Tinnitus: The Sound of Nothing

In the first six months after Covid19 swept the world, many patients presented to my clinic with sudden hearing loss, and many more with tinnitus minus the hearing loss.  I had not seen so many such patients in the whole of 2019. Was it stress? Could tinnitus be a presentation of Covid19? After my first Covid19 vaccination, my ears rang incessantly for a few days, bombarding me with techni-colour sounds, allowing me a peek into the world of my patients afflicted with tinnitus. It is overwhelming, the sound of nothing.

My patients were pretty desperate. Many doctors had told them there is nothing to be found, and nothing they can do.

10 Things to Know About Tinnitus
  1. A Phantom Sound
    • Tinnitus is a tonal phantom sound usually (Subjective Tinnitus), where the sound is heard only by yourself. There can be ringing, static, hissing, roaring, cricket, whistling sounds. If the sound is timed to happen with your heartbeat, it is a specific type of pulsatile tinnitus, which could have vascular or brain pathologies.
  2. Tinnitus Others Hear
    • Some tinnitus may be heard by others near you (Objective Tinnitus). A clicking type of tinnitus may be due to rhythmic muscle contractions of the middle ear, eustachian tube or soft palate. However, should you hear actual words being said, this is hallucination and not tinnitus; this is often related to psychiatric or drug causes.
  1. Myth: Tinnitus causes deafness
    • It is hearing loss, with deprivation of sound input to the brain, that causes tinnitus, not vice versa. I liken tinnitus to a fill-gap noise generated by brain neural circuits that have rewired aberrantly. Only 30% to 50% of tinnitus is caused by ear issues or hearing loss, and most patients do not continue on to severe or total hearing loss. Additionally, only 50% of patients with hearing loss have tinnitus. A formal hearing test in sound-proof rooms is best, and the audiometry test has to be performed to frequencies beyond the usual 8kHz, and in more detail than the usual hearing tests, so as not to wrongly diagnose normal hearing.
  1. Myth: There is no Cure
    • Hearing loss is easily missed without a proper hearing test. A computer-based test or with your phone app at home is not the gold standard test. Tinnitus can be tamed with treatment of the underlying cause of hearing loss. Hearing aids can dually rehabilitate hearing and provide sound therapy for tinnitus nowadays. Treatment should not be delayed, as chronic tinnitus makes it harder to rehabilitate. Tinnitus retraining therapy and cognitive behavior therapy have also been helpful in chronic cases.
  1. Not just the ear
    • The sound heard in the ear may not be due to ear problems nor hearing loss. Many do not know that brain, heart, blood vessels, drugs, craniofacial, neck, jaw, dental, temporomandibular jaw joint, psychiatric or psychological problems can cause tinnitus.
  1. Teeth Grinding and Tinnitus
    • In somatic tinnitus, tinnitus intensity can be modulated by tactile manipulation and contraction of the jaw, head and neck muscles. Severe teeth grinding or bruxism, which is worse with stress, can exacerbate tinnitus. Some people can even modulate their tinnitus with eye movements or pressure on their neck myofascial trigger points. Addressing underlying muscle tension can help. Cervical neck problems, common in this age of computer and handphone overuse, can aggravate tinnitus. Likewise, a long-forgotten whiplash injury may aggravate tinnitus.
  1. Stress, Depression and Tinnitus
    • Only 20% of patients with tinnitus find it distressing. Distress is more common if the tinnitus is associated with negative events. Negative feelings lead to fear & automatic emotional responses that causes a vicious cycle of hypervigilance, distorted perceptions, functional disability and more stress. There is a strong correlation of tinnitus with stress, anxiety and depression. Stress also releases cortisol hormone which dysregulates ion dynamics in the inner ear and aggravates somatic tinnitus. There can be significant impact on the quality of life, and even suicidal thoughts. Without psychological or mental health support, there cannot be resolution of the tinnitus in such cases.
  1. Women and Tinnitus
    • Estrogen hormone drops around the time of menopause, and there is increased incidence of tinnitus then. Though estrogen is beneficial to hearing, the role of hormone replacement therapy on tinnitus is still controversial. Women tend to also have more autoimmunity disorders which may cause fluctuating hearing loss, tinnitus, pressure in the ear and giddiness. Women frequently report more anxiety and depression, aggravating factors for tinnitus.
  1. Covid and Tinnitus
    • A systematic review published in February 2021 in the International Journal of Audiology by Almufarrii and Munro reported on Covid19 and audio-vestibular symptoms. Sudden hearing loss, tinnitus and rotatory vertigo were reported in adults with a pooled estimated prevalence of 7.6%, 14.8% and 7.2%.  High quality studies are still lacking however, as ear symptoms tend to be overshadowed by acute respiratory and cardiac symptoms. However, viruses are known to cause hearing loss, tinnitus and vertigo, so it is not surprising that Covid19 can do so. Even in asymptomatic Covid19 patients aged between 20 to 50, Mustafa reported in American Journal of Otology in April 2020 that high frequency hearing loss was significantly worse when compared to compared to non Covid19 patients.
  1. Not Just Sound
    • Sudden hearing loss and tinnitus should be managed like an emergency, within the first few days to a week. A long-term hearing loss still needs exclusion of the rare tumor compressing on the hearing nerve, especially if it is worse in one ear. Rarely, tinnitus can be due to nose conditions like sinus infections, ear infections or nose tumor. Tinnitus associated with a headache, with trauma, or other brain or heart symptoms should also raise a red flag.

The sound of nothing can be scary and distressing. However, patients can continue to live full lives like everyone else, once they understand more about their tinnitus, and take active steps to mitigate it.