Editors

AnttiAarnisalo

Tinnitus

Establish the aetiology. In some cases, the symptom may be caused by
- uni- or bilateral hearing loss
- noise-induced hearing damage
- otosclerosis or
- vestibular schwannoma (acoustic neurinoma).
Remember the possibility of Ménière's disease.
Explain to the patient that the sympton is not dangerous despite it being disturbing.

Tinnitus refers to an auditory perception in the absence of external auditory signal.
Subjective tinnitus is heard only by the patient. Objective tinnitus is also audible to the examiner, either with or without the use of a stethoscope. Objective tinnitus is rare.
If tinnitus is pulsating in the rhythm of the heart beat it might be caused by a vascular anomaly, and the patient should be referred for further investigation.
Almost everybody has experienced transient tinnitus at some time during the life. In about 10 % of the population, tinnitus is continuous and disturbing.
The prevalence of severe tinnitus is approximately 1%. Tinnitus becomes more common with age.

In tinnitus, acoustic trauma may be the background cause (noise at workplace, music, explosion, fireworks, gunshot).
Tinnitus is often associated with sensorineural or conductive hearing impairment irrespective of its aetiology.
Tinnitus is usually caused by inner ear damage which leads to increased automatic activity of the cochlear nerve and erroneous perception of noise by the brain.

Tinnitus can be in both ears or unilateral, and the quality varies (ringing, fluctuating, whistling, whining, hissing, humming, buzzing etc.)
A low pitch noise may often be associated with a middle ear disease or Ménière's disease.
The pitch of the noise is not enough to determine the aetiology.
The degree of disturbance caused by tinnitus also varies; from tinnitus only heard in noiseless surroundings to tinnitus interfering with the quality of life.
Tinnitus may lead to difficulties in falling asleep, decline in sleep quality, irritability, poor concentration and depression.

Clarify the characteristics of the tinnitus and assess its effects on the patient's quality of life.
Ask whether tinnitus is associated with vertigo (for diagnosis and treatment of vertigo see article Vertigo).
Ask about possible exposure to noise and ototoxic medication (e.g. among cytostatics cisplatin and its derivatives).
Inspect the eardrum and test its mobility
Weber's and Rinne's tuning fork tests
Audiogram
In unilateral cochlear (sensorineural) hearing impairment further investigations to rule out vestibular schwannoma (acoustic neurinoma) are always indicated. Refer the patient to an ENT specialist.
If the patient has conductive hearing loss with a normal eardrum, refer the patient for investigations to verify possible otosclerosis Otosclerosis.
If the patient's hearing is not impaired or the impairment is bilateral the indications for consultation are determined by the need for treatment of tinnitus. Usually a referral is not necessary.

The disturbance caused by the symptoms can be decreased by
- counselling the patient (and explaining the commonness and benign nature of the symptom)
- producing background noise in the environment, e.g. by keeping a radio on or using music headphones
- treatment of concomitant depression (the harmful effect on the patient's quality of life caused by tinnitus may be alleviated) Antidepressants for Treatment of Tinnitus.
In patients who need a hearing aid, the amplification of sound will help to mask tinnitus.
There is no reliable evidence on the effectiveness of the various pharmacological treatments.
Other treatment modalities in severe tinnitus that deteriorates the patient's quality of life include sound-based therapy Sound Therapy (Masking or Using Amplification Devices and/or Sound Generators) in the Management of Tinnitus, desensitization training, tinnitus retraining therapy (TRT) Tinnitus Retraining Therapy (Trt) for Tinnitus, as well as relaxation and mindfulness exercises.
Surgical treatment is possible in otosclerosis Otosclerosis, in vascular anomalies and in vestibular schwannoma.
Peer support (tinnitus associations)

Jarach CM, Lugo A, Scala M, et al. Global Prevalence and Incidence of Tinnitus: A Systematic Review and Meta-analysis. JAMA Neurol 2022;79(9):888-900 [PubMed]
Fuller T, Cima R, Langguth B, et al. Cognitive behavioural therapy for tinnitus. Cochrane Database Syst Rev 2020;1(1):CD012614 [PubMed]
McKenna L, Marks EM, Hallsworth CA, et al. Mindfulness-Based Cognitive Therapy as a Treatment for Chronic Tinnitus: A Randomized Controlled Trial. Psychother Psychosom 2017;86(6):351-361. [PubMed]
McKenna L, Marks EM, Vogt F. Mindfulness-Based Cognitive Therapy for Chronic Tinnitus: Evaluation of Benefits in a Large Sample of Patients Attending a Tinnitus Clinic. Ear Hear 2018;39(2):359-366. [PubMed]