Tinnitus is the subjective or objective perception of a ringing or tingling sound in one or both ears without an external stimulus. The perception of ringing or head noises may range from a low roar to a high squeal or whine. Sounds may include a buzzing, roaring, clicking, whistling or hissing noise. The noise may come and go or be present constantly. There are two types of tinnitus: tinnitus that the individual can hear subjectively and tinnitus that others can hear (objectively). This second type of tinnitus occurs more rarely and is related to abnormalities in blood vessels around the ear or by muscle spasms, which may sound like clicks or crackling inside the ear.

The exact cause is unknown however, a common cause of tinnitus is hearing loss related to damage to the inner ear cells. Multiple causes have been implicated including: impacted cerumen; myringitis; otitis media; labyrinthitis; closed head injury (concussion); acoustic trauma (loud noises, gunfire, aircraft engine noise, or explosions). It may also be caused by ototoxic drugs.

Medications causing tinnitus include:

• Non-steroidal anti-inflammatory medications (ibuprofen (Motrin), naproxen (Aleve), nabumetone (Relafen)
• aspirin and other medications containing aspirin
• Lasix and other "loop" diuretics e.g. Furosemide, Bumetanide, Ethacrynic acid, Torsemide
• "mycin" antibiotics e.g. Gentamycin; Cortisporin otic drops
• Quinine and related drugs: Mefloquine (Lariam) or quinidine (Cardioquin, Quinidex, Quinaglute, Alka-Seltzer)
• Chemotherapy e.g. Cis-platin
• Rarely, some selective serotonin reuptake inhibitor (SSRI) antidepressants e.g. citalopram, escitalopram, fluoxetine, fluvoxamine, paroxetine, sertraline, and venlafaxine

Tinnitus may also be caused by allergy, high or low blood pressure, a tumor, diabetes, fusing of the middle ear bones, stress/depression, or thyroid problems. The condition may occur as a symptom of nearly all ear disorders.

The sensation is characterized by a continuous, intermittent or pulsatile (synchronous with the heart beat), buzzing, roaring, whistling or hissing, or ringing in the ears. Hearing loss may or may not be present

The diagnostic assessment includes otoscopy, audiometry, and other tests to determine sensory and neural hearing loss such as electrocochleography. A computed tomography (CT) scan and magnetic resonance imagery (MRI) may be done. Arteriograms also may be indicated as well as central nervous system (CNS) arteriography.

Eyes should be examined for papilledema (swelling of the "optic disk" at the back of the eye) since increased intracerebral pressure can cause tinnitus.

Temporomandibular joints (TMJs) should be examined for TMJ syndrome since 28% of individuals with TMJ syndrome experience tinnitus. A brainstem auditory evoked response (BAER) test, an electrocochleography (ECOG), and a magnetic resonance image (MRI) and magnetic resonance angiography (MRA) of the brain can reveal abnormalities in ear structure and vessels.

Blood tests should include the following:

• Antinuclear Antibody (ANA) test to screen for auto-immune disorders
• Vitamin B12 level to screen for pernicious anemia
• Fluorescent treponemal antibody absorbed (FTA-ABS) blood test to screen for syphilis
• Erythrocyte sedimentation rate (ESR) is a nonspecific screening test that indirectly measures how much inflammation is in the body.
• SMA-24 or SMA-12 chemistry panel screens for metabolic disorders of the body (includes random glucose, liver and kidney function, cholesterol etc.) Include a fasting blood glucose.
• Hemoglobin A1C (HBA-1C) measures glucose control in diabetics over a 2-3 month period.
• Thyroid Stimulating Hormone (TSH) blood test screens for underactive (hypothyroid) or overactive (hyperthyroid) disorders. Microsomal antibody blood test measures antithyroid microsomal antibodies in the blood.

The focus of treatment is to determine the underlying disease. Once the specific cause has been diagnosed directed medical or surgical treatment may be prescribed. For example, if there is associated hearing loss a hearing aid may eliminate or decrease tinnitus. In some cases a tinnitus masker and biofeedback is effective.

There are several new therapies described below:

• Cochlear Implants/Electrical Stimulation is comprised of an electrode placed into the cochlea and a receiver placed just beneath the skin behind the ear. The electrode sends sound signals to the brain from the ear. They are most useful in reducing tinnitus in individuals who are deaf or near deaf.
• Cognitive Behavioral Therapy
  Cognitive behavioral therapy is a form of psychotherapy that emphasizes the important role of thinking in how we feel and what we do. A counselor will help the patient identify negative behaviors and thought patterns about the tinnitus, then alter them. Counseling programs are most effective when other tinnitus treatments, such as masking or medication are being prescribed.
• Drug Therapy
  Some drugs that have been studied to reduce the perception of tinnitus include anti-anxiety drugs like Xanax, antidepressants like nortriptyline, antihistamines, anticonvulsants like gabapentin, and even anesthetics like lidocaine. All have been successful in reducing tinnitus for some people.
• Temporomandibular Joint (TMJ) Treatment
  Tinnitus can be a symptom of a jaw joint (temporomandibular joint, or TMJ) problem. The muscles and nerves around this joint are closely connected to those in the ear and can sometimes interfere with the ear's nerves. Dental treatment or bite realignment can help relieve TMJ pain and tinnitus.

Tips to lessen the perception of tinnitus severity include:

• Avoid exposure to loud sounds and noises
• Exercise daily to improve circulation
• Get adequate rest and avoid fatigue

Residuals may include persistent sound and hearing loss.

• Compensation is payable for the combinations of service-connected and nonservice-connected disabilities specified in 38 CFR 3.383(a)(3) (see below) as if both disabilities were service-connected, provided the nonservice-connected disability is not the result of the veteran's own willful misconduct.

Notes

• A separate evaluation for tinnitus may be combined with an evaluation under diagnostic codes 6100, 6200, 6204, or other diagnostic code, except when tinnitus supports an evaluation under one of those diagnostic codes.
• Assign only a single evaluation for recurrent tinnitus, whether the sound is perceived in one ear, both ears, or in the head.
• Do not evaluate objective tinnitus (in which the sound is audible to other people and has a definable cause that may or may not be pathologic) under this diagnostic code, but evaluate it as part of any underlying condition causing it.