//fpnotebook.com/
Tinnitus
Aka: Tinnitus, Ear Ringing
- Definition
- Ringing in the ears, unrelated to external sounds
- Epidemiology
- Moderate tinnitus Prevalence: 8% of age over 48 years old (U.S.)
- Older adults typically have persistent Tinnitus (rather than transient)
- Pathophysiology
- CNS maladaptive response to insufficient, distorted or abnormal signals from the ear
- 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)
- Ototoxic
- See 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
- Multiple Sclerosis
- Vestibular Migraine
- Type I Chiari Malformation
- Idiopathic Intracranial Hypotension (Postdural Puncture Headache)
- Pseudotumor Cerebri
- Infectious
- Various infections have been associated including Syphilis
- Metabolic
- Hypothyroidism
- Vitamin B12 Deficiency
- Diabetes Mellitus
- 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
- 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
- Hyperacusis
- Temporomandibular Joint Dysfunction
- Headaches
- Idiopathic Intracranial Hypotension (Postdural Puncture Headache)
- Pseudotumor Cerebri
- Hearing Loss
- Most common cause of Tinnitus
- Vertigo
- Meniere Disease
- Vestibular Schwannoma
- Tinnitus characteristics (see history below)
- Bilateral (most common) or unilateral
- High pitched (most common) or low pitched
- Pulsatile, fluttering, clicking or crunching
- History: Tinnitus Distribution
- Bilateral Tinnitus in two thirds of cases
- Unilateral causes
- Somatosensory (e.g. TMJ, head or neck injury)
- Acoustic Neuroma
- Meniere Disease
- 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
- 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
- Otosclerosis
- History: Other Tinnitus characteristics
- Fluttering Tinnitus
- Intermittent spasm of tensor tympani muscle
- Associated with eye irritation or acute anxiety
- Clicking Tinnitus
- Palatal Myoclonus
- Rapid rhythmic twitching of ipsilateral Palate
- May respond to mild sedation
- Crunching Tinnitus
- Temporomandibular JointArthritis
- Foreign body (e.g. hair) rubbing against TM
- History: Tinnitus and Hearing Loss
- Tinnitus and unilateral Sensorineural Hearing Loss
- Acoustic Neuroma
- Roaring or low pitched Tinnitus, Hearing Loss and Vertigo
- Meniere's Disease
- Bilateral subjective Tinnitus without Hearing Loss
- Endocrine causes (e.g. Hypothyroidism)
- Ototoxic Medications
- Mood Disorder
- Exam
- Otoscopy
- Cerumen Impaction
- Otitis Media
- Cholesteatoma
- 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
- Labs
- Complete Blood Count
- Thyroid Stimulating Hormone
- Lipid profile
- 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]
- 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
- 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
- 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
- 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
- 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
- Rejali (2004) Clin Otolaryngol 29:226-31 [PubMed]
- Resources
- American Tinnitus Association
- http://www.ata.org
- References
- (2019) Presc Lett 26(2): 12
- Crummer (2004) Am Fam Physician 69(1):120-8 [PubMed]
- Lloyd (2008) Clin Otolaryngol 33(1): 25-8 [PubMed]
- Yew (2014) Am Fam Physician 89(2): 106-13 [PubMed]