Information ⬇
Editors
Tinnitus
Essentials
- Establish the aetiology. In some cases, the cause may be eliminated (noise, otosclerosis, vestibular schwannoma).
- Remember the possibility of Ménière's disease.
- No cure is available in the majority of cases. Explain to the patient that the condition is harmless despite it being disturbing.
Definition and epidemiology
- 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.
Aetiology
- The most common cause is noise (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.
Clinical picture
- The quality of the perceived noise 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.
Investigations and indications for referral
- 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 drug history (e.g. aspirin, valproic acid, ototoxic medication).
- 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 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 personal stereo
- 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. However, the following drug types may be tried as they may be helpful in individual cases:
- 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)
References
- McKenna L, Marks EM, Hallsworth CA ym. 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]
Evidence Summaries ⬆