I Have Tinnitus due to the Dental Work by an Incompetent Dentist

My story in a nutshell starts with bad dentistry. Five years ago I allowed a dentist to remove two crowns to replace them. He put temporary crowns on without properly adjusting the height of the crowns. I did not understand this at the time, but when your bite is off, it causes enough pressure to severely inflame the nerve of the tooth, especially if you grind your teeth at night.

I ended up in the endodontist office getting root canals. I had four separate root canals in less than one year. The tinnitus started right around the first root canal. I would have severe pain from my neck up through my ear, and the tooth would throb. And the ear would ring. The first root canal was in February and three more followed through out the year. I was too sick to think clearly enough to leave my very sweet, but unbelievably incompetent local dentist.

In the beginning, the ringing was lower pitched and very loud. I went to a older primary care physician who told me that I was young for tinnitus (40 years old), but that it happens. I went to a ENT who was gave me a half-assed hearing test (a good hearing test is given by an Audiologist and involves acoustic reflex, word repetition etc). This very bad ENT told me that I have hearing loss, and that there is no cure for tinitus and I should go home and live with it.

At this same time, I also started having bad neck pain. My chiropractor would adjust C1/C2. My C1/Atlas would get misaligned by the next morning.The ringing was worse when my neck was out of alignment. I changed desks, chairs, wore a posture corrector band, etc and nothing helped.

I asked my dentist to check my bite and he said it was fine. He suggested that I get braces, so I paid his office thousands to get orthodontic services. The orthodontist did adjust my bite some to begin with, but not very well. (never use a orthodontist that travels from dentist to dentist. You want one that has their own office.) In addition, after I got the braces off, one of the crowns came off (yes, it came unglued) and the dentist glued it back on, leaving my bite high on the left side again! Remember, I keep asking him to check the bite, and he says it is OK.

Over the years, I learned to control the tinnitus through, avoiding salt, alcohol, sugar, taking supplements, avoiding high stress, stretching etc. And contrary to what the first doctor told me, the ringing did become more bearable. It settled into a higher pitch and lower volume.

In March of this year 2013, I decided to make a list of all the possible causes for my tinnitus, and one by one get them checked out by specialists. It got off to a really bumpy start. I decided to have the root canals reviewed to make sure they were done properly. The first Endodontist that I went to told me that my tooth was fractured and needed to be pulled. I was smart enough this time to get two more opinions, and both the 2nd and 3rd Endodontists told me that the tooth was absolutely fine with NO fracture.

The last Endodontist was excellent, and spent 2 hours reviewing my teeth, and then recommended that I go to a Prosthodontist. I had never heard of a Prosthodontist.

A Prosthedontist is a dentist that goes to school for 3 extra years and is an expert at fixing your bite, crowns (and implants and dentures too). Adjusting a dental bite is an art, and the average dentist is not very good at it. Most patients bite down and immediate shift their jaw to try to get the teeth to all touch. And then the little blue piece of paper shows that all of the teeth are contacting. A proper bite check involves making sure that the patient is doing a natural bite to see which teeth make contact. All teeth should make contact at the same time.

This Prosthodontist was wonderful! He took 30 minutes and fixed my bite. For the first time in five years, my bite feel right. Within days, I realized that 90% of my neck pain had already diminished. My ringing has decreased further too.

The prosthodontist reviewed my night time bite guard and informed me that it had been created improperly. I am going in next week to have a new one made. My tinnitus has always been louder in the morning, which is a good indication of night time bruxism / grinding. And it also could be because the fit of the night guard has been incorrect.

I'm learning over and over that you have to ask in order to find the good doctors. If they are good, you find that their names come up over and over.

I saw an allergist too. This allergist told me that I had fluid in my middle ear. He gave me a shot of long lasting corticosteroid called Depromedrol. Within hours my ears were ringing twice as loud. It took two weeks for the effects of the Depromedrol to subside. I don't plan on going back to this allergist, but I may find a new one to get the allergy tests I originally intended. In addition, neck problems can cause blocked eustachian tubes and therefore fluid in the middle ears. Therefore if your bite is incorrect, then it can cause blocked Eustachian tubes and fluid in your middle ears.

I also switched ENTs and had a real Audiologist do my hearing test. It showed better results than the other one. This ENT did not tell me to 'go home and deal with it'. He confirmed that the muscles in the neck and jaw affect the ears.

I won't get back the thousands of dollars I spent on chiropractors, and acupuncturists. I won't get back the lost time or missed opportunities from not feeling well in the last five years. And I will always have these root canals which weaken the structure of the tooth. But I have learned valuable lessons about 1 out of 3 doctors being dead wrong on their diagnosis. And maybe posting my story will help someone else along the way.

I still have ringing, but it is less, and I have hopes that this will eventually disappear.

Thanks for reading.

 

Very interesting. Not surprised about dentists, I've had similar experiences, same with the "falsely" cracked tooth.

Did he have any proof? I'm investigating allergies / food intolerance atm. What is your theory on this? At the moment I'm thinking mine operated this way:

High chronic stress (moved overseas permanently, difficulty with buying first house, 2 kids that don't sleep well constantly waking up at night for years) > lead to development of allergy / intolerance > leads to inflammation > lead to tinnitus.

I sometimes get odd reactions to some food, like cheap beer gives me heart palpitations about 2 days later, green tea gives me itchy left elbow about a week later (took me years to find out what caused that!). I'm wondering if there is simply something I'm eating that causes this chronic inner ear inflammation.

I also seem to have a degradation of my mental state (unexplained depression and anxiety) that correlates with the tinnitus. Symptoms that are on the list of intolerance.... however, I'm not stupid, these are also on the list of a lot of other diseases out there. However, after having been checked up properly (blood, scans, etc) for common and dangerous stuff, turns out nothing can be found by the local medical mob. So I have to fall back on the more "fuzzy" explanations / theories.

Keep in touch

 

Hi Serge,

The allergist's theory was that blocked Eustachian tubes lead to middle ear fluid which leads to pressure which can lead to tinnitus. He felt that the blocked Eustachian tubes were an allergic reaction to pollens/cats etc.

BUT, I think he was incorrect on the origin of my middle ear issues. Neck problems can also cause inflammation and blocked Eustachian and middle ear fluid. My sister has similar neck pain, and also gets ear problems from upper cervical misalignment. You don't mention neck issues, so this is probably not a catalyst for you.

Yes, I think stress and inflammation is a big factor in most diseases/disorders. My siblings and Mother have very strong auto-immune responses, and lots of strange food allergies / intolerance. At the time my tinnitus appeared I also was highly stressed because my siblings were fighting after my Dad died. So I do think stress, and inflammation were a factor in the short circuit leading to T for me.

I think some people are able to lower their T by clean living (no salt, no sugar, no meat etc) because this reduces inflammation, and lowers physical stress. I think a lot of people have louder T when they do not get enough sleep. Conversely you should be able to lower it some if you are living clean and getting enough sleep.

You may want to read some about food allergies versus intolerances IgG and IgE. The Alcat test is supposed to help identify food intolerance http://www.alcat.com/. But a friend of mine with a PhD in microbiology thinks it has questionable science. Starting with an allergist to test for food allergies could be a good start. Then move on to a food intolerance test.

Also today a doctor friend of mine told me that he had positive responses when he prescribed .5mg of Xanax 3x per day for 2 weeks. It seemed to break the pathway, and eliminate the T. I plan to try this if physical therapy does not help.

Thoughts?

 

To me, things fall in two categories, either:

1. They cause the tinnitus (causal)
or
2. They aggravate / reduce perception of tinnitus (modulate intensity)

I think caffeine, poor sleep, anti-depressants, etc fall in #2. I'm not very interested in those at all. I'm more into what would go into the #1 category.

Aside computers, I'm also trained as a remedial massage therapist and I've practiced for about 3 years (stopped for financial reasons, IT pays more). I've had plenty of time of studying the neck with its various muscles, blood vessels, lymph network, bone / join structure and I can say that it's very, very unlikely that neck "misalignement" would cause tinnitus. However, that's what your local chiro would like you to think because he's making lots of money out of it.

Inflammation is an immune response to a breakage in a body tissue or to an antigen. Failure to find any soft tissue injury, we're left with finding the antigen (bacteria, virus, other particle the immune system decide is offensive)...

Have a look at the video on this page: http://www.precisionnutrition.com/fix-gut-fix-health

Not sure how accurate this is but it makes senses, a cascade of issues leading to normal food creating temporary intolerances. Would have to research more if that's the case.

 

Note: If 2 weeks of xanax cured tinnitus, the community would know by now

 

I think I'd rather be an optimist, and not rule out any possibilities. Tinnitus is a symptom of so many conditions, that what works for one person may not work for another.

Interesting link where people write about what helped them.

http://www.ata.org/sites/ata.org/fi...ngcalm_macrobioticdiet_earmassage_june_07.pdf

 

Here are some more stories of tinnitus relief;

http://www.ata.org/sites/ata.org/fi...r/prednisone_acupuncture_food_tmj_sept_06.pdf

http://www.ata.org/sites/ata.org/files/pdf/Letters_to_Editor_Apr_11.pdf

http://www.ata.org/sites/ata.org/files/pdf/Letters_to_Editor_Lamictal_pulsatile_Lorazepam_Dec_07.pdf

 

http://www.ata.org/sites/ata.org/files/files/Winter2011_QA.pdf

 

Thanks for letting me know about the prosthodontist. I had occlusion work once where all my teeth touch down at the same time.

 

http://cloudb.com/sound/gentle-giraffe-on-the-go

This is my fav under-pillow sound masker. I took the sound box out of the giraffe, and I keep it under my pillow.

 

Even though this post a year old, thank you for this! I remember my "T" started right around the time I also had a root canal. As a matter of fact, I recall asking the endodontist if the temporary filling was too high.. especially after she noticed I grinded my teeth. She said "No, it needs to be that way". Wondering if she was wrong.

On top of this, my regular dentist gave me two gold crowns next to each other. I truly believe he messed me up (Have had issues with balance since then, scared of heights now -- and I've legit had my head in the clouds and been at edge of grand canyon in past, neck pain and of course ear ringing). My dentist, ironically, retired last month. I think he did something to me due to my father and step-mother leaving his practice 6 months earlier. I even contracted Hep B a month after leaving his office.

I saw a new dentist and he checked my bite and told me it was "off". He then suggested I get new crowns as well, as the regular gold crowns could have been causing a ranging of symptoms against my nerves, etc. Unfortunately, the dentist cancelled my appointment and now I can't get into anything as he has no openings. So, I am going to make an appointment with a posthedontist on Monday in hopes the dental work can help/cure me of all the issues I have.

Like you, I have tried everything (chiropractic, etc.) to no avail. My ENT said the "T" is due to hearing loss... no buddy, the "T" is causing my hearing loss! I've been to loud concerts, seen events in high stadiums, been on super high mountains, played music in a band, etc. I never had the "T" issue nor did I have any of the other issues until 3 days after my first crown was put on. If worse comes to worse, I'll at least have new crowns that aren't metal.

 

Hello I have my T since April 15/2014..having a hard time sleeping .did not sleep for 2 night in a row. I I took atavin and other sleeping , they make me dpressed and full of anxiety ..what can I take to sleep , please help me ,keep in touch need help in sleeping . I take sleeping time ter , does not help , take benedril , does not help , took Melotonim ..feel crazy the next day..would appreciate your help on sleeping..thanks

 

I also have a neck problem from a few years ago , started taking physo and a few months after my T started ..Went on a 14 hours flight back and forth..not sure if this started it ..I also feel dizzy and wobbly all day long did this happen to you? going for an mri Saturday..hope they can find a cure for us ..God bless you..This too shall pass

 

Hi there, I do have problems with sleeping sometimes, especially cuz mine fluctuates like crazy, but I noticed that oxazepam /lorazepam /diazepam etc relaxes my muscles and lowers my T. Maybe you should try to take one of those when going to sleep. They also help against anxiety and make you full drowsy and sleepy. Hope it helps.

 

\Thanks

 

Wanted to update on this one too, since I posted. I never went to the prosthodondist and my regular dentist did a slight adjustment on a bite, which helped a lot after I was experience pain on the crown with a root canal. However, a few weeks later, my original crown that was not cemented in came out for the first time in 11 months. In those 3 days time I had it out, a lot of neck pain went away as did a lot of balance issues and shakiness and the tinnitus was reduced. I went to my regular dentist and he cemented it in. He checked my bite and obviously, I told him it felt fine... the next day, my tinnitus spiked a little again and my shakiness and balance issues came back. Not only this, but the eye on the side with the crowns has been red for 3 weeks after this was cemented in.

I got worried I had mercury poisoning at this point and talked to my old/retired dentist at this point. He told me they were mercury free since 1986 (I got the crowns there and started going to him in 2003, so I ruled this out). He suggested an occlusal interference and that I needed to get the bite on the crowns adjusted, as this would be the first thing he'd check too. He also said my crowns were made of high noble gold. As I sit here, the crowns are touching my upper teeth with my mouth closed and the teeth on the other side are barely missing touching each other. I'm now re-considering the prosthodondist. My new dentist did make me a night guard, but it's been of no help.

I'll update when I have more... doubt it will cure my tinnitus but since the issues came about right when I had dental work, it's worth a shot.

 

@stickywicket I'm hoping to than you for this in 2 days. I had this done today and guess what? My bite feels right. My dentist didn't adjust the crowns though, since gold is hard to do, but adjusted the opposing tooth. But it feels right. I came home and decided to take a nap and immediately noticed I was not clenching or grinding my teeth before I took the nap or after. Hoping some neck issues go away and that it reduces the tinnitus as well in a could of days.

 

Hi there Luckyman316, Has this had a permanent effect on your neck pain? Any improvement in T?

 

Hi Serge, Sorry for the super long delayed response. Thank you for the excellent link. Through a combination of posts on this forum (from you, Click etc), and googling "foods that make your ears ring" in May 2013 I decided to try a low salicylate diet. Within two days I noticed a huge significant difference. My left ear was virtually quiet and my right ear went down to a low ring. I've learned that high salicylate foods such as spices (ginger turmeric etc) are specifically reactive with my tinnitus.

And I think you are right about the leaky gut issues. When my ringing started, I had a few different high stress situations. I also was taking ibuprofen for teeth pain. These things could easily have damaged my gut.

I had read that a anti-inflammatory diet would be the best thing for my inflamed tooth, and for my health, and I even began taking a half spoonful of turmeric with black pepper in hot water because I read that this was helpful. Now if your body already has a hard time with PST enzymes/ making sulfate, then this overload will produce and/or aggravate tinnitus. http://healingautismandadhd.wordpress.com/diet-2/phenolssalicylates/

I do think there is a genetic component though. My Mom is very reactive to high salicylate foods. My mother has a high pain tolerance and rarely complains, but when she tried juicing, she almost went to the hospital with stomach pain. So perhaps I aggravated a pre-existing genetic sensitivity to salicylates by over-doing it.

My diet now is heavier on beans, and lentils etc, which are no cholesterol, but high protein, and lower salycilate. I also take enzymes and probiotics which seem to be helping. I like the No-Phenol products at Kirkman and I take their no salicylate multi-vitamin now too.
http://kirkmanlabs.com/SiteSearchResult.aspx?strSiteSearch=phenol

From a different post that I had written, here is a list of the things that have worked for me. I know you don't believe that chiropractors help, but for me, it has helped to reduce pain, and therefore stress.

Here are the areas that seemed to make the most improvement for my tinnitus:
1. I found a Prosthodontist (like a dentist but they have two extra years of training) who fixed my bite. My bite was high on one side. Make sure all of your teeth touch at the same time when you slowly close your mouth. If one side touches first, then you have a bite issue. This has helped both my neck pain and my jaw stress. He also made me a night guard which I faithfully wear at night. I used to love my previous dentist.. nice guy, but in hindsight, a terrible dentist. 2nd and 3rd opinions are key.
2. I have a regular chiropractor (with whom I have a negotiated cash price) that I see 2-3 times per week. The doctor identified my particular muscles that tend to pull my C1/C2 out of alignment. (I also had upper and lower spine MRIs to check for stenosis which I do have at C6/7 but is probably not a tinnitus issue)
3. I found a doctor whose focus is spine & pain, who worked with me to test botox on my jaw (no effect) and also on specific back & neck muscles. This does not eliminate the ringing, but I do think it has reduced my neck pain, which lowers stress and therefore ringing volume.
4. I have started allergy shots because I seem to have Eustachian tube issues. I feel a glug-glug in my ears when I bend over. And I wake with a stuffed up nose in the AM. The jury is still out on whether the allergy shots will help.
5. I have always been a very healthy eater. And with the start of the teeth issues, and subsequent tinnitus I began eating more and more anti-inflammatory foods such as ginger root tea and turmeric. I found that the salicylates in these foods doubled the volume of my ringing. I am now on a vegetarian but low salicylate diet (lots of lentils, beans etc). For those of you wondering if this would apply to you; If taking asprin (which is salicylic acid) makes your ringing noticeably worse, then high salicylate diets will do the same.
Supposedly a significant percentage of people do have salicylate sensitivities/intolerance. This salicylate intolerance could be considered comparable to people who are lactose intolerant. Similarly, people who have dairy sensitivities lack the enzymes (or the enzymes are weak) to bind to/digest lactose (dairy). In addition, these sensitivities can be compounded by leaky gut. Leaky gut basically means that you have damaged your stomach lining. The stress of the root canals, the ibuprofen etc could have contributed to leaky gut issues.
6. Also in line with the salicylate sensitivity, I take regular Epsom Salt baths now. The Magnesium Sulfate works to eliminate salicylates (it works with the PST enzyme to bind with toxins) and has a significant impact on the ringing volume. I use 3-4 full cups of Epsom Salt and soak for a good 30-40 minutes.
7. I try to continue masking whenever possible. The theory is that your brain has been trained to hear this pitch, so after eliminating other factors, retraining your brain with masking may also be important. I was also told this by an audiologist here in Miami that specializes in tinnitus for over 20 years.

 

Hi @stickywicket unfortunately no improvements, at least nothing drastic. Like you, I went to my dentist first. He's done an "adjustment" twice. I'm still convinced my bite being wrong is causing these issues. I'm seeing the prosthodonist on Tuesday. I may opt to also have my crowns replaced for porcelain. I suspect this metal in my mouth is causing the inner ear issue I keep experiencing, especially since it happened 3 days after my first crown.

On top of this issue, I did contract a virus, which attacks my liver. I've been on an anti-viral for this and things got a lot better in the last 3 months for me in general, but the issue still lingers with my inner ear and the tinnitus. If this specialist does what I suspect he will do, and a lot of these issues remains and show no improvement, then I will narrow it down to an issue with my neck or my liver.

 

@ luckyman316 Thanks for the update. I've read that anti-viral medications can also cause tinnitus. Good luck with the Prosthodontist.

 

Thanks @stickywicket and yes, I am almost positive these issues are from my misaligned bite and possibly from the crowns themselves. It'll be good to see what happens, only 4 more days to hang in there. Also, the tinnitus started 6-7 months before my antivirals. If anything, the antivirals reduced the tinnitus. I'm convinced this whole time, I've had 2 underlying issues so now I'm fixing the second one, causing me the most frustration at this point. Hope it's a quick process for me and hope things go back to normal very quickly too!

 

after fixing cavity on my 8th tooth I got big pain on my other surrouding teeth and some other teeth in my upper side that I never had any problem with, I think it is connected and 2 weeks after I got tinnitus after listening to some loud but not unusually loud music, my hearing is great, -10db and I think it is due to the tooth. Should I remove the tooth asap or try to somehow calm the irritation to it down so that when I remove or fix it the second time do not have some phantom nerve missinformation? I realla need advice on this? I am heavily inclined to remove the tooth asap.

 

@ Hengist, I would not jump to pulling a tooth so quickly. Removing a tooth can result in other teeth shifting, further misalignment of your bite etc. If you are able to, I suggest that you try one or two more dental consults to identify the issue.

 

Most people have their 8th teeth pulled, I have had one pulled for years and never noticed any problems. You would advise more talking with dentists? What am I supposed to get out of those talks the level of medicine is not very high compared to where you are and my finances do not allow for me to whatever I want.

 

Silver fillings & Tinnitus
http://www.tinnitusformula.com/libr...for-health-hearing-and-tinnitus/#.U9LFmleCWq0

 

I am not sure which tooth is the 8th. This web site shows tooth 8 in the front.
http://dentalimplants-usa.com/generalinfo/toothnumbering.html

It is easy to make quick decisions when you are desperate to get rid of the ringing. I understand that you may have limited resources. Please be careful. And let us know how things go.

 

Of course, yankee gotta screw up numbering of every single thing, here is what 8th tooth is. This is how everybody counts and labels teeth without logic being destroyed by "exceptionalism".



I am anything but independent in my decisions, I am consulting my family, my ex, my friends, my current and past doctors and alternative and bio-energy people. The general and dominating opinion is that I should remove the tooth and that waiting will produce nothing, except make some people feel warm and fuzzy inside because an obvious course of action was "not rushed".

 

@stickywicket wanted to update you and the rest on this story. I seeked out a prosthodontist and had the appointment with him yesterday. He spent time on my teeth, in particular the area with my crowns. He said that in fact, one of the crowns was too high (Tooth #30). While he could have adjusted it, he was reluctant to do so due to the fact that it was a gold crown and he did not know how thin it was, and an adjustment to get it right could lead to putting a hole in the crown which would make it worthless and force him to redo my crowns. He actually suggested both my crowns next to each other were a little high (#30 being worst though) and that since it was done by previous dentist, it might have been his style to do it this way -- shame on him!

I spoke to him about the tinnitus and he said that is a myth but there have been cases where high dental crowns have caused it, though not documented. He talked to me about how the high crowns were not allowing my muscles to work properly and how other parts of my body were trying to compensate for it. With the adjustment, it would get my body back to normal. He said to keep wearing he night guard which would help.

He left it in my hands to decide whether I want to get this done or not so I told him I'd take a couple of weeks to think about it. His suggestion was that I should get new crowns, as that would be ideal and told me himself or my regular dentist could do this (he wasn't forcing me to go with him). Now, I'm unsure of what to do. I obviously don't want to wait this out but at the same time, I don't want to risk getting things worse. He said with new crowns, they may have to cut more of the tooth and if they do that, it could cause complications with the tooth if they get down to the nerves, those needed a root canal, or worse yet they may need to cut some of the gums (ouch!). Thankfully, one tooth had the root canal already.. tooth #30. Unsure of what to do now!

 

@luckyman316 Based on your earlier statement of, " my original crown that was not cemented in came out for the first time in 11 months. In those 3 days time I had it out, a lot of neck pain went away as did a lot of balance issues and shakiness and the tinnitus was reduced." if I were you, I would seriously consider replacing those crowns. In addition, your first dentist who left the crowns high, but adjusted the surrounding teeth does not sound very competent. You may even consider getting a 2nd Prosthodontist opinion.

I understand how daunting it can be to have to replace crowns, and have unknown risks. After my Prosthodontist adjusted my bite my neck and T were much better. There was one crown that had been made improperly, and had decay under it. The Prosthodontist replaced this crown. I was so concerned about the other crowns having been made improperly, that I had him replace the other two as well. He used a material called e.Max for the new crowns. I was also warned that there may not be much left of the tooth and that they would need to push the gum down, but this was not needed. I really cannot tell you if this improved my T (but the left side where crowns were replaced is practically silent), but I know for sure that it fixed my painful neck/back issues.

I don't understand why so many people are quick to tell you that your neck or your teeth or whatever cannot cause tinnitus. Our bodies are basically machines, and just like an engine, if one part is not working properly, it can affect the other parts. If we have misalignment in the teeth, then this can cause misalignment in the neck, and also effect the auditory nerves. Or if we have a physical reaction to a metal, this too can affect your nervous system.

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2686891/

Causes and Pathophysiology
Causes
Tinnitus does not represent a disease itself but instead is a symptom of a variety of underlying diseases. Otologic causes include noise-induced hearing loss, presbycusis, otosclerosis, otitis, impacted cerumen, sudden deafness, Meniere's disease, and other causes of hearing loss. Neurologic causes include head injury, whiplash, multiple sclerosis, vestibular schwannoma (commonly called an acoustic neuroma), and other cerebellopontine-angle tumors. Infectious causes include otitis media and sequelae of Lyme disease, meningitis, syphilis, and other infectious or inflammatory processes that affect hearing. Tinnitus is also a side effect of some oral medications, such as salicylates, nonsteroidal anti-inflammatory drugs, aminoglycoside antibiotics, loop diuretics, and chemotherapy agents (e.g., platins and vincristine). Temporomandibular-joint dysfunction and other dental disorders can also cause tinnitus. However, in many cases no underlying physical cause is identifiable.28 For many years, hearing loss has been understood to be the most common cause of tinnitus,29 and population-based data indicate that excessive noise exposure represents the second most common cause of tinnitus. However, about 40% of patients cannot identify any cause associated with tinnitus onset.26

Any pathologic lesion in the auditory pathway or any reduction in auditory nerve function has the potential to produce tinnitus.19 The location of the hearing problem (i.e., in the middle ear or in the inner ear) and the otologic disorder causing the hearing loss do not appear to influence the etiologic potential.6 Interestingly, most patients with tinnitus complain about a sensation of fullness or blockage in the middle ear, suggesting a problem with middle ear pressure or increased impedance of the ossicular chain.30

Trigger factors
Small temporary changes in the outer hair cells (OHCs) following noise exposure can trigger the emergence of tinnitus by increasing the gain of the central auditory system.8 In general, tinnitus represents a threshold phenomenon for which any one factor, such as chronic progressive hearing loss, is insufficient to elicit its emergence-two or more trigger factors (i.e., psychosocial stress, noise exposure, and somatic factors) can act synergistically to produce symptomatic tinnitus.15 About 75% of new cases are related to emotional stress as the trigger factor rather than to precipitants involving cochlear lesions.8

Pathophysiology
Tinnitus represents a symptom of diverse pathologies. It is proposed that all levels of the nervous system are, to varying degrees, involved in tinnitus manifestation.1,31