2Surgery for the Underlying Ear Disease

FThe middle ear as a tinnitus generator

Some tinnitus is generated, sustained, or amplified by disease the surgeon can correct. A fixed ossicular chain, a chronically infected and eroded middle ear, or a hydropic inner ear can each produce tinnitus alongside their hallmark hearing loss. In these cases the noise is a symptom of the disease rather than an independent disorder, and removing or correcting the disease is the rational route to relief.

The key teaching point runs through all three diseases below: the operation is done to treat the disease and its hearing loss; tinnitus improvement is a welcome but variable secondary outcome that should never be promised as the goal.

TOtosclerosis and stapes surgery

Otosclerosis fixes the stapes footplate, producing a conductive loss and, in many patients, tinnitus. Stapedotomy or stapedectomy restores ossicular mobility, and a substantial proportion of patients report that their tinnitus improves or resolves afterwards. A prospective study of stapedotomy in otosclerosis found measurable reductions in tinnitus severity scores after surgery, tracking with the hearing gain [2019].

A review of the literature similarly concluded that most patients experience some degree of tinnitus improvement after stapes surgery, although a minority are unchanged and a small number report worsening [2018]. The honest message to the patient is that tinnitus often improves with the hearing, but it is not the primary reason to operate and cannot be guaranteed.

TChronic otitis media: tympanoplasty and mastoidectomy

Chronic suppurative otitis media, with or without cholesteatoma, can drive tinnitus through ongoing inflammation, ossicular erosion, and conductive loss. Tympanoplasty to repair the drum and reconstruct the ossicular chain, with mastoidectomy where disease demands it, is performed first and foremost to eradicate disease, restore a dry safe ear, and improve hearing.

Where the tinnitus has been tied to the active disease or the conductive deficit, it frequently settles once the ear is dry and hearing is restored. But if a sensorineural component has developed — from long-standing disease or labyrinthine involvement — that portion of the tinnitus is central in origin and will not be abolished by middle-ear surgery. Counselling should separate the conductive, potentially improvable component from the sensorineural component that surgery cannot reach [2013].

CMeniere’s disease procedures

Meniere’s disease produces fluctuating tinnitus alongside vertigo, aural fullness, and low-frequency loss. Treatment escalates from medical management to procedures aimed mainly at the vertigo: intratympanic steroid or gentamicin, endolymphatic sac surgery, and, in refractory cases, vestibular nerve section or labyrinthectomy.

Tinnitus response to these procedures is inconsistent. Endolymphatic sac surgery may stabilise the ear and ease tinnitus in some, while ablative options such as intratympanic gentamicin or labyrinthectomy can abolish vertigo yet leave tinnitus unchanged or, by deafferenting the ear, occasionally worsen it. As elsewhere, the procedure is chosen to control the dominant disabling symptom — usually vertigo — with tinnitus managed as a secondary and unpredictable beneficiary, framed within a multidisciplinary plan [2019].