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Tinnitus
Donna I. Meltzer, MD
image BASICS
DESCRIPTION
  • 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” (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 10-15% of adults
  • Prevalence increases with age and peaks between ages of 60 and 69 years (5).
  • Prevalence of 13-53% 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, Ménière 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
  • Causes of objective tinnitus: patulous eustachian tube
    • Vascular: 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
RISK FACTORS
  • Hearing loss (but can have tinnitus with normal hearing)
  • High level noise exposure
  • Advanced age
  • Use of ototoxic medications
  • Otologic disease (otosclerosis, Ménière 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
image DIAGNOSIS
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) Nonpulsatile tinnitus: auditory hallucinations (8)
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:
  • 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.
Diagnostic Procedures/Other
Electronystagmography (vestibular testing for Ménière disease)
image 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.
P.1045

MEDICATION
No pharmacologic agent has been shown to cure or consistently alleviate tinnitus.
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 are 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
  • 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 Ménière disease not alleviated by medications: installation of endolymphatic shunt, labyrinthectomy, or vestibular neurectomy 2 years of therapy; might be more effective than sound masking (18)[B].
  • 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
image 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
1. Baguley D, McFerran D, Hall D. Tinnitus. Lancet. 2013;382(9904):1600-1607.
2. Langguth B, Kreuzer PM, Kleinjung T, et al. Tinnitus: causes and clinical management. Lancet Neurol. 2013;12(9):920-930.
3. Yew KS. Diagnostic approach to patients with tinnitus. Am Fam Physician. 2014;89(2):106-113.
4. Shargorodsky J, Curhan GC, Farwell WR. Prevalence and characteristics of tinnitus among US adults. Am J Med. 2010;123(8):711-718.
5. Zimmerman E, Timboe A. Tinnitus: steps to take, drugs to avoid. J Fam Pract. 2014;63(2):82-88.
6. Bae SC, Park SN, Park JM, et al. Childhood tinnitus: clinical characteristics and treatment. Am J Otolaryngol. 2014;35(2):207-210.
7. Galazyuk AV, Wenstrup JJ, Hamid MA. Tinnitus and underlying brain mechanisms. Curr Opin Otolaryngol Head Neck Surg. 2012;20(5):409-415.
8. Smith GS, Romanelli-Gobbi M, Gray-Karagrigoriou E, et al. Complementary and integrative treatments: tinnitus. Otolaryngol Clin North Am. 2013;46(3): 398-408.
9. Sajisevi M, Weissman JL, Kaylie DM. What is the role of imaging in tinnitus? Laryngoscope. 2014;124(3):583-584.
10. Hoare DJ, Edmondson-Jones M, Sereda M, et al. Amplification with hearing aids for patients with tinnitus and co-existing hearing loss. Cochrane Database Syst Rev. 2014;(1):CD010151.
11. Baldo P, Doree C, Molin P, et al. Antidepressants for patients with tinnitus. Cochrane Database Syst Rev. 2012;(9):CD003853.
12. Hurtuk A, Dome C, Holloman CH, et al. Melatonin: can it stop the ringing? Ann Otol Rhinol Laryngol. 2011;120(7):433-440.
13. Hoekstra CE, Rynja SP, van Zanten GA, et al. Anticonvulsants for tinnitus. Cochrane Database Syst Rev. 2011;(7):CD007960.
14. Dehkordi MA, Abolbashari S, Taheri R, et al. Efficacy of gabapentin on subjective idiopathic tinnitus: a randomized, double-blind, placebocontrolled trial. Ear Nose Throat J. 2011;90(4): 150-158.
15. Glicksman JT, Curhan SG, Curhan GC. A prospective study of caffeine intake and risk of incident tinnitus. Am J Med. 2014;127(8):739-743.
16. Hobson J, Chisholm E, El Refaie A. Sound therapy (masking) in the management of tinnitus in adults. Cochrane Database Syst Rev. 2012;(11):CD006371.
17. Martinez-Devesa P, Perera R, Theodoulou M, et al. Cognitive behavioural therapy for tinnitus. Cochrane Database Syst Rev. 2010;(9):CD005233.
18. Phillips JS, McFerran D. Tinnitus retraining therapy (TRT) for tinnitus. Cochrane Database Syst Rev. 2010;(3):CD007330.
19. Meng Z, Liu S, Zheng Y, et al. Repetitive transcranial magnetic stimulation for tinnitus. Cochrane Database Syst Rev. 2011;(10):CD007946.
20. Bennett MH, Kertesz T, Perleth M, et al. Hyperbaric oxygen for idiopathic sudden sensorineural hearing loss and tinnitus. Cochrane Database Syst Rev. 2012;(10):CD004739.
21. Coelho C, Witt SA, Ji H, et al. Zinc to treat tinnitus in the elderly: a randomized placebo controlled crossover trial. Otol Neurotol. 2013;34(6):1146-1154.
22. Hilton MP, Zimmermann EF, Hunt WT. Ginkgo biloba for tinnitus. Cochrane Database Syst Rev. 2013;(3):CD003852.
23. Tunkel DE, Bauer CA, Sun GH, et al. Clinical practice guideline: tinnitus. Otolaryngol Head Neck Surg. 2014;151(Suppl 2):S1-S40.
Codes
&NA;
ICD10
  • H93.19 Tinnitus, unspecified ear
  • H93.11 Tinnitus, right ear
  • H93.12 Tinnitus, left ear
Clinical Pearls
&NA;
  • 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.