Tinnitus (Ringing in Ears): Causes, Insight and Management

Non Pulsatile Tinnitus

Tinnitus, characterized by constant ringing in ears, is the perception of persistent additional sounds in the ears or head without an external source. Approximately 1 in 10 people will experience an episode of tinnitus at some point in their life. Although sometimes considered a minor symptom of ‘ringing in ears‘, it can also be described as buzzing, hissing, or humming noise, causing distress to patients and occasionally indicating a serious underlying condition. Ringing in Ear Causes, Assessment, and Management are discussed in this section.


Causes of Tinnitus:

Tinnitus causes can be divided into primary or idiopathic and secondary categories. Primary (idiopathic) Tinnitus occurs when an underlying secondary cause cannot be identified, while Secondary Tinnitus is associated with specific factors. These are some of the factors that cause ringing in ears which include:

1. Meniere’s Disease:

Associated with hearing loss, vertigo, tinnitus and sensation of fullness or pressure in one or both ears.

2. OtosclerosisOnset:

Onset is usually at 20-40 years, presenting with conductive deafness, Tinnitus, positive family history and normal tympanic membrane although 10% of patients may have a ‘flamingo tinge’, caused by hyperaemi

3.Acoustic Neuroma:

Symptoms include hearing loss, vertigo, and absent corneal reflex.

  • Absent corneal reflex is an important sign
  • Associated with neurofibromatosis type 2
4. Hearing loss:

Caused by excessive loud noise exposure and presbycusis.

5. Drugs:

Such as aspirin/NSAIDs, aminoglycosides, loop diuretics, and quinine.

6. Impacted Ear Wax:

Usually obvious on Otoscopy

7. Psychological Factors:

Depression and anxiety. and Anxiety

8. Infection:

Infection in ears can also cause tinnitus,

Sometimes Tinnitus may be associated with the following systemic diseases like;

  • Anemia
  • Diabetes Mellitus
  • Hyperthyroidism or Hypothyroidism
  • Hyperlipidemi

Pulsatile Tinnitus:

Pulsatile tinnitus is characterized by the perception of rhythmic or pulsating sounds in the ears that coincide with the heartbeat or blood flow. The perceived sound may be described as high pitch ringing in ear as a throbbing, pulsing, or whooshing noise. Pulsatile tinnitus is often caused by abnormal blood flow or vascular conditions near the ear such as:

Vascular Abnormalities:

Conditions like arteriovenous malformations (AVMs), carotid artery stenosis, or arterial aneurysms can lead to turbulent blood flow near the ear, causing pulsatile tinnitus.

High Blood Pressure (Hypertension):

Increased blood pressure can result in turbulent blood flow in the arteries and contribute to pulsatile tinnitus.


Hardening and narrowing of the arteries can disrupt normal blood flow and contribute to pulsatile tinnitus.

Eustachian Tube Dysfunction:

Dysfunction of the Eustachian tube, which regulates pressure in the middle ear, can lead to changes in blood flow and contribute to pulsatile tinnitus.

Assessment of Tinnitus:

Proper assessment of tinnitus involves:

  • Audiological Assessment:
  • Detect Underlying Hearing Loss
  • Imaging
  • Not all patients will require imaging. Generally, Non-Pulsatile tinnitus does not require imaging unless it is unilateral or there are other neurological or otological signs. MRI of the internal auditory meatuses (IAM) is first-line
  • Pulsatile tinnitus generally requires imaging as there may be an underlying vascular cause. Magnetic resonance angiography (MRA) is often used to investigate pulsatile tinnitus

Managing Tinnitus:

Management of Tinnitus and strategies include:

  • Tends to improve over time
  • Investigate and treat any underlying cause
  • Hearing aids to treat hearing loss
  • Sound therapy to mask underlying tinnitus
  • psychological therapy may help a limited group of patients,examples include cognitive behavioral therapy
  • tinnitus support groups

Understanding the causes and management of tinnitus is crucial for individuals experiencing these symptoms to improve their quality of life.

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