Tinnitus

Not in the sense of a treatment that switches it off. Tinnitus is the brain’s response to some damage, however small, somewhere in the hearing pathway — the ear and brain set up alternative pathways that reach the hearing centre, so you hear a sound. Short-lived tinnitus after a loud concert or a night in a nightclub is familiar to most people and settles as the ear recovers, but it is a marker of exactly that irritation. When the tinnitus is persistent, the brain has not compensated, and the goal of management is to exclude a serious underlying cause and then reduce how intrusive the tinnitus is, so the brain stops registering it. Most people reach that point.

Rarely — but the serious causes are the reason every case is assessed. Any primary ear disease that causes hearing loss can cause tinnitus: a perforation, otosclerosis, cholesteatoma, Ménière’s disease and others. Most of the time no such ear pathology is found. What concerns an ENT surgeon is asymmetry — tinnitus in one ear only, hearing that is worse on one side, or an abnormal ear examination — because one-sided symptoms can be the first sign of a vestibular schwannoma (acoustic neuroma), a benign tumour of the hearing nerve. That is excluded with a hearing test and, where there is asymmetry, an MRI. Tinnitus that is in both ears and came on gradually with a symmetrical mild hearing loss is not a sign of anything serious. Tinnitus that starts suddenly should be checked within days to make sure there has not been a sudden hearing loss.

Yes — it is essential, even if you are not aware of any hearing loss, and whether the tinnitus is in one ear or both. The hearing test shows whether there is a hearing loss driving the tinnitus (and therefore whether a hearing aid will help), and whether the hearing is asymmetric, which decides whether an MRI is needed. A medical assessment — ear examination, blood pressure, blood tests including thyroid function, and attention to neck and jaw problems — completes the initial work-up.

This answer is about the common form of tinnitus: persistent, in both ears, with a symmetrical mild hearing loss and no specific ear disease — not tinnitus that is secondary to a defined problem such as a perforation or a nerve tumour, which is treated by treating the cause. For the common form, the first and most important step is a proper medical assessment that excludes those causes, because reassurance itself reduces the tinnitus. After that there are two treatments with strong evidence: hearing aids when there is any significant hearing loss, and tinnitus retraining therapy, a form of cognitive behavioural therapy run by clinical psychologists and audiologists with a special interest in tinnitus. Around these sit the ear-side measures — sound enrichment with white noise, a fan or music so the brain is never in silence — and the non-ear measures: the tinnitus pathways run through the brain’s stress and muscle-control centres, so sleep, stress, mood, and tension in the neck and jaw all turn the volume up or down. Physiotherapy or acupuncture for the neck and jaw, treating temporomandibular joint problems, and correcting anything found on blood tests (such as thyroid function) all help. Bimodal neuromodulation (the Lenire device) has emerging evidence in selected cases. The surgeon’s role is assessment, exclusion of serious causes and improving hearing where possible; the treatment is delivered by the audiologist and the psychologist. See the self-help measures and the list of clinical psychologists above.

One-sided tinnitus needs proper assessment, because it points to something specific in that ear or its nerve: wax, fluid, a perforation, otosclerosis, cholesteatoma, Ménière’s disease, a sudden hearing loss — or, uncommonly, a vestibular schwannoma. A hearing test and ear examination come first, and an MRI of the inner ear and hearing nerve is arranged when the hearing or the tinnitus is asymmetric. Most people with one-sided tinnitus turn out not to have a serious cause, but it is the group in which one must be excluded.