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Tinnitus
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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 Medication
s
Aspirin
(high dose>2-3 g/day)
NSAID
s
Loop Diuretic
s
PDE5 Inhibitor
s (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 Medication
s
Associated symptoms
Hyperacusis
Temporomandibular Joint Dysfunction
Headache
s
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
Soma
tosensory (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 Joint
Arthritis
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 Medication
s
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 Test
s
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 Canal
s
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 tumor
s
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 Medication
s
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 Lesion
s
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
Corticosteroid
s (See SSNHL)
Reassurance
Cognitive Behavioral Therapy
(psychology)
Antidepressant
s (
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]
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