proved
to be problematic for Mrs. C.
Taking her medication and following a low-salt diet, she did well for
two more weeks and then stopped taking the Methazolamide. Six weeks later
she attended a party and unconsciously ate heavily salted snacks. The next
day, her tinnitus returned with dizziness and a low tone hearing loss, all
in the right ear. Now she felt a pressure in that ear. Fortunately, she
responded to therapy.
Even though she had a recurrence of hydrops symptoms, her condition was
not classified as Meniere's because the incidents were close enough to
perhaps be part of the initial diagnosis. If in 3 months or more the
hydrops reoccurs, then it would be classed as Meniere's.
Murray Grossan, MD, practices at Cedars Sinai Medical Towers in Los
Angeles. His complete biography is available at www.ent-consult.com.
Contact him at firstname.lastname@example.org.