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Tinnitus – The Different Types, Causes, and Treatments for Ear Ringing

In this article, I will be compiling information about tinnitus and the different ways to treat and perhaps even cure tinnitus. You know, I feel that in our modern time, we should be able to cure this significant debilitating problem of ringing in the ear. I mean, we can perform brain surgery. We can make artificial hearts. We can even grow organic blood vessels[1] to replace defective ones in live human beings. But why isn’t there a cure to tinnitus already?

Let’s start by first defining what tinnitus is.

What is Tinnitus?

baby ear pointed by finger
Do you wonder how we hear things? Well, if you take a look at the anatomy of the ear, you will be amazed at how intricately the ear is designed so that we can hear sounds from high to low pitch at different volumes.

Tinnitus is when a person hears a sound without an external source of that sound being observable. Tinnitus usually sounds like ringing, clicking, hissing, or even roaring (like a waterfall). The tinnitus can sound low or high pitched, perhaps somewhat like the sound that a glass harp produces. Tinnitus can be soft or loud, depending on the damage to the cochlea (ear hair) and/or the factors that caused the tinnitus in the first place. Tinnitus can be in one or both ears; and if in one ear, the ringing can switch from ear to ear.

Some people also have constant ringing, whereas other people have ringing that comes on and off.

You may also notice that your tinnitus becomes louder in quieter environments, given that background noise may help mask the tinnitus.

Tinnitus is a major problem, because it interferes with concentration and may cause anxiety and/or depression. I mean, its one thing to have a bee buzz near your ear once in a while. But to have buzzing in your ear every single hour of the day, 24/7, for the rest of your life? Either you learn to ignore it or go insane…

The Different Types & Causes for Tinnitus

Not all ringing in the ears are the same. The tinnitus that someone experiences in the ear depends on what caused it in the first place, and the part of the ear that gets damaged to induce the tinnitus. That means tinnitus isn’t a disease itself, but rather a symptom of an underlying problem. Common types of tinnitus include:

  • pulsatile tinnitus
  • muscular tinnitus

And common causes for tinnitus include:

  • Noise-Induced Hearing Loss
  • Ear Infections (this is how I got my tinnitus)
  • Disease of the heart or blood vessels
  • Muscular disorder
  • Ménière’s disease
  • Brain tumors
  • Emotional stress
  • Exposure to certain medications (for this reason, always check warning labels)
  • Head Injuries
  • Earwax

What is Pulsatile Tinnitus & Its Causes?

Pulsatile tinnitus is when a person hears a sound comes and goes with the pace of their heart beat. The sound that you hear in your ear from pulsatile tinnitus is a type of whooshing, like the sound of a wave crashing on the shore of a beach, but deeper. You can somewhat replicate the sound of pulsatile tinnitus if you put the palms of both of your hands firmly against your ear, as if you are trying to block sound from entering your ear. The sound from your palms is like pulsatile tinnitus, except imagine this sound pulsating or coming and going, on and off.

blood cells floating in vein
Most causes of Pulsatile Tinnitus deal with problems with the vascular system or blood vessels near the ear.

So what causes pulsatile? Well, pulsatile tinnitus is basically hearing an abnormal noise produced from blood vessels that are very close to the part of your ear that hears sound, which is the cochlea. So what would allow you to hear this sound all of a sudden? Well, any disorder of the blood vessels near the cochlea may be a cause for hearing pulsatile tinnitus.

Here’s a short list of what causes pulsatile tinnitus, which may be covered more in depth further along this article:

  • high blood pressure
  • atherosclerosis
  • stenosis
  • sigmoid sinus diverticulum
  • sigmoid sinus dehiscence
  • superior semicircular canal dehiscence
  • arterial bruit
  • dural arteriovenous shunts
  • pseudotumor cerebri

And any other vascular problems (i.e. obstructions, stenosis) involving the blood vessels that connect the heart and the brain may cause pulsatile tinnitus, given that these blood vessels eventually pass by the ear and may produces sounds audible to the ear.

High Blood Pressure

Well, I notice that I can hear the sound of a blood vessel when I lay down, and perhaps after physical exertion. I believe that pulsatile tinnitus may by caused by high blood pressure, since I imagine that low blood pressure would cause less sound to be produced when blood moves through a vein or artery, and vise versa.

Imagine that blood vessels are like rubber tubes that can constrict and widen. When the a blood vessel is narrower than usual, blood may travel with significantly more force through these “rubber tubes”, causing high blood pressure and the production of more sound.

For example, you can definitely hear blood rushing through your body when you exercise. So pulsatile tinnitus may be caused by abnormally having high blood pressure when you aren’t exercising or exerting yourself.

Treating High Blood Pressure to Improve Pulsatile Tinnitus
black & white cardamom side by side
By Autopilot (Own work) [GFDL or CC BY-SA 3.0], via Wikimedia Commons Many spices have blood pressure lowering properties, like cardamom, turmeric, and ginger.
So treating high blood pressure may be one way to treat pulsatile tinnitus. Substances that lower blood pressure include blood thinners like turmeric, ginger, and cardamom– although I would suggest consulting a doctor first for any medical problem.

Additional ways to treat high blood pressure include losing weight if you are overweight or obese, exercise- especially aerobic exercises like jogging, a diet that lower high blood pressure, avoiding alcohol, and reducing harmful stress.

Medical drugs that treat high blood pressure include diuretics, beta blockers, angiotensin-converting enzyme inhibitors, angiotensin II receptor blockers, calsium channel blockers, alpha blockers, alpha-beta blockers, central acting agents that has the brain signal blood vessels to expand, and vasodilators[2].

Atherosclerosis

Another disorder that may cause pulsatile tinnitus is atherosclerosis[3]. Atherosclerosis is the condition where blood vessels become weakened and damaged by the hardening of arteries. Atherosclerosis can cause pulsatile tinnitus by hardening an artery called the carotid artery. The carotid artery is the main artery that supply oxygenated blood to the brain & neck, including ears.

Atherosclerosis of the carotid artery would cause blood to flow abnormally through them, decreasing the space inside the blood vessel with atherosclerosis plaques (a.k.a. stenosis), increasing the pressure of blood in the artery, and thereby producing sounds of blood flow loud enough for the ear to hear.

diagram showing atherosclerosis and its cross sections
By Npatchett (Own work) [CC BY-SA 4.0], via Wikimedia Commons Atherosclerosis is the disease process in which an artery wall thickens and narrows the space for blood to flow. Atherosclerosis happens as a result of invasion and accumulation of white blood cells (foam cells) and proliferation of intimal-smooth-muscle cell creating an atheromatous (fibrofatty) plaque. Note that when a blood vessel becomes narrower due to a pathology, this is called “stenosis”.
Treating Atherosclerosis to Improve Pulsatile Tinnitus

Again, blood thinners may help improve the flow of blood through vessels affected by atherosclerosis. According to the NHLBI[4], other treatments methods for atherosclerosis includes lowering the risk of blood clots; life-style changes that improves cardiovascular health, such a healthy diet & weight, lower unhealthy stress levels, raising fitness levels and to quit smoking.

Statins are also prescribed by doctors to lower cholesterol levels, given that high cholesterol levels are thought to contribute to cardiovascular disease. How true this is, I do not know.

Additionally, a more invasive methods to surgically remove the blockages made by atherosclerosis, such as percutaneous coronary interventioncoronary artery bypass grafting, and carotid endarterectomy. For the treatment of pulsatile tinnitus caused by atherosclerosis, I imagine that carotid endarterectomy is the most relevant of the three.

Also, stenosis caused by atherosclerosis may be treated with a stent, which is the insertion of a slender tube that provides structure to the blood vessel and restores proper blood flow by widening the blood vessel.

If you have pulsatile tinnitus, you can check if atherosclerosis of the carotid artery is the cause of it with a Doppler ultrasonographic study[3].

Sigmoid Sinus Abnormalities

Yet another disorder that commonly causes pulsatile tinnitus is Sigmoid Sinus Diverticulum (SSD)[5][6][7]. But what is Sigmoid Sinus Diverticulum?

Sigmoid refers to an object having an “S” shape. Sinus refers to a part of the body that has a cavity or “empty space”. Sigmoid sinus, also known as pars sigmoid, is a s shaped hollow curve in the skull that has venous sinuses which receives blood from the posterior dural venous sinus veins. Finally, in biology diverticulum refers to the formation of a pouch or sac of an organ or structure.

sigmoid sinus diagram
Sigmoid Sinus is also known as Pars Sigmoid, it runs near the occipital lobe & near where the ears are located. The transverse sinus leads into the sigmoid sinus.

Altogether, Sigmoid Sinus Diverticulum is the formation of a pouch or sac, from the sigmoid sinus blood vessels, that may breaks through the sigmoid plate. When the sigmoid plate breaks apart, or is absent, it is called a dehiscence.  Note that the sigmoid plate is a thin bone that separates the sigmoid sinus from other structures.

Stenosis May Cause Sigmoid Sinus Diverticulum

Note that stenosis (which is the decrease of space inside of a blood vessel due to the formation of plaques that stick inside it) is associated with sigmoid sinus diverticulum. My conjecture is that stenosis precedes the formation of sigmoid sinus diverticulum.

What happens is that stenosis increases the pressure inside a blood vessel. And the stenosis isn’t uniform throughout the blood vessel, but in only in specific places. So what ends up happening is that some parts of the blood vessels are weaker and experience higher pressures than other parts. The weaker parts of the blood vessels with the highest amount of pressure start distending or pushing out, forming the sacs or pouches (diverticulum). And I do believe that’s how sigmoid sinus diverticulum develops in the first place.

Also note that stenosis of the blood vessel that leads into the sigmoid sinus, called the transverse sinus, may also contribute to the existence of pulsatile tinnitus.

Treating Sigmoid Sinus abnormalities to Improve Pulsatile Tinnitus

One treatment for pulsatile tinnitus, caused by sigmoid sinus diverticulum & stenosis, is to surgically fill up the diverticulum with a coil wire and stent the stenosis, to restore proper blood flow. Afterwards, complete remission of pulsatile tinnitus was reported by the patient[5]. Treatment may involves surgically reconstructing the walls of sigmoid sinus.

Other actions that may be involved in treating the Sigmoid Sinus Diverticulum and stenosis includes mastoidectomy, removal of tissue from the affected sinus walls, reducing the size of a diverticulum with a bipolar cautery, reinforcement of sinus walls with a soft tissue graft taken from the temporal fascia, and reconstruction of bone defects.

Note that Mastoidectomy refers to the removal of mastoid air cells that is located on the temporal bone of the skull, behind the earlobe. And Bipolar cautery refers to a type of cauterization or burning that is done to remove or close off a part of the body. In this cause, a pouch/sac that forms on a blood vessel.

The Superior Semicircular Canal

Inside the inner ear, there are a couple of key structures that allow us to sense things other than sound. For example, the semicircular ducts are part of a system that allows us to detect movements.

structures inside the internal ear canal
By BruceBlaus | Blausen.com staff (2014). “Medical gallery of Blausen Medical 2014”. WikiJournal of Medicine 1 (2). DOI:10.15347/wjm/2014.010. ISSN 2002-4436. (Own work) [CC BY 3.0], via Wikimedia Commons The inner ear is mainly responsible for sound detection and balance. It consists of the bony labyrinth, a hollow cavity in the temporal bone of the skull with a system of passages comprising two main functional parts: 1. The cochlea, dedicated to hearing; converting sound pressure patterns from the outer ear into electrochemical impulses which are passed on to the brain via the auditory nerve. 2. The vestibular system, dedicated to balance. Note that the anterior semicircular duct is also known as the superior semicircular canal or duct. It’s the highest semicircular duct.
The semicircular ducts refer to 3 interconnected tubes that opens out to the utricle at one end, and leads out into an ampulla that connects back to the utricle at the other end. Thus the duct forms a “semi” circular shape.

The 3 semicircular ducts are separately called the horizontal (lateral), superior (anterior), and posterior semicircular canals. The functions of these 3 semicircular ducts is to assist in our ability to detect movement in the xyz planes. In other words, detecting angular acceleration in 3D space.

ampulla cross section with semicircular duct
The cupula is located within the ampullae of each of the three semicircular canals. The cupula has embedded within it hair cells with stereocilia projections that detect the movement of endolymph fluid when the head rotates.

Specifically, the semicircular canals carry a fluid called endolymph, which moves through them when our head turns or when our body experiences acceleration (ie. the acceleration of a car). Inside the ampulla of each canal, there are hair cells that detect the movement of the endolymph fluid, and thereby allowing use to sense movements or angular acceleration. Consider this fact when spinning on a chair or on a merry-go-round. The reason why you feel dizzy from spinning is because the endolymph fluid is still moving through the semicircular canals, and stimulating the movement-detecting hair cells inside the ampulla.

Superior Semicircular Canal Dehiscence

But how are the semicircular canals relevant to pulsatile tinnitus?

Well there is a condition called the “dehiscence of the superior semicircular canal”. In this condition, there is an opening or hole in the bone that overlays the superior semicircular canal. This causes a whole host of symptoms, including vertigo, oscillopsia, autophony, and an increased sensitivity to sound. The increased sensitivity to sound may also mean that the person is more likely to hear blood that pumps through blood vessels near the inner ear, thereby causing the pulsatile tinnitus.

An interesting point to notice is that people are diagnosed with superior semicircular canal dehiscence when they are around 45 years old. My conjecture is that after a certain point in our age, our bones become weaker as a part of the natural aging process. Which allows a hole, or “dehiscence” to form in the first place.

The treatment for the dehiscence of the superior semicircular duct is surgery that reconstructs the missing bone layer overlaying the canal.

What is Muscular Tinnitus & Its Causes?

Muscular tinnitus is a type of sound that a person hears due to a disorder of muscles that are located near the cochlea or the part of the ear that detects sound.

Muscular tinnitus can be caused by diseases that affect the head & neck, such as:

Myoclonus refers to the brief, involuntary contractions a muscle or group of muscles may experience. It’s another word for muscle spasms, seizures, tremors, twitching etc. Diseases that may show myoclonus as a symptom are usually diseases of the nervous system, such as multiple sclerosis, Parkinson’s disease, Dystonia, Alzheimer’s disease, Gaucher’s disease, subacute sclerosing panencephalitis, Creutzfeldt–Jakob disease (CJD), serotonin toxicity, some cases of Huntington’s disease, some forms of epilepsy, and occasionally in intracranial hypotension.

structures inside middle ear
Blausen.com staff (2014). “Medical gallery of Blausen Medical 2014”. WikiJournal of Medicine 1 (2). DOI:10.15347/wjm/2014.010. ISSN 2002-4436. (Own work) [CC BY 3.0], via Wikimedia Commons The stapes bone is the one that looks like a stirrup and is touching the cochlea at the oval window. Irregular spasms or tremors of the muscles connected to the stapes may produce irregular sounds- tinnitus in other words.
One way myoclonus can cause muscular tinnitus, is by affecting the muscles that are a part of the auditory system. For example, Muscular tinnitus may be caused by the tremor or spasm of the stapedius muscles, which is attached to the small stapes bone in the middle ear. The stapes bone is 1 of 3 the ossicles bones that together has the function of transferring sound vibrations from the eardrum to the cochlea at the oval window. So if the stapes bone experiences tremors & spams, they are transferred to the cochlea and therefore “heard”.

ALS is a disease that causes muscle or motor neurons to die, thereby reducing the functionality of the muscles. After a period of time, without the neurons required to control the muscles, the muscles themselves atrophy (waste away). ALS can contribute to muscular tinnitus because of this. For example, muscles that undergo atrophy (which is one thing that ALS causes) may experience tremors that are called fasciculations. Muscular fasciculations close to the auditory system may be detectable, and thereby cause muscular tinnitus. My conjecture is that ALS may also affect the muscles of stapes, and cause muscular tinnitus like that.

Now, I wonder if something like Lion’s Mane mushroom can improve muscular tinnitus caused by the death of neurons, given that Lion’s mane significantly promotes neurogenesis in the body. In fact, this mushroom was found to substantially speed up the injury of a peripheral neurons[8], thereby returning proper function to the muscles.

Tinnitus Caused by Loud Noise

megaphone man yelling
Loud noises can damage the ear, obviously enough…

Inside the ear, there are some really delicate equipment that allow us to hear a vast range of sound volumes and frequencies. That means that the ear is also subject to being damaged very easily. For example, Noise-Induced Hearing Loss (NIHL) refers to hearing loss that is caused by exposing your ear to very loud sounds, like having a gun fire next to your ear or going to a music concert without hearing protection.

The hearing loss occurs because inside the ear, there are hair-like projections called “stereocilia” on top of hair cells in the cochlea which are very delicate. These stereocilia can detect very low volumes of sounds. But when exposed to very high volumes, they become damaged. It’s like the difference between looking around a well lit room vs. looking directly at the sun. Our eyes aren’t designed for such high light exposure. Similarly, our ears aren’t designed for exposure to high volumes.

To protect yourself from acquiring tinnitus caused by NIHL, it is advisable to use ear protection like sound dampening earplugs and/or sound dampening ear muffs in places or events that expose you to high volumes of sound.

And don’t discard this piece of advice. The damage to the inner ear is almost insured without protection at a gun firing range. Construction workers are often surrounded by loud sounds almost constantly, and it adds up. And many people go to music concerts, and end up severely damaging their ears because they don’t bother with protection. If you have any friend who go do concerts, just ask them if they have any ringing in their ears after the concert, and whether they go away or not. And damage to the auditory system isn’t the same as damage in other places. Paper cuts, bruises, sore and tore muscles, and even broken bones heals eventually. But damage to the hearing cells inside the cochlea isn’t something you can really treat directly. Not only is the regeneration of hair cells poor, but also you can’t directly do anything to improve the healing process if the ears are damaged. Bones can be cast, bruises and be iced, cuts can be bandaged. But you can’t just reach inside your eat to apply some sort of treatment. This is probably one of the major reasons why tinnitus is very hard to treat in the first place.

The take away is this: An ounce of prevention is worth a pound of cure. Moreso for something as hard to treat as tinnitus.

Tinnitus Caused by Ear Infection

Ear infections can also damage the equipment in the ear, most easily affecting the hair cells in the cochlea, and then the auditory neurons that take audio information from the hair cells to the brain. Specifically, inflammation and pathogens from ear infections can destroy any number of things inside the ear.

When there is an infection inside the ear, it can affect the delicate organs that we require to hear properly. Specifically, the inflammation in the inner ear causes swelling and blood vessel constriction, leading to lower oxygen levels reaching the cochlea and other hearing organs. If not enough oxygen is supplied to the inner ear, then the hair-cells that allow us to “hear sound” may start dying.

This is how I acquired tinnitus. I went running in the cold weather one day, right after a quick shower, and without any ear-mufflers to protect against the wind. Thereafter, I got an ear infection and the next day found that I kept hearing a distinct ringing in my ears.

So some good advise for avoiding tinnitus is not to expose your ears to cold weather. You may want to keep a pair of fleece ear muffs handy for this reason.

My Observations Living with Tinnitus

I personally notice that how loud my tinnitus is changes from time to time. Sometimes its really loud. Sometimes its really soft- almost as if it is gone. And if I am really focused on a task, I don’t notice the tinnitus whining at all. I also notice that the ringing sometimes switches from one ear to the other ear. Most of the time my tinnitus is isolated to my left ear. But occasionally it switches to my right ear.

At first, it was really hard to concentrate on working and reading when I acquired the tinnitus in my left ear. Music helped me out a lot by masking the sound pretty well. I tried brown noise for masking the ear ringing, but the I clearly noticed the tinnitus given that brown noise had a different frequency of sound, compared to my tinnitus. Music works because the sounds that you hear are dynamically changing, and the brain becomes attune to those changing sounds.

But after a while, I got used to the ear ringing. Most of the time it wasn’t too loud, and if I just focused a little on what I was doing I wouldn’t notice that I even had tinnitus.

Related Links

Books about Tinnitus

Sources

  1. In Vivo Application of Tissue-Engineered Veins Using Autologous Peripheral Whole Blood: A Proof of Concept Study [ScienceDirect]
  2. How Is High Blood Pressure Treated? [NHLBI]
  3. Pulsatile tinnitus and carotid artery atherosclerosis [Int Tinnitus J.]
  4. How Is Atherosclerosis Treated? [NHLBI]
  5. Endovascular Management of Sigmoid Sinus Diverticulum [Interv Neurol.]
  6. Sigmoid Sinus Diverticulum, Dehiscence, and Venous Sinus Stenosis: Potential Causes of Pulsatile Tinnitus in Patients with Idiopathic Intracranial Hypertension? [AJNR Am J Neuroradiol.]
  7. Surgical Treatment of Pulsatile Tinnitus Caused by the Sigmoid Sinus Diverticulum [Medicine (Baltimore).]
  8. Neuroregenerative potential of lion’s mane mushroom, Hericium erinaceus (Bull.: Fr.) Pers. (higher Basidiomycetes), in the treatment of peripheral nerve injury. [Int J Med Mushrooms.]

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