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Tinnitus is derived from the Latin word tinnire, meaning to ring. Tinnitus can be classified as subjective and objective. This classification not only explains the underlying etiology but also directs the management of tinnitus. In the normal functioning auditory pathway, there is ordered tonotopic frequency mapping from the cochlea to the auditory cortex via midbrain. Conditions associated with cochlear damage result in altered tonotopic organization and ultimately tinnitus. The pathophysiology of tinnitus can be explained by the tinnitus model. Common causes of tinnitus include Ototoxicity, Presbycusis, noise induced hearing loss, late onset congenital hearing loss, meniere's disease, and Loop diuretics. The incidence rate of tinnitus increases with age and is more prevalent in older people. Tinnitus is more prevalent in men compared to women and smokers compared to non-smokers. If left untreated, patients may progress to functional impairment, insomnia, anxiety, and depression. TSI is used to rank the patient's based upon their severity. The score ranges from 0-45. Symptoms and history include sounds such as ringing, buzzing, pulsatile, roaring and humming and progressive hearing loss. An extensive neurological examination may rule out underlying brainstem damage or hearing loss. The Weber and Rinne test are done to establish sensorineural or conductive hearing loss. They are usually abnormal. MRI with contrast is followed by CT/CTA and ultimately interventional angiography, if needed. Initial audiometric tests are done to identify asymmetries between the ears and to locate the site of abnormality such as middle ear, cochlea, and brainstem. These tests include: pure-tone audiogram, tympanometry, auditory reflex testing, determination of speech discrimination abilities, otoacoustic emissions testing and auditory brainstem response testing (ABR). Tinnitus is a symptom and not a disease itself. It is a chronic condition that can be managed by treating the underlying etiology. The treatment of tinnitus is usually directed towards improvement in the quality of life by decreasing awareness or desensitizing towards tinnitus. It is usually achieved by identifying the underlying pathology or the associated disease. It is recommended to treat underlying insomnia and depression (Grade 1B). Cochlear implants may be considered for tinnitus associated with severe sensorineural hearing loss. Other therapies include: tinnitus retraining therapy (TRT) (Grade 1C), biofeedback (Grade 2C), and cognitive behavioral therapy (CBT) as an adjunct to TRT (Grade 2C). Acupuncture and electrical stimulation are considered equally effective as placebo, no significant role established so far.
- In the early 19th century, Frenchman and Jean Marie Gaspard Itard introduced the concept of masking. They were the first ones to differentiate between subjective and objective tinnitus.
- Later in the 19th Century, with the introduction of germ theory and anesthesia, surgical therapy such as incudectomy was established.
- Tinnitus is derived from the Latin word tinnire, meaning to ring.
Tinnitus can be classified as subjective and objective. This classification not only explains the underlying etiology but also directs the management of tinnitus.
- It is only experienced by the affected individual in the absence of any auditory stimulation
- More common, usually described as continuous ringing, high pitch sound
- It is experienced not only by the affected individual but also by anyone else
- Relative rare, usually described as intermittent venous hum, low pitch sound
- It has an underlying vascular (abnormality of the carotid artery, jugular bulb or jugular vein) or muscular etiology (degenerative conditions such as amyotrophic lateral sclerosis) and usually caused by sound produced in ear, head or neck.
In the normal functioning auditory pathway, there is ordered tonotopic frequency mapping from the cochlea to the auditory cortex via midbrain. Conditions associated with cochlear damage result in altered tonotopic organization and ultimately tinnitus. The pathophysiology of tinnitus can be explained by the tinnitus model.
Lesion projection zone (LPZ):
- Accelerated spontaneous firing rate
- Increased representation of neurons that represent the damaged cochlear region also known as lesion edge frequencies in the LPZ
- Hyperactivity in the lesion projections zone (LPZ)
- Increased cortical representation of the lesion-edge frequencies in the LPZ
Causes of subjective tinnitus
Sensorineural hearing loss:
- Systemic hypertension
- Sickle cell anemia
- Small vessel disease
- Hypercoagulable state
- Diabetic vasculopathy
- ACE inhibitors
- Antimalarial medications
- Calcium channel blockers
- COX-2 inhibitors
- Loop diuretics
- Tricyclic antidepressant
Differential Diagnosis of Tinnitus
|Diseases||Clinical manifestations||Para-clinical findings||Gold standard||Additional findings|
|Acute onset||Recurrency||Nystagmus||Hearing problems, tinnitus|
||+||+/−||−||+/−||+ VZV antibody titres|
(air-bone gaps on audiometry)
||−||+||+/−||+||Increased ESR and cryoglobulins||
||Increased acute phase reactants||
||−||+||+/−||+/−||Elevated concentration of CSF oligoclonal bands|
||+/−||+||+||+||Cerebral spinal fluid (CSF) may show cancerous cells|
|Brain stem ischemia||+||−||+/−||+/−||−||
VZV= Varicella zoster virus, MRI= Magnetic resonance imaging, ESR= Erythrocyte sedimentation rate, EEG= Electroencephalogram, CSF= Cerebrospinal fluid, GPe= Globus pallidus externa, ICHD= International Classification of Headache Disorders
Epidemiology and Demographics
- Tinnitus affects 10 to 15% of the population.
- 85% of the population presenting with ear symptoms/disorders report tinnitus as an associated symptom.
- The incidence rate of tinnitus increases with age and is more prevalent in older people.
- Tinnitus is more prevalent in men compared to women and smokers compared to non-smokers.
Common risk factors of tinnitus include
- Sensorineural hearing loss
- Loud noise exposure
- Vestibular schwannoma
- Ototoxic medication
- History of anxiety and depression
- History of head trauma
- History of multiple sclerosis
Natural History, Complications and Prognosis
- Early clinical features may include ear fullness, huming or ringing sensations in the ear
- If left untreated, patients may progress to functional impairment, insomnia, anxiety, and depression.
Tinnitus severity index (TSI)
- TSI is used to rank the patient's based upon their severity
- The score ranges from 0-45
Tinnitus handicap questionnaire:
- This questionnaire includes 27 questions and is used to estimate the social, physical and emotional handicap severity
Tinnitus handicap inventory:
- This questionnaire has 4 categories to classify severity
- None, mild, moderate, and severe.
History and Symptoms:
- Sounds such as ringing, buzzing, pulsatile, roaring and humming
- Progressive hearing loss
- Recent exposure to excessive or loud noise or head trauma
- Poor hygiene leading to cerumen impaction
- Ear pain
- History of certain medication exposure
- The ear examination may show signs of cerumen impaction, underlying infection or tympanic membrane perforation.
- Auscultation of neck, orbits and periauricular areas as helpful in establishing the diagnosis of vascular causes
- An extensive neurological examination may rule out underlying brainstem damage or hearing loss
- The Weber and Rinne test are done to establish sensorineural or conductive hearing loss. They are usually abnormal.
- There are no specific lab findings associated with tinnitis.
- MRA and CTA are the gold standard diagnostic tests for arteriovenous fistula related tinnitus.
- MRI with contrast is the initial preferred diagnostic test of choice for suspected vascular tinnitus.
- MRI with contrast is followed by CT/CTA and ultimately interventional angiography, if needed.
Other Diagnostic Testing:
- Initial audiometric tests are done to identify asymmetries between the ears and to locate the site of abnormality such as middle ear, cochlea, and brainstem. These tests include:
- Pure-tone audiogram
- Auditory reflex testing
- Determination of speech discrimination abilities
- Otoacoustic emissions testing
- Auditory brainstem response testing (ABR)
- Tinnitus is a symptom and not a disease itself. It is a chronic condition that can be managed by treating the underlying etiology.
- The treatment of tinnitus is usually directed towards improvement in the quality of life by decreasing awareness or desensitizing towards tinnitus. It is usually achieved by identifying the underlying pathology or the associated disease.
- It is recommended to treat underlying insomnia and depression. (Grade 1B)
Following medications have minimal to modest role in relieving tinnitus.
- Lidocaine (intratympanic or intravenous)
- Benzodiazepine (alprazolam)
- Steroids such as dexamethasone (intratympanic)
Following medications have been studied for tinnitus but are not found to be effective and have no role in the treatment of tinnitus
- Tinnitus retraining therapy (TRT) (Grade 1C)
- Biofeedback (Grade 2C)
- Cognitive behavioral therapy (CBT) as an adjunct to TRT (Grade 2C)
- Acupuncture and electrical stimulation are considered equally effective as placebo, no significant role established so far.
- Tinnitus may be been prevented by limiting the exposure to loud noise.
- Minen MT, Camprodon J, Nehme R, Chemali Z (October 2014). "The neuropsychiatry of tinnitus: a circuit-based approach to the causes and treatments available". J. Neurol. Neurosurg. Psychiatry. 85 (10): 1138–44. doi:10.1136/jnnp-2013-307339. PMID 24744443.
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- Melcher JR, Sigalovsky IS, Guinan JJ, Levine RA (February 2000). "Lateralized tinnitus studied with functional magnetic resonance imaging: abnormal inferior colliculus activation". J. Neurophysiol. 83 (2): 1058–72. doi:10.1152/jn.2000.83.2.1058. PMID 10669517.
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- Tunkel DE, Bauer CA, Sun GH, Rosenfeld RM, Chandrasekhar SS, Cunningham ER, Archer SM, Blakley BW, Carter JM, Granieri EC, Henry JA, Hollingsworth D, Khan FA, Mitchell S, Monfared A, Newman CW, Omole FS, Phillips CD, Robinson SK, Taw MB, Tyler RS, Waguespack R, Whamond EJ (October 2014). "Clinical practice guideline: tinnitus executive summary". Otolaryngol Head Neck Surg. 151 (4): 533–41. doi:10.1177/0194599814547475. PMID 25274374.