Tinnitus

From Latin tinnire ( to ring or tinkle )- a sensation of any sound perceived in the head or in the ears without 
an evident external stimulus.

At any point in time around 10 % of the population experiences tinnitus ( BTA ) There is no standard diagnostic criterion for tinnitus and is normally determined by self -report typically in reponse to a single question Tinnitus has a reported prevalence of about 8-25.3 % in the US A systemic review ( Abby McCormack et al 2016 ) reported a range from 5.1 to 42.7 % No gender discrimination in incidence Higher incidence among- military personnel, stage workers , drummers and those who perform in front of loudspeakers

Subjective tinnitus –Occurs in absence of any physical sound reaching 
the ear – audible only to the patient. Causes- wax in external ear . Middle ear causes – otosclerosis , middle ear effusion

Inner ear causes –Noise-induced hearing loss Presbyacusis Meniere’s dis Trauma ( surgery , head injury ) Ototoxic drugs Labyrinthitis Acoustic neuroma

Two-thirds of people with tinnitus have a disorder causing hearing impairment Most commonly tinnitus is associated with disorders causing sensorineural hearing loss- includes
○ age related
○ noise related ( less common )
○ Meniere’s dis ( uncommon ) Less commonly tinnitus is associated with disorders causing conductive hearing loss
○ wax
○ otosclerosis ( rare ) Ototoxic drugs ( uncommonly ) Ear infections – including
○ otitis media
○ otitis media with effusion
○ chronic suppurative otitis media Neurological disorders
○ acoustic neuroma
○ multiple sclerosis Metabolic disorder – thyroid disease and diabetes Psychological →anxiety and depression Trauma of the head or neck


Objective tinnitus –Generated in the body and reaches the ear through conduction in body tissues and is audible to the patient as well as the clinician 
( also called somatosounds ).High cardiac output
○ treatment of hypertension with ACEi’s or CCB’s Benign intracranial hypertension Dural or extracranial AV fistula Carotid or vertebral artery stenosis , tortuosity , dissection or aneurysm Aortic dissection and mitral regurgitation Dural or cervcal AVM ( arteriovenous malformation ) High jugular bulb Vestibular schwannoma Temporomandibular joint syndrome Haemangioma Glomus tumour Otosclerosis Paget’s disease. Has a vibratory , clicking or pulsatile character
 Audible with a stethoscope
○ place the stethoscope close to external auditory meatus over the carotid arteries , and on the skull in front and behind th ear. If patient c/o pulsatile tinnitus – clinician should conduct extensive search for a skull base tumour
 Numerous vascular causes of pulsatile tinnitus
most common being 
○ arteriovenous malformations ( AVM ) and 
○ fistulas
 Benign intracranial hypertension has been reported as a major cause of pulsatile tinnitus in toung women


History–No known objective tests that can determine the severity of subjective tinnitus
 unilateral or bilateral constant or intermittent triggers around onset when did it start become annoying associated symptoms
○ deafness
○ dizziness
○ hyperacusis
○ otalgia h/o sig noise exposure drug history ( ototoxic drug use ) family h/o hearing loss from otosclerosis 
Otosclersosis → bone around the base of stapes becomes thickened and eventually fuses with the bone of cochlea → reduces normal sound transmission leading to conductive hearing loss effect on life psychological

Examination –Otoscopy
○ wax
○ infections Tuning fork tests ( conductive or sensory hearing loss ) Bedside hearing test General neurological assessment
○ acoustinc neuroma
○ multiple sclerosis Check blood pressure Blood tests
○ hypo and hyperthyroidism
○ FBC
○ random or fasting BM Auscultate ears , head and neck if pulsatile tinnitus
○ exclude bruit Fundoscopy ( benign intracranial hypertension ) Refer for formal hearing test
○ pure tone audiometry with assessment of air and bone conduction MRI- for vestibular schwannoma ( acoustic neuroma )

Red flags Sudden onset pulsatile tinnitus Tinnitus in association with significant/severe vertigo Unilateral tinnitus Tinnitus in association with asymmetric hearing loss or tinnitus with unexplained sudden hearing loss Tinnitus in association with significant neurological symptom and or signs Tinnitus following head trauma Tinnitus causing psychological distress

Hearing test –Arrange a hearing test for all patients with tinnitus- CKS advice’s an audiology referral if tinnitus persists for tinnitus that lasts 6 months or more

Twenty percent of persons visiting tinnitus clinics have normal hearing

discuss impact , concerns any recent assessment , management plans reassure that tinnitus is common & may resolve by itself commonly associated with hearing loss but not commonly associated with other underlying physical problems reassure that management strategies exist which may help people live well with tinnitus.

Referral – refer immediately -people with tinnitus who are at high risk of suicide to the crisis team
 refer immediately if tinnitus is associated with
○ sudden onset of significant neurological symptoms or signs ( eg facial weakness ) or
○ acute uncontrolled vestibular symptoms ( e,g vertigo ) or
○ suspected stroke
 refer to be seen within 24 hrs if they have tinnitus and have hearing loss that has developed suddenly -
( ie over a period of 3 days or less ) in the past 30 days
 refer to be seen within 2 weeks if tinnitus &
○ distress affecting mental well being ( even if they have received tinnitus support at first point of contact )
○ hearing loss that developed suddenly more than 30 days ago or rapidly worsening hearing loss ( over a period of 4 -90 days )
 refer for tinnitus assessment if 
○ continues to be bothersome
○ persistent objective tinnitus
○ associated with asymmetric or unilateral hearing loss
 consider a referral if
○ persistent pulsatile tinnitus
○ persistent unilateral tinnitus

 

NICE recommends using questionnaires to assess the impact of tinnitus
 Tinnitus Functional Index – how tinnitus affects them Visual analogue scale – if questionnaire cannot be used Discuss how this affects their QoL Insomnia Severity Index – if it impacts sleep Tinnitus questionnaire ( TQ ) or mini- TQ alongside Tinnitus Functional Index to assess psychological impact Assess for depression and anxiety using a questionnaire or an ability appropriate measure and agree on a management plan in line with current guidance

Investigations – some recommendations may relate to specialists investigations can include
○ audiological assessment ( follow NICE guidance )
○ psychoacoustic tests
○ imaging offer MRI of internal auditory meati ( IAM )
○ those with non-pulsatile tinnitus with associated neurological , otological or head & neck signs and symptoms
○ contrast enhanced CT ( IAM ) is an alternative technique
○ do not offer imaging for people with symmetrical non-pulsatile tinnitus with no associated neurological , audiological , otological or head & neck signs and symptoms synchronous pulsatile tinnitus consider
○ MRA or MRI of head , neck , temporal bone and IAM if clinical examination & audiological assessment are normal OR
○ contrast enhanced CT of head , neck , temporal bone and IAM if they cannot have MRA or MRI non- synchronous pulsatile tinnitus ( for e,g if caused by palatal myoclonus ) consider MRI of head or contrast enhanced CT of head.

 

Amplification device – offer hearing aid if they have a hearing loss that affects their ability to communicate consider a hearing aid if they have a hearing loss but do not have difficulties communicating hearing aid is not indicated in absence of hearing loss.

Sound therapy – NICE has not made any recommendations for practice in this area due to lack of evidence of these interventions in isolation.

 

Psychological therapies – stepped care approach digital tinnitus related CBT by psychologist group based tinnitus related psychological interventions by trained practitioners, which can include ○ mindfulness based CBT , acceptance and committee therapy or CNT

British Tinnitus Association top tips for GPs –Most tinnitus is mild An underlying pathology is rare but be vigilant Tinnitus can be associated with a blocked sensation in ears ( cause is not clear ) Giving a negative prognosis is actively harmful There is no direct role for drugs Referral routes vary according to local protocols Tinnitus is more common in people with hearing loss- hearing aids can be helpful Having some continuous low level unobtrusive sound in the background can reduce the starkness of tinnitus Self-help is often effective ( see under links & resources )

LINKS AND RESOURCES

PATIENT INFORMATION

Refer all patients for self-education to this fabulous resource https://www.tinnitus.org.uk/pages/category/information-leaflets

Printable 2page leaflet from Center for Integrated Healthcare https://www.mirecc.va.gov/cih-visn2/Documents/Patient_Education_Handouts/Tinnitus_Fact_Sheet_Version_3.pdf

ENT UK on tinnitus https://www.entuk.org/sites/default/files/files/2012-2015%20About%20Tinnitus%206pp%20DL%20(09028).pdf

Action on hearing loss on tinnitus https://www.actiononhearingloss.org.uk/-/media/ahl/documents/publications/factsheets-and-leaflets/factsheets/tinnitus/factsheet-pulsatile-tinnitus.pdf

Health Navigator New Zealand on tinnitus https://www.healthnavigator.org.nz/health-a-z/t/tinnitus/

Hearing link Org – How to manage tinnitus https://www.hearinglink.org/your-hearing/tinnitus/how-to-manage-tinnitus/

American Academy of Otolaryngology – Head and Neck Surgery – Plain language summary tinnitus https://www.entnet.org/sites/default/files/TinnitusGuidelinePLS.pdf

INFORMATION FOR CLINICIANS

 

References Fortnightly review : tinnitus – investigations and management BMJ 1997: 314:728 Clinical practice guidelines : tinnitius American Aacdemy of Otolaryngology-2014 Oct;151(2 Suppl):S1-40 Primary Care Tinnitus Consultation accesses via https://www.tinnitus.org.uk/primary-care-tinnitus-consultation Diagnostic Approach to Patients with Tinnitus Am Fam Physician.2014 Jan 15;89(2):106-113 Top tips for GPs on managing tinnitus Ear Published 1Feb 2013 Nottingham Hearing Biomedical Research Unit Understanding tinnitus-Action on hearing loss January 2015 Tinnitus BMJ 2014;348:bmj.g216 www.tinnitus.org.uk Merck Manual ENT CKS NHS Tinnitus Stat Pearls Tinnitus by Murray Grossan ; Diana C Peterson