Causes and Types Flashcards
Is tinnitus a heterogeneous condition?
Yes
Numerous pathophysiological mechanisms
Different clinical manifestations
Tinnitus does not represent a disease itself but instead is a symptom of a variety of underlying diseases
What are the six dimensions in which tinnitus patients differ?
Perception of tinnitus (e.g., laterality, pitch, sound quality, temporal pattern)
Etiologies (e.g., hearing loss, TMJ disorders, psychological conditions, aging)
Related comorbidities (e.g., anxiety, depression, sleep disorders)
Inter-individual variability of the interference of tinnitus with sounds, orofacial maneuvers, or pharmacological interventions.
Associated psychological distress
Treatment responses
What are the researched causes of tinnitus?
Hearing loss
Noise exposure
Head & neck injury
Disease or health conditions
Medications
Lifestyle factors
What is subjective tinnitus?
Only heard by the patient
What is objective tinnitus?
Can be heard by the examiner
What are things that increase your risk of subjective tinnitus?
Acoustic trauma
Autoimmune disease
Barotrauma
Cerumen blockage
Ear and/or sinus infection
Endocrine disorder
Exposure to loud noise
Hormonal changes
Medication side effects
Meniere’s disease
Metabolic disorder
Migraine/vestibular migraine
Mineral and vitamin deficiencies
Noise induced hearing loss
Otosclerosis
Presbycusis
Sudden SNHL
TMJ
TBI
Tumors
Viral infections of the inner ear
Whiplash
What are things that increase your risk of objective tinnitus?
Anemia
Arterial bruit
Arteriovenous malformation
Atherosclerotic carotid arteries
Benign intracranial hypertension
Changes in blood flow in the vessels near the ear
ET dysfunction
Glomus tumors
Head or neck trauma
Microvascular compression of CN VIII
Middle ear muscle spasms
Palatal myoclonus
What is the most common cause of tinnitus?
Deprivation of sensory input to the central auditory system
Hearing loss can lead to tinnitus, but tinnitus does not cause hearing loss
Tinnitus is about twice as common in older adults compared to younger individuals, potentially linked to age-related hearing loss and other health issues
What is the second most common form of tinnitus?
NIHL
Associated with exposure to hazardous levels of occupational or recreational noise
The severity of NIHL is influenced by the duration, intensity, and energy content of the noise
Is the mechanisms of tinnitus from meniere’s disease completely understood?
No
Possibly due to increased endolymph pressure, rupture of the reissner’s membrane, or loss of hair cells
How is the tinnitus described in those with meniere’s?
Low frequency tone (125-250 Hz)
Less attention given to tinnitus when treating these patients
How common is tinnitus in those diagnosed with vestibular schwannoma or other CPA lesions?
In about 75% of these patients
Patients complain about unilateral hearing loss and tinnitus
Also can experience loss of balance, dizziness, and facial numbness
Patients often report a higher severity and annoyance of tinnitus compared to other causes
Is tinnitus a common symptoms in otosclerosis patients?
Yes
Described as high-pitched or resembling white noise
It can appear as the first symptom and may initially be pulsatile
What are the theories that describe how otosclerosis causes tinnitus?
Conductive hearing loss causing deafferentation (loss of environmental noise, which can make the noise inside more noticeable)
Reduction of masking effect
Rich blood supply causes pulsatile tinnitus (Gibson, 1973)
Arteriovenous malformations (Sismanis and Smoker, 1994)
Cochlear tinnitus caused by toxic enzymes produced by otosclerotic bone, bony invasion of the cochlea, and damage to the cochlear blood supply
Is tinnitus a common side effect of various ototoxic drugs?
Yes
Most drug-induced tinnitus is reversible upon discontinuation of the drug, except in cases associated with permanent hearing loss from certain drugs (aminoglycoside antibiotics, cisplatin, carboplatin) or prolonged high-dose use of salicylates
Combined exposure to noise and aminoglycosides can lead to greater auditory damage than either factor alone (synergistic effects)
Can severe tinnitus be associated with high stress levels?
Yes
Stress can worsen tinnitus in people who already have it, or stress can induce tinnitus on its own
What prevalence of tinnitus doesn’t have a known cause?
40%
Often appears long after hearing loss with unrelated triggers
8-18% of patients report tinnitus without any hearing loss of obvious somatic issues (could be undetectable venous hums, narrow cochlear dead regions, or childhood CHL affecting pitch)
What are tinnitus classifiers?
Temporal characteristics
Duration
Impact
What are the different kinds of tinnitus?
Spontaneous (a sudden sound, usually unilateral lasting 2-3 minutes)
Temporary (lasts minutes to days often after noise exposure or medications)
Occasional (occurs less than weekly, lasts at least 5 minutes)
Intermittent (occurring regularly and lasts at least 5 minutes)
Constant (continuous sound)
What is recent/acute tinnitus?
Tinnitus that has been experienced for less than 6 months
What is persistent/chronic tinnitus?
Tinnitus that has been experienced for longer than 6 months
What percentage of adults experience chronic tinnitus?
10 to 15%
80% of these individuals have non-bothersome tinnitus
What is primary tinnitus?
Tinnitus that is idiopathic and may or may not be associated with SNHL
Source of tinnitus unknown
What is secondary tinnitus?
Tinnitus that is associated with a specific underlying cause (other than SNH) or an identifiable organic origin
What is pulsatile tinnitus?
Tinnitus that is rhythmic and resembles a heartbeat
Usually caused by a change in blood flow in the vessels near the ear or by a change in awareness of that blood flow
Described as a whooshing sound that has a constant rhythm
What is somatic tinnitus?
Tinnitus that is caused or influences by sensory input in the body
Example: muscle spasms
What are some auditory causes of secondary tinnitus?
Cerumen impaction
Middle ear diseases
Cochlear abnormalities
Auditory nerve pathology
What are some non-auditory causes of secondary tinnitus?
Vascular anomalies
Myoclonus
Intracranial hypertension
Tonic tensor tympani syndrome
TMJ disorder
What are some possible causes of pulsatile tinnitus?
Venous hums
Stenosis of the carotid arteries
Heart murmur
Hypertension
Hyperthyroidism
Vascular stenosis
Aneurysms
Coronary artery disease
Can a glomus jugulare result in pulsatile tinnitus?
Yes
These tumors are usually slow growing and are usually diagnosed later when the tumor is extensive
Hearing loss is the main feature of this, but pulsatile tinnitus can occur
Cranial nerve involvement, vertigo, and otorrhea can occur
Has a rising sun appearance on otoscopy exam
Pulsatile tinnitus on tympanometry and decrease amplitude with carotid pressure
PTA (Unilateral conductive / mixed hearing loss)
What questions are important to ask when evaluating pulsatile tinnitus?
Ask about medications that can be related to blood pressure
History of heart disease or BP issues
If they are currently taking meds, it’s important to ask if their BP is under control or if its still variable
Can a patient’s history give clues about the source of the pulsatile tinnitus?
Yes
Abrupt onset with unilateral neck or head pains suggests a carotid dissection.
Changes in tinnitus intensity with head turning suggests a venous source for the tinnitus
What are the different ways to diagnose pulsatile tinnitus?
MRI (uses magnetic fields and radio waves)
Magnetic resonance angiography (images of blood vessels to show irregularities)
CT (uses x-rays to generate detailed images of head and neck structures
CTA (combines CT with contrast injection to visualize blood vessels)
Angiography (x-ray imaging of blood vessels using injected contrast)
Ultrasound (uses sound waves to show blood flow in neck vessels)
Other tests (may include blood tests for anemia or thyroid issues)
How do you test for pulsatile tinnitus?
Complete audio testing, includes DPOAEs, Thresholds, Tymps/reflexes
Find pulse of pt to determine if their pulsing matches their pulse
Tinnitus of venous origin can be suppressed by compression of the ipsilateral jugular vein (use two fingers to press firmly on the SCM muscle and carotid artery for 10 sec on the right and left sides of the neck, ask the patient is the pulsing changes in any way)
It could stay the same, get louder, go away, or change to a different sound
If the pulsing changes, refer for medical workup of vascular pathways
What is clicking tinnitus?
A relatively rare form of tinnitus
May be objective (somatosounds)
Appears to be due to contractions of the middle ear muscles that control the patency of the ET (tensor tympani or the nasopharyngeal muscles)
Diagnosis can be established by inspection of the nasopharynx either directly or with nasopharyngoscopy for muscle contractions coincident with the clicking
What can clicking be a symptom of?
Middle ear myoclonus (jerking of a muscle group)
If bilateral clicking, usually associated with a palatal myoclonus
Muscle relaxants or Botox may be prescribed to stop the contractions
What should you ask during a case history when evaluating a clicking tinnitus?
What does the clicking sound like? A clicking of a pen?
When did is start? Is it progressing with time?
Is it 1 ear or both? (usually one ear)
Is it random and coincide with some movement that they do?
What do the test results look like for a clicking tinnitus?
May see abnormalities during impedance testing
May be detectable using acoustic reflex testing or reflex decay testing; occasionally you may see it with tympanograms
Sometimes reflexes are too short in duration so you can capture it doing reflex decay testing
Ask patient to tap leg when clicking is heard
True clicking is likely caused by middle ear spasms
Refer to ENT
What questions should you ask when you suspect somatic tinnitus?
Does tinnitus get better or worse or change with position changes or head movement?
Did it begin with any neck injury, chiropractic manipulation or massage?
Single sided tinnitus or bilateral?
What are some characteristic features of somatic tinnitus?
Tinnitus is closely associated with factors related to the head or upper neck
The tinnitus is always perceived in the ear ipsilateral to the somatic event and is described as a high-pitched constant ringing
There are no other hearing or vestibular complaints, and neurological examinations show no abnormalities
Hearing sensitivity is within normal limits
What are some common causes of somatic tinnitus?
Muscle tension
TMJ
Dental disorders
Head injuries
Cervical spine issues
Chronic stress
What questions should you ask for a TMJ tinnitus evaluation?
Ask pt is any jaw issues currently or in the past?
Any clenching or grinding of teeth?
Any jaw pain/popping on either side?
Any tightness in the jaw or fatigue while chewing?
What is the diagnostic criteria for somatosensory tinnitus?
Tinnitus and neck/jaw pain complaints appeared simultaneously
Tinnitus and neck/jaw pain symptoms aggravate simultaneously
Tinnitus is preceded by head or neck trauma
Tinnitus increases with bad posture
Tinnitus pitch, loudness, and/or location are reported to vary
In case of unilateral tinnitus, audiogram does not show a correspondent hearing loss
Frequent pain in the cervical spine, head, or shoulder girdle
Presence of tender myofascial trigger points
Increased muscle tension in the suboccipital muscles
Increased muscle tension in the extensor muscles of the cervical spine
Temporomandibular disorders
Teeth clenching
Dental diseases
Can the presence of somatosensory modulation be tested through different maneuvers?
Yes
Each one being sustained for 5 to 10s in a silent environment
What maneuvers involve the temporomandibular joint?
Clenching and opening jaw wide
Making these movements and seeing if there is any change in tinnitus
What are the maneuvers involving the neck?
Head/neck turning
Passive muscular palpation (search for myofascial trigger points)
Done both with and without resistance by the examiner
What are the limb maneuvers?
Right/left shoulder abduction against resistance applied by the patient
Flexion of the right/left hip against resistance applied by the patient
What are the eye maneuvers?
Movement of eye horizontally
Movement of eye vertically
