TINNITUS

David A. Godin, MD
Gerard J. Gianoli, MD


Tinnitus is an auditory perception of sound that is not present in the external environment. It
is common, affecting up to 7% of the U.S. population, with the incidence increasing with age.
Tinnitus is usually minor and noted only in quiet environments, such as at bed time. For some
patients, however awareness of tinnitus can result in severe dysphoria that can lead to
depression and rarely, suicide.
Most patients presenting with tinnitus describe the noise as a ringing, buzzing, or humming,
whereas others report sounds such as a rhythmic ocean rumble or a chirping cricket. One half
of patients with tinnitus localize sound to one ear, and the other half hear noise either from
both ears or from the head in general, twenty percent of tinnitus suffers complain of
significant effects on their quality of life, including difficulty sleeping and concentrating and
problems in social interaction and daily work. Depression is often associate with tinnitus,
especially in the elderly. Approximately three quarters of patients with ear disease have
associated tinnitus, making common the associated otologic complaints of hearing loss, vertigo
and aural fullness.

Anatomy and Physiology
The pathophysiology of tinnitus can be divided in two main categories:
Para-auditory noise (arising from structures outside of the auditory system) and sensorineural
auditory noises (arising from structures within the auditory system [e.g., cochlea, cochlera
nerve]).
Tinnitus of para-auditory origin is seen with vascular malformations (e.g., acquired conditions
such as carotid stenosis) palatal myoclonus, increased intracranial pressure (begin intracranial
hypertension), and conductive hearing loss. The mechanism of tinnitus occurring with vascular
disorders is thought to be mechanical energy from the increased blood pressure. The rhythmic
muscular contractions of palatal myoclonus can cause a clicking sound. Increased intracranial
pressure allows transmission of pulses from Circles of Willis vessels to the cerebrospinal fluid
and dural sinuses, resulting in pulsatile tinnitus. A conductive hearing loss is caused by
imposing a physical change on the mechanical system of the outer or diddle ear (e.g., cerumen
impaction). Tinnitus results from attenuation of background sounds, making normally
inaudible skull sounds audible.

Sensorineural tinnitus is associated most frequently with hearing loss, but the mechanism that
causes this type of tinnitus is unknown. Theories include hyperactivity of hair cells or never
fibers, cell injury, efferent cochlear neuron loss, or increased endolymphatic fluid pressure.
Recent investigation suggests that, in some cases, the perception of sound may within the
cochlear nucleus in the brainstem.


HISTORY
A thorough history is essential for evaluating a patient with tinnitus. Basic information includes
age of onset, mode of progression, and precipitating events. The subjective history includes
pitch, loudness, and location of tinnitus, although these correlate poorly with the underlying
cause. Associated audiovestibular complaints (e.g., hearing loss, vertigo, aural fullness, otalgia,
otorrhea) and a history can reveal heavy caffeine intake, the cessation of which may improve
the tinnitus. Allergic and other forms of rhinosinusitis can contribute to Eustachian tube
dysfunction that worsens the patients otologic symptoms.
The patient should be questioned about headaches, visual changes, focal neurological
complaints weight loss, possibility of pregnancy, symptoms of thyroid dysfunction, and
depression (Case 7.1). Recent weight loss can be associate with a patulous Eustachian tube,
and the resultant transmission of pharyngeal sounds may be interpreted by the patient as a
sound in the ear.
Tinnitus can interfere with sleep, work, and enjoyment of social situations. Tinnitus handicap
questionnaires are available for evaluating the lifestyle effect of tinnitus. Certain medications,
especially aspirin, can result in tinnitus; other drugs (e.g., aminoglycosides, antimalarials, loop
diuretics) can cause hearing loss.

















Case 7.1
Elderly man with tinnitus exacerbated by Depression
A male veteran 75 years of age complains of a constant, high-pitched whine that is gradually
increasing in intensity. The noise increased only recently and is now keeping him awake at night.
He is not aware of any hearing loss. but he does have some difficulty understanding conversational
speech in noisy environments .He has hypertension. Which is well controlled .He is a nonsmoker with
no other known medical problems .He has had only minimal noise exposure since his combat
experience in wwll .Review of systems was negative, but questioning revealed that he first began
having difficulties with tinnitus keeping him awake when his wife of 52 years died 6 months
previously.
The physical examination is normal. With no evidence of bruits other head and neck abnormalities An
audiogram reveals significant high-frequency hearing loss. With levels of 60 and 70 Db at 40000 Hz
speech discrimination scores are 87% and 88%
The patient is thought to have tinnitus secondary to his hearing loss that was exacerbated by
depression occurring after the loss of his wife. He is counseled about the relationship between tinnitus
and hearing loss an amplification trial is suggested .but he is not he is not interested. However. he
does agree to see a mental health professional for treatment of his suspected depression , and he
responds well to counseling and a short course of mood-elevating medication.
DISCUSSION
Sensorineural tinnitus is the most characteristic form of tinnitus encountered in the typical practice.
The recent exacerbation associated with depression is common and often requires additional history
to uncover. Most patients perceive that the tinnitus is the cause of sleeplessness, so the diagnosis of
depression must be suspected by their physician. ( Contributed by Dr. David Eibling)
Other disease states can cause or be related to tinnitus, so past medical histories of the
following may be useful: atherosclerotic carotid disease, hypertension, diabetes, thyroid
dysfunction, anemia, otosclerosis, otitis media, Meniers disease, presbycusis, multiple
sclerosis, hyperlipidemia, neoplasms,and syphilis. Family history may reveal tinnitus associated
with disease processes such as otosclerosis, neurofibromatosis, or familial hearing loss.

Physical Examination

The external ear and mastoid are inspected, palpated, and auscultated.
Erythema, tenderness, audible sounds, and bruits are noted. The external canal is inspected
with an otoscope for infection and obstruction due to cerumem, osteomas, tumors, or foreign
bodies. Auscultation of the external canal may reveal objective tinnitus. This auscultation is
easier to perform with a powered electronic stethoscope (Auscultear), although a regular
stethoscope will suffice. Asking the patient to stop breathing during auscultation is helpful.

Pneumatic massage is used to asses tympanic membrane mobility, effusion, retractions,
retractions, perforations, masses, infection, and other abnormalities. With mild Eustachian
tube dysfunction, and minimal negative middle ear pressure, mobility of the tympanic
membrane may be diminished. Asking the patient to autoinsufflated (i.e., Hold your nose and
pop your ears) often overcomes the mild Eustachian tube dysfunction, returning the middle
ear pressure and the tympanic membrane mobility to normal.
Tuning fork test are performed to assess both conductive and sensorineural hearing loss. The
oropharynx is evaluated, looking for palatal myoclonus or masses. The nose is inspected for
masses or evidence of infection.
The neck examination includes auscultation for bruits. When a bruit is found, carefully
palpated for a thrill. Pulsatile tinnitus is compared with the patients heart rate- a process that
is simplified by asking the patient to mimic the sound while you palpate the pulse.
Gently applying pressure on the neck, being careful not to occlude the carotid sometimes
relieves tinnitus of venous origin. The neck is carefully palpated for many masses. Fundoscopic
examination is performed to rule out evidence of increased intracranial pressure (as with
benign intracranial hypertension). A complete neurological examination is performed with
special attention to cranial nerves V, VI, VII, and VIII because they have an intimate
relationship to the petrous bone within which reside the cochlea and the middle and external
ear.



Differential diagnosis
There are many classification system for tinnitus, the most straightforward of which divides
tinnitus into objective and subjective forms (Table 7.1) objective of tinnitus, which is audible
to both patient and examiner, is uncommon but dramatic when encountered (Case 7.2).
Sounds is in this category are usually pulsating, rapid clicking, or blowing. Tinnitus noise is
typically audible only to the patient, commonly occurs with intrinsic ear disease, and usually is
described as ringing or buzzing. The cause of subjective tinnitus can be otologic (e.g., cerumen
impaction, noise-incluced hearing loss) (Case 7.3) pharmacologic (e.g., aspirin use), or
metabolic (e.g., hyperlipidemia) (see Table 7.1).

ADDITIONAL DIAGNOSTIC EVALUATION
Investigating the causes of tinnitus using diagnostic test can be focused by information from
the history and physical examination. Audiologic evaluation is performed on all patients with
tinnitus. This evaluation consist of puretone audiometry, speech audiometry (speech
discrimination and speech reception threshold), and impedance audiometry (tympanometry
and acoustic reflex). Vestibular test include electronystagmography, rotational studies, and
posturography and are used when there is evidence of vestibular pathology in the initial work-
up. With pulsatile tinnitus, a complete blood count may be warranted to rule out anemia as a
contributing factor.
A variety of imaging modalities can be used to evaluate a tinnitus patient, depending on ist
suspected origin. Imaging is not required if the history and Audiologic examination suggest
uncomplicated hearing loss as the cause. High-resolution computed tomography of the head
and temporal bone can be used to evaluate abnormal findings on physical examination.
Contrast-enhanced magnetic resonance imaging of the cerebellopontile angle is helpful in
excluding posterior cranial fossa tumors (e.g., acoustic neuroma). Magnetic resonance
angiography allows visualization of vascular pathology. Vascular studies are indicated for the
work-up of objectives pulsatile tinnitus, including duplex carotid ultrasound, carotid
angiography, and venography. Electro physiologic test, such as electromyography, are used to
evaluate palatal myoclonus, and the auditory brainstem response test is used to evaluate
cochlear never or brainstem function. Studies that are required less commonly include lumbar
puncture to evaluate cerebrospinal fluid pressure (for disease processes such as benign
intracranial hypertension) and allergy testing for food and environmental agents.






Case 7.2
Woman with Objective Tinnitus Caused by an Arteriovenous Malformation
A woman 38 years of age complains of low-pitch, roaring tinnitus that is gradually increasing in
intensity. The roaring fluctuates, is worse on the left side, and occasionally seems to be pulsatile. She
has no history of noise exposure, familial hearing loss, assoiate medical problems, or dizziness. She
denies otalgia, previous ear disease, and drainage. Physical examination is normal. An audiogram
reveals a binaural, flat sensorineural hearing loss, with thresholds of 35 dB in her right ear and 45dB
in her left Speech discrimination scores are 100% bilaterally.
A hearing aid is fitted on her worse hearing ear. She returns 3 months later, staring that she can hear
better with her aid but that the roaring has persisted. In fact, it is now so loud that her husband can
hear it. Ausculation in her left ear canal and over her mastoid. Imaging shows an arteriovenous
malformation (AVM) of the posterior fossa dura and temporal bone on the left, with a large draining
mastoid emissary vein. She undergoes surgical excision of the dural AVM in a combined procedure
with the otolanrygology and neurosurgery departments. Postoperatively, she has normal hearing and
no longer requires the hearing aid.

Discussion

This case illustrate the importance of an adequate history and physical in the evaluation of tinnitus.
In retrospect, this patient had been clearly describing a venous hum with pulsatile component,
auscultation of the skull was not performed at the initial examination. Moreover, the noise created
by the venous flow resulted in masking of the presented sound during the initial audiogram,
leading to the false assumption that she was experiencing tinnitus due to hearing loss, when in fact
she had normal hearing (Contributed by Dr. David Eibling)









Management and Follow-up
Treatment of tinnitus is difficult, and therapy is often frustrating for both patient and
physician. Potentially curable causes of tinnitus are rare and include vascular anomalies,
otosclerosis, otitis media, cerumen impaction, and neoplasm. Unfortunately, most tinnitus falls
into the noncurable category; thus, successful elimination of the symptom is elusive. Many
therapies have been tried over the years, including, masking, hearing aids, biofeedback,
medical therapy, acupuncture, electrical stimulation, behavior modification, and surgery. None
has had dramatic success.
The first and foremost treatment for tinnitus is reassurance. Once the patient has had a
through medial evaluation that fails to reveal a specific cause for the tinnitus, the patient
should be told that the tinnitus is unlikely to represent a tumor or life-endangering disease
process. This is the most important aspect of managing most case of tinnitus. Patients who are
severely bothered by their tinnitus may become clinically depression, and sleeplessness may
be attributed to the tinnitus rather than to the depression. Recognizing and treating such
depression is vital, but it may or may not affect the tinnitus. The management of tinnitus is
outlined in the algorithm.
Nonmedical therapy, including avoidance of loud noises, abstinence from drinking caffeinated
beverage, cessation of smoking, and elimination of precipitating drugs ( e.g., aspirin
nonsteroidal anti-inflammatory drugs, antimalarials agents), if possible . Other forms of
therapy such as hypnotherapy, acupuncture, and yoga have shown limited success.

Masking is a technique of applying an external noise to the patient to cover up the tinnitus
and makes it inaudible. This can include simply setting the bedside clock radio between
stations at night when the tinnitus is loudest ( to compensate for the lack of natural masking
by ambient external sounds) or using a combined hearing aid/masking unit. Masking device
provided relief for only 10% to 15% of patients. Hearing aids (with or without a masking unit)
are an option for patients with associated hearing loss, because they amplify ambient noise,
thereby masking the tinnitus.
Medical therapy has had limited success. The fallowing drugs have been studied: nortriptyline ,
alprazolam, carbamazepine, Lidocaine, procaine, tocainide, and varios calcium-channel
blockers. The overall evidence of tinnitus relief, however, is conflicting and limited. Lidocaine is
one of the few drugs that has been proven to suppress tinnitus subjectively; whoever, it is
limited by its short duration of action, intravenous-only route of administration (for this
purpose), and potential side effects. Carbamazepine seems promising and is thought to act
similarly to how it acts with trigeminal neuralgia; however, side effects and the lack of well-
controlled studies have limited its use.
Biofeedback is used to approach tinnitus from a more psychological perspective. This therapy
focuses on the patients emotional reaction to tinnitus and assumes that stress plays an
important role in its severity. Patients who benefit most from this type of therapy are those
with the highest agitation levels due to their tinnitus. Relaxation techniques are key to this
type of treatment. Self-monitoring of vital sings, body temperature, and electromyography are
the most common forms of feedback. The goal in this form of therapy is not necessarily the
elimination of tinnitus, but rather a better understanding and mitigation of the factors related
to the stress associated with the tinnitus. Although there is no evidence from controlled
studies that biofeedback works for tinnitus, some patients find it helpful. The usefulness of this
modality is impaired by cost and by the fact is not covered by medical insurance.
Habituation, one of the newest approaches to tinnitus, seems promising and involves directive
counseling combined with low-level, broad-band noise produced by wearable generators. The
directive counseling is designed to educate the patient about the tinnitus and its possible
causes. The background-noise generator facilitates habituation. According to the theory
behind this therapy has not been investigated under controlled experimental conditions and is
not currently covered by third-party payers.
Surgery plays a role in some cases of tinnitus, such as that cause by cerebellopontile-angle
lesion, neoplasm, vascular abnormalities, otosclerosis, infectious complications, and other
causes of conductive hearing loss.
Lumbar-peritoneal shunting can help with tinnitus that is caused by elevations in intracranial
pressure resulting from benign intracranial hypertension. Tinnitus associate with Menieres
disease occasionally can be relived by surgery. Surgery (e.g., cochlear implantation, cochlear
nerve sectioning) has been studied in only a very small subset of patients.

Appropriate follow-up for patients with tinnitus depends on the underlying cause. A patient
with an unremarkable examination and normal Audiologic studies may be followed yearly with
an annual audiogram if there are no further complaints. The patient with a defined underlying
disease process, worsening symptoms, or serve lifestyle disruption should be fallowed more
closely.

DANGER SKIN

Tinnitus is a rarely an emergency; whoever, when it presents with a symptom that suggests
intracranial pathology (e.g., unilateral vestibular weakness, focal neurologic deficits, severe
headache, visual changes and profuse vomiting), emergent treatment is warranted. Tinnitus
that is accompanied by under uncontrolled ear infections, abnormalities on otoscopy, head
and neck masses, bruits, thrills, or other suspicious lesions should prompt a thorough
evaluation. Because tinnitus is relatively common, the primary danger is the temptation for the
physician to skip to the work-up stage and proceed to patient reassurance. Every patient with
persistent tinnitus deserves, at minimum, an accurate audiologic evaluation and, if interaural
hearing asymmetry is present, an auditory response test and/or magnetic resonance imaging.


Case 7.3
Young Man With Tinnitus Caused by Noise Induced Hearing Loss
A man 22 years of age complains of high-pitched tinnitus that becomes worse at night. Occasionally
keeping him awake. He first noted the ringing several month ago and also has a periodic sensation of
blocked ears, worse on the left. He denies hearing loss, head trauma, or ear infection. He has no
history of significant medical problems of familial hearing loss. However, he does have a history of
significant noise exposure from recreational music and shooting, furthermore, he works in a small,
excessively noisy fabrication shop with stamping machines, grinders, and other equipment. He does
not wear ear protection and notes occasional ear pain during shooting. He also notes that, when
driving in his stereo-equipment car, he has to shout to by heard by his friends and that
communication is all but impossible in the fabrication shop. In the past, he has noted tinnitus after
exposure to noise, but it always ceased by the next day. Now however, he notes that it is more o less
continuously present and worse when in a quiet location. He states that his tinnitus recently became
acutely louder when he was shooting his pistol next to a building that seemed to reflect the sound
toward his left ear.
Physical examination and a are normal, with the exception of a binaural dip in hearing thresholds at
4000 Hz to 25 dB on the right and to 40 dB on the left. Speech discrimination scores are normal.
Auditory-evoked potentials are normal,. He is counseled on the necessity to avoid loud noises and on
the significance of hearing protection. The other three men working in the shop are contacted and it
was recommended that he enroll his employees in a hearing-conservation program.
DISCUSSION
This young man has developed noise-inducted hearing loss that is probably permanent. Although
previous episodes of tinnitus most likely indicated temporary threshold shifts, the persistent nature
of his tinnitus now suggest significant hair cell damage.
The occupational Health and Safety (OSHA) requires that all employees who works in a noise-
hazardous area (defined as exposure to 85 dB averaged over 8 hours) must be enrolled in a formal
hearing-conservation program. Unfortunately, not all businesses are required to comply with OSHA
regulations, and it is not uncommon to find case such as this. Education about the long-term squeale
of exposure to hazardous noise should be a part of patient wellness counseling. (contributed by Dr.
David Eibling.)
References

1. Jastreboff PJ,Gray WC,Gold SL.Neurophysiologic approach to tinnitus patients. Am f Otol.
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SUGGESTED READINGS

Jastreboff PJ, Gray WC,Gold SL.Neurophysiologic approach to tinnitus patients. Am f Otol.
1996;17:236-40.
This article reviews the neurophysiology of this symptom complex and discusse the physiology and
mechanics of habituation trealment.
Merchant SN, Rauch SD,Nadol JB Jr. Menieres disease. Eur Arch Otorhinolaryngol. Tails include the
natural history, pathogenesis, and trealment.
Seidman MD, Jacobson GP. Update on tinnitus. Otolaryngol Clin North Am 1996;29:455-65
This article give a good basic overview of tinnitus and includes a thorough review of the varying
origins of this subjective symptom approaches to treatment.