Systemic Lupus Erythematosus (SLE) is a chronic autoimmune disease where the body’s immune system mistakenly attacks its own tissues and organs. Tinnitus, commonly described as a ringing, buzzing, or whooshing sound in the ears, is a neurological symptom stemming from the auditory system. Although not one of the most common manifestations, there is a recognized association between SLE and auditory symptoms, including tinnitus. The presence of tinnitus in an individual with lupus can arise either directly from the disease’s effects on the inner ear structures or as a side effect of the necessary medications used for treatment.
Establishing the Link Between Lupus and Tinnitus
Auditory involvement in Systemic Lupus Erythematosus is an established neuro-otologic manifestation of the disease. Research indicates that individuals with SLE have a significantly higher risk of experiencing hearing-related issues compared to the general population. The prevalence of hearing impairment, most commonly sensorineural hearing loss, is reported to be as high as 27% in SLE patients, a substantial increase over healthy controls.
Tinnitus often appears alongside sensorineural hearing loss. Studies focusing specifically on tinnitus report that it affects approximately 23.7% of patients with SLE. This symptom results from damage to the structures of the inner ear or the auditory nerve pathway. The presence of tinnitus, sometimes accompanied by vertigo or dizziness, suggests the autoimmune process is actively affecting the audiovestibular system.
Underlying Causes: How Lupus Affects Hearing
Lupus can directly trigger tinnitus through several distinct pathophysiological mechanisms that damage the inner ear. The immune response can mistakenly target the cochlea and auditory nerve, often manifesting as sensorineural hearing loss. Tinnitus is often a secondary consequence of this auditory pathway disruption.
A primary mechanism involves vasculitis, the inflammation and narrowing of the small blood vessels supplying the inner ear structures. The cochlea has a specialized blood supply; when this flow is restricted by vasculitis, it causes ischemia (lack of oxygen), damaging the hair cells. This damage and the subsequent lack of input to the brain result in the perception of phantom sounds.
Another process centers on immune complex deposition within the inner ear. Lupus produces immune complexes (clumps of antibodies bound to antigens). These complexes can deposit in the microvessels of the stria vascularis, a tissue that helps maintain cochlear fluid balance. This deposition and resulting inflammation can lead to fluid imbalance and structural injury to the sensory cells.
Lupus may also trigger or mimic Autoimmune Inner Ear Disease (AIED), where the immune system specifically attacks the inner ear. This immune-mediated attack can cause rapid, fluctuating, or progressive sensorineural hearing loss and tinnitus. Furthermore, the overall inflammatory state of the disease can lead to cytotoxic damage, where toxic substances released by immune cells directly injure the cochlear and vestibular hair cells, resulting in auditory symptoms.
Medication as a Contributing Factor
While lupus itself can cause tinnitus, the symptom is often a side effect caused by the treatments for the disease. Several classes of medications used to manage SLE activity are known to be toxic to the ear structures, or ototoxic. Differentiating between disease-related and medication-related tinnitus is important for clinical management.
Nonsteroidal Anti-inflammatory Drugs (NSAIDs), frequently used to manage joint pain and inflammation, can cause tinnitus, especially at high doses. The mechanism involves temporary impairment of the outer hair cells in the cochlea, which amplify sound. Tinnitus caused by NSAIDs, such as high-dose aspirin or ibuprofen, is usually temporary and reversible once the medication is stopped or the dosage is reduced.
Antimalarials, particularly hydroxychloroquine, are a foundational treatment for most SLE patients and are generally well-tolerated. They carry a small risk of ototoxicity because hydroxychloroquine can accumulate in the melanin-rich tissues of the inner ear, including the stria vascularis. This accumulation can lead to irreversible damage to the stereocilia of the hair cells, potentially causing permanent sensorineural hearing loss and tinnitus, necessitating regular audiological monitoring.
High-dose corticosteroids are a common first-line treatment for acute lupus flares, including those affecting the inner ear. These drugs can induce auditory side effects, including tinnitus and hearing changes. This ototoxicity is generally dose-dependent, and the symptoms are often reversible, resolving after the patient completes the course of treatment or the dosage is tapered down.
Clinical Evaluation and Treatment Approaches
When a lupus patient reports new or worsening tinnitus, a comprehensive clinical evaluation is required to determine the underlying cause. The diagnostic process begins with a detailed patient history and physical examination, followed by specialized audiological testing. Pure-tone audiometry and extended high-frequency audiometry assess the degree and pattern of any associated hearing loss, helping pinpoint the location of the damage.
Laboratory tests gauge lupus disease activity, including markers like Antinuclear Antibody (ANA) levels, complement proteins (C3/C4), and inflammatory markers. If sudden sensorineural hearing loss is present, blood tests may check for antiphospholipid antibodies, suggesting a thrombotic event restricting blood flow to the inner ear. Identifying the cause dictates the management strategy.
If tinnitus is a direct manifestation of active SLE, the primary treatment is aggressive control of the disease activity. This often involves high-dose corticosteroids, sometimes combined with immunosuppressants like cyclophosphamide or mycophenolate mofetil, to halt immune-mediated damage. For sudden hearing loss, early treatment with high-dose steroids is important to maximize the chance of recovery.
If the tinnitus is linked to a medication, treatment adjustment is necessary, which might include lowering the dosage or switching to an alternative drug. For persistent tinnitus, general management strategies can be employed as adjuncts to the lupus treatment, including tinnitus retraining therapy (TRT) or the use of sound-masking devices. These methods help the brain habituate to the phantom noise and reduce its perceived intensity.