Tinnitus

• Objective: there is actually a noise to be heard being generated within the head.
  These are either:
  • Pulsatile: due to movement of blood, e.g. carotid stenosis, vascular anomalies or tumours, valvular heart disease, high cardiac output states.
  • Muscular or anatomical: palatal myoclonus, spasm of tympanic muscles, patulous Eustachian tube.
  • Spontaneous: otoacoustic emissions.
• Subjective: there is no acoustic stimulus.
  Common causes are:
  • Otological: noise-induced and other forms of hearing loss, presbyacusis, otosclerosis, impacted cerumen, ear infection, Ménière's disease.
  • Neurological: head injury, multiple sclerosis, acoustic neuroma and other similar tumours.
  • Infectious: meningitis, syphilis.
  • Drug-related: salicylates, non-steroidal anti-inflammatory drugs (NSAIDs), aminoglycosides, loop diuretics, cytotoxicity.
  • Jaw disorders: temporomandibular joint dysfunction.

This is a common complaint. The British Tinnitus Association estimates 1 in 10 people suffer from this symptom.¹ It is more common in males.

Symptoms

Patients often take a long time before seeking medical attention.
Commonest sounds are:

• Ringing
• Buzzing
• Cricket-like
• Hissing
• Whistling
• Humming

Condition is reported to be unilateral in 22%, equal in both ears 34% and one side dominant in the rest, usually the left.²

• Thorough examination of head, neck, ears and jaw should be made.
• Hearing test.
• Other examinations suggested by clinical findings.

Although patients report sound as being loud, hearing tests demonstrate that they are at an intensity that is only just louder than the softest sound audible at that frequency - usually above 3 kHz.

NB: exclude an acoustic neuroma in unilateral tinnitus.

General measures

• Explanation and reassurance that the condition will not progress and that there are no sinister findings.
• There is a strong association between tinnitus and stress; relaxation techniques or relaxing background music can distract or mask some tinnitus.
• Tinnitus retraining therapy shows improvement in 75-82% of patients. It links negative emotional associations with tinnitus-related neural activity.^3,4It may take over a year to complete the therapy, with a goal of habituating the patient to the tinnitus rather than abolishing it. Results are sustained in the long-term.⁵
• Masking devices can be used in those patients who obtained relief from masking during the hearing test. Tinnitus maskers create and deliver constant low-level white noise to the ear. Patients should be advised to wear the device during their waking hours, but successful wearers may wear the device while sleeping.⁶

Pharmacological

• There are few treatments with good quality evidence of efficacy.⁷
• Consider antidepressants for associated depression, but SSRIs have been shown significantly to reduce tinnitus severity, as well as anxiety and depression symptoms.⁸

Surgical

• Microvascular decompression of auditory nerve/nerve resection is controversial.^9,10
• As tinnitus is an integral part of Ménière's disease, treating that condition may provide relief from tinnitus.