Definition
A.The word tinnitus
comes from the Latin tinnire, which means to ring.
Tinnitus is the perception of an auditory sensation such as hissing, sizzling, or ringing in the absence of external stimuli. Rarely, more complex sounds such as voices or music are heard indistinctly. Sounds can be constant or intermittent and vary in intensity from patient to patient. The tinnitus can also be categorized as rhythmical or pulsatile and corresponding with a heartbeat (this may suggest a vascular origin).
Incidence
A.It is estimated that approximately 10% to 15% of the adult population has experienced tinnitus.
B.Prevalence is similar between men and women and is known to increase with age.
Pathogenesis
A.Tinnitus is poorly understood. It is best described as a nonspecific manifestation of pathology of the inner ear, eighth cranial nerve, or the central auditory mechanism.
Predisposing Factors
A.High levels of noise exposure, either recreational or occupational.
B.Otological conditions:
1.Neoplasms.
2.Hearing loss.
3.Cerumen impaction.
4.Otitis media.
5.Mastoiditis.
6.Labyrinthitis.
C.Neurologic conditions:
1.Vertigo.
2.Migraines.
3.Epilepsy.
4.Meningitis.
5.Multiple sclerosis.
D.Trauma to head or neck or issues with temporomandibular joint (TMJ) disorder.
E.Immune system disorders such as rheumatoid arthritis, systemic lupus erythematosus, or systemic sclerosis.
F.Endocrine influences such as diabetes, hypothyroidism, and pregnancy.
G.Psychological disorders:
1.Anxiety.
2.Depression.
3.Posttraumatic stress disorder.
H.Hypertension.
I.Ototoxic drugs: More than 130 medications are known to cause tinnitus or hearing loss. Patients should be assessed for concurrent use of multiple ototoxic medications, especially when other risk factors are present. The most common broad categories include the following:
1.Analgesics.
2.Antibiotics.
3.Antineoplastics and immunosuppressives.
4.Diuretics.
5.Corticosteroids.
Common Symptoms
A.Ringing.
B.Roaring.
C.Buzzing.
D.Clicking.
E.Hissing.
F.Hearing loss.
Other Signs and Symptoms
A.Muffled
hearing.
B.Change in own voice, lower pitch.
Subjective Data
A.Review the onset, duration, course, and type of symptoms; note whether they are bilateral or unilateral.
B.Determine the frequency and quality of sound; is the ringing constant, intermittent, or pulsating?
C.Review all medications, including over-the-counter (OTC) drugs and prescriptions.
D.Determine if there is a family history of tinnitus, hearing loss, or neurofibromatosis.
E.Ask whether the patient has experienced recent physical or emotional trauma.
F.Inquire about any past history of ontological disorders, either acute or chronic.
G.Ask about associated symptoms:
1.Headache.
2.Hearing loss.
3.Noise intolerance.
4.TMJ.
5.Vertigo.
H.Review work, hobbies, and music habits for noise levels (potential damage).
I.Assess the date of last hearing exam, and determine whether there was any known hearing loss.
J.Review whether patient uses cotton-tipped swabs or other small objects for ear cleaning.
Physical Examination
A.General: The goal of the physical exam is to evaluate for the most common known causes of tinnitus.
B.Inspect:
1.Observe the external ear for discharge; note color and odor.
2.Conduct otoscopic exam of the auditory canal for cerumen impaction or foreign body.
3.Inspect tympanic membrane for color, landmarks, contour, perforation, and acute otitis media (AOM):
a.The landmarks (umbo, handle of malleus, and the light reflex) should be visible on a normal exam.
b.The tympanic membrane should be pearly gray in color and translucent.
c.A bulging tympanic membrane is more conical, usually with a loss of bony landmarks and a distorted light reflex.
d.A retracted tympanic membrane is more concave, usually with accentuated bony landmarks and a distorted light reflex (pathologic conditions in the middle ear may be reflected by characteristics of the tympanic membrane).
C.Auscultation: Assess for bruits or murmurs over the ear canal, auricular areas, neck, and chest.
D.Palpate:
1.Palpate auricle and mastoid area for tenderness, swelling, or nodules.
2.Palpate the TMJ for tenderness or crepitus.
E.Visual exam:
1.Inspect for papilledema.
2.Assess for visual field changes and for nystagmus.
F.Neurologic exam:
1.Assess all cranial nerves.
2.First evaluate how the patient responds to your questions.
3.Patients who speak in a monotone or with erratic volume may have hearing loss.
4.Check the patient’s response to a soft whisper (should respond at least 50% of the time).
5.Rinne and Weber testing: The Rinne test is performed by placing the struck tuning fork against the mastoid bone. Begin counting or timing the interval from the start to when the patient can no longer hear. Continue counting or timing the interval to determine the length of time sound is heard by air conduction. Air-conducted sound should be heard twice as long as bone-conducted sound after bone conduction stops.
Diagnostic Tests
A.When tinnitus is acute (<3 weeks) and has no associated neurologic deficits or hearing loss, consider audiometry. Any focal neurologic findings warrant an MRI and/or prompt physician referral. Tinnitus lasting longer than 3 weeks should be referred to an otolaryngologist. Appropriate diagnostics are influenced by intermittent hearing loss, vertigo, abnormal physical exam findings, pulsatile quality, and unilateral presentation.
Differential Diagnoses
A.Tinnitus.
B.Hearing loss that could be related to multiple otologic conditions:
1.Cerumen impaction.
2.Foreign body.
3.AOM.
4.Ménière’s disease.
5.Presbycusis.
6.Cholesteatoma.
C.TMJ syndrome.
D.Ototoxicity.
E.Central nervous system lesion.
Plan
A.General interventions:
1.Assess for underlying cause of tinnitus.
2.Refer to otolaryngologist for tinnitus lasting longer than 3 weeks.
B.Patient teaching:
1.Educate the patient regarding techniques/therapies to improve symptoms of tinnitus such as sound therapy, interventions to reduce distress such as counseling, and cognitive behavior therapy.
2.Encourage the patient to attend therapy sessions as indicated.
C.Pharmaceutical therapy:
1.Medications do not have a beneficial role in the treatment of tinnitus.
Follow-Up
A.Length of follow-up depends on whether the patient has an identified and/or treatable cause of tinnitus. A 3-week follow-up to determine chronicity and need for specialist referral is important in the management of tinnitus.
Consultation/Referral
A.Consult with an otolaryngologist as indicated.
Individual Considerations
A.Geriatrics:
1.Tinnitus onset later in life tends to be more abrupt and distressing than with younger adults. It is important to monitor this population closely for comorbid anxiety/depression, psychosocial changes and sleep pattern disruptions.
2.Ringing in the ears can be a severe distraction that could increase risks for unexpected accidents and falls.
3.Geriatrics with arterial bruits, venous hums, shunts, and high cardiac output are particularly vulnerable to exacerbative tinnitus. Monitor for social isolation and conversational withdrawal. Encourage referral for cochlear implants to those who have long-term tinnitus with profound hearing loss.