Tinnitus

• Tinnitus

  A persistent additional sound that is heard but is not present in the surrounding environment. It may be described as a "ringing in the ears", but it can also be a buzzing, hissing or humming noise.
• Cause of tinnitus

  The additional noise experienced with tinnitus is thought to be the result of a background sensory signal produced by the cochlea that is not effectively filtered out by the central auditory system
• In a quiet enough environment, almost everyone will experience some background noise (tinnitus). This becomes more prominent the more attention it is given.
• Causes of secondary tinnitus

  • Impacted ear wax
  • Ear infection
  • Ménière's disease
  • Noise exposure
  • Medications (e.g., loop diuretics, gentamicin and chemotherapy drugs such as cisplatin)
  • Acoustic neuroma
  • Multiple sclerosis
  • Trauma
  • Depression
• Systemic conditions associated with tinnitus

  • Anaemia
  • Diabetes
  • Hypothyroidism or hyperthyroidism
  • Hyperlipidaemia
• Objective tinnitus

  When the patient can objectively hear an extra sound within their head, which can also be observable on examination by auscultating with a stethoscope around the ear
• Causes of objective tinnitus

  • Carotid artery stenosis (pulsatile carotid bruit)
  • Aortic stenosis (radiating pulsatile murmur sounds)
  • Arteriovenous malformations (pulsatile)
  • Eustachian tube dysfunction (popping or clicking noises)
• TOM TIP: 'I think of primary tinnitus as the ears trying to "turn up the volume" when they cannot hear the surrounding noises as well. This is a helpful way of explaining it to patients who have tinnitus associated with hearing loss. Using hearing aids allows the ears to pick up noises better and "turn the volume down", improving the tinnitus. The actual cause of tinnitus is not entirely understood, so this is not entirely accurate, but it is a helpful analogy.'
• Assessment of tinnitus

  1. Ask about the pattern of symptoms (unilateral or bilateral, frequency and duration, severity, pulsatile or non-pulsatile)

  2. Focused history and examination to identify any underlying causes (contributing factors, associated symptoms, stress and anxiety, otoscopy, Weber's and Rinne's tests)
• Investigations for tinnitus

  • Blood tests (full blood count, glucose, TSH, lipids)
  • Audiology
  • Imaging (e.g., CT or MRI)
• Red flags for tinnitus

  • Unilateral tinnitus
  • Pulsatile tinnitus
  • Hyperacusis (hypersensitivity, pain or distress with environmental sounds)
  • Associated unilateral hearing loss
  • Associated sudden onset hearing loss
  • Associated vertigo or dizziness
  • Headaches or visual symptoms
  • Associated neurological symptoms or signs (e.g., facial nerve palsy or signs of stroke)
  • Suicidal ideation related to the tinnitus
• Management of tinnitus

  1. Tinnitus tends to improve or resolve over time without any interventions

  2. Treat underlying causes (e.g., impacted ear wax or infection)

  3. Measures to help improve and manage symptoms (hearing aids, sound therapy, cognitive behavioural therapy)