Contents

Search

tinnitus

An abnormal sound perceived as a ringing, hissing, buzzing, whistling or roaring not originating from an external source. Etiology: 1) otologic causes (90%) a) high-frequency sensorineural hearing loss (presbycusis) - frequency loss 3000-8000 Hz - unilateral in 50% b) noise-induced hearing loss - exposure to road traffic noise (RR=1.06) [16] c) Meniere's disease - low-pitched - associated with vertigo d) Herpes zoster oticus (Ramsay Hunt syndrome type 2) e) acoustic neuroma f) otosclerosis g) chronic otitis media h) cerumen impactation i) cholesteoma 2) pharmacologic agents (ototoxic agents) [15] a) antibiotics: - aminoglycoside antibiotics, vancomycin, erythromycin, clarithromycin, quinolones, neomycin, polymixin B b) antimalarials - quinine, chloroquine, hydroxychloroquine c) salicylates d) non-steroidal anti-inflammatory agents (NSAIDs) [15] e) tricyclic antidepressants f) loop diuretics g) benzodiazepines h) carbamazepine i) quinidine j) calcium channel blockers k) chemotherapeutic agents - mechlorethamine, vincristine, carboplatin, cisplatin 3) turbulent blood flow in local blood vessel (pulsatile tinnitus) a) arteriovenous shunts b) arterial bruits c) carotid occlusive disease 4) neuromuscular spasms a) palate b) nasopharynx c) middle ear 5) temporomandibular joint (TMJ) syndrome 6) hypertension, uncontrolled 7) head trauma 8) hypothyroidism or hyperthyroidism 9) hyperlipidemia 10) demyelinating diseases - multiple sclerosis 11) mental disorders a) anxiety b) depression c) psychosocial stress [14] 12) insufficient sleep [14] 13) other a) osteoarthritis b) rheumatoid arthritis c) asthma [14] Epidemiology: - overall prevalence is 10%, 30% over age 55 years [3]; 25% of American [14] - 40% of children with normal hearing report some form of tinnitus [4] - affects quality of life in ~10% of affected individuals Pathology: - cochlear damage, loss of hair cells Clinical manifestations: - subjective ringing, cracking or whistling in the ears - pulsatile tinnutus due to a vascular etiology may be objective in that the examiner may be able to hear the stimulus - normal tinnitus lasts < 5 minutes & occurs < weekly - hearing loss is common - vertigo (&/or vestibular dysfunction), asymmetric hearing loss & tinnitus suggests acoustic neuroma - fluctuating tinnitus, low-frequency hearing loss & episodic vertigo with horizontal nystagmus suggests Meniere's disease [14] - persistent tinnitus is tinnitus lasting > 6 months [14] Laboratory: 1) complete blood count (CBC): hemoglobin 2) serum glucose 4) lipid panel 5) thyroid function tests Special laboratory: - audiometric testing - carotid ultrasound (pulsatile tinnitus) - cerebral angiography (pulsatile tinnitus) Radiology: - pulsatile tinnitus (ACR) - CT angiography of head & neck - magnetic resonance angiography of head - MRI of head & internal auditory canal - asymmetric or unilateral, nonpulsatile tinnitus (ACR) - MRI head & internal auditory canal, especially if accompanied by hearing loss [2] - symmetric or bilateral, nonpulsatile tinnitus (ACR) - imaging generlly not appropriate Complications: - hearing impairment - agitation - depression - insomnia - irritability [3] Management: 1) general a) ear exam b) clean out ear wax (ear irrigation) c) distinguish bothersome from non-bothersome tinnitus [14] d) audiometry [3] 2) withdraw offending medications 3) avoid stimulants (caffeine & nicotine) which may exacerbate tinnitus 4) treat anxiety & depression - frequently associated with intractable tinnitus 5) cognitive behavioral therapy [3,10] - Tinnitus Retraining Therapy [7,8] 6) referral to audiologist for co-existing hearing loss - hearing aids may improve hearing & mask tinnitus 7) pharmacologic agents not effective [2]; not recommended [11] - alprazolam, nortriptyline, meclizine (used but not effective) 8) referral to ENT for pulsatile tinnitus 9) competing noise (i.e. music) may help with sleep 10) unproven therapies - transcranial magnetic stimulation not recommended [NGC] - acupuncture: insufficient evidence to recommend [NGC] - use of both sound & electrical stimulation to slow firing rates of hyperactive, synchronized neurons causing the phantom ringing or buzzing of tinnitus [12] - induces long-term depression in fusiform neurons of the dorsal cochlear nucleus in guinea pigs [12] - no medications, supplements, or herbal remedies have been shown to substantially reduce the severity of tinnitus [13] 11) patient education [4] a) tinnitus often diminishes with time b) although disturbing, etiology is generally benign c) avoid exposure to loud noises d) supplements, including Ginkgo biloba, melatonin, zinc, or other dietary supplements of little or no benefit

Related

hearing loss (hearing impairment, hard of hearing, HOH) vertigo

Specific

pulsatile tinnitus

General

sign/symptom

References

  1. Saunders Manual of Medical Practice, Rakel (ed), WB Saunders, Philadelphia, 1996, pg 44-46
  2. Medical Knowledge Self Assessment Program (MKSAP) 11, 15, 16, 17, 18. American College of Physicians, Philadelphia 1998, 2009, 2012, 2015, 2018.
  3. Prescriber's Letter 17(9): 2010 Tinnitus Treatments: What's the Buzz? Detail-Document#: 260915 Detail-Document#: 261014 (subscription needed) http://www.prescribersletter.com
  4. Juul J et al. Tinnitus and hearing in 7-year-old children. Arch Dis Child 2012 Jan; 97:28. PMID: 22100742
  5. Geriatric Review Syllabus, 7th edition Parada JT et al (eds) American Geriatrics Society, 2010
  6. Geriatrics at your Fingertips, 13th edition, 2011 Reuben DB et al (eds) American Geriatric Society
  7. Tinnitus & Hyperacusis Center Jastreboff PJ Emory University http://www.tinnitus-pjj.com
  8. Cima RFF et al Specialised treatment based on cognitive behaviour therapy versus usual care for tinnitus: a randomised controlled trial The Lancet, 379(9830):1951-1959, May 26, 2012 PMID: 22633033 http://www.thelancet.com/journals/lancet/article/PIIS0140-6736%2812%2960469-3/fulltext - Langguth B Tinnitus: the end of therapeutic nihilism The Lancet, 379(9830):1926-1928, May 26, 2012 PMID: 22633023 http://www.thelancet.com/journals/lancet/article/PIIS0140-6736%2812%2960561-3/fulltext
  9. Hobson J, Chisholm E, El Refaie A. Sound therapy (masking) in the management of tinnitus in adults. Cochrane Database Syst Rev. 2010 Dec 8;(12):CD006371. PMID: 21154366
  10. Tunkel DE et al Clinical Practice Guideline. Tinnitus Otolaryngol Head Neck Surg. October 2014. 151(2) suppl S1-S40 PMID: 25274374 http://oto.sagepub.com/content/151/2_suppl/S1.full
  11. Bhatt JM, Lin HW, Bhattacharyy N Prevalence, Severity, Exposures, and Treatment Patterns of Tinnitus in the United States. JAMA Otolaryngol Head Neck Surg. Published online July 21, 2016 PMID: 27441392 http://archotol.jamanetwork.com/article.aspx?articleid=2533660
  12. Voelker R. Experimental Device Could Offer Hope for Millions With Tinnitus. JAMA. Published online March 14, 2018 PMID: 29541776 https://jamanetwork.com/journals/jama/fullarticle/2675187 - Marks KL, Martel DT, Wu C et al Auditory-somatosensory bimodal stimulation desynchronizes brain circuitry to reduce tinnitus in guinea pigs and humans. Sci Transl Med. 2018 Jan 3;10(422). pii: eaal3175 PMID: 29298868 http://stm.sciencemag.org/content/10/422/eaal3175.short
  13. Bauer CA Tinnitus. N Engl J Med 2018; 378:1224-1231. March 29, 2018 PMID: 29601255 http://www.nejm.org/doi/full/10.1056/NEJMcp1506631
  14. Meyers AD. Fast Five Quiz: Tinnitus Medscape - Apr 07, 2021. https://reference.medscape.com/viewarticle/948493
  15. Windle ML Rapid Rx Quiz: Headache Medications Medscape. Sept 12, 2022 https://reference.medscape.com/viewarticle/980181
  16. Cantuaria ML et al Transportation Noise and Risk of Tinnitus: A Nationwide Cohort Study from Denmark Environ Health Perspect. 2023 Feb;131(2):27001 PMID: 36722980 Free article https://ehp.niehs.nih.gov/doi/10.1289/EHP11248
  17. American Tinnitus Association Prescription Medications, Drugs, Herbs & Chemicals Associated with Tinnitus https://www.ata.org/sites/default/files/Drugs%20Associated%20with%20Tinnitus%202013_Updated2017.pdf
  18. American Tinnitus Association P.O. Box 5 Portland, OR 97207 http://www.ata.org/