Tinnitus

• an auditory perception in the absence of stimulation, often very annoying to the patient
• commonly described as a hissing, roaring, ringing or whooshing sound in one or both ears

Type of Tinnitus	Description	Possible Causes/Differentials
Subjective Tinnitus	Only the affected individual can hear the sound	– Noise-induced hearing loss – Presbycusis – Ototoxic medications – Meniere’s disease – Acoustic trauma – Inner ear infections/inflammation – Stress and anxiety
Objective Tinnitus	The sound can also be heard by the examiner	– Vascular abnormalities – Muscular disorders – TMJ disorders
Pulsatile Tinnitus	Produces sound of regular pulsations; may be subjective or objective	– Vascular anomalies – Intracranial hypertension – Atherosclerosis – Middle ear effusion
Primary Tinnitus	Idiopathic; may or may not be associated with symmetrical SNHL	– Idiopathic – Age-related hearing loss – Noise exposure – Genetic predisposition
Secondary Tinnitus	Associated with a specific underlying cause (other than symmetrical SNHL)	– Middle ear pathology – Vestibular schwannoma – TMJ disorders – Vascular disorders – Ototoxic medications – Eustachian tube dysfunction – Meniere’s disease – Sudden SNHL – Head and neck trauma
Acute or Recent Onset Tinnitus	Apparent for less than 6 months	– Acute otitis media – Sudden SNHL – Acoustic trauma – Recent noise exposure – Acute stress or anxiety – Medication side effects
Chronic Tinnitus	Apparent for more than 6 months	– Chronic noise-induced hearing loss – Presbycusis – Chronic otitis media – Meniere’s disease – Persistent TMJ disorders – Chronic ototoxic medication use – Long-term vascular conditions (e.g., atherosclerosis, arteriovenous malformations)

Common secondary causes of tinnitus

External ear  = Cerumen impaction = Otitis externa

Middle ear  = Otosclerosis = serous otitis media (most common cause in young)Cholesteatoma

Inner ear   = presbycusis (most common cause in elderly) = acoustic neuroma/Vestibular schwannoma = Meniere’s disease = labyrinthitis = acoustic neuronitis = Cochleitis/neuritis = Ototoxic medications: antibiotics (eg aminoglycosides and vancomycin)diuretics (eg frusemide)Aspirin or other salicylates

Non-auditory cause = pulsatile tinnitus : Vascular anomalies  – glomus jugulare – hemangioma – scarotid body tumours – AVM -internal carotid artery bruits -patulous eustachian tube = clicking tinnitus – myoclonus of muscles – stapedius, tensor tympani, levator and tensor palati – tetany = Myoclonus, such as stapedial myoclonus = Nasopharyngeal carcinoma (can cause unilateral otitis media with effusion, leading to hearing loss and tinnitus

History 

• Timeline:
  •  When did the experience of tinnitus begin? Duration will determine whether tinnitus is in the acute or chronic state.
• Character:
  • Obtain a description of the sound. Is it constant or pulsatile? 
  • Pulsatile tinnitus raises the possibility of a vascular lesion, such as a glomus tumour.
• Is the tinnitus unilateral or bilateral?
  • Unilateral tinnitus raises the possibility of a focal lesion, such as a vestibular schwannoma.
• associated otological symptoms (eg otalgia, otorrhoea, vertigo)?
  • Such symptoms raise the possibility of secondary tinnitus. 
  • Vertigo may be associated with inner ear disease
• associated hearing loss?
  • If so, is this sudden in onset?
    • Sudden onset sensorineural hearing loss (SNHL) requires prompt pure tone audiogram, steroid therapy, and the patient referred to an otolaryngologist urgently. 
    • if unilateral tinnitus and hearing loss may raise the possibility of a focal lesion, magnetic resonance imaging (MRI) is often part of the work-up.
• history of noise exposure, whether occupational or social?
  • This can lead to hearing loss and tinnitus
• Medication history
• Is it bothersome or non-bothersome
  • Some people have a very negative response to tinnitus, whereas others are not bothered by it.
• Associated anxiety or depression:
  • A link between tinnitus and comorbid psychological disorder has been demonstrated, and a high prevalence of anxiety and depression is seen in tinnitus sufferers

Examination 

• Cranial nerve and otological examination is required. 
• Tuning fork assessment 
• head and neck, including the carotid and periauricular regions

Investigation 

• Audiology
  • pure tone audiogram (PTA) and tympanogram. 
  • A PTA provides information about whether the patient has conductive hearing loss or SNHL.
    • Conductive hearing loss almost always indicates a secondary cause for tinnitus. 
    • SNHL may indicate a primary or secondary cause. 
    • A tympanogram provides information about middle ear status and eustachian tube function.

Imaging 

• imaging of the head and neck is indicated only if the patient has:
  • unilateral tinnitus, which may suggest a focal lesion
  • pulsatile tinnitus, which may suggest a vascular anomaly; this is best investigated by computed tomography (CT) angiography in the general practice setting
  • asymmetrical hearing loss, defined as ≥10 dB difference between the two sides in three or more frequencies; such patients will need an MRI of the cerebellopontine angle and internal acoustic meatus (MRI-CPA/IAM) to rule out a vestibular schwannoma
  • focal neurological deficit
  • otosclerosis, which often occurs in the third to fifth decade of life, and presents with a slowly progressive hearing loss and often with coexisting tinnitus – a tuning fork exam will suggest a conductive hearing loss, which can be confirmed by audiometry; in this situation, CT of the temporal bone is warranted.
  • CT of the temporal bone may also be indicated in the setting of trauma to the head and if cholesteatoma is suspected

Management 

• avoid loud noise to prevent worsening of symptoms
• mask tinnitus
  • white noise masking devices
  • hearing aid
  • music earphones
• tinnitus workshops
• Sound therapy 
• Psychotherapy
  • patient sees tinitus as harmful, which induces anxiety as duration of tinnitus is unpredictable, and the patient feels a loss of control over the condition.
  • CBT treatments include
    • cognitive restructuring – aims to reduce or correct one’s negative response to tinnitus to a more realistic and positive thought.
    • relaxation training
    • imagery techniques
    • exposure to difficult situations