II. Definitions
- Tinnitus
- Perception of sound (e.g. Ringing in the ear) unrelated to objective internal or external sounds
- Secondary Tinnitus
- Referred sound from regional source external to the ear
III. Epidemiology
- Older adults typically have persistent Tinnitus (rather than transient)
- Moderate tinnitus Prevalence increases with age (U.S.)
- Age over 48 years: 8%
- Age 60 to 69 years: 10-15% (peak Prevalence)
IV. Pathophysiology
- CNS maladaptive response to insufficient, distorted or abnormal signals from the ear
- Although there are many causes, most Tinnitus cases are a result of Sensorineural Hearing Loss
- Secondary Tinnitus represents <1% of cases
V. Causes: Subjective Tinnitus (audible only to patient)
- Primary ear conditions
- See Objective Tinnitus below
- Sensorineural Hearing Loss (Presbycusis, occupational noise exposure)
- Most common Tinnitus cause
- Cerumen Impaction (or after cerumen removal)
- Meniere's Disease
- Acoustic Neuroma (Vestibular Schwannoma)
- Cholesteatoma
- Ear Foreign Body
- Ear Trauma (e.g. cerumen removal)
- Tympanic Membrane Perforation
- Otosclerosis
- Otitis Media
- Middle Ear Effusion
- Ototoxic
- See Medication Causes of Tinnitus (includes Ototoxic Medications)
- Aspirin (high dose>2-3 g/day)
- NSAIDs
- Loop Diuretics
- PDE5 Inhibitors (e.g. Sildenafil)
- Quinine
- Mefloquine
-
Musculoskeletal Injury
- Head Injury
- Neck Injury
- Temporomandibular Joint Dysfunction
- Neurologic
- Infectious
- Various viral, fungal and Bacterial Infections have been associated including Syphilis, Lyme Disease
- Metabolic
VI. Causes: Objective Tinnitus (actual internal sound heard, accounts for only 1% of cases)
- Vascular (e.g. pulsatile Tinnitus)
- Arterial Bruit (e.g. Carotid Stenosis)
- Venous Hum
- Vascular tumors
- Arteriovenous Malformation
- Arterial dissection (e.g. carotid dissection, Vertebrobasilar Dissection)
- Non-vascular
VII. History: General
- Associated events or exposures
- Chronic noise exposure or acoustic Trauma
- Recurrent otitis meda
- Head Injury or neck injury
- Preceding dental work
- Ototoxic Medications
- Associated symptoms
- Hyperacusis
- Temporomandibular Joint Dysfunction
- Focal ear symptoms or signs (e.g. Ear Drainage or Otalgia)
- Headaches
- Hearing Loss
- Most common cause of Tinnitus
- Vertigo
- Provocative Measures
- Position change or physical exertion
- Consider vascular causes
- Consider neurologic causes (e.g. Spontaneous Intracranial Hypotension)
- Position change or physical exertion
- Duration
- Acute Tinnitus: <6 months (consider reversible causes, see below)
- Chronic Tinnitus: >6 months
- Severity
- Tinnitus characteristics (see history below)
- Bilateral (most common) or unilateral
- High pitched (most common) or low pitched
- Pulsatile, fluttering, clicking or crunching
VIII. History: Tinnitus Distribution
- Bilateral Tinnitus in two thirds of cases
- Often associated with Sensorineural Hearing Loss
- Unilateral causes (typically requires imaging)
- Somatosensory (e.g. TMJ, head or neck injury)
- Acoustic Neuroma (Vestibular Schwannoma)
- Vascular tumor
- Meniere Disease
IX. History: Tinnitus Frequency and Quality
- Middle or high frequency ringing or buzzing or hissing (e.g. cicada-like)
- Most common form of Tinnitus (consistent with primary Tinnitus)
- Inner ear etiology
- Often results from Ototoxic Drug (e.g. Aspirin)
- Low pitched or frequency Tinnitus
- Conductive Hearing Loss (roaring sounds)
- Meniere Disease
X. History: Pulsatile Tinnitus
- Pulsating sounds (especially unilateral in synchrony with heart beat)
- Vascular loop adjacent to Cranial Nerve VIII (see work-up under imaging)
- Cardiac murmur
- Carotid Bruit
- Cerebral Aneurysm
- Fistula or AV Malformation
- Pulsating alone
- Increased fluid pressure at middle ear
- Pulsating, high pitched, irregular sounds
XI. History: Other Tinnitus characteristics
- Fluttering Tinnitus
- Intermittent spasm of tensor tympani Muscle
- Associated with eye irritation or acute anxiety
- Rhythmic Clicking Tinnitus
- Crunching Tinnitus
- Temporomandibular JointArthritis
- Foreign body (e.g. hair) rubbing against TM
XII. History: Tinnitus and Hearing Loss
- Tinnitus and unilateral Sensorineural Hearing Loss
- Roaring or low pitched Tinnitus, Hearing Loss and Vertigo
- Bilateral subjective Tinnitus without Hearing Loss
- Endocrine causes (e.g. Hypothyroidism)
- Ototoxic Medications
- Mood Disorder
XIII. Exam
- Otoscopy
-
Neurologic Exam
- Fundoscopic exam (for Papilledema and Increased Intracranial Pressure)
- Nystagmus
- Visual Field cut
- Cranial Nerve deficit
- Cerebellar Function Test (e.g. Finger-Nose-Finger Test for dysmetria, gait for Ataxia)
- Head and Neck Exam
- Temporomandibular Joint Dysfunction
- Carotid Bruit
- Provocative maneuver testing
- Tinnitus on jaw clenching
- Tinnitus on neck range of motion
- Change in pulsatile Tinnitus with light pressure on ipsilateral Jugular Vein
- Other bedside diagnostic testing
XIV. Labs
- Precautions
- Lab testing is typically normal in Tinnitus
- Consider lab testing as specifically indicated (low yield in Tinnitus evaluation unless directed by findings)
- Complete Blood Count
- Thyroid Stimulating Hormone
- Lipid profile
- Serum Vitamin B12
- Syphilis Serology (e.g. RPR, VDRL)
- Lyme Titer
XV. Diagnostics
- Pure tone Audiometry (Formal audiology testing)
- Comprehensive Audiologic Exam is indicated in all Tinnitus cases
- Testing is optional in isolated, symmetric, mild primary Tinnitus
- Asymmetric Hearing Loss may suggest Acoustic Neuroma (Vestibular Schwannoma)
- Average difference >10 dB over 1 to 8 KHz range (high Test Sensitivity for Acoustic Neuroma)
- Average difference >15 dB over 0.5 to 3 KHz range (high Test Specificity for Acoustic Neuroma)
- Cheng (2012) Otolaryngol Head Neck Surg 146(3): 438-47 [PubMed]
- Comprehensive Audiologic Exam is indicated in all Tinnitus cases
- Electronystagmography
- Group of 4 tests of eye movement in response to external stimuli
- Consider if Meniere Disease is suspected
- Meniere Disease will demonstrate unilateral vestibular hypofunction
XVI. Imaging
- Precautions
- Avoid imaging in bilateral, nonpulsatile Tinnitus with symmetric Hearing Loss and a normal history and exam
- Imaging indications
- Unilateral Tinnitus
- Pulsatile Tinnitus
- Asymmetric Hearing Loss
- Focal Neurologic deficits
-
MRI Brain with and without contrast and including Internal Auditory Canals (esp. cerebelopontine angle)
- Consider based on history and exam (especially if Acoustic Neuroma suspected)
- Best study for identifying Acoustic Neuroma (Vestibular Schwannoma)
- Replaces Auditory Brainstem Testing (ABR) for Acoustic Neuroma diagnosis
- CNS Arterial imaging (CT angiogram head and neck, MR Angiogram brain and neck)
- Consider in arterial pulsatile Tinnitus
- Evaluate for Cerebrovascular Disease
- Carotid Stenosis
- Dural Arteriovenous Fistula
- Intracranial Hypertension
- Non-contrast Temporal Bone CT
- Paraganglioma
- Adenomatous middle Ear Tumor
- CNS Venous imaging (e.g. CT or MR Venography)
- Consider in venous pulsatile Tinnitus (along with a Lumbar Puncture)
- Evaluate for Pseudotumor Cerebri
XVII. Evaluation: Less than 3 weeks (acute)
- Assess for and correct acute Tinnitus causes
- See causes above
- Loud noise exposure
- Otitis Media
- Cerumen Impaction
- Ototoxic Medication
- Head or neck injury
- Focal neurologic deficit
- Indications for early diagnostic evaluation (e.g. Audiometry, MRI Brain)
- Focal neurologic deficit
- Focal exam finding (e.g. Cholesteatoma, retrotympanic lesion)
- Unilateral Tinnitus >3 weeks (exclude Acoustic Neuroma)
- Acute symptoms persist >3 weeks
XVIII. Evaluation: More than 3 weeks (chronic)
- Abnormal exam findings (same approach as described above under the acute, <3 week evaluation)
- Manage acute causes (e.g. Cerumen Impaction, Otitis Media, TMJ Dysfunction)
- MRI Brain and Audiometry indications as above
- Includes evaluation for unilateral Tinnitus (Acoustic Neuroma)
- Tinnitus with intermittent Hearing Loss or Vertigo
- Evaluate for Meniere Disease
- Diagnostics: Audiometry, Electronystagmography, MRI Brain
- ENT referral
- Pulsatile Tinnitus
- Most commonly caused by Pseudotumor Cerebri, Carotid Stenosis and Glomus tumors
- See Imaging above for arterial and venous cause evaluation
- Consider CT Temporal Bone
- Consider CT Angiogram Head and Neck
- Consider nonvascular causes in negative work-up (e.g. Otosclerosis, tensor tympani Muscle, stapedius Muscle)
- Abnormal Audiometry
- Asymmetric Sensorineural Hearing Loss should prompt MRI Brain for Acoustic Neuroma evaluation
- Consider ENT Consult
XIX. Management: Exclude Reversible Causes
- Exclude localized cause (e.g. Cerumen Impaction, Otitis Media, Eustachian Tube Dysfunction)
- Correct underlying medical problem
- Eliminate possible Ototoxic Medications
- Eliminate loud noise exposures with ear protection (e.g. ear plugs)
- Loud noise exposure may worsen Tinnitus
- Exclude serious causes
- Acoustic Neuroma and other CNS Lesions
- Carotid Stenosis and other vascular conditions
- Cholesteatoma and other other treatable local ear lesions
- Meniere Disease (Vertigo and Hearing Loss)
- Infectious disease (e.g. Syphilis, Lyme Disease)
- Sudden Sensorineural Hearing Loss
- Acute Hearing Loss with Tinnitus (consider acute onset Meniere's Disease)
- Dose Corticosteroids (See SSNHL)
XX. Management: Symptomatic
- Reassurance
- Approach
- Isolated, symmetric, mild primary Tinnitus does not require further evaluation if not bothersome
- Symptomatic management is indicated in moderate to severe Tinnitus
- See severity history above (with links to severity surveys)
-
Cognitive Behavioral Therapy (psychology)
- Supported by moderate to high quality evidence
- In contrast, other measures (sound therapy, Tinnitus retraining) have only low quality evidence to date
-
Antidepressants (SSRI, SNRI or Tricyclic Antidepressant)
- Effective if comorbid Major Depression or Anxiety Disorder
- May also be effective in Insomnia related to Tinnitus
- Noise masking or sound therapy
- Soft, monotonous noise (e.g. fan, radio, smartphone applications) at night
- Hearing Aid amplifies background noise
- Insomnia Management
- Avoid ineffective measures
- Avoid Benzodiazepines
- Avoid anticonvulsants (e.g. Acamprosate, Carbamazepine, Gabapentin, Lamotrigine)
- Avoid ineffective procedures
- Avoid repetitive transcranial magnetic stimulation
- Avoid electrical stimulation (e.g. TENS)
- Avoid bimodal stimulation
- Avoid hyperbaric oxygen
- Avoid Nitrous Oxide
- Avoid Acupuncture
- Avoid microvascular decompression (otolaryngology surgery)
- Avoid supplements (pycnogenol, zinc)
- No significant evidence to support use
- Ginkgo Biloba is not effective
XXI. Prevention
- Prevent Noise-Induced Hearing Loss with Hearing protection (ear plugs, ear muffs)
- Avoid Ototoxic Medications
XXII. Resources
- American Tinnitus Association