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Tinnitus

BASICS

DESCRIPTION

  • Perception of sound without external stimulus
  • Described as: ringing, buzzing, clicking, whooshing
  • May be unilateral, bilateral, or central
  • Types:
  • Subjective (most common): perceived only by the patient
  • Objective: audible to examiner (rare)
  • Primary tinnitus: idiopathic ± sensorineural hearing loss (SNHL)
  • Secondary tinnitus: due to identifiable cause

EPIDEMIOLOGY

  • Increasing due to noise exposure
  • Higher rates in smokers, HTN, diabetics, obesity
  • 35–50 million US adults report tinnitus; 12 million seek care
  • Prevalence increases with age (peaks ~6th decade)
  • 8% prevalence post-COVID
  • 13–53% prevalence in pediatrics
  • More common in whites > blacks/Hispanics; males > females

ETIOLOGY AND PATHOPHYSIOLOGY

  • Theories: hair cell damage → auditory cortex hyperactivity
  • Secondary causes:
  • Otologic: cholesteatoma, cerumen, otosclerosis, Ménière disease, schwannoma
  • Medications: aminoglycosides, macrolides, chemo agents, diuretics, etc.
  • Somatic: TMJ dysfunction, neck/head trauma
  • Neurologic: MS, intracranial HTN, vestibular migraine, Chiari I
  • Infectious: viral (including COVID-19), bacterial, fungal
  • Metabolic: DM, dyslipidemia, B12 deficiency
  • Vascular: AV malformations, anemia, paragangliomas
  • Genetics: limited evidence

RISK FACTORS

  • Hearing loss (SNHL or conductive)
  • Noise exposure
  • Age, ototoxic medications
  • Otologic diseases
  • Depression, anxiety

GENERAL PREVENTION

  • Avoid loud noises, use hearing protection
  • Limit ototoxic medications

COMMONLY ASSOCIATED CONDITIONS

  • SNHL (presbycusis, loud noise)
  • Conductive loss (cerumen, cholesteatoma)
  • Psychiatric: depression, anxiety, insomnia, suicidal ideation
  • Functional impact: sleep, focus, social life

DIAGNOSIS

HISTORY

  • Onset: gradual (presbycusis) vs. abrupt (noise trauma)
  • Duration: acute vs. chronic (>6 months)
  • Timing: continuous (SNHL), intermittent (Ménière)
  • Pattern: nonpulsatile > pulsatile (vascular)
  • Location: bilateral > unilateral
  • Pitch: high (SNHL), low (Ménière)
  • Associated: hearing loss, vertigo, TMJ pain
  • Triggers: noise, jaw/neck motion
  • Alleviation: hearing aids, meds
  • Assess psychosocial burden: use THI, TFI

PHYSICAL EXAM

  • Full HEENT, neurologic, vascular, TMJ
  • Cerumen, ear exam, fundus (papilledema)
  • Tuning fork: 512/1024 Hz for Weber, Rinne
  • Auscultation for bruits; jugular compression if venous etiology suspected

DIFFERENTIAL DIAGNOSIS

  • Pulsatile tinnitus: carotid stenosis, AVM, glomus tumor, hyperthyroid, anemia
  • Nonpulsatile: auditory hallucinations, TMJ

DIAGNOSTIC TESTS

  • Audiologic tests:
  • Pure tone audiometry
  • Tympanometry
  • Tuning fork tests
  • Labs (selective): CBC, BUN, glucose, lipids, B12, TSH, HIV, RPR, Vit D
  • Imaging (per ACR guidelines):
  • Pulsatile + normal otoscopy: MRA, MRI (IAC), CTA head/neck
  • Pulsatile + retrotympanic lesion: CT temporal bone
  • Unilateral nonpulsatile: MRI with/without contrast
  • Bilateral nonpulsatile: no imaging if exam normal

TREATMENT

GENERAL MEASURES

  • CBT: for coping and distress reduction
  • Education, relaxation, reassurance
  • Treat underlying pathology
  • Hearing aids (if hearing loss)
  • Sound masking (e.g., white noise machines)
  • Avoid ototoxic drugs

MEDICATIONS

  • No consistent benefit for any specific drug

First-line (for associated mood disorders)

  • SSRIs, TCAs: may help with distress, not tinnitus itself
  • Anxiolytics: limited benefit

Second-line

  • Anticonvulsants: not recommended for routine use

ISSUES FOR REFERRAL

  • Audiologist: hearing testing
  • ENT, neurologist, neurosurgeon (based on cause)
  • Dentist: TMJ dysfunction
  • Therapist: CBT, biofeedback

ADDITIONAL THERAPIES

  • CBT: most effective non-drug therapy
  • Sound therapy: low-level noise generators
  • Tinnitus retraining therapy (TRT)
  • TMS (experimental)
  • Botulinum toxin (palatal myoclonus)
  • Not recommended: intratympanic steroids

SURGERY / OTHER PROCEDURES

  • Cochlear implants (for severe SNHL)
  • Stapedectomy (otosclerosis)
  • Labyrinthectomy / vestibular neurectomy (severe Ménière)
  • Carotid endarterectomy (if vascular cause)
  • Tumor resection / radiation (e.g., vestibular schwannoma)

COMPLEMENTARY & ALTERNATIVE MEDICINE

  • Some report benefit from:
  • Acupuncture
  • Melatonin, Ginkgo biloba, Zinc
  • Antioxidants
  • Evidence limited

ONGOING CARE

FOLLOW-UP

  • Audiology, mental health as needed
  • Family physician for coordination
  • Reassess impact and functional impairment

PATIENT EDUCATION

PROGNOSIS

  • Persistent in ~80% of older adults
  • Worsens in 50%
  • Focus on function, not cure
  • Goal: symptom reduction + coping strategies

ICD-10 CODES

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

CLINICAL PEARLS

  • Patients perceive tinnitus differently; many with chronic cases have depression
  • Avoid loud noise, reduce stress
  • Management is multimodal, not curative