Tinnitus (ringing in the ears)

Tinnitus is the perception of sound — most commonly a high-pitched ringing — in the absence of an external acoustic source. Roughly 10-15% of adults experience some tinnitus; about 1-2% report it as significantly bothersome. The most common pathway is sensorineural hearing loss: damaged cochlear hair cells (from ageing, noise exposure, ototoxic drugs) stop sending signals to certain auditory cortex regions, which respond by 'inventing' input — the tinnitus is the cortex's response to silence. Bilateral high-pitched tinnitus with high-frequency hearing loss in an older adult is classic age-related (presbyacusis) tinnitus. Other patterns: unilateral progressive tinnitus → exclude acoustic neuroma (vestibular schwannoma) with MRI; pulsatile tinnitus (rhythm matches heartbeat) → vascular workup (carotid stenosis, AV malformation, glomus tumour, idiopathic intracranial hypertension); episodic tinnitus with vertigo and fluctuating hearing loss → Ménière's disease.

• Age-related sensorineural hearing loss (presbyacusis) — bilateral, high-pitched, gradual onset.
• Noise-induced hearing loss — concerts, occupational noise, headphone use.
• Ototoxic drugs — aminoglycosides, cisplatin, high-dose aspirin, loop diuretics, quinine.
• Ear wax (cerumen impaction) — abrupt onset, often unilateral; cleared by removal.
• Otitis media, eustachian tube dysfunction — paired with congestion / fluid.
• Ménière's disease — episodic vertigo + fluctuating hearing loss + ear fullness + tinnitus.
• Acoustic neuroma (vestibular schwannoma) — unilateral progressive tinnitus + hearing loss; MRI excludes.
• Pulsatile tinnitus — heartbeat rhythm; vascular (carotid stenosis, AV malformation, glomus tumour, idiopathic intracranial hypertension, severe anaemia, hyperthyroidism).
• TMJ dysfunction — clicking jaw + tinnitus.
• Migraine, anxiety, depression — modulators rather than causes.
• Iron-deficiency / B12 deficiency / hypothyroidism — modest contributors; treat them anyway.

Bloodwork has a supporting role: full blood count + ferritin + B12 (anaemia and B12 deficiency worsen tinnitus and are easy to fix), TSH (hypothyroidism contributes), HbA1c + lipid profile (cardiovascular contribution), basic metabolic. Audiogram is the diagnostic essential. MRI internal auditory meatus if unilateral or asymmetric. CT or MRA / MRV for pulsatile tinnitus. Mediora.AI flags the iron + B12 + TSH cluster as part of the workup.