II. Definition
- Ringing in the ears, unrelated to external sounds
III. Epidemiology
- Moderate tinnitus Prevalence: 8% of age over 48 years old (U.S.)
- Older adults typically have persistent Tinnitus (rather than transient)
IV. Pathophysiology
- CNS maladaptive response to insufficient, distorted or abnormal signals from the ear
V. Causes
- Subjective Tinnitus (audible only to patient)
- Primary ear conditions
- Sensorineural Hearing Loss (Presbycusis, occupational noise exposure)
- Most common Tinnitus cause
- Cerumen Impaction (or after cerumen removal)
- Meniere's Disease
- Acoustic Neuroma (Vestibular Schwannoma)
- Sensorineural Hearing Loss (Presbycusis, occupational noise exposure)
- Ototoxic
- See Ototoxic Medications
- Aspirin (high dose>2-3 g/day)
- NSAIDs
- Loop Diuretics
- PDE5 Inhibitors (e.g. Sildenafil)
- Quinine
- Mefloquine
- Musculoskeletal Injury
- Neurologic
- Infectious
- Various infections have been associated including Syphilis
- Metabolic
- Primary ear conditions
- Objective Tinnitus (actual internal sound heard, accounts for only 1% of cases)
- Arterial Bruit (e.g. Carotid Stenosis)
- Venous Hum
- Arteriovenous malformation
- Arterial dissection (e.g. carotid dissection, vertebrobasilar dissection)
- Palatal Myoclonus
- Spasm of stapedius muscle or tensor tympani muscle
- Patulous eustachian tube
VI. History
- 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
- Tinnitus characteristics (see history below)
- Bilateral (most common) or unilateral
- High pitched (most common) or low pitched
- Pulsatile, fluttering, clicking or crunching
VII. History: Tinnitus Distribution
- Bilateral Tinnitus in two thirds of cases
- Unilateral causes
- Somatosensory (e.g. TMJ, head or neck injury)
- Acoustic Neuroma
- Meniere Disease
VIII. History: Tinnitus Frquency
- Middle or high frequency ringing or buzzing (e.g. cicada-like)
- Most common form of Tinnitus
- Inner ear etiology
- Often results from Ototoxic Drug (e.g. Aspirin)
- Low pitched or frequency Tinnitus
- Conductive Hearing Loss (roaring sounds)
- Meniere Disease
IX. 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
X. History: Other Tinnitus characteristics
- Fluttering Tinnitus
- Intermittent spasm of tensor tympani muscle
- Associated with eye irritation or acute anxiety
- Clicking Tinnitus
- Crunching Tinnitus
- Temporomandibular JointArthritis
- Foreign body (e.g. hair) rubbing against TM
XI. 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
XII. Exam
- Otoscopy
-
Neurologic Exam
- Fundoscopic exam (for Papilledema)
- Visual field cut
- Cranial Nerve deficit
- Finger-Nose-Finger Test
- Head and neck exam
- Provocative maneuver testing (e.g. Tinnitus on jaw clenching, neck range of motion)
- Carotid Bruit
- Tympanometry
- Hearing Testing
- Tuning Fork Tests
XIII. Labs
XIV. Diagnostics
- Pure tone Audiometry (Formal audiology testing)
- Asymmetric Hearing Loss may suggest Acoustic Neuroma
- 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]
- Asymmetric Hearing Loss may suggest Acoustic Neuroma
- 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
XV. Imaging
- MRI brain with contrast and including Internal Auditory Canals
- Consider based on history and exam (especially if Acoustic Neuroma suspected)
- Best study for identifying Acoustic Neuroma
- Replaces Auditory Brainstem Testing (ABR) for Acoustic Neuroma diagnosis
- CNS Arterial imaging (CT angiogram head and neck, MR Angiogram brain and neck or carotid Ultrasound)
- Consider in arterial pulsatile Tinnitus
- Evaluate for Cerebrovascular Disease
- CNS Venous imaging (e.g. CT or MR Venography)
- Consider in venous pulsatile Tinnitus (along with a Lumbar Puncture)
- Evaluate for Pseudotumor Cerebri
XVI. 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
XVII. 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 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
XVIII. Management
- 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)
- Sudden Sensorineural Hearing Loss
- Acute Hearing Loss with Tinnitus (consider acute onset Meniere's Disease)
- Dose Corticosteroids (See SSNHL)
- Reassurance
- Cognitive Behavioral Therapy (psychology)
-
Antidepressants (SSRI or SNRI)
- Effective if comorbid Major Depression or Anxiety Disorder
- May also be effective in Insomnia related to Tinnitus
- Noise masking
- Soft, monotonous noise (e.g. fan, radio, smartphone applications) at night
- Hearing Aid amplifies background noise
- Avoid ineffective measures
- Supplements (Melatonin, pycnogenol, zinc) have no significant evidence to support use
- Ginkgo Biloba is not effective
XIX. Resources
- American Tinnitus Association
XX. References
Images: Related links to external sites (from Bing)
Related Studies
| Definition (MEDLINEPLUS) |
Tinnitus is often described as a ringing in the ears. It also can sound like roaring, clicking, hissing, or buzzing. It may be soft or loud, high pitched or low pitched. You might hear it in either one or both ears. Millions of Americans have tinnitus. People with severe tinnitus may have trouble hearing, working or even sleeping. Causes of tinnitus include
Treatment depends on the cause. Treatments may include hearing aids, sound-masking devices, medicines, and ways to learn how to cope with the noise. NIH: National Institute on Deafness and Other Communication Disorders |
| Definition (MSHCZE) | Ušní šelest, vnímání zvuku bez akustického stimulu. Má různý charakter, intenzitu, často je spojen s poruchou sluchu. Může jej způsobit většina nemocí ucha. K příčinám patří např. prostá mazová zátka, poškození bubínku, záněty zevní i střední otitidy, labyrintitida, neprůchodnost Eustachovy trubice, Meniérova nemoc, otoskleróza, léky (chinin, aminoglykosidy), nádory v oblasti ucha, traumata vč. akustického, některé nemoci CNS, kardiovaskulární choroby aj. Často se zjevná příčina zejm. ve vyšším věku nenalezne. Není-li možná kauzální terapie, je léčba někdy obtížná, podávají se např. vazodilatancia, reologika, vitaminy. K překrytí t. se někdy používají zařízení, která jej mohou „přehlušit“. (cit. Velký lékařský slovník online, 2013 http://lekarske.slovniky.cz/ ) |
| Definition (NCI_NCI-GLOSS) | A disorder in which a person hears noises such as buzzing, ringing, clicking, or the sound of a pulse, when no outside sound is causing them. Tinnitus may have many different causes, and may be a symptom of another disease or condition. It may be caused by certain tumors and anticancer drugs. |
| Definition (NCI) | A noise in the ears, such as ringing, buzzing, roaring, clicking. |
| Definition (NCI_CTCAE) | A disorder characterized by noise in the ears, such as ringing, buzzing, roaring or clicking. |
| Definition (NCI_FDA) | A noise in the ears, such as ringing, buzzing, roaring, clicking. |
| Definition (MSH) | A nonspecific symptom of hearing disorder characterized by the sensation of buzzing, ringing, clicking, pulsations, and other noises in the ear. Objective tinnitus refers to noises generated from within the ear or adjacent structures that can be heard by other individuals. The term subjective tinnitus is used when the sound is audible only to the affected individual. Tinnitus may occur as a manifestation of COCHLEAR DISEASES; VESTIBULOCOCHLEAR NERVE DISEASES; INTRACRANIAL HYPERTENSION; CRANIOCEREBRAL TRAUMA; and other conditions. |
| Definition (CSP) | symptom of hearing disorder characterized by the sensation of buzzing, ringing, clicking, pulsations, roaring or other noises in the ear. |
| Concepts | Finding (T033) |
| MSH | D014012 |
| ICD9 | 388.30, 388.3 |
| ICD10 | H93.1 , H93.19 |
| SnomedCT | 139621009, 139624001, 162355009, 194393005, 194395003, 300200005, 155248003, 194392000, 139618007, 60862001, 162349004, 162352007 |
| English | EAR NOISES, EAR RINGING, Tinnitus, unspecified, Unspecified tinnitus, Tinnitus, Tinnitus Aurium, Tinnitus symptom NOS, tinnitus, ringing in ears (symptom), tinnitus (diagnosis), ringing in the ears (tinnitus), ringing in ears, Ear noises, Ear ringing, Ringing in ears, Ringing Buzzing Tinnitus, Ringing-Buzzing-Tinnitus, Tinnitus NOS, Tinnitus, unspecified ear, Tinnitus [Disease/Finding], ear ringing, Noises in;ear, Ringing (in);ear, symptoms tinnitus, tinnitus symptom (non-specific), ear noises, ringing in the ear, ears ring, ringing of ears, ear noise, ears noises, ears ringing, Tinnitus symptom NOS (finding), Unspecified tinnitus (finding), Tinnitus NOS (finding), Finding of tinnitus (finding), Hearing noises, Finding of tinnitus, Tinnitus (disorder), (Tinnitus) or (hearing noises) (disorder), (Tinnitus) or (hearing noises), EARS, RINGING IN, RINGING IN EARS, TINNITUS, Noise in ears, Noises in ear, Noises in head, Ringing in ear, Observation of tinnitus, Noises in ear (finding), Ringing in ear (finding), Tinnitus (finding), Tinnitus, ringing/buzzing ear, ear; murmur, murmur; ear, Tinnitus, NOS, noises in ear, ringing in ear |
| Italian | Tinnitus, Rumori nella testa, Ronzio nelle orecchie, Rumori auricolari, Tinnitus, non specificato, Acufene, Tinnito |
| Dutch | oorrinkelen, geluiden in het hoofd, rinkelen in de oren, oorgeluiden, niet-gespecificeerde duizeligheid, geruis; oor, oor; geruis, tinnitus, Oorsuizen, Tinnitus |
| French | Bruits dans les oreilles, Tintements d'oreille, non précisés, Tintements d'oreilles, Bruits dans la tête, BOURDONNEMENTS D'OREILLE, BRUITS DIVERS DANS L'OREILLE, TINTEMENTS D'OREILLE, Acouphènes, Acouphène, Bourdonnement d'oreille, Bourdonnement d'oreilles, Sifflement d'oreilles, Tintement d'oreilles |
| German | Tinnitus, unspezifisch, Geraeusche im Kopf, Ohrenklingeln, Klingeln im Ohr, Ohrengeraeusche, OHRGERAEUSCHE, OHRKLINGELN, OHRKLINGEN, TINNITUS, Tinnitus, Tinnitus aurium |
| Portuguese | Ruídos nos ouvidos, Campaínhas nos ouvidos, Zumbidos NE, Ruídos na cabeça, CAMPAINHAS NOS OUVIDOS, RUIDOS NO PAVILHAO AURICULAR, TINITUS, ZUMBIDOS NOS OUVIDOS, Tinido, Zumbidos, Zunido, Acufenos, Zumbido |
| Spanish | Pitido en oídos, Ruidos en oídos, Acúfenos no especificados, Ruidos en la cabeza, ACUFENOS, OIDO, CAMPANILLEO, OIDO, RUIDO, OIDO, TINTINEO, acúfenos no especificados (hallazgo), tinitus, SAI (hallazgo), tinitus - hallazgo, acúfenos no especificados, tinitus, SAI, tinitus - hallazgo (hallazgo), acúfenos, SAI (hallazgo), tinitus no especificado, Tinnitus symptom NOS, acúfenos, SAI, Acúfenos, Zumbido, acúfenos (hallazgo), acúfenos, campanilleo en el oído (hallazgo), campanilleo en el oído, ruidos en oído (hallazgo), ruidos en oído, sonidos en oído, tinnitus, zumbido en los oídos, Acúfeno |
| Japanese | 詳細不明の耳鳴, ﾐﾐﾅﾘ, ｼｮｳｻｲﾌﾒｲﾉｼﾞﾒｲ, ｼﾞﾒｲ, ｼｮｳｻｲﾌﾒｲﾉﾐﾐﾅﾘ, 耳鳴り, 耳鳴(ジメイ), 耳鳴 |
| Swedish | Öronsusning |
| Czech | tinnitus, Tinnitus, Zvonění v uchu, Blíže neurčený tinitus, Zvuky v uchu, Zvuky v hlavě, Zvonění v uších, ušní šelest, tinitus |
| Finnish | Tinnitus |
| Russian | SHUM V USHAKH, UKHO, SHUMY, УХО, ШУМЫ, ШУМ В УШАХ |
| Korean | 이명(귀울림) |
| Polish | Szum w uszach, Szum uszny |
| Hungarian | Fülzörejek, Tinnitus, Fül csengése, Fülcsengés, Tinnitus, nem meghatározott, Zajok a fejben |
| Norwegian | Tinnitus aurium, Tinnitus, Øresus |
