BOTTOM LINE ✔ Pulsatile tinnitus, unilateral tinnitus, tinnitus with a focal neurological deficit, tinnitus with asymmetric hearing loss, or objective tinnitus merit specialist referral +/- imaging studies |
Background
- Defined as the perception of sound without an external acoustic stimulus – not always “ringing”; the patient may describe it as rustling, buzzing, static, etc.
- Estimated that it affects 50 million adults in the US, but associated distress is variable; only 1/5thof patients with persistent tinnitus seek medical attention for it
- For some patients, however, it results in significant harm to quality of life, due to impairments in sleep, concentration, and understanding of speech
Differential diagnosis
- Majority of patients have primary tinnitus, which has no identifiable cause and is often associated with sensorineural hearing loss (SNHL); evaluation should be focused on ruling out secondary causes
- Secondary causes:
- Middle ear: otitis media, otosclerosis, Eustachian tube dysfunction
- Inner ear: Meniere’s disease, superior semicircular canal dehiscence
- Vascular causes: aberrant internal carotid artery, carotid cochlear dehiscence, intracranial and/or dural arteriovenous fistula, intracranial vascular stenosis, persistent stapedial artery, glomus tumors, vascular loops, jugular diverticulum
- associated with pulsatile tinnitus
- CNS causes: idiopathic intracranial hypertension (associated with pulsatile or non-pulsatile tinnitus), acoustic neuroma, MS
- MSK: TMJ dysfunction, sigmoid sinus diverticulum, palatal myoclonus, migraine associated
- Ototoxic medications: aspirin (often reversible), aminoglycosides, cisplatin, NSAIDs, loop diuretics, quinine
- Psych: auditory hallucinations
Evaluation History
- Important to distinguish:
- Unilateral vs. bilateral
- Pulsatile vs. constant
- If pulsatile, whether it changes with turning the head to L or R may help localize
- How bothersome? (Tinnitus Handicap Inventory may be helpful)
- Duration
- Hearing loss?
- If sudden sensorineural hearing loss, should prompt high dose steroids and urgent ENT referral
- If asymmetrical hearing loss, merits audiologic evaluation and often imaging
- Other associated symptoms: vertigo, aural fullness, autophony, otorrhea (or other signs of infection) or headache
- Past medical history:
- head trauma, history of ear infections, prolonged noise exposure, ear surgery, or family history of ear problems
- Physical exam
- Ear exam
- Otoscopic exam of the external auditory canal and TM
- Evaluate hearing acuity in each ear
- Rinne/Weber (see “Hearing Loss” chapter for details) if seems bilaterally decreased
- Auscultate over affected ear(s) for bruits, if present assess whether changes with compression of the neck
- Head and neck exam
- Neurological exam, with focus on cranial nerves
- Assess for co-morbid mood or anxiety disorders (consider PHQ-9 and GAD-7)
Diagnostic tests
- Prompt audiologic examination in patients with persistent (lasting 6+ months) tinnitus, unilateral tinnitus, or tinnitus accompanied by sudden hearing loss
- Vestibular testing for patients with associated vertigo
- Pulsatile tinnitus or objective tinnitus should be evaluated with CT angiography and venography to evaluate for vascular lesions
- Unilateral tinnitus associated with asymmetric hearing loss should be evaluated with an MRI with contrast to evaluate for a lesion in the retrocochlear pathology, e.g. acoustic neuroma.
Treatment
- Management of secondary tinnitus is typically dictated by the underlying medical condition – many of which are co-managed in conjunction with specialists (ENT, neurology) – and is beyond the scope of this primary care text
- For patients with persistent, bothersome primary tinnitus consider:
- Education about the natural history of tinnitus: between 20%-50% of patients experience spontaneous improvement in symptoms – especially associated with younger age and shorter duration of tinnitus
- Hearing aid evaluation for patients with evidence of hearing loss on audiologic exam
- Combination devices (hearing aids with sound generators) are an area of active research
- Tinnitus retraining therapy, a form of CBT – improves quality of life
- AAOHNS guidelines consider recommendation of sound therapy optional
- AAOHNS guidelines recommend against antidepressents, anticonvulsants, anxiolytics, intratympanic medications, melatonin, zinc, ginkgo, or transcranial magnetic stimulation, and they recommend neither for or against acupuncture
When to refer
- Pulsatile tinnitus, tinnitus with a focal neurological deficit, objective tinnitus, or unilateral tinnitus/tinnitus with asymmetric hearing loss (unless clearly explained by a cause of treatable unilateral conductive hearing loss, e.g. otitis media)
References
Sajisevi M, Weissman JL, Kaylie DM. What is the role of imaging in tinnitus? Laryngoscope. 2014; 124(3):583-584.
Tunkel DE, Bauer CA, Sun GH, et al. Clinical practice guideline: tinnitus. Otolaryngol Head Neck Surg. 2014;151(2)(suppl):S1-S40.
Bauer, CA. Tinnitus. N Engl J Med. 2018; 378:1224-1231
- Ear exam