Tinnitus (Vestibular Disorders)

Question 1

Background

Answer 1

It’s a symptoms not disease.
It is perception of sound in the absence of any external auditory stimulus. The sound may be perceived as ringing, roaring, hissing, buzzing, clicking, pulsing, tonal, whistling, or humming

Types
Objective T - sound heard by patient and examiner
Subjective T - sound hard by patient only

Question 2

Possible causes (some)

Answer 2

age-related hearing loss, ear injury or a circulatory system disorder (stroke), ear infection, wax.

Age related- damage and loss of the tiny sensory hair cells in the cochlea of the inner ear happens from ageing and prolong loud noise

Other cause:
Sounds pass from the outer ear through to the inner ear, which contains the cochlea and auditory nerve. The cochlea is a coiled, spiral tube containing a large number of sensitive hair cells. The auditory nerve transmits sound signals to the brain.
If part of the cochlea is damaged, it will stop sending information to the brain. The brain may then actively “seek out” signals from parts of the cochlea that still work.
These signals might then become over-represented in the brain, which may cause the sounds of tinnitus.

Otosclerosis - bone growth in middle ear.
Meniere disease

Question 3

Diagnosis/ Assessment

Answer 3

Medical history (socrates, etc),

Examination of head and neck (otoscope, weber & rine etc)

if underlying issue sus do FBC, LFT, TFT, BG, HbA1c, lipid, U&E.

if T pulsatile look at CVD

Question 4

Treatment (NON pharmacological)

Answer 4

• Correct any hearing loss. Hearing loss increases risk of tinnitus. Use HEARING AIDS or surgery.
• Sound therapy. Fill silent times with sound. Tinnitus heard in silent environments if there is none then Tinnitus chance reduced. Can use hearing aids with built in sound generator.
• Counselling. Ways to live with tinnitus.
• CBT. Retrain thoughts on tinnitus.
• Tinnitus retraining therapy (TRT). Retrains brains reaction to sound so patient becomes less aware of tinnitus.
• Self-management techniques such as relaxation, sleep hygiene, avoiding caffeine or alcohol shortly before going to bed, hobbies and activities
• remind not to listen to loud music.
  Loud music = tiny hairs in inner ear becoming flattened. Usually bounce back up after loud music is gone but for prolonged time the hairs can snap.

Question 5

Treatment (cks guide) and referral

Answer 5

NO REAL MEDs. SO:
Treat underlying cause.
Review meds.
Discuss sound therapy (non pharmacological part).
Psychological interventions (CBT).
Hearing aid is offered if they also have hearing loss and struggle to communicate.
Address mental health conditions.
Provide self care advise.

REFER
Immediate if Suicide risk, sudden, stroke sus, pulsatile T.
Very Urgent if hearing loss too <30 days
Urgent if hearing loss too >30 days, mental health affected.
Less Urgent if cause unknown.
DO ABOVE IF NOT REFFERED

Question 6

Ototoxic drugs (EXTRA) Pre reg stuff

Answer 6

Limit risk of tinnitus by reducing dose and frequency and not using >1 at a time. DRUGS:
CALM EAR acronym -
C- cisplatin/carboplatin
A- Aminoglycoside
L- Loop diuretic
M- malaria drug (quinine)/Macrolides
E- Erythromycin
A- Asprin/NSAIDs
R- redman syndrome (vancomycin)

• Valproate.
• Loop diuretics (inc. furosemide and bumetanide) can cause tinnitus and reversible hearing loss.
• Aspirin and NSAIDs (same reasons as loop)
• Antimalarials (quinine, chloroquine).
• Tetracyclines (eg, doxycycline, minocycline).
• Macrolide antibiotics (eg, erythromycin).
• Aminoglycoside antibiotics (eg, gentamicin) can cause tinnitus and permanent hearing loss associated with cochlear damage.
• Cytotoxic drugs (including cisplatin) can cause tinnitus and permanent hearing loss