Tinnitus
Tinnitus literally means ringing in the ears, but 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, some patients are so disturbed by the sounds that they 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 in the auditory pathway, resulting in spontaneous altered firing of sensory auditory neurons. It may stem from an ear disorder, a cardiovascular or systemic disorder, or the effects of certain drugs. Nonpathologic causes of tinnitus include acute anxiety and presbycusis. (See Common causes of tinnitus.)
History and physical examination
Ask the patient to describe the sound he hears, including its onset, pattern, pitch, location, and intensity. Ask whether it’s accompanied by other symptoms, such as vertigo, headache, or hearing loss. Next, take a health history, including a complete drug history.
Using an otoscope, inspect the patient’s ears and examine the tympanic membrane. To check for hearing loss, perform the Weber and Rinne tuning fork tests. (See Differentiating conductive from sensorineural hearing loss, page 396.)
Also, auscultate for bruits in the neck. Then compress the jugular vein 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
An early symptom of this eighth cranial nerve tumor, unilateral tinnitus precedes 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
In this disorder, 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
In this 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, the patient may experience tinnitus, conductive hearing loss, itching, 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.
Glomus jugulare or glomus tympanicum tumor
A pulsating sound is usually the first symptom of these tumors. Other early features include a reddish blue mass behind the tympanic membrane and progressive conductive hearing loss. Later, total unilateral deafness is accompanied by ear pain and dizziness. Otorrhagia may also occur if the tumor breaks through the tympanic membrane.
Hypertension
Severe hypertension (diastolic blood pressure exceeding 120 mm Hg) may cause bilateral high-pitched tinnitus, a severe throbbing headache, restlessness, nausea, vomiting, blurred vision, seizures, and decreased level of consciousness.
Intracranial arteriovenous malformation
A large malformation may cause pulsating tinnitus accompanied by a bruit over the mastoid process.
Labyrinthitis (suppurative)
In this disorder, tinnitus may accompany sudden, severe attacks of vertigo, unilateral or bilateral sensorineural hearing loss, nystagmus, dizziness, nausea, and vomiting.
Ménière’s disease
Most common in adults—especially in men between ages 30 and 60—this 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 in this disorder, tinnitus may result if debris in the external ear canal impinges on the tympanic membrane. More typical findings include pruritus, a 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
This infection 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
In this disorder, 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.
Palatal myoclonus
In this disorder, muscles of the palate contract rhythmically, either intermittently or continuously, causing a clicking sound in the ear and vibratory tinnitus. The contractions are visible with a nasopharyngeal mirror.
Presbycusis
This otologic effect of aging produces tinnitus and progressive, symmetrical, bilateral sensorineural hearing loss, usually of high-frequency tones.
Tympanic membrane perforation
Tinnitus and hearing loss go hand-in-hand in this disorder. 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 bilateral hearing loss. These symptoms may be temporary or permanent.
Special considerations
Tinnitus is typically difficult to treat successfully. If reversible causes have been ruled out, 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 the features of a masker and a hearing aid may be used to block out tinnitus.
Pediatric pointers
An expectant mother’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 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: Professional Guide to Signs & Symptoms (Fifth Edition)
- Author(s): Springhouse
- Year of Publication: 2006
- Copyright Details: Professional Guide to Signs & Symptoms (Fifth Edition), Copyright © 2006 Lippincott Williams & Wilkins.
Other Book Chapters Related to Sensitive hearing
Read excerpts from these other book chapters related to Sensitive hearing:
Medical Books Excerpts
- DEAFNESS
- "Algorithmic Diagnosis of Symptoms and Signs" (2003)
- [ read ]
- TINNITUS
- "Algorithmic Diagnosis of Symptoms and Signs" (2003)
- [ read ]
- Tinnitus
- "In A Page: Pediatric Signs and Symptoms" (2007)
- [ read ]
- Tinnitus
- "Handbook of Signs & Symptoms (Third Edition)" (2006)
- [ read ]
- Deafness
- "A Pocket Manual of Differential Diagnosis" (1999)
- [ read ]
- Hearing loss
- "Professional Guide to Signs & Symptoms (Fifth Edition)" (2006)
- [ read ]
- Tinnitus
- "Professional Guide to Signs & Symptoms (Fifth Edition)" (2006)
- [ read ]
- Hearing Loss
- "The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter" (2000)
- [ read ]
- Tinnitus
- "The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter" (2000)
- [ read ]
- Tinnitus
- "Signs & Symptoms: A 2-in-1 Reference for Nurses" (2007)
- [ read ]
- Tinnitus
- "Nursing: Interpreting Signs and Symptoms" (2007)
- [ read ]
Copyright Details: Professional Guide to Signs & Symptoms (Fifth Edition), Copyright © 2008 Williams & Wilkins.
More About Causes of Sensitive hearing
» Next page: Hearing Loss (The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter)
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