Tinnitus

Tinnitus: Excerpt from In a Page: Signs and Symptoms

Tinnitus is a perception of noise (usually ringing, buzzing, or hissing) in the ears, which may be constant or intermittent, temporary or permanent. The pitch and other characteristics of tinnitus should be identified, if possible, to more effectively narrow the differential diagnosis. Additionally, the presence or absence of associated symptoms, including hearing deficits, further narrow the differential, and a hearing test is indicated in most cases of tinnitus when the diagnosis is unclear. The degree of distress caused by tinnitus varies widely.

Differential Diagnosis

• Acute or chronic otitis media
• Impacted cerumen
• Eustachian tube dysfunction
  –“Ocean roar” that may wax and wane with respiration
• Dysfunctional hearing aid
• Presbycusis (high pitch)
• Idiopathic (low pitch)
• Noise-induced hearing loss (high pitch)
• Meniere's disease
  –Triad of tinnitus, hearing loss, and vertigo
• Ototoxicity secondary to drugs
  –High pitch
  –May persist after medication (e.g., aminoglycosides)
  –May be dose-related (e.g., aspirin)
• Trauma
  –Commonly associated with airbag, whiplash, barotrauma
  –May have ruptured tympanic membrane
• TMJ syndrome
  –Nonpulsatile tinnitus (Costen's syndrome)
  –Associated jaw symptoms (e.g., pain, clicking)
• Migraine headache
• Vascular disease (e.g., atherosclerosis, diabetic vasculopathy, arteriovenous malformation, small vessel disease, hypertension)
• Stroke
• Otosclerosis
  –Associated with chronic otitis media or tympanic membrane trauma
• Pseudotumor cerebri
• Tumor
  –Glomus tympanicum or jugulare: Pulsatile tinnitus with hearing loss
  –Acoustic neuroma: Unilateral hearing loss and tinnitus, headache
• Infections (e.g., meningitis, Lyme disease, rubella)
• Less common etiologies (“zebras”) include thyroid disease, Paget's disease, myoclonus of palatal muscles, fetal insults (infections, toxins), sickle cell disease, osteogenesis imperfecta, neurosyphilis, symptomatic Chiari malformation, late onset congenital hearing loss, dissecting aneurysm, carotid cancer, and multiple sclerosis

Workup and Diagnosis

• History and physical exam, including medication history and complete head and neck examination
  –Include neurologic and/or systemic exam if indicated by history
  –Evaluate temporomandibular joint for clicking, popping, and dislocation
• Tympanometry to diagnose otitis media and eustachian tube dysfunction
• Full audiology evaluation if possible sensorineural etiology
• Consider CBC (anemia) and glucose tolerance test (occult diabetes mellitus)
• Head CT scan is indicated if glomus tumor is suspected (delineates base of skull involvement)
• MRI (with enhancement) if possible Chiari malformation, multiple sclerosis, pseudotumor cerebri, or acoustic neuroma
• Angiography
• MRA if CT and MRI are negative but vascular etiology is suspected
• Consider referral to otolaryngologist or neurologist
• Consider screening for secondary depression or insomnia, because this is common in patients with tinnitus

Treatment

• Treat underlying cause if possible
• Discontinue ototoxic medications
• Presbycusis: Hearing aids
• Tinnitus retraining therapy may reduce tinnitus by habituation training
• Masking devices may be used to create a low level sound to decrease or eliminate perceived tinnitus
• Biofeedback or stress reduction may be useful, because tolerance to tinnitus decreases with stress and fatigue
• Surgery to correct conductive defect with outer or middle ear disease or to remove tumors
• Cochlear implants are indicated for severe hearing loss in patients that do not benefit from hearing aids
• Botulinum toxin injection is used for myoclonus of palatal muscles
• Treat underlying depression and insomnia if present

Book Source Details

• Book Title: In a Page: Signs and Symptoms
• Author(s): Scott Kahan, Ellen G. Smith
• Year of Publication: 2004
• Copyright Details: In a Page: Signs and Symptoms, Copyright © 2004 Lippincott Williams & Wilkins.

More About Hearing Impairment

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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.

More About This Book: Title: In a Page: Signs and Symptoms Authors: Scott Kahan, Ellen G. Smith Publisher: Lippincott Williams & Wilkins Copyright: 2004 ISBN: 1-4051-0368-X

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• Hearing Loss – Acquired (In A Page: Pediatric Signs and Symptoms)
• Hearing Loss – Congenital (In A Page: Pediatric Signs and Symptoms)
• TINNITUS AND DEAFNESS (Differential Diagnosis in Primary Care)
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