3.7 Tinnitus
Key Features
Tinnitus is the perception of sound without an unrelated external source of sound.
Retrocochlear pathology in unilateral tinnitus must be excluded.
Vascular anomalies and neoplasms should be excluded in pulsatile tinnitus.
Tinnitus is a common but poorly understood disorder. Its severity can range from insignificant to disabling. Tinnitus is a nonspecific symptom characterized by the sensation of buzzing, ringing, clicking, pulsations, and other noises in the ear. Objective tinnitus, or somatosounds, refers to noises generated from within the ear or adjacent structures. The term “subjective tinnitus” is used when the sound is audible only to the affected patient.
Epidemiology
Fifty million Americans report tinnitus, representing an estimated prevalence of 10 to 15% of adults in the United States. Twelve million will seek medical attention. Males report it more frequently than females.
Clinical
A targeted history at the initial evaluation of the patient, including risk factors for hearing loss, should be obtained to identify conditions that, if promptly identified and managed, can relieve tinnitus. It is important to determine whether the tinnitus is unilateral, pulsatile, new onset, or sudden onset with hearing loss. A history of hearing loss (unilateral, bilateral, asymmetric), noise exposure, ototoxic exposure, and head trauma should be elicited. Additional neurotologic symptoms such as vertigo, imbalance, dizziness, and even otalgia and otorrhea may help determine the etiology of the tinnitus. Depression, anxiety, and cognitive impairment often coexist with tinnitus. Tinnitus can also impair concentration, memory, and sleep. It is also important to elicit whether the tinnitus is mild, moderate, or severed based on effect on quality of life (i.e., how bothersome it is to the patient). Duration of tinnitus may facilitate discussion about natural history, treatment, and follow-up care. Persistent tinnitus occurs when symptoms last for ≥ 6 months.
Differential Diagnosis
Subjective (Nonpulsatile)
Otologic: Hearing loss, otosclerosis, Ménière′s disease
Neurologic: Multiple sclerosis, trauma, vestibular schwannoma
Infectious: Lyme disease, syphilis, otitis, meningitis
Drug-induced: Aspirin, nonsteroidal anti-inflammatory drugs (NSAIDs), aminoglycosides, furosemide, vincristine, platinum-based chemotherapeutics
Miscellaneous: TMJ or myofascial, dental, depression, idiopathic
Objective (Pulsatile)
Turbulent flow: Glomus tumors, carotid atherosclerosis, benign intracranial hypertension, dural arteriovenous malformations, cerebral aneurysms
Muscle contractions: Palatal myoclonus—stapedial, tensor tympani
Spontaneous otoacoustic emissions
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