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Tinnitus

BASICS

DESCRIPTION

- Precise pathophysiology is unknown; numerous theories have been proposed. Cochlear damage from ototoxic agents or noise exposure damage hair cells so that the central auditory system compensates, resulting in hyperactivity in cochlear nucleus and auditory cortex. Animal models have identified brain abnormalities resulting in increased firing and synchrony in auditory cortex (7). - Causes of subjective tinnitus are the following: - Otologic: hearing loss, cholesteatoma, cerumen impaction, otosclerosis, Meni пїЅ пїЅre disease, vestibular schwannoma - Ototoxic medications: anti-inflammatory agents (aspirin, NSAIDs); antimalarial agents (quinine, chloroquine); antimicrobial drugs (aminoglycosides); antineoplastic agents, loop diuretics, miscellaneous drugs (antiarrhythmics, antiulcer, anticonvulsants, antihypertensives, psychotropic drugs; anesthetics (3,5) - Somatic: temporomandibular joint (TMJ) dysfunction, head or neck injury - Neurologic: multiple sclerosis, spontaneous intracranial hypertension, vestibular migraine, type I Chiari malformation - Infectious: viral, bacterial, fungal

  • Tinnitus is a perceived sensation of sound in the absence of an external acoustic stimulus; often described as a ringing, hissing, buzzing, or whooshing
  • Derived from the Latin word tinnire, meaning "to ring " пїЅ (1)
  • May be heard in one or both ears or centrally within the head (2)
  • Two types: subjective (most common) and objective tinnitus
  • Subjective tinnitus: perceived only by the patient; can be continuous, intermittent, or pulsatile
  • Objective tinnitus: audible to the examiner; usually pulsatile; <1% cases (3)

EPIDEMIOLOGY

Prevalence

  • Tinnitus reported by 35 to 50 million adults in United States; although underreported, 12 million seek medical care (4).
  • Affects 10 " пїЅ15% of adults
  • Prevalence increases with age and peaks between ages of 60 and 69 years (5).
  • Prevalence of 13 " пїЅ53% in general pediatric population (6)
  • Ethnic: whites > blacks and Hispanics (4)
  • Gender: males > females

Incidence

  • Incidence increasing in association with excessive noise exposure
  • Higher rates of tinnitus in smokers and hypertensives (5)

ETIOLOGY AND PATHOPHYSIOLOGY

  • Precise pathophysiology is unknown; numerous theories have been proposed. Cochlear damage from ototoxic agents or noise exposure damage hair cells so that the central auditory system compensates, resulting in hyperactivity in cochlear nucleus and auditory cortex. Animal models have identified brain abnormalities resulting in increased firing and synchrony in auditory cortex (7).
  • Causes of subjective tinnitus are the following:Otologic: hearing loss, cholesteatoma, cerumen impaction, otosclerosis, Meni пїЅ пїЅre disease, vestibular schwannomaOtotoxic medications: anti-inflammatory agents (aspirin, NSAIDs); antimalarial agents (quinine, chloroquine); antimicrobial drugs (aminoglycosides); antineoplastic agents, loop diuretics, miscellaneous drugs (antiarrhythmics, antiulcer, anticonvulsants, antihypertensives, psychotropic drugs; anesthetics (3,5)Somatic: temporomandibular joint (TMJ) dysfunction, head or neck injuryNeurologic: multiple sclerosis, spontaneous intracranial hypertension, vestibular migraine, type I Chiari malformationInfectious: viral, bacterial, fungal
  • Causes of objective tinnitus: patulous eustachian tubeVascular: aortic or carotid stenosis, venous hum, arteriovenous fistula or malformation, vascular tumors, high cardiac output state (anemia)Neurologic: palatal myoclonus, idiopathic stapedial muscle spasm

Genetics

Minimal genetic component пїЅ пїЅ

RISK FACTORS

  • Hearing loss (but can have tinnitus with normal hearing)
  • High level noise exposure
  • Advanced age
  • Use of ototoxic medications
  • Otologic disease (otosclerosis, Meni пїЅ пїЅre disease, cerumen impaction)

GENERAL PREVENTION

  • Avoid loud noise exposure and wear appropriate ear protection to prevent hearing loss.
  • Monitor ototoxic medications and avoid prescribing more than one ototoxic agent concurrently.

COMMONLY ASSOCIATED CONDITIONS

  • Sensorineural hearing loss caused by presbycusis (age associated hearing loss) or prolonged loud noise exposure
  • Conductive hearing loss due to cerumen, otosclerosis, cholesteatoma
  • Psychological disorders: depression, anxiety, insomnia, suicidal ideation
  • Despair, frustration, interference with concentration and social interactions, work hindrance

DIAGNOSIS

HISTORY

  • Onset gradual (presbycusis) or abrupt (following loud noise exposure)
  • Timing: can be continuous (hearing loss) or intermittent (Meni пїЅ пїЅre disease)
  • Pattern: nonpulsatile >> pulsatile (often vascular cause)
  • Location: bilateral > unilateral (vestibular schwannoma, cerumen, Meni пїЅ пїЅre disease)
  • Pitch: high pitch (with sensorineural hearing loss) > low pitch (Meni пїЅ пїЅre disease)
  • Associated symptoms: hearing loss, headache, noise intolerance, vertigo, TMJ dysfunction, neck pain
  • Exacerbating factors: loud noise; jaw, head, or neck movements
  • Alleviating factors: hearing aid, position change, medications
  • Medication use (prescription, OTC, supplements)
  • Hearing and past noise exposure (occupational, military, recreational)
  • Psychosocial history (depression, sleep habits)
  • Impact of tinnitus: Tinnitus Handicap Inventory, Tinnitus Functional Index

PHYSICAL EXAM

  • HEENT, neck, neurologic, and vascular examinations
  • Ear: cerumen impaction, effusion, cholesteatoma
  • Check hearing; air and bone conduction testing with 512- or 1,024-Hz tuning fork (Weber and Rinne tests)
  • Eye: funduscopic exam for papilledema (intracranial hypertension) or visual field change (mass)
  • TMJ: Palpate for tenderness and crepitus with movement.
  • Cranial nerve, Romberg test (equilibrium), finger to nose, gait
  • Auscultate for bruits or murmurs over ear canal, periauricular areas, orbit, neck, chest

DIFFERENTIAL DIAGNOSIS

Pulsatile tinnitus: carotid stenosis, aortic valve disease, AV malformation, high cardiac output state (anemia, hyperthyroidism), paraganglioma (glomus tumor) пїЅ пїЅ

Nonpulsatile tinnitus: auditory hallucinations (8) пїЅ пїЅ

DIAGNOSTIC TESTS & INTERPRETATION

  • Tinnitus is a symptom; no objective test to confirm diagnosis
  • Pure tone audiometry (air and bone conduction)
  • Speech discrimination testing
  • Tympanometry
  • Auditory brainstem response (ABR); less sensitive and specific than MRI for diagnosis of vestibular schwannoma (3)
  • Carotid Doppler ultrasonography (neck bruit)

Initial Tests (lab, imaging)

Little evidence to support lab testing other than targeted lab studies based on history and physical exam. Lab investigation is not indicated in all patients; use clinical judgment. Consider the following: пїЅ пїЅ

  • CBC
  • BUN/creatinine, fasting glucose, lipid panel
  • Thyroid-stimulating hormone
  • Clinical evaluation should precede radiologic studies.
  • Nonpulsatile tinnitus: MRI with or without contrast
  • Pulsatile tinnitus: Contrast-enhanced temporal bone CT, MRI, MRA/MRV, CTA/CTV, carotid ultrasound, and conventional angiography all have been used to work up pulsatile tinnitus.
  • CTA/CTV; CTA evaluates middle ear and arterial causes (carotid artery stenosis, aberrant ICA, persistent stapedial artery); CTV evaluates venous causes (sinus thrombosis, sinus stenosis, dehiscent jugular bulb) (9)[C].
  • No studies have compared sensitivity and specificity of MRA/V with CTA/V in the evaluation of pulsatile tinnitus.
  • Cerebral angiography is gold standard for diagnosis of suspected dural arteriovenous fistula.

Follow-Up Tests & Special Considerations

Consider HIV, RPR, autoimmune panel, Lyme test, vitamin B12 level. пїЅ пїЅ

Diagnostic Procedures/Other

Electronystagmography (vestibular testing for Meni пїЅ пїЅre disease) пїЅ пїЅ

TREATMENT

GENERAL MEASURES

  • Individualize treatment based on the severity of tinnitus and impact on function
  • Reassure patient.
  • Manage treatable pathology.
  • Education, relaxation therapy, cognitive-behavioral therapy (CBT)
  • Hearing aids (corrects hearing and might mask tinnitus); can be tried even if there is minimal hearing loss; no evidence to support or refute the use of hearing aids (10)[B]
  • Protect hearing against future loud noise.
  • Masking sound devices or generators on discontinuation might have decreased tinnitus (residual inhibition).
  • Discontinue ototoxic medications.

MEDICATION

No pharmacologic agent has been shown to cure or consistently alleviate tinnitus. пїЅ пїЅ

First Line

  • Antidepressants (SSRIs or TCAs): probably help with psychological distress. Newer review states insufficient evidence that antidepressant drug therapy improves tinnitus (11)[B].
  • Melatonin decreases tinnitus intensity and improves sleep quality; most effective in men, those without depression or prior treatment, and those with more severe bilateral tinnitus (12)[B].

Second Line

  • Anticonvulsants (used to treat tinnitus for years. Recent studies indicate that they may have a small effect (of doubtful clinical significance) on tinnitus (13)[A].
  • Benzodiazepines help reduce tinnitus distress, but regular use discouraged.
  • No difference between gabapentin and control group in patients with isolated tinnitus (14)[B].
  • Higher caffeine intake associated with lower incidence of tinnitus in women (15)[B]

ISSUES FOR REFERRAL

  • Audiologist for comprehensive hearing evaluation and management
  • Otolaryngologist, neurologist, or neurosurgeon depending on pathology
  • Dental referral for TMJ treatment and dental orthotics (splint, night guard)
  • Therapists for cognitive-behavioral therapy (CBT), biofeedback, education, and relaxation techniques

ADDITIONAL THERAPIES

  • Sound therapy (masking): Patients wear low-level noise generators to mask the tinnitus noise; commonly used, but no strong evidence for its efficacy (16)[B].
  • CBT employs relaxation exercises, coping strategies, and deconditioning techniques to reduce arousal levels and reverse negative thoughts about tinnitus. Depression and severity of tinnitus improved with CBT (17)[A].
  • Tinnitus retraining therapy (TRT) combines counseling, education, and acoustic therapy (soft music, sound machine) to minimize bothersome nature of tinnitus; often requires a team approach and up to 2 years of therapy; might be more effective than sound masking (18)[B].
  • Transcranial magnetic stimulation (TMS): A noninvasive method to stimulate neurons in the brain by rapidly changing magnetic fields; insufficient data to support long-term safety of repetitive TMS (19)[B]
  • Neurofeedback: a method to help patients regulate abnormal oscillatory brain activity and reduce intensity of tinnitus
  • Hyperbaric oxygen therapy: no beneficial effect on tinnitus (20)[A]

SURGERY/OTHER PROCEDURES

  • Cochlear implants (for severe sensorineural hearing loss)
  • Ablation of cochlear nerve (destroys hearing)
  • Epidural stimulation of secondary auditory cortex with implanted electrodes suppressed tinnitus in small subset of patients.
  • Otosclerosis: stapedectomy surgery with implantation of ossicular prosthesis
  • Severe Meni пїЅ пїЅre disease not alleviated by medications: installation of endolymphatic shunt, labyrinthectomy, or vestibular neurectomy
  • Auditory neoplasms: surgical resection/radiation
  • Pulsatile tinnitus due to atherosclerotic carotid artery disease: carotid endarterectomy

COMPLEMENTARY & ALTERNATIVE MEDICINE

  • Zinc supplements might improve tinnitus in those with zinc deficiency. One study in elderly did not demonstrate effectiveness of zinc treatment (21)[B].
  • Ginkgo biloba has potential benefit but recent reviews question the effectiveness (22)[B].
  • One evidence-based practice guideline does not recommend Ginkgo biloba, melatonin, zinc, or other dietary supplements for treatment of persistent, bothersome tinnitus (23)[C].
  • Botulinum toxin (for palatal myoclonus)
  • Acamprosate (used to treat alcohol dependence): Small studies noted improvement in tinnitus severity.
  • Hypnosis (unknown effectiveness)
  • Acupuncture (unknown effectiveness)

INPATIENT CONSIDERATIONS

Admission Criteria/Initial Stabilization

Not applicable пїЅ пїЅ

ONGOING CARE

FOLLOW-UP RECOMMENDATIONS

  • Audiologist: for hearing evaluation and therapy
  • Counseling as needed for psychological distress
  • Family physician: as needed for support and guidance

PATIENT EDUCATION

  • Help patients understand the relatively benign nature of tinnitus.
  • Self-help groups
  • American Tinnitus Association: (800) 634-8978; http://www.ata.org/
  • National Institute on Deafness and Other Communication Disorders: (800) 241-1044; http://www.nidcd.nih.gov/Pages/default.aspx
  • American Academy of Family Physicians: http://familydoctor.org

PROGNOSIS

  • Tinnitus persisted in 80% of older patients and increased in severity in 50% (3).
  • Focus on managing tinnitus and reducing severity, not curing.

REFERENCES

11 Baguley пїЅ пїЅD, McFerran пїЅ пїЅD, Hall пїЅ пїЅD. Tinnitus. Lancet. 2013;382(9904):1600 " пїЅ1607.22 Langguth пїЅ пїЅB, Kreuzer пїЅ пїЅPM, Kleinjung пїЅ пїЅT, et al. Tinnitus: causes and clinical management. Lancet Neurol. 2013;12(9):920 " пїЅ930.33 Yew пїЅ пїЅKS. Diagnostic approach to patients with tinnitus. Am Fam Physician. 2014;89(2):106 " пїЅ113.44 Shargorodsky пїЅ пїЅJ, Curhan пїЅ пїЅGC, Farwell пїЅ пїЅWR. Prevalence and characteristics of tinnitus among US adults. Am J Med. 2010;123(8):711 " пїЅ718.55 Zimmerman пїЅ пїЅE, Timboe пїЅ пїЅA. Tinnitus: steps to take, drugs to avoid. J Fam Pract. 2014;63(2):82 " пїЅ88.66 Bae пїЅ пїЅSC, Park пїЅ пїЅSN, Park пїЅ пїЅJM, et al. Childhood tinnitus: clinical characteristics and treatment. Am J Otolaryngol. 2014;35(2):207 " пїЅ210.77 Galazyuk пїЅ пїЅAV, Wenstrup пїЅ пїЅJJ, Hamid пїЅ пїЅMA. Tinnitus and underlying brain mechanisms. Curr Opin Otolaryngol Head Neck Surg. 2012;20(5):409 " пїЅ415.88 Smith пїЅ пїЅGS, Romanelli-Gobbi пїЅ пїЅM, Gray-Karagrigoriou пїЅ пїЅE, et al. Complementary and integrative treatments: tinnitus. Otolaryngol Clin North Am. 2013;46(3):398 " пїЅ408.99 Sajisevi пїЅ пїЅM, Weissman пїЅ пїЅJL, Kaylie пїЅ пїЅDM. What is the role of imaging in tinnitus? Laryngoscope. 2014;124(3):583 " пїЅ584.1010 Hoare пїЅ пїЅDJ, Edmondson-Jones пїЅ пїЅM, Sereda пїЅ пїЅM, et al. Amplification with hearing aids for patients with tinnitus and co-existing hearing loss. Cochrane Database Syst Rev. 2014;(1):CD010151.1111 Baldo пїЅ пїЅP, Doree пїЅ пїЅC, Molin пїЅ пїЅP, et al. Antidepressants for patients with tinnitus. Cochrane Database Syst Rev. 2012;(9):CD003853.1212 Hurtuk пїЅ пїЅA, Dome пїЅ пїЅC, Holloman пїЅ пїЅCH, et al. Melatonin: can it stop the ringing? Ann Otol Rhinol Laryngol. 2011;120(7):433 " пїЅ440.1313 Hoekstra пїЅ пїЅCE, Rynja пїЅ пїЅSP, van Zanten пїЅ пїЅGA, et al. Anticonvulsants for tinnitus. Cochrane Database Syst Rev. 2011;(7):CD007960.1414 Dehkordi пїЅ пїЅMA, Abolbashari пїЅ пїЅS, Taheri пїЅ пїЅR, et al. Efficacy of gabapentin on subjective idiopathic tinnitus: a randomized, double-blind, placebo-controlled trial. Ear Nose Throat J. 2011;90(4):150 " пїЅ158.1515 Glicksman пїЅ пїЅJT, Curhan пїЅ пїЅSG, Curhan пїЅ пїЅGC. A prospective study of caffeine intake and risk of incident tinnitus. Am J Med. 2014;127(8):739 " пїЅ743.1616 Hobson пїЅ пїЅJ, Chisholm пїЅ пїЅE, El Refaie пїЅ пїЅA. Sound therapy (masking) in the management of tinnitus in adults. Cochrane Database Syst Rev. 2012;(11):CD006371.1717 Martinez-Devesa пїЅ пїЅP, Perera пїЅ пїЅR, Theodoulou пїЅ пїЅM, et al. Cognitive behavioural therapy for tinnitus. Cochrane Database Syst Rev. 2010;(9):CD005233.1818 Phillips пїЅ пїЅJS, McFerran пїЅ пїЅD. Tinnitus retraining therapy (TRT) for tinnitus. Cochrane Database Syst Rev. 2010;(3):CD007330.1919 Meng пїЅ пїЅZ, Liu пїЅ пїЅS, Zheng пїЅ пїЅY, et al. Repetitive transcranial magnetic stimulation for tinnitus. Cochrane Database Syst Rev. 2011;(10):CD007946.2020 Bennett пїЅ пїЅMH, Kertesz пїЅ пїЅT, Perleth пїЅ пїЅM, et al. Hyperbaric oxygen for idiopathic sudden sensorineural hearing loss and tinnitus. Cochrane Database Syst Rev. 2012;(10):CD004739.2121 Coelho пїЅ пїЅC, Witt пїЅ пїЅSA, Ji пїЅ пїЅH, et al. Zinc to treat tinnitus in the elderly: a randomized placebo controlled crossover trial. Otol Neurotol. 2013;34(6):1146 " пїЅ1154.2222 Hilton пїЅ пїЅMP, Zimmermann пїЅ пїЅEF, Hunt пїЅ пїЅWT. Ginkgo biloba for tinnitus. Cochrane Database Syst Rev. 2013;(3):CD003852.2323 Tunkel пїЅ пїЅDE, Bauer пїЅ пїЅCA, Sun пїЅ пїЅGH, et al. Clinical practice guideline: tinnitus. Otolaryngol Head Neck Surg. 2014;151(Suppl 2):S1 " пїЅS40.

CODES

ICD10

  • H93.19 Tinnitus, unspecified ear
  • H93.11 Tinnitus, right ear
  • H93.12 Tinnitus, left ear
  • H93.13 Tinnitus, bilateral

ICD9

  • 388.30 Tinnitus, unspecified
  • 388.31 Subjective tinnitus
  • 388.32 Objective tinnitus

SNOMED

  • 60862001 Tinnitus (finding)
  • 62452009 Subjective tinnitus
  • 28715001 Objective tinnitus
  • 4831000119102 Bilateral tinnitus (finding)
  • 4841000119106 Tinnitus of left ear (finding)
  • 4851000119108 Tinnitus of right ear (finding)

CLINICAL PEARLS

  • People have different levels of tolerance to tinnitus. It may affect sleep, concentration, and emotional state. Many patients with chronic tinnitus have depression.
  • To keep tinnitus from worsening, avoid loud noises and minimize stress.
  • Optimal management may involve multiple strategies.