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 1/5^thof 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