Tinnitus

Aka: Tinnitus, Ear Ringing

1. See Also
   1. Hearing Loss
   2. Medication Causes of Tinnitus
2. Definitions
   1. Tinnitus
      1. Perception of sound (e.g. Ringing in the ear) unrelated to objective internal or external sounds
   2. Secondary Tinnitus
      1. Referred sound from regional source external to the ear
3. Epidemiology
   1. Older adults typically have persistent Tinnitus (rather than transient)
   2. Moderate tinnitus Prevalence increases with age (U.S.)
      1. Age over 48 years: 8%
      2. Age 60 to 69 years: 10-15% (peak Prevalence)
4. Pathophysiology
   1. CNS maladaptive response to insufficient, distorted or abnormal signals from the ear
   2. Although there are many causes, most Tinnitus cases are a result of Sensorineural Hearing Loss
      1. Secondary Tinnitus represents <1% of cases
5. Causes: Subjective Tinnitus (audible only to patient)
   1. Primary ear conditions
      1. See Objective Tinnitus below
      2. Sensorineural Hearing Loss (Presbycusis, occupational noise exposure)
         1. Most common Tinnitus cause
      3. Cerumen Impaction (or after cerumen removal)
      4. Meniere's Disease
      5. Acoustic Neuroma (Vestibular Schwannoma)
      6. Cholesteatoma
      7. Ear Foreign Body
      8. Ear Trauma (e.g. cerumen removal)
      9. Tympanic Membrane Perforation
      10. Otosclerosis
      11. Otitis Media
      12. Middle Ear Effusion
   2. Ototoxic
      1. See Medication Causes of Tinnitus (includes Ototoxic Medications)
      2. Aspirin (high dose>2-3 g/day)
      3. NSAIDs
      4. Loop Diuretics
      5. PDE5 Inhibitors (e.g. Sildenafil)
      6. Quinine
      7. Mefloquine
   3. Musculoskeletal Injury
      1. Head Injury
      2. Neck Injury
      3. Temporomandibular Joint Dysfunction
   4. Neurologic
      1. Multiple Sclerosis
      2. Vestibular Migraine
      3. Type I Chiari Malformation
      4. Intracranial Hypotension (Postdural Puncture Headache)
      5. Pseudotumor Cerebri (Idiopathic Intracranial Hypertension)
   5. Infectious
      1. Various viral, fungal and Bacterial Infections have been associated including Syphilis, Lyme Disease
   6. Metabolic
      1. Hypothyroidism
      2. Vitamin B12 Deficiency
      3. Diabetes Mellitus
      4. Hyperlipidemia
6. Causes: Objective Tinnitus (actual internal sound heard, accounts for only 1% of cases)
   1. Vascular (e.g. pulsatile Tinnitus)
      1. Arterial Bruit (e.g. Carotid Stenosis)
      2. Venous Hum
      3. Vascular tumors
      4. Arteriovenous malformation
      5. Arterial dissection (e.g. carotid dissection, Vertebrobasilar Dissection)
   2. Non-vascular
      1. Palatal Myoclonus
      2. Spasm of stapedius muscle or tensor tympani muscle
      3. Patulous eustachian tube
7. History: General
   1. Associated events or exposures
      1. Chronic noise exposure or acoustic Trauma
      2. Recurrent otitis meda
      3. Head Injury or neck injury
      4. Preceding dental work
      5. Ototoxic Medications
   2. Associated symptoms
      1. Hyperacusis
      2. Temporomandibular Joint Dysfunction
      3. Focal ear symptoms or signs (e.g. Ear Drainage or Otalgia)
         1. Otitis Media
         2. Otitis Externa
         3. Ear Foreign Body
         4. Eustachian Tube Dysfunction
      4. Headaches
         1. Idiopathic Intracranial Hypotension (Postdural Puncture Headache)
         2. Pseudotumor Cerebri
      5. Hearing Loss
         1. Most common cause of Tinnitus
      6. Vertigo
         1. Meniere Disease
         2. Acoustic Neuroma (Vestibular Schwannoma)
         3. Migraine Headache
   3. Provocative Measures
      1. Position change or physical exertion
         1. Consider vascular causes
         2. Consider neurologic causes (e.g. Spontaneous Intracranial Hypotension)
   4. Duration
      1. Acute Tinnitus: <6 months (consider reversible causes, see below)
      2. Chronic Tinnitus: >6 months
   5. Severity
      1. Tinnitus Surveys
         1. https://hearing.health.mil/For-Providers/Progressive-Tinnitus-Management/PTM-Provider-Resources/Tinnitus-Questionnaires
      2. Tinnitus Handicap Inventory (THI)
         1. https://www.ata.org/sites/default/files/Tinnitus_Handicap_Inventory.pdf
      3. Tinnitus Questionnaire
         1. https://starkeypro.com/pdfs/THI_Questionnaire.pdf
      4. Hearing and Tinnitus Survey
         1. https://hearing.health.mil/For-Providers/Progressive-Tinnitus-Management/PTM-Provider-Resources/Tinnitus-Questionnaires
   6. Tinnitus characteristics (see history below)
      1. Bilateral (most common) or unilateral
      2. High pitched (most common) or low pitched
      3. Pulsatile, fluttering, clicking or crunching
8. History: Tinnitus Distribution
   1. Bilateral Tinnitus in two thirds of cases
      1. Often associated with Sensorineural Hearing Loss
   2. Unilateral causes (typically requires imaging)
      1. Somatosensory (e.g. TMJ, head or neck injury)
      2. Acoustic Neuroma (Vestibular Schwannoma)
      3. Vascular tumor
      4. Meniere Disease
9. History: Tinnitus Frequency and Quality
   1. Middle or high frequency ringing or buzzing or hissing (e.g. cicada-like)
      1. Most common form of Tinnitus (consistent with primary Tinnitus)
      2. Inner ear etiology
      3. Often results from Ototoxic Drug (e.g. Aspirin)
   2. Low pitched or frequency Tinnitus
      1. Conductive Hearing Loss (roaring sounds)
      2. Meniere Disease
10. History: Pulsatile Tinnitus
    1. Pulsating sounds (especially unilateral in synchrony with heart beat)
       1. Vascular loop adjacent to Cranial Nerve VIII (see work-up under imaging)
       2. Cardiac murmur
       3. Carotid Bruit
       4. Cerebral Aneurysm
       5. Fistula or AV malformation
    2. Pulsating alone
       1. Increased fluid pressure at middle ear
    3. Pulsating, high pitched, irregular sounds
       1. Otosclerosis
11. History: Other Tinnitus characteristics
    1. Fluttering Tinnitus
       1. Intermittent spasm of tensor tympani muscle
       2. Associated with eye irritation or acute anxiety
    2. Rhythmic Clicking Tinnitus
       1. Stapedial or tensor tympani muscle spasm
       2. Palatal Myoclonus
          1. Rapid rhythmic twitching of ipsilateral Palate
       3. May respond to mild sedation
    3. Crunching Tinnitus
       1. Temporomandibular JointArthritis
       2. Foreign body (e.g. hair) rubbing against TM
12. History: Tinnitus and Hearing Loss
    1. Tinnitus and unilateral Sensorineural Hearing Loss
       1. Acoustic Neuroma
    2. Roaring or low pitched Tinnitus, Hearing Loss and Vertigo
       1. Meniere's Disease
    3. Bilateral subjective Tinnitus without Hearing Loss
       1. Endocrine causes (e.g. Hypothyroidism)
       2. Ototoxic Medications
       3. Mood Disorder
13. Exam
    1. Otoscopy
       1. Cerumen Impaction
       2. Middle ear effusion
       3. Otitis Media
       4. Otitis Externa
       5. Cholesteatoma
       6. Ear Foreign Body
       7. Tympanic Membrane Perforation
    2. Neurologic Exam
       1. Fundoscopic exam (for Papilledema and Increased Intracranial Pressure)
       2. Nystagmus
       3. Visual Field cut
       4. Cranial Nerve deficit
       5. Cerebellar Function Test (e.g. Finger-Nose-Finger Test for dysmetria, gait for Ataxia)
    3. Head and Neck Exam
       1. Temporomandibular Joint Dysfunction
       2. Carotid Bruit
       3. Provocative maneuver testing
          1. Tinnitus on jaw clenching
          2. Tinnitus on neck range of motion
          3. Change in pulsatile Tinnitus with light pressure on ipsilateral Jugular Vein
    4. Other bedside diagnostic testing
       1. Tympanometry
       2. Hearing Testing
       3. Tuning Fork Tests
14. Labs
    1. Precautions
       1. Lab testing is typically normal in Tinnitus
    2. Consider lab testing as specifically indicated (low yield in Tinnitus evaluation unless directed by findings)
       1. Complete Blood Count
       2. Thyroid Stimulating Hormone
       3. Lipid profile
       4. Serum Vitamin B12
       5. Syphilis Serology (e.g. RPR, VDRL)
       6. Lyme Titer
15. Diagnostics
    1. Pure tone Audiometry (Formal audiology testing)
       1. Comprehensive Audiologic Exam is indicated in all Tinnitus cases
          1. Testing is optional in isolated, symmetric, mild primary Tinnitus
       2. Asymmetric Hearing Loss may suggest Acoustic Neuroma (Vestibular Schwannoma)
          1. Average difference >10 dB over 1 to 8 KHz range (high Test Sensitivity for Acoustic Neuroma)
          2. Average difference >15 dB over 0.5 to 3 KHz range (high Test Specificity for Acoustic Neuroma)
          3. Cheng (2012) Otolaryngol Head Neck Surg 146(3): 438-47 [PubMed]
    2. Electronystagmography
       1. Group of 4 tests of eye movement in response to external stimuli
       2. Consider if Meniere Disease is suspected
          1. Meniere Disease will demonstrate unilateral vestibular hypofunction
16. Imaging
    1. Precautions
       1. Avoid imaging in bilateral, nonpulsatile Tinnitus with symmetric Hearing Loss and a normal history and exam
       2. Imaging indications
          1. Unilateral Tinnitus
          2. Pulsatile Tinnitus
          3. Asymmetric Hearing Loss
          4. Focal Neurologic deficits
    2. MRI brain with and without contrast and including Internal Auditory Canals (esp. cerebelopontine angle)
       1. Consider based on history and exam (especially if Acoustic Neuroma suspected)
       2. Best study for identifying Acoustic Neuroma (Vestibular Schwannoma)
          1. Replaces Auditory Brainstem Testing (ABR) for Acoustic Neuroma diagnosis
    3. CNS Arterial imaging (CT angiogram head and neck, MR Angiogram brain and neck)
       1. Consider in arterial pulsatile Tinnitus
       2. Evaluate for Cerebrovascular Disease
          1. Carotid Stenosis
          2. Dural arteriovenous fistula
          3. Intracranial Hypertension
    4. Non-contrast Temporal Bone CT
       1. Paraganglioma
       2. Adenomatous middle Ear Tumor
    5. CNS Venous imaging (e.g. CT or MR Venography)
       1. Consider in venous pulsatile Tinnitus (along with a Lumbar Puncture)
       2. Evaluate for Pseudotumor Cerebri
17. Evaluation: Less than 3 weeks (acute)
    1. Assess for and correct acute Tinnitus causes
       1. See causes above
       2. Loud noise exposure
       3. Otitis Media
       4. Cerumen Impaction
       5. Ototoxic Medication
       6. Head or neck injury
       7. Focal neurologic deficit
    2. Indications for early diagnostic evaluation (e.g. Audiometry, MRI Brain)
       1. Focal neurologic deficit
       2. Focal exam finding (e.g. Cholesteatoma, retrotympanic lesion)
       3. Unilateral Tinnitus >3 weeks (exclude Acoustic Neuroma)
       4. Acute symptoms persist >3 weeks
18. Evaluation: More than 3 weeks (chronic)
    1. Abnormal exam findings (same approach as described above under the acute, <3 week evaluation)
       1. Manage acute causes (e.g. Cerumen Impaction, Otitis Media, TMJ Dysfunction)
       2. MRI brain and Audiometry indications as above
          1. Includes evaluation for unilateral Tinnitus (Acoustic Neuroma)
    2. Tinnitus with intermittent Hearing Loss or Vertigo
       1. Evaluate for Meniere Disease
       2. Diagnostics: Audiometry, Electronystagmography, MRI Brain
       3. ENT referral
    3. Pulsatile Tinnitus
       1. Most commonly caused by Pseudotumor Cerebri, Carotid Stenosis and Glomus tumors
       2. See Imaging above for arterial and venous cause evaluation
          1. Consider CT Temporal Bone
          2. Consider CT Angiogram Head and Neck
       3. Consider nonvascular causes in negative work-up (e.g. Otosclerosis, tensor tympani muscle, stapedius muscle)
    4. Abnormal Audiometry
       1. Asymmetric Sensorineural Hearing Loss should prompt MRI Brain for Acoustic Neuroma evaluation
       2. Consider ENT Consult
19. Management: Exclude Reversible Causes
    1. Exclude localized cause (e.g. Cerumen Impaction, Otitis Media, Eustachian Tube Dysfunction)
    2. Correct underlying medical problem
    3. Eliminate possible Ototoxic Medications
    4. Eliminate loud noise exposures with ear protection (e.g. ear plugs)
       1. Loud noise exposure may worsen Tinnitus
    5. Exclude serious causes
       1. Acoustic Neuroma and other CNS Lesions
       2. Carotid Stenosis and other vascular conditions
       3. Cholesteatoma and other other treatable local ear lesions
       4. Meniere Disease (Vertigo and Hearing Loss)
       5. Infectious disease (e.g. Syphilis, Lyme Disease)
       6. Sudden Sensorineural Hearing Loss
          1. Acute Hearing Loss with Tinnitus (consider acute onset Meniere's Disease)
          2. Dose Corticosteroids (See SSNHL)
20. Management: Symptomatic
    1. Reassurance
    2. Approach
       1. Isolated, symmetric, mild primary Tinnitus does not require further evaluation if not bothersome
       2. Symptomatic management is indicated in moderate to severe Tinnitus
          1. See severity history above (with links to severity surveys)
    3. Cognitive Behavioral Therapy (psychology)
       1. Supported by moderate to high quality evidence
       2. In contrast, other measures (sound therapy, Tinnitus retraining) have only low quality evidence to date
    4. Antidepressants (SSRI, SNRI or Tricyclic Antidepressant)
       1. Effective if comorbid Major Depression or Anxiety Disorder
       2. May also be effective in Insomnia related to Tinnitus
    5. Noise masking or sound therapy
       1. Soft, monotonous noise (e.g. fan, radio, smartphone applications) at night
       2. Hearing Aid amplifies background noise
    6. Insomnia Management
       1. Melatonin
       2. Trazodone
    7. Avoid ineffective measures
       1. Avoid Benzodiazepines
       2. Avoid anticonvulsants (e.g. Acamprosate, Carbamazepine, Gabapentin, Lamotrigine)
       3. Avoid ineffective procedures
          1. Avoid repetitive transcranial magnetic stimulation
          2. Avoid electrical stimulation (e.g. TENS)
          3. Avoid bimodal stimulation
          4. Avoid hyperbaric oxygen
          5. Avoid Nitrous Oxide
          6. Avoid Acupuncture
          7. Avoid microvascular decompression (otolaryngology surgery)
       4. Avoid supplements (pycnogenol, zinc)
          1. No significant evidence to support use
       5. Ginkgo Biloba is not effective
          1. Rejali (2004) Clin Otolaryngol 29:226-31 [PubMed]
21. Prevention
    1. Prevent Noise-Induced Hearing Loss with hearing protection (ear plugs, ear muffs)
    2. Avoid Ototoxic Medications
22. Resources
    1. American Tinnitus Association
       1. http://www.ata.org
23. References
    1. (2019) Presc Lett 26(2): 12
    2. Crummer (2004) Am Fam Physician 69(1):120-8 [PubMed]
    3. Dalrymple (2021) Am Fam Physician 103(11):663-71 [PubMed]
    4. Lloyd (2008) Clin Otolaryngol 33(1): 25-8 [PubMed]
    5. Yew (2014) Am Fam Physician 89(2): 106-13 [PubMed]