Sudden Tinnitus: An ENT Emergency in Singapore?

Have you noticed a sudden annoying noise in your ear or ears recently? This is called Tinnitus, a word used to describe any humming, whistling, crackling, popping, screeching or ringing sound in your ear(s). The meaning of the word Tinnitus originates from the Latin term, “tinnire” : To ring or tinkle. Tinnitus is all about having the perception of a noise in your ear, which in most cases, only the sufferer is able to hear i.e. subjective tinnitus. Objective tinnitus where everyone else can hear the noise in your ear too, is much rarer and definitely needs urgent investigation as it may signify the presence of an abnormal blood vessel condition or malformation. Subjective tinnitus is much more common but if it comes on suddenly, then it should be investigated promptly in case it leads on to other issues such as hearing loss, dizziness and vertigo.

So if only YOU can hear the tinnitus in your ear, then what could be the cause? Is the tinnitus something you should worry about? Remember, tinnitus is a word used to describe only the symptom itself, and it is NOT a diagnosis. Multiple causes of tinnitus exist and we will list a few of the common causes below, although the list is not meant to be exhaustive:

1. Infection of your ear and surrounding structures: As tinnitus is usually the earliest sign of something not quite right in your ear, even the mildest infection of your ear can give rise to tinnitus. Severe ear infections lead to a blocked ear, ear pain, hearing loss, and can go on to cause facial swelling and neck swelling too due to the associated inflammation of the surrounding lymph nodes.

2. Impacted earwax: The ear is a self-cleaning organ in most people so you should not dig your ears, even with cotton buds or your fingernails. Digging your ears will just end up pushing the earwax even deeper to make it worse, or you might end up injuring your ear canal or eardrum!

3. Underlying hearing loss, especially Sudden Hearing Loss: Tinnitus can sometimes be the earliest sign of something abnormal occurring inside your inner ear, where the cochlea and its nerve endings lie. Sudden hearing loss needs to be treated by your ENT specialist in Singapore as soon as possible to maximise the recovery of your hearing!

4. Prolonged or excessive noise exposure, commonly with earphone use: Many people now use earphones for their work from phone and as a result, we have seen a significant increase in the number of tinnitus sufferers since the start of the Covid-19 pandemic.

5. Previous ear surgery: We see many patients in our ENT clinics in Singapore who have previously undergone ear surgery elsewhere but who now want a second opinion from us.

6. Sinus infections: Even the common cold or flu may result in tinnitus if there is too much congestion of the nose and Eustachian pressure tubes. So tinnitus management will include management of your nasal and sinus conditions if they appear related.

7. Allergy flareups inside the nose (Allergic rhinitis): Sneezing, runny nose, itchy nose, itchy watery eyes, itchy throat, feeling of a lump in throat, difficulty breathing through your nose, may all be caused by nasal allergy issues. Having an allergy test, focusing on inhaled substances, is very important to manage your allergic rhinitis properly.

8. Migraines: Although headaches may be more common, tinnitus can also be a symptom of migraines or a parallel condition which is triggered by suffering bad migraines. Often, stress can be a trigger to exacerbate both migraine and tinnitus conditions.

9. Temporomandibular joint dysfunction (Jaw Joint or TMJ abnormalities): TMJ problems may be worsened by excessive chewing, teeth-grinding and jaw-clenching, all usually signs of underlying muscle tension and stress issues. TMJ dysfunction should be treated early to avoid it causing chronic headaches, neck ache and migraines.

10. Tumours of the postnasal space or inner ear: More rarely, tumours can grow at the back of your nose to block off the pressure tubes leading to your ears, leading to tinnitus. Tumours from the balance nerve in the inner ear can also lead to sudden tinnitus and sudden hearing loss (acoustic neuroma). We do pick these tumours up in clinic and because tinnitus can sometimes be the very first sign of such conditions, sudden onset of tinnitus means you should go and get the tinnitus checked out properly by your best ENT specialist in Singapore, without unnecessary delay. The picture (credit to the Mayo Clinic) below illustrates how an inner ear nerve tumour can grow inside your ear towards the brain.

For most tinnitus sufferers though, the MRI scan of your inner ears will be normal. So what can you do about your tinnitus? Is it driving you mad to the point of having difficulty sleeping or disturbing your sleep so that you wake up in the middle of the night? Is it bothering you so much that you are unable to focus on your work and perform your usual daily activities? Tinnitus is basically a stress reflex of the ear: Anything that can stress the ear out, may theoretically lead to the onset of tinnitus. Tinnitus is also often what I call “the tip of the iceberg”, meaning that it is a very common symptom that sometimes has other deep-seated causes, such as anxiety and depression. But it’s tricky sometimes to try to decide which came first: The “chicken vs egg” situation! Was it the tinnitus that was truly causing the sleep issues? Or was it the lack of good quality sleep which led to the more noticeable tinnitus noise disturbing you?

Tinnitus management essentially centres around four key principles:

1. Distraction: Keeping yourself busy and avoiding overly quiet/overly noisy situations can help distract you from the tinnitus noise. Tinnitus sufferers often find their tinnitus disturbs them more at night when it tends to be quieter at bedtime.
2. Masking: This involves applying a band of usually soothing sounds or noises to cover up the irritating tinnitus noise itself, or at least soften the intensity. Masking techniques can range from using your favourite relaxing music in the background, to downloading a tinnitus app, all the way to investing a special sound machine to apply calming sounds to alleviate the effects of your tinnitus symptoms.
3. Adaptation and modulation: Over time, many tinnitus sufferers find that they don’t seem to notice their tinnitus as much as before. This is thought to be due to the nerve endings of the inner ear gradually adapting to the constant tinnitus stimulus to tone it down to try to focus on new different and more useful sounds around us. What studies have so far been unable to precisely identify is how the inner ear nerve endings can actually change and adapt to achieve this.
4. Habituation: Adaptation is very closely linked to the process of habituation. After a while, ranging from days to weeks to months, the inner ear nerve endings become habituated and no longer respond so sensitively. The brain also plays a very important role in adaptation and habituation, and may start to process the constant tinnitus stimulus differently over time. Individuals with perhaps a more neurotic type personality may be more sensitive to the processing of sound and so, may stand a higher risk of developing tinnitus which is less likely to adapt and habituate with time.

Although most tinnitus sufferers can and do eventually adapt to their noise in ear symptoms, some patients may need a prescription for antidepressants, anti-anxiety pills and muscle relaxants to help them manage their tinnitus better. Tinnitus counselling may also play an important role in helping the tinnitus sufferer, as it often involves cognitive behavioural therapy to help tinnitus patients understand and hence cope better. Sometimes, tinnitus counselling may also involve a trial of a white noise masking device to offer a form of auditory adaptation, a type of special hearing aid whose aim is to match the frequency band of the tinnitus noise to mask it and hence reduce its disturbing effects on your ear. However, it can be challenging to obtain a precise match between the sound frequency of your tinnitus and the white noise masker so visiting an experienced tinnitus counsellor is important. Tinnitus counsellors are usually experienced audiologists who have been trained specifically in tinnitus management.

Finally, from my perspective as a busy ENT specialist in Singapore looking after many patients with ear problems, I just want to say that if you suffer tinnitus suddenly out of the blue, it might be a warning sign of impending sudden hearing loss and dizziness….so please don’t delay seeking the help of your friendly ENT specialist.

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