3Anaemia and Haematologic Causes

FAnaemia: the high-output, hyperdynamic ear

When the blood carries too little oxygen, the body compensates by moving it faster. Cardiac output rises, blood viscosity falls, and flow through the great vessels becomes more turbulent — a hyperdynamic circulation. In the ear, this can become audible as pulsatile tinnitus, often bilateral, in a patient who also reports fatigue, breathlessness, and pallor [2003].

The reason anaemia matters so much in a tinnitus clinic is that it is common, easy to test for, and treatable. Population and clinic data show that anaemic patients have characteristic tinnitus profiles and a measurable association with the symptom [2018]. Correcting the anaemia — not the ear — can quieten or abolish the sound.

TIron deficiency in particular

Iron-deficiency anaemia deserves special attention because it is both the most common anaemia worldwide and disproportionately affects menstruating women, in whom new tinnitus is easy to dismiss. A retrospective cohort study found that iron-deficiency anaemia was associated with an increased risk of new-onset tinnitus in female patients, supporting the clinical practice of checking iron status in this group [2025].

Beyond the high-output mechanism, iron is needed for myelination, neurotransmitter synthesis, and the oxygen-handling machinery of the cochlea itself, so deficiency may also act on the auditory pathway directly. Whatever the precise mechanism, the practical point is that ferritin and transferrin saturation belong in the work-up of a fatigued patient — especially a woman — with new pulsatile or bilateral tinnitus [2013].

TPolycythaemia, hyperviscosity and sickle cell disease

Anaemia is one end of the spectrum; too many cells, or cells that flow badly, sit at the other. Polycythaemia and the hyperviscosity syndromes (for example from paraproteinaemias or chronic myeloid leukaemia) raise blood viscosity, sludge the cochlear microcirculation, and can cause hearing loss and tinnitus — sometimes sudden [2002]. Here the ear is a sentinel for a serious haematologic disorder.

Sickle cell disease threatens the cochlea through vaso-occlusion and chronic hypoxia, with sensorineural hearing loss and tinnitus among its otologic complications. The unifying theme across these conditions is the same vulnerable end-arterial supply: whether the blood is too thin and fast, too thick and slow, or prone to occlusion, the cochlea is among the first organs to complain.

CThe haematologic work-up

The investigation is reassuringly concrete. A full blood count screens for both anaemia and polycythaemia in one test; iron studies (ferritin and transferrin saturation) characterise the most common deficiency; and vitamin B12 and folate cover the megaloblastic anaemias, one of which — pernicious anaemia — has been reported with tinnitus as a presenting symptom [1979]. A blood film, haemoglobin electrophoresis, or viscosity studies are added when the history points that way.

This targeted panel fits squarely within the guideline-based approach of seeking modifiable contributors before chronic management [2014], and its breadth is why associations between tinnitus and systemic disease are increasingly recognised across age groups, including adolescents [2024]. The clinical payoff is real: in the anaemic patient, correcting the deficiency can make the tinnitus go away.