Tinnitus

Question 1

What is tinnitus

Answer 1

Perception of a sound without a corresponding external source;
Often described as a high-pitched ringing or buzzing

Question 2

Common causes of tinnitus

Answer 2

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

Question 3

Is tinnitus usually associated with serious pathology?

Answer 3

Serious pathology is rare

Question 4

Patients with tinnitus and suspected hearing loss should ideally be referred to ___________

Answer 4

An audiologist for a hearing assessment

Question 5

Sudden sensorineural hearing loss that has started in the last 30 days should be referred to…

Answer 5

Urgently referred to or discussed with ENT

Question 6

Risk factors for tinnitus

Answer 6

Hearing loss
Older age
Noise exposure
Smoking

Question 7

Causes of constant tinnitus

Answer 7

Recent trauma
Noise exposure
Ototoxic medication

Question 8

Tinnitus due to trauma should resolve over _________ (timeframe)

Answer 8

Hours

Question 9

Examples of trauma that can cause tinnitus

Answer 9

Loud noise
Head injury
barotrauma

Question 10

Examples of ototoxic medications

Answer 10

Gentamicin
Vancomycin
Macrolides
Loop diuretics
Salicylates
NSAIDs
Quinine

Question 11

Fluctuating tinnitus, with or without vertigo or deafness could suggest…

Answer 11

Meniere’s disease

Question 12

Pulsatile tinnitus could suggest a ________ cause

Answer 12

Vascular

Question 13

Examples of vascular causes of tinnitus

Answer 13

Atherosclerosis of vessels in the head and neck.
AV malformations
Vascular tumours
Benign intracranial hypertension

Question 14

What co-morbidities are commonly associated with chronic tinnitus

Answer 14

Anxiety and depression which are commonly associated with chronic tinnitus

Question 15

Examination should include…

Answer 15

Examine ears
Head and neck – If pulsatile tinnitus:
look for a vascular cause
Neurological examination, if unilateral tinnitus

Question 16

Questions to consider when asking the patient to describe the tinnitus

Answer 16

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?

Question 17

Associated symptoms - consider _________ if the patient reports otalgia, otorrhoea or aural fullness

Answer 17

Middle ear pathology

Question 18

Associated symptoms - vertigo may indicate…

Answer 18

Vertigo may indicate an inner ear disorder or a central cause, e.g. vestibular schwannoma (acoustic neuroma), vestibular migraine or stroke.

Question 19

A description of bilateral ringing/buzzing/hissing may suggest what cause of tinnitus?

Answer 19

Symmetrical sensorineural hearing loss (primary tinnitus)

Question 20

A description of pulsatile tinnitus (particularly if tinnitus is pulse-synchronous) may suggest what cause?

Answer 20

Vascular

Question 21

A description of rhythmic clicking could suggest what cause of tinnitus?

Answer 21

Palatal myoclonus

Question 22

A description of unilateral tinnitus may suggest what cause?

Answer 22

Conductive hearing loss
Ménière’s disease
Vestibular schwannoma (acoustic neuroma)
Vestibular migraine
Stroke

Question 23

A description of tinnitus as sounds that vary with head and neck movement could suggest what cause of tinnitus?

Answer 23

Somatosensory tinnitus

Question 24

The Weber test detects patients with _______________ hearing loss

Answer 24

Unilateral or asymmetric

Question 25

Normal Weber test

Answer 25

Sound is heard equally in both ears --> indicates normal hearing or symmetric hearing loss, e.g. age-related hearing loss

Question 26

Abnormal Weber test

Answer 26

Sound lateralises to one ear, i.e. is heard better in that ear --> indicates unilateral or asymmetric hearing loss

Question 27

An abnormal Weber test should be followed by _________ to determine what?

Answer 27

The Rinne test to determine whether there is conductive hearing loss in that ear (ipsilateral) or sensorineural hearing loss in the opposite ear (contralateral)

Question 28

Positive Rinne test; normal result

Answer 28

Patients with normal hearing or sensorineural hearing loss will hear the tuning fork best when it is held near the ear canal

Question 29

Negative Rinne test; abnormal result

Answer 29

Patients with significant conductive hearing loss will hear the tuning fork best when it is held to the mastoid process

Question 30

The Rinne test identifies patients with significant ________ hearing loss

Answer 30

Conductive

Question 31

Habituation with tinnitus

Answer 31

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

Question 32

Primary tinnitus management

Answer 32

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

Question 33

Hearing aids for tinnitus

Answer 33

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.

Question 34

How to explain tinnitus to patients

Answer 34

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

Question 35

Can tinnitus be treated/cured

Answer 35

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

Question 36

What is sound enrichment

Answer 36

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

Question 37

Are there any medicines that are effective in the treatment of tinnitus

Answer 37

None have sufficient evidence to recommend them for routine use (exception: betahistine for Meniere's)

Question 38

Management of patients with depression and tinnitus

Answer 38

Likely to benefit from antidepressants; effective treatment of depression may also alleviate their tinnitus

Question 39

Lifestyle measures apart from stress/sleep

Answer 39

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.