Tinnitus

Tinnitus literally means ringing in the ears; although many other abnormal sounds fall under this term. For example, tinnitus may be described as the sound of escaping air, running water, or the inside of a seashell or as a sizzling, buzzing, or humming noise. Occasionally, it’s described as a roaring or musical sound. This common symptom may be unilateral or bilateral and constant or intermittent. Although the brain may adjust to or suppress constant tinnitus, tinnitus may be so disturbing that some patients contemplate suicide as their only source of relief.

Tinnitus can be classified in several ways. Subjective tinnitus is heard only by the patient; objective tinnitus is also heard by the observer who places a stethoscope near the patient’s affected ear. Tinnitus aurium refers to noise that the patient hears in his ears; tinnitus cerebri, to noise that he hears in his head.

Tinnitus is usually associated with neural injury within the auditory pathway, resulting in altered, spontaneous firing of sensory auditory neurons. Commonly resulting from an ear disorder, tinnitus may also stem from a cardiovascular or systemic disorder or from the effects of drugs. Nonpathologic causes of tinnitus include acute anxiety and presbycusis.

History

Ask the patient to describe the sound he hears, including its onset, pattern, pitch, location, and intensity. Ask whether the sound is accompanied by other symptoms, such as vertigo, headache, or hearing loss. Next, take a health history, including a complete drug history.

Physical assessment

Using an otoscope, inspect the patient’s ears and examine the tympanic membrane. To check for hearing loss, perform Weber’s and Rinne tuning fork tests. Also, auscultate for bruits in the neck. Then compress the jugular or carotid artery to see if this affects the tinnitus. Finally, examine the nasopharynx for masses that might cause eustachian tube dysfunction and tinnitus.

Medical causes

Acoustic neuroma

Acoustic neuroma, a tumor of the eighth cranial nerve, causes unilateral tinnitus that precedes early symptoms of unilateral sensorineural hearing loss and vertigo. Facial paralysis, headache, nausea, vomiting, and papilledema may also occur.

Anemia

Severe anemia may produce mild, reversible tinnitus. Other common effects include pallor, weakness, fatigue, exertional dyspnea, tachycardia, bounding pulse, atrial gallop, and a systolic bruit over the carotid arteries.

Atherosclerosis of the carotid artery

With atherosclerosis of the carotid artery, the patient has constant tinnitus that can be stopped by applying pressure over the carotid artery. Auscultation over the upper part of the neck, on the auricle, or near the ear on the affected side may detect a bruit. Palpation may reveal a weak carotid pulse.

Cervical spondylosis

With cervical spondylosis, a degenerative disorder, osteophytic growths may compress the vertebral arteries, resulting in tinnitus. Typically, a stiff neck and pain aggravated by activity accompany tinnitus. Other features include brief vertigo, nystagmus, hearing loss, paresthesia, weakness, and pain that radiates down the arms.

Ear canal obstruction

When cerumen or a foreign body blocks the ear canal, tinnitus may occur with conductive hearing loss, itching, blockage, and a feeling of fullness or pain in the ear.

Eustachian tube patency

Normally, the eustachian tube remains closed, except during swallowing. However, persistent patency of this tube can cause tinnitus, audible breath sounds, loud and distorted voice sounds, and a sense of fullness in the ear. Examination with a pneumatic otoscope reveals movement of the tympanic membrane with respirations. At times, breath sounds can be heard with a stethoscope placed over the auricle.

Hypertension

Bilateral, high-pitched tinnitus may occur with severe hypertension. Diastolic blood pressure exceeding 120 mm Hg may also cause severe, throbbing headache; restlessness; nausea; vomiting; blurred vision; seizures; and decreased level of consciousness.

Intracranial arteriovenous malformation

A large intracranial arteriovenous malformation may cause pulsating tinnitus accompanied by a bruit over the mastoid process. Other manifestations include severe headache, seizures, and progressive neurologic deficits.

Labyrinthitis (suppurative)

With suppurative labyrinthitis, tinnitus may accompany sudden, severe attacks of vertigo, unilateral or bilateral sensorineural hearing loss, nystagmus, dizziness, nausea, and vomiting.

Ménière’s disease

Ménière’s disease, a labyrinthine disease, is characterized by attacks of tinnitus, vertigo, a feeling of fullness or blockage in the ear, and fluctuating sensorineural hearing loss. These attacks last from 10 minutes to several hours; they occur over a few days or weeks and are followed by a remission. Severe nausea, vomiting, diaphoresis, and nystagmus may also occur during attacks.

Ossicle dislocation

Acoustic trauma, such as a slap on the ear, may dislocate the ossicle, resulting in tinnitus and sensorineural hearing loss. Bleeding from the middle ear may also occur.

Otitis externa (acute)

Although not a major complaint with otitis externa, tinnitus may result if debris in the external ear canal impinges on the tympanic membrane. More typical findings include pruritus, foul-smelling purulent discharge, and severe ear pain that’s aggravated by manipulation of the tragus or auricle, teeth clenching, mouth opening, and chewing. The external ear canal typically appears red and edematous and may be occluded by debris, causing partial hearing loss.

Otitis media

Otitis media may cause tinnitus and conductive hearing loss. However, its more typical features include ear pain, a red and bulging tympanic membrane, high fever, chills, and dizziness.

Otosclerosis

With otosclerosis, the patient may describe ringing, roaring, or whistling tinnitus or a combination of these sounds. He may also report progressive hearing loss, which may lead to bilateral deafness, and vertigo.

Presbycusis

Presbycusis, an otologic effect of aging, produces tinnitus and a progressive, symmetrical, bilateral sensorineural hearing loss, usually of high-frequency tones.

Tympanic membrane perforation

With tympanic membrane perforation, tinnitus and hearing loss go hand-in-hand. Tinnitus is usually the chief complaint in a small perforation; hearing loss, in a larger perforation. These symptoms typically develop suddenly and may be accompanied by pain, vertigo, and a feeling of fullness in the ear.

Other causes

Drugs and alcohol

An overdose of salicylates commonly causes reversible tinnitus. Quinine, alcohol, and indomethacin may also cause reversible tinnitus. Common drugs that may cause irreversible tinnitus include the aminoglycoside antibiotics (especially kanamycin, streptomycin, and gentamicin) and vancomycin.

Noise

Chronic exposure to noise, especially high-pitched sounds, can damage the ear’s hair cells, causing tinnitus and a bilateral hearing loss. These symptoms may be temporary or permanent.

Special considerations

Tinnitus is typically difficult to treat successfully. After ruling out any reversible causes, it’s important to educate the patient about strategies for adapting to the tinnitus, including biofeedback and masking devices.

In addition, a hearing aid may be prescribed to amplify environmental sounds, thereby obscuring tinnitus. For some patients, a device that combines features of a masker and a hearing aid may be used to block out tinnitus.

Pediatric pointers

A pregnant woman’s use of ototoxic drugs during the third trimester of pregnancy can cause labyrinthine damage in the fetus, resulting in tinnitus. Many of the disorders described above can also cause tinnitus in children.

Patient counseling

Advise the patient to avoid further exposure to excessive noise, ototoxic agents, and other factors that may cause cochlear damage. Inform him that even people with normal hearing may experience intermittent periods of mild, high-pitched tinnitus that can last for several minutes.

Pictures

Book Source Details

• Book Title: Signs & Symptoms: A 2-in-1 Reference for Nurses
• Author(s): Springhouse
• Year of Publication: 2007
• Copyright Details: Signs & Symptoms: A 2-in-1 Reference for Nurses, Copyright © 2007 Lippincott Williams & Wilkins.

Other Book Chapters Related to Ear sounds

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Copyright Details: Signs & Symptoms: A 2-in-1 Reference for Nurses, Copyright © 2008 Williams & Wilkins.

More About Causes of Ear sounds

• Back to symptom: Ear sounds: Introduction (review 109 causes)
• Next Book Extract About Ear sounds: Earache (The Diagnostic Approach to Symptoms and Signs in Pediatrics)
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More About This Book: Title: Signs & Symptoms: A 2-in-1 Reference for Nurses Authors: Springhouse Publisher: Lippincott Williams & Wilkins Copyright: 2007 ISBN: 1-58255-318-1

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