Tinnitus Flashcards
What is tinnitus
Perception of a sound without a corresponding external source;
Often described as a high-pitched ringing or buzzing
Common causes of tinnitus
Hearing loss e.g., presbyacusis
Noise exposure
Neck or head injuries e.g., whiplash
Ear related e.g., infection, damage from scuba diving, wax blocking canal
Stress or anxiety
Raised blood pressure
Ototoxic medication
Is tinnitus usually associated with serious pathology?
Serious pathology is rare
Patients with tinnitus and suspected hearing loss should ideally be referred to ___________
An audiologist for a hearing assessment
Sudden sensorineural hearing loss that has started in the last 30 days should be referred to…
Urgently referred to or discussed with ENT
Risk factors for tinnitus
Hearing loss
Older age
Noise exposure
Smoking
Causes of constant tinnitus
Recent trauma
Noise exposure
Ototoxic medication
Tinnitus due to trauma should resolve over _________ (timeframe)
Hours
Examples of trauma that can cause tinnitus
Loud noise
Head injury
barotrauma
Examples of ototoxic medications
Gentamicin
Vancomycin
Macrolides
Loop diuretics
Salicylates
NSAIDs
Quinine
Fluctuating tinnitus, with or without vertigo or deafness could suggest…
Meniere’s disease
Pulsatile tinnitus could suggest a ________ cause
Vascular
Examples of vascular causes of tinnitus
Atherosclerosis of vessels in the head and neck.
AV malformations
Vascular tumours
Benign intracranial hypertension
What co-morbidities are commonly associated with chronic tinnitus
Anxiety and depression which are commonly associated with chronic tinnitus
Examination should include…
Examine ears
Head and neck – If pulsatile tinnitus:
look for a vascular cause
Neurological examination, if unilateral tinnitus
Questions to consider when asking the patient to describe the tinnitus
What does it sound like? Is it heard in one ear, both ears or elsewhere inside the head? Is it pulsatile? Is it intermittent or continuous? Does anything make it better or worse?
Associated symptoms - consider _________ if the patient reports otalgia, otorrhoea or aural fullness
Middle ear pathology
Associated symptoms - vertigo may indicate…
Vertigo may indicate an inner ear disorder or a central cause, e.g. vestibular schwannoma (acoustic neuroma), vestibular migraine or stroke.
A description of bilateral ringing/buzzing/hissing may suggest what cause of tinnitus?
Symmetrical sensorineural hearing loss (primary tinnitus)
A description of pulsatile tinnitus (particularly if tinnitus is pulse-synchronous) may suggest what cause?
Vascular
A description of rhythmic clicking could suggest what cause of tinnitus?
Palatal myoclonus
A description of unilateral tinnitus may suggest what cause?
Conductive hearing loss
Ménière’s disease
Vestibular schwannoma (acoustic neuroma)
Vestibular migraine
Stroke
A description of tinnitus as sounds that vary with head and neck movement could suggest what cause of tinnitus?
Somatosensory tinnitus
The Weber test detects patients with _______________ hearing loss
Unilateral or asymmetric
Normal Weber test
Sound is heard equally in both ears –> indicates normal hearing or symmetric hearing loss, e.g. age-related hearing loss
Abnormal Weber test
Sound lateralises to one ear, i.e. is heard better in that ear –> indicates unilateral or asymmetric hearing loss
An abnormal Weber test should be followed by _________ to determine what?
The Rinne test to determine whether there is conductive hearing loss in that ear (ipsilateral) or sensorineural hearing loss in the opposite ear (contralateral)
Positive Rinne test; normal result
Patients with normal hearing or sensorineural hearing loss will hear the tuning fork best when it is held near the ear canal
Negative Rinne test; abnormal result
Patients with significant conductive hearing loss will hear the tuning fork best when it is held to the mastoid process
The Rinne test identifies patients with significant ________ hearing loss
Conductive
Habituation with tinnitus
Most people report that tinnitus becomes less noticeable over time, similar to becoming accustomed to background sounds in the daily environment, e.g. air conditioning or a clock ticking
Primary tinnitus management
Identifying and treating hearing loss
Providing appropriate education and addressing contributing lifestyle factors, e.g. stress, sleep
CBT could be considered for tinnitus-related distress
Hearing aids for tinnitus
Hearing aids may be appropriate for some patients with hearing loss, and may also improve their tinnitus symptoms (if there are no other triggers).
The use of hearing aids to relieve tinnitus in people who do not have hearing loss is not recommended.
How to explain tinnitus to patients
Tinnitus is often associated with or caused by hearing loss. Reduced hearing means the brain does not receive the same sound signals it used to, so the brain “turns up the volume” to try to detect the missing sounds—this can result in tinnitus. Reassure that tinnitus does not make hearing loss worse, and it is only rarely associated with more serious medical conditions
Can tinnitus be treated/cured
For most the symptoms become less noticeable/annoying over time, although they may not completely go away.
In some cases tinnitus can be completely eliminated, esp if the cause of hearing loss is treatable
What is sound enrichment
May be able to improve tinnitus symptoms in quiet situations by adding a background sound source.
Eg a sound that has a similar pitch and character as their tinnitus. Neutral noises (fan or nature sounds) are most effective. Best volume is just quieter than the tinnitus
Are there any medicines that are effective in the treatment of tinnitus
None have sufficient evidence to recommend them for routine use
(exception: betahistine for Meniere’s)
Management of patients with depression and tinnitus
Likely to benefit from antidepressants; effective treatment of depression may also alleviate their tinnitus
Lifestyle measures apart from stress/sleep
Avoid exposure to loud noise.
Foods do not directly cause tinnitus but eliminating alcohol, caffeine, cheeses, salty food, and quinine (tonic water) may help.
Stopping smoking may help.
Advise regular exercise, relaxation, and avoiding becoming overtired.
Control blood pressure.
