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Objective: Tinnitus is a common otologic symptom secondary to numerous etiologies such as noise exposure, otitis, Meniere’s disease, otosclerosis, trauma, medications, and presbycusis.
Conclusion: Treating physicians need to have a very compassionate attitude towards these patients and statements such as “ there is nothing that can be done” are very inappropriate and should be strongly condemned.
Non-pulsatile tinnitus (henceforth referred as tinnitus) is more common than the pulsatile type and is prevalent in patients between the ages of 50 and 71 years, although it can occur in younger individuals (1). There is evidence that tinnitus can arise not only from disease processes affecting the cochlea, but also from disorders affecting the central auditory pathways. The time of onset and any possible causative factors, such as exposure to noise, medications, viral infections, or head trauma, should be elicited from the history.
This should include otoscopic and neuro-otologic examination for patients suspected of retrocochlear lesions.
Audiogram (air conduction, bone conduction, speech discrimination) should be obtained in all patients. Impedance audiometry (tympanometry, acoustic reflexes, acoustic reflex decay) should be considered in selected cases.
Auditory evoked responses (ABR), instead of imaging studies, should be considered for patients with a low index of suspicion for an acoustic neuroma. Electronystagmography (ENG) can be helpful in patients with associated vestibular symptoms. Computed tomography (CT) of the temporal bones should be considered for patients suspected of otic capsule pathology (otosclerosis, Paget’s disease, marble bone disease). Tinnitus analysis by an experienced audiologist for pitch and loudness matching, minimum masking level and residual inhibition should be considered in patients with severe tinnitus affecting their life styles (1). The test results should be given to the patient and an overview of the anatomy and physiology of the auditory system should be made.
This technique involves a process by which using specific protocols, patients can reach a state of being unaware of the presence of tinnitus except when they deliberately concentrate their attention on it. Transcutaneous electrical stimulation has been reported to decrease tinnitus in 53 percent of patients (10). Tinnitus reduction has been reported up to 75 percent of patients undergoing cochlear implantation (11). Antidepressants such as Nortriptyline (Pamelor) and Amitriptyline (Elavil) have been found useful for patients with severe tinnitus and associated depression (5,12).
Systemic and intratympanic administration of lidocaine has been used with controversial results (13-16).
For patients experiencing improvement of tinnitus following intravenous administration of lidocaine, carbamazepine has been reported to be effective in maintaining improvement (17). Melatonin has recently been found helpful for patients with tinnitus especially for those with associated insomnia (18). Intratympanic injection of Gentamicin in patients with Meniere’s disease has been reported to be effective in reducing tinnitus in 65 percent of patients (20). Nimodipine, an L-Calcium channel antagonist, has been reported to provide relief for a small number of tinnitus sufferers (22). Anti-convulsive medications such as Primidone (Mysoline), Phenytoin (Dilantin), and Carbamazepine (Tegretol), have been used without any significant success (23).

Labyrinthectomy and translabyrinthine section of the eighth nerve have been reported to provide relief of tinnitus in up to 70 percent of cases (24).
Cochleovestibular neurectomy, vestibular neurectomy, and labyrinthectomy have been reported to improve tinnitus in 31 to 76 percent of patients (24-32). Of 18 tinnitus patients undergoing microvascular decompression of the eighth nerve, tinnitus subsided in 8 and decreased in 9 (33).
Tinnitus associated with otosclerosis subsided following successful stapedectomy in 64 percent and improved in 16 percent of cases (34). National Center for Health Statistics: Basic data on hearing levels of adults 25-74 years, United States 1971-1975.
Sismanis A, Callari RH, Slomka WS, Butts FM: Auditory evoked responses in benign intracranial hypertension syndrome.
Many people experience tinnitus--a type of ringing, swooshing, or other type of noise that seems to originate in the ear or head. In addition to a full ENT exam, other tests may be needed to look for any treatable causes of tinnitus.
Tinnitus with an obvious cause, such as an object in the ear canal or a middle ear infection, can usually be treated easily. Household products: Eliminate use of perfumes, antiseptics, cleaning chemicals, and suntan lotions. Prescription medications: Reduce or eliminate use of drugs that list tinnitus as a side effect or have a toxic effect on the ear. Over-the-counter drugs: Reduce or eliminate use of aspirin or aspirin-type products (Empirin, Ecotrin, Bufferin, ibuprofen, Anacin, Midol, Pepto Bismol, and Aleve) and some antihistamines.
Anti-anxiety medications, anticonvulsants, and tricyclic antidepressants are groups of drugs used to treat various conditions including depression, anxiety, seizure, panic, pain, muscle spasms, dizziness, and tinnitus. Medical intervention in the treatment of tinnitus has gone beyond the realm of traditional treatments. Based upon sound characteristics, tinnitus can be classified as non-pulsatile (or continuous) which is the most common type and pulsatile. This type of tinnitus can be differentiated into a mild form, audible occasionally or only when in a quiet environment and a severe form, audible at all times and usually very disturbing and affecting patient’s quality of life (2). Between 28 and 60 percent of patients with severe tinnitus have been reported as clinically depressed (5). It has been speculated that peripheral pathologies can sensitize central structures resulting in hyperactivity and tinnitus (6). The psychological impact of tinnitus also should be determined by seeking symptoms of depression, anxiety, sleep disturbances, and inability to concentrate. Tinnitus retraining is a different t from masking and is thought to be a reconditioning of connections within subcortical centers (7). Controlled studies are needed, however, to validate the results of this very promising technique.
This is potentially a habit-forming medication and should be used in cases that have failed other modalities of treatments. Intratympanic injections of dexamethasone has also been found to be helpful in patients with low tone tinnitus and associated endolymphatic hydrops (21).

The effectiveness of medications with gamma-amino butyric acid (GABA) or GABA-like effects such as Baclofen are promising, however, they remain investigational (23).
The effectiveness of these medications, however, has not been established with controlled studies.
Tinnitus Retraining Therapy (TRT) as a method for treatment of tinnitus and hyperacusis patients. Treatment of tinnitus by intratympanic instillation of lignocaine (lidocaine) 2 per cent through ventilation tubes. Lidocaine test in patients with tinnitus: rationale of accomplishment and relation to the treatment with carbamazepine. Effect of intratympanically administered gentamycin on hearing and tinnitus in Meniere’s disease. The usefulness of nimodipine, an L-calcium channel antagonist, in the treatment of tinnitus.
Otologic manifestations of benign intracranial hypertension syndrome: diagnosis and management. Benign intracranial hypertension without papilledema: Role of 24-hour cerebrospinal fluid pressure. Since these two types of tinnitus have very diverse etiologies, pathophysiology as well as treatment, they will be described as separate entities. Once serious pathology has been eliminated, the patient should be appropriately informed and reassured. These devices are a combination of a hearing aid and a tinnitus masker and are available as either in-the-ear or behind-the-ear unit. The majority of tinnitus patients have an associated otologic pathology, however, many other factors and medical conditions can be responsible for this symptom. Many of these patients are very concerned about having a life threatening condition such as a brain tumor, or fear that are becoming deaf. Hearing aids are useful for patients with hearing loss and tinnitus pitch at or below about 4 KHz, because normal ambient environmental sounds are below this frequency. Tinnitus habituation requires at least 12 months of treatment, and it is recommended that patients continue for an additional 6 months (9). An average of 30-decibel (dB) hearing loss between 3 and 8 kilohertz (KHz) has been reported in 75 percent of tinnitus patients (4).
The majority of these patients has the mild form of tinnitus and responds quite well to reassurance. Patients are advised to avoid noise and intake of stimulants, such as caffeine and nicotine.
Side effects from medications, especially aspirin, aspirin containing compounds and anti-inflammatory agents also can cause tinnitus. Tinnitus etiologies and medications associated with tinnitus are summarized in Tables 1 and 2.

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