• Clinical science

Tinnitus

Summary

Tinnitus is a common condition in which sound (whistling, hissing, buzzing, ringing, pulsating) is perceived in the absence of an external source. It can be unilateral or bilateral, acute or chronic, and intermittent or constant. Tinnitus is not a specific disease but a symptom that can be connected to a wide variety of etiologies, most commonly conditions associated with hearing loss. Evaluation should include a detailed history of the tinnitus, as well as an ENT, neck, cardiac, and neurological examination. Patients should also undergo a complete audiological examination. Imaging is recommended for patients with unilateral tinnitus, asymmetric tinnitus, pulsatile tinnitus, and/or focal neurological deficits. If an underlying cause is identified, appropriate treatment should be initiated. However, most patients receive supportive therapy, which might include sound therapy (i.e., hearing aids, cochlear implants) and supportive counseling. The prognosis is favorable for individuals with acute tinnitus (∼ 80% recovery rate) but is significantly worse for those with chronic symptoms (∼ 25% recovery rate).

Epidemiology

  • Prevalence:
    • Most people will experience tinnitus at some point in their lifetime.
    • ∼ 10–15% overall prevalence in the US adult population
    • Increases with age
    • More common in men and smokers
  • Associations: hearing loss, hyperacusis

References:[1][2][3][4][5]

Epidemiological data refers to the US, unless otherwise specified.

Etiology

  • Tinnitus is a symptom, not a specific disease, and its presence can indicate an underlying abnormality.
  • Objective tinnitus; : tinnitus that can perceived by others; , which is due to sounds created by the body (e.g., carotid artery stenosis, stapedial myoclonus)
  • Subjective tinnitus; : tinnitus that is only perceived by the affected individual; , which can be due to a wide range of etiologies (e.g., otosclerosis, tumor, infections)

References:[1][6]

Clinical features

  • Perceived sound without an external source (whistling, hissing, buzzing, ringing, pulsating, etc.)
  • Symptoms of an underlying disease may be present as well (e.g., hearing loss )

References:[7]

Diagnostics

  • History: characterize the tinnitus (e.g., unilateral vs. bilateral, symptom duration, quality) and risk factors (sound exposure, chronic illness, and recent use of ototoxic medication)
  • Initial exam
    • Otoscopic exam: exclude infection, impacted cerumen
    • Head and neck auscultation to assess for bruits or hums
    • Neurologic examination to look for focal deficits
    • Audiological examination for all patients presenting with tinnitus
  • Additional tests
    • Imaging is recommended for patients with one or more of the following: unilateral tinnitus, asymmetric tinnitus, pulsatile tinnitus, and/or focal neurological deficits
    • Routine blood work if a treatable cause of tinnitus is suspected (e.g., hypothyroidism, anemia)
    • Infectious workup (FTA-ABS for syphilis) and autoimmune workup (ANA, sedimentation rate, rheumatoid factor) if suspected

References:[1]

Treatment

  • After symptom onset, treatment should be started as early as possible to prevent the condition from becoming chronic.
  • Treat any underlying conditions.
  • Supportive treatment: counseling , cognitive behavioral therapy , sound therapy

References:[1][8]

Prognosis

In up to 80% of cases of acute tinnitus, symptom resolution occurs spontaneously or with treatment, whereas resolution occurs in only ∼ 25% of patients with chronic tinnitus.

last updated 08/25/2019
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